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Fear of Falling (fof) as a Risk Factor of Falling in Older Adults

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The human aging process catalyzes many psychological developments which, analogous to physiological changes, can lead to an increased risk of falling in elderly age. Fear of falling (FOF) represents the psychosocial difficulties that older adults face in being able to experience life without falling. FOF has been identified as a risk factor for future falls. Cognitive impairment often affects older adults whom suffer from conditions including Alzheimer’s disease, Parkinson’s disease, and stroke. Cognitive impairment has been identified as a risk factor for falls, particularly severe fall injuries such as hip fracture. Furthermore, anxiety in older adults can lead to a two-fold increase in fall risk. These psychological contributors to fall-risk will be discussed in greater detail within this section.

Fear of Falling

Fear of falling is an umbrella term representing the psychosocial difficulties of anxiety, loss of confidence and negative perception of being able to walk without falling. Approximately half of community dwelling older adults experience FOF. Activity avoidance, as well as decreased self-confidence, and self-efficacy are associated with FOF. Whilst FOF was originally thought to develop following a fall, research suggests FOF affects individuals whom have not suffered from a fall. Lachman et al. (1998) conducted a survey in which self-reported FOF was higher in older adults aged 76 or over, in comparison to older adults aged between 62 and 75. Further research has associated increased FOF prevalence with increasing age. In addition, numerous studies suggest FOF to be slightly more prevalent in females in comparison to males.

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Risk Factors for FOF development

A review conducted by Scheffer et al. (2008) outlines numerous risk factors for the development of FOF. As FOF has been found in higher prevalence in older adults over the age of 76, age can be identified as a risk factor for FOF development. This may likely be due to multiple chronic conditions leading to an overall decrease in general health. Additionally, FOF is suggested to be more prevalent in females. This may be because elderly females tend to be weaker in lower limb muscle groups such as the knee extensors. This can lead to decreased gait speed and impaired balance, which is strongly associated with FOF. Pohl et al. (2014) investigated gender differences in FOF, and suggest that FOF can be influenced by traditional gender stereotypes. Pohl et al. state that masculine ideals, favored by males, may lead to males being less open to presenting themselves as vulnerable, and therefore, less likely to admit to FOF than females. Pohl et al. state that females are often perceived to have lower self-esteem than males, which may manifest in the perceived inability to walk without falling. Furthermore, males may be more likely to engage in risky behaviors, such as refraining from use of mobility aids, suggesting males perceive their risk of falling to be lower. Crucially, Pohl et al. state that not all males or females are receptive of these stereotypical presumptions. Fall history is a risk factor for developing FOF. Experiencing just one fall can lead to FOF development in older adults. Subsequent falls have also been identified as a risk factor for developing FOF. “Postfall syndrome” can lead to increased activity avoidance and loss of independence beyond that warranted by the physical injuries alone.

On the contrary, research has also identified that some older adults have developed FOF despite having no history of falls. This suggests FOF to be a highly individualistic experience. Delbaere, Close, Brodaty, Sachdev, & Lord (2010) identified that there often disparities between older adults’ physiological fall risk and their perceived fall risk. Delbaere et al. report that anxious older adults may perceive their risk of falling to be high, despite being identified as being of low physiological risk. This can subsequently increase their risk of falling, due to increased activity avoidance and physical deconditioning. Therefore, interventions aimed at reducing FOF must be receptive of each patient’s individual circumstance. Research has identified a link between depression and FOF in older adults.

Symptoms of depression can include loss of confidence and motivation. This can manifest within FOF, as a negative perception to carry out tasks without falling over. Low self-efficacy in the ability to not fall may lead to activity avoidance, as a protective strategy. Whilst activity avoidance is a well-established consequence of depression, activity avoidance is often prevalent in older adults whom are not depressed. Activity avoidance, particularly the cessation of physical activities such as walking or gardening, can accelerate processes of physical deconditioning, such as sarcopenia, which may lead to loss of independence, reduction in quality of life, and FOF development.

How does fear of falling increase risk of falling?

As previously mentioned, FOF is associated with activity avoidance and in turn, physical deconditioning. Physical deconditioning is a process of physiological change following a period of inactivity, and is associated with functional losses in independence. Activity avoidance may lead to older adults not fulfilling physical activity guidelines, such as participating in two activities per week intending to improve balance and coordination. Research indicates physical activity can reduce the rate of sarcopenia in older adults. However, if older adults are avoiding activities which can reduce sarcopenia, then they may be at increased risk of falling. This is because sarcopenia is a risk factor for falling, as it can lead to impaired balance and gait disorders.

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