Deborah Brauser

March 20, 2014

ORLANDO, Florida ― Treating fear of falling through fall prevention programs (FPPs) may also help improve depressive symptoms in elderly patients, new research suggests.

A naturalistic study of 69 participants showed that participation in FPPs was associated with improvement in the overall group in falls/self-confidence and in fear of falling.

In addition, the subgroup that had a depressive disorder at baseline showed significantly greater improvement in falls efficacy scores after undergoing an FPP, which was itself then associated with significantly improved depressive symptom scores.

"These are common interventions now for adults who have risk of falls. We were curious whether depression, which we knew was a risk factor for falls, would impact program outcomes," lead author Andrea Iaboni, MD, from the Department of Psychiatry at the University Health Network in Toronto, Ontario, Canada, told Medscape Medical News.

The investigators note that, contrary to their hypothesis, depression was not an obstacle to improving a fear of falling. Instead, the disorder actually predicted greater program success "in parallel with improvement in depressive symptoms."

"These findings suggest the need to evaluate the benefit of an intervention targeted at the detection and treatment of depression in FPPs," they write.

The results were presented here at the American Association for Geriatric Psychiatry (AAGP) 2014 Annual Meeting.

Common Comorbid Conditions

According to the researchers, 1 in 3 seniors will experience at least 1 fall in any given year. Half of these individuals will go on to develop a fear of falling, and a quarter will allow this fear to curtail their daily activities.

Dr. Andrea Iaboni

In addition, a recent study showed that "approximately 40% of fallers who had moderate to severe fear of falling met criteria for a depressive disorder," report the investigators.

They add that although FPPs, including low-intensity exercise and balance training, have shown "modest success" in preventing falls, the programs often have little impact on the fear of falling itself.

For the current study, the researchers sought to examine whether having depressive symptoms would negatively affect the potential benefits of an FPP.

"Basically, we wanted to see if having depression was a limiting factor that would keep people from improving in these programs," explained Dr. Iaboni.

The researchers recruited 69 individuals older than 55 years (64% women; mean age, 81 years) who had entered 1 of 2 hospital-based FPPs in Toronto. All participants had fallen at least once in the previous year. Both programs included 12 2-hour sessions in which patients met weekly with physiotherapists and nurses. One of the hours focused on exercise, and the other hour focused on education.

At baseline, the midpoint, and end of study, the Structured Clinical Interview for DSM-IV (SCID) was administered to assess depressive or anxiety disorders. And the self-rated Hospital Anxiety and Depression Scale (HADS) was used to measure severity of symptoms.

Other measures included the modified version of the Falls Efficacy Scale (mFES) and the Survey of Activities and Fear of Falling in the Elderly.

"Our main goal was to look at fear of falling and at falls efficacy, which is their self-confidence in being able to do day-to-day activities without falling," said Dr. Iaboni.

Greater Confidence

Results showed that for the entire group, the FPPs were associated with significant improvement in both fear of falling and falls efficacy.

A total of 21 of the participants (76% women; mean age, 78 years) had a depressive disorder at baseline vs 48 who did not (28% women; mean age, 82 years).

"The people who were depressed tended to be frailer and slower, tended to have a lot more worry about falls, and tended to have more serious falls in the past, where they were not able to get up off the ground," reported Dr. Iaboni.

Of those who had a depressive disorder, 62% lived alone. In addition, 71% had had a fall that required medical attention (vs 56% of those without the disorder), and 43% had had a fall that resulted in a fracture (vs 27% of those without the disorder).

Interestingly, having depression or depressive symptoms did not significantly increase fear of falling. In fact, only baseline dizziness significantly contributed to this fear (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.86 - 0.97; P = .006).

However, having a depressive disorder was significantly associated with greater improvement in falls efficacy after undergoing 1 of the FPPs (P = .04), as was being younger in age (P = .03).

In addition, the percentage of those with depression who answered "very" to the question of whether they were afraid of falling decreased from nearly 50% before undergoing an FPP to 17% after.

Improvement in falls efficacy after undergoing an FPP, as measured on the mFES, was also significantly associated with improvement in depressive symptoms, as measured on the HADS (P < .05).

"Overall, it did seem that the subset of people who were depressed were less fearful of falling at the end of the program," said Dr. Iaboni. "And in some ways, the fall prevention program helped them with their depression ― and they became more confident as a result of that."

She admitted that it is unclear what part of the program contributed to the improvement in depression scores, "but my thought is that we need to think about ways of further tailoring or tweaking [FPPs] to help those with this disorder even more."

When asked, Dr. Iaboni noted that the FPPs used in this study "were not dramatically intensive interventions," but they did offer basic education and an opportunity to interact with health professionals and other individuals.

"It was a very basic, multicomponent program that I think is not all that different from others that have been studied in depth," she said.

She reported that her next analysis will examine gait data for these study participants.

Spillover Benefits

"This is a very important area of study," Eric Lenze, MD, geriatric psychiatrist and professor of psychiatry at Washington University School of Medicine in St. Louis, Missouri, told Medscape Medical News.

Dr. Eric Lenze

Dr. Lenze, who was not involved with this research, is also the research committee chair for the AAGP.

He noted that the National Institute on Aging and the new Patient Centered Outcomes Research Institute (P-CORI) "are putting a lot of money into the development and testing" of new and effective FPPs.

"In this case, the investigators found that a fairly intensive, at least in my mind, intervention for physical disability was also helpful for depression and fear of falling. And I would have to say I'm not the least bit surprised about that," he said.

"Rehabilitation or improvement of functional disability or functional performance has been shown to have some marked effects on improving depression in older adults. In fact, disability is 1 of the biggest predictors of depressive symptoms in these individuals," said Dr. Lenze.

"So it was great that they were looking at this issue and conceptualizing falls risk and falls prevention as a physical and mental phenomenon with lots of spillover benefits."

The study authors and Dr. Lenze did not disclose any relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2014 Annual Meeting. Abstract EI-06. Presented March 16, 2014.


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