Friday August 20 2010
There is a psychological element to falls
“Elderly people who worry about falling may double the chances that they will take a tumble,” reported The Daily Telegraph.
This study followed a group of elderly people between the ages of 70 and 90 for a year and looked at their risk of falling according to physiological measures such as their balance, strength and stability, and how this was affected by their fear of falling. It found that both physiological and psychological factors affected risk. People whose physiological profile suggested that they were at risk of a fall, but who did not perceive themselves to be, were less likely to fall than people who had a more realistic awareness of their likelihood of falling.
The researchers suggest this is because people who think they have a low risk of falling may be more likely to engage in physical activity, thereby retaining their strength and stability. These findings could lead to tailored training sessions that take into account individuals’ anxieties. This was a preliminary study and further research is needed to establish how this might be done.
Where did the story come from?
The study was carried out by researchers from the University of Sydney. It was funded by the Australian National Health and Medical Research Council and published in the peer-reviewed British Medical Journal.
This research was covered well by the BBC. It is not clear where the “doubling of risk” figure stated in the Telegraph was taken from, as this figure was not directly quoted in the research.
What kind of research was this?
This prospective cohort study investigated whether there was an association between elderly people’s fear of falling, their strength, stability and the chance they would actually fall over.
The researchers say that fear of falling can be rational or it can be like a phobia, affecting a person’s participation in physical and social activities. This leads to becoming unused to being in situations where they might fall, which in turn makes the likelihood of falling greater. The researchers wanted to assess the psychological side of fall risk. They say this is under-researched and may impact on fall-prevention programmes for the elderly, which tend to focus on the physical side of the problem.
What did the research involve?
For one year, the study followed 500 people aged between 70 and 90 and living in Sydney, Australia. The participants were all part of a larger study looking at memory and ageing. The participants for this study were free from dementia, Parkinson’s disease or other neurological conditions that may affect balance.
At the start of the study, all participants took part in extensive medical, physiological and neuropsychological assessments. The medical history assessment noted medical conditions, medication use and a history of falls.
The participants were assessed for how capable they were at understanding and communicating, mobility, self-care, household and work activities, participation in society and interpersonal interactions.
The average amount of physical activity undertaken by each of the participants each week for the previous three months was assessed. The participants’ fall-related physiological skills, such as balance skills, spatial awareness and reaction time.
To assess the participants’ fear of falling, researchers asked them about how concerned they were about falling in a range of activities from daily living situations such as cleaning the house, shopping or walking on uneven surfaces. The participants were given a score, with the higher the score equating to a greater perceived fear of falling. Psychological factors that may be associated with a fear of falling were also assessed, such as depression, anxiety, neuroticism and how much attention they received.
At the start of the study, the number of falls in the past year was recorded. Participants also completed a fall diary where they documented how many falls per month they had in the follow-up year.
After preliminary analysis the researchers then split the participants into the following four groups and analysed these separately:
- Vigorous group (29%): Low physiological fall risk and low perceived fall risk
- Anxious group (11%): Low physiological fall risk but high perceived fall risk
- Stoic group (20%): High physiological fall risk but low perceived fall risk
- Aware group (40%) : High physiological fall risk and high perceived fall risk
What were the basic results?
Of the participants, 30% reported one or more falls in the year prior to the study and 43% reported falls in the follow-up year.
A statistical technique called “multivariate logistic regression” indicated that people who were more likely to experience a fall that resulted in injury or a multiple fall, had poorer balance and reaction time skills. Those most at risk also had an association with a greater fear of falling (odds ratio (fall related physiological skills =1.23, 95% confidence interval 1.01 to 1.49) odds ratio (fear of falling and risk of falling) = 1.29 95% confidence interval 1.01 to 1.57).
People in the anxious group were more likely to be women, have a higher level of self-rated disability, a lower reported quality of life, more symptoms of depression and higher levels of neuroticism. They also performed badly on tests of stability compared to the vigorous group that had an accurate perception of their low fall risk. Despite their fear of falling, the anxious group did a similar amount of planned exercise to the vigorous group.
The people who rated their fall risk inappropriately low (the stoic group) tended to be younger, on less medication, and reported a better quality of life than the aware group. They also had fewer symptoms of depression, were less neurotic, stronger and performed better on a test of stability. The stoics did more planned exercise than the aware group and experienced fewer falls.
How did the researchers interpret the results?
The researchers say that both physiological fall risk and perceived fall risk contribute to a person’s future fall risk. They say that almost a third of elderly people in their sample overestimated or underestimated their fall risk. Psychological measures also seemed to strongly influence the probability of falling.
They suggest that when doctors make assessments on the risk of a peron falling, they should consider both the physiological risk and perceived risk.
The researchers found that anxiety about falling may contribute to the risk of falling in the elderly. They speculate that this may be due in part to a lower fear of falling contributing to greater physical activity and increased strength. At this point further research is needed to fully understand the reasons behind the association.
The researchers highlight a limitation to their study in that the psychological measures used were self-reported, which may have affected the results. They used a “decision tree” method to make provisional cut-off values, dividing people into high and low perceived and physiological risk of falls. The researchers suggest that further studies are necessary to assess whether these cut-off values or the methods are valid.
A basic interpretation of the results suggests that 33% of the anxious group, despite their low physiological fall risk, experienced multiple or injurious falls during the one year follow-up compared with 17% in the vigorous group (p=0.017).
This was an interesting study that highlights the impact of a person’s perceived risk of falling on their actual risk of falling. Further research is needed to assess how a person’s perception affects this risk. Presently, gentle exercise is encouraged to maintain strength and stability as people age: this research may assist in helping to make tailored programmes to help prevent falls in elderly people, which in this age group is clearly a major problem.