Factors Associated with Fear of Falling and Associated Activity Restriction in Community-Dwelling Older Adults: A Systematic Review

Objective

Fear of falling (FOF) is an important threat to autonomy. Current interventions to reduce FOF have yielded conflicting results. A possible reason for this discrepancy could be its multicausality. Some risk factors may not have been identified and addressed in recent studies. The last systematic review included studies until 2006.

Methods

To identify additional risk factors for FOF and to test those mentioned previously, we conducted a systematic literature review. Studies examining FOF in community-dwelling older adults between 2006 and October 2013 were screened.

Results

Outcomes are summarized with respect to different constructs such as FOF, fall-related self-efficacy/balance confidence, and FOF-related activity restriction. Odds ratios and p values are reported. There is no clear pattern with regard to the different FOF-related constructs studied. The only parameters robustly associated across all constructs were female gender, performance-based and questionnaire-based physical function, the use of a walking aid, and, less robust, a history of falls and poor self-rated health. Conflicting results were identified for depression and anxiety, multiple drugs, and psychotropic drugs. Other potentially modifiable risk factors were only mentioned in one or two studies and warrant further investigation. Parameters with mainly negative results are also presented.

Conclusion

Only few risk factors identified were robustly associated across all FOF-related constructs and should be included in future studies on FOF. Some newer factors have to be tested again in different cohorts. The comprehensive overview might assist in the conceptualization of future studies.

Introduction

Fear of falling (FOF) is often used as an umbrella term that can be disentangled into distinct psychological concerns such as the specific fall-related fear, fall-related self-efficacy, balance confidence, and others.¹ Although these parameters are highly related, distinctions can be made when interpreting the results of different studies. In a review article, Hadjistavropoulos et al.² called for a clear distinction between the terms “falls efficacy” (fall-related self-efficacy) including balance confidence and “fear of falling.” In their proposed model, supported by a focused literature review, FOF itself influenced activity avoidance, balance/functional performance, and subsequently falls indirectly through falls efficacy. This model is in line with findings that FOF can (directly or indirectly) have serious consequences for mobility and quality of life in older adults both in the community³ and in nursing homes,⁴ often through activity restriction and avoidance.5, 6 It was also predictive of delayed recovery from incident disability in geriatric rehabilitation.⁷ Hence, in recent years, FOF has been clearly identified as one of the most important and potentially modifiable threats to autonomy in older individuals.

Interventional studies have mostly proven beneficial in reducing FOF and other endpoints, especially in frail, older, fall-prone populations, as demonstrated by different (systematic) reviews.8, 9, 10 Interventions were typically based on Tai Chi, multicomponent interventions, or exercise. Tai Chi has been identified as the most consistent intervention, especially with regard to balance confidence.⁸ However, in another meta-analysis, evidence on Tai Chi was considered insufficient, especially because of inconsistent effects when compared with different controls and missing long-term effects.¹¹ Multicomponent and exercise interventions have been considered positive, although significance of effects was rated low in a review.⁸ In addition, another well-conducted study in community-dwelling older adults at risk¹² failed to show benefits of three different multicomponent exercise interventions on fall rates and FOF-related parameters. Thus, the ideal type of intervention and the individual components are still a subject of debate.¹³ Another difficulty of many interventional trials and observational studies could be that psychological measures differentiating certain risk groups (people with objective risk as associated to motor status and subjective risk as associated to individual risk perception/ psychological status according to the study by Delbaere et al.¹⁴) were often not available.

To improve future interventional programs in older adults and to get a better picture of factors influencing FOF across different constructs, the search for further and potentially modifiable factors associated with FOF seems mandatory. In a review by Scheffer et al. in 2008,³ a list of known risk factors from cross-sectional and longitudinal studies with publication dates until 2006 was reported. To identify additional predictors and analyze those previously mentioned, we performed an updated, comprehensive, and systematic literature search linked to and stratified according to the various aspects of FOF.