Alicia Ault

March 24, 2016

WASHINGTON ― A fear of falling, especially fear that persists 3 months after a hip fracture, appears to be predictive of worse outcomes 1 year later and, surprisingly, may impede recovery to a greater extent in those who are higher-functioning before the fracture, new research shows.

There are 1.6 million hip fractures annually in the United States, and up to half of patients will experience a fear of falling 3 to 6 months later, said Emily S. Bower, a doctoral candidate in clinical psychology at a joint San Diego State University/University of California, San Diego (UCSD), program.

Bower and colleagues studied the effects of persistent fear on recovery at 4 and 12 weeks after a fall that resulted in a hip fracture. The data were presented here at the American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting and have been submitted for publication.

"Fear of falling earlier in the process seemed to be kind of normal and potentially adaptive," Bower told Medscape Medical News. "But at the 3-month point, it seemed that fear of falling was a maladaptive process."

She said that it was important for clinicians to consider the fear factor when treating post–hip fracture patients. "One in five have a fear of falling — that is overlooked but important to assess," Bower told Medscape Medical News.

Maladaptive Process

A study in 2010 explored the potential consequences of that maladaptive process, finding that for patients who were high functioning before a fall and who had a high fear of another fall, the rate of a subsequent fall was almost the same as that for patients who were lower functioning before the fall but who had a similar degree of fear.

Bower conducted a secondary analysis of a prospective longitudinal study that included 501 adults aged 60 years and older who underwent surgical repair of a hip fracture. They were recruited at eight St. Louis hospitals within 1 week of a fracture. Bower focused on those who had at least one score on the Falls Self-Efficacy Scale–Internationl (FES-I) from week 4 or week 12.

The FES-I measures the degree of concern someone has about falling when conducting activities of daily living. Higher scores indicate a greater fear. A modified 7-item version of the FES-I was used for the study.

The fear itself is usually characterized by activity restriction, a change in balance or gait, and an increased risk for another fall.

The Bower study included patients who had a Functional Recovery Score (FRS) from week 52 and who were community dwelling before the fracture. The FRS score ranges from 0 to 100, with a lower score indicating greater impairment.

The study included 241 patients. Seventy-four percent were women, 92% were white, and 92% were injured from a fall. The vast majority were independent, and 75% walked without assistance.

The patients were assessed in person 2 days post surgery. Data were collected by telephone at weeks 12 and 26, after which a last in-person visit was conducted at week 52. At week 4, only 5% of patients had reached full recovery, said Bower. That rose to just under 50% 1 year post surgery.

Sixty percent of patients reported a fear of falling at week 4 and also at week 12, but the earlier fear did not seem to have any effect on recovery at 6 months or 1 year, said Bower. The persistent fear at week 12 was predictive of a worse outcome at both 6 months and 1 year.

Bower also found that patients who were deemed at baseline to be "high functioning" — those who did not require any assistance with activities of daily living — had a higher risk for a worse recovery, she said.

She and her colleagues found that as the FES-I score increased, the odds of functional recovery decreased. This was mainly seen in high-functioning patients. Each 1 point increase in the FES-I score was associated with a 22% increase in the odds of decline, said Bower. However, for those with low function at baseline, not much of an effect was seen with regard to an increase in FES-I score.

A limitation of the study was that it could not control for concurrent functioning, meaning that patients were perhaps doing worse than expected at 12 weeks and that that increased their fear of falling, Bower told Medscape Medical News.

Higher-functioning patients may have had worse outcomes because they had attempted to return to a higher level of functioning at 12 weeks. This, again, may have led to some frustration and increased fears, she said.

Time to Intervene

Both Bower and discussant Julie Wetherell, PhD, suggested that some kind of intervention is warranted for patients whose fear persists at 12 weeks.

Dr Wetherell, who is a coauthor of the study, is professor in residence at UCSD and is a staff psychiatrist at the Veterans Affairs (VA) San Diego Healthcare System. The VA uses a team-based approach that includes physical therapists who conduct exposure therapy with patients who have a fear of falling. Therapy may be as simple as repeatedly walking side by side with the patient and gradually moving further away from the patient with each exposure, said Dr Wetherell.

"Exposure can be very helpful to reduce fear," Bower said. However, she added that the evidence of potential interventions for fear of falling is scant. The most helpful interventions seem to be having people exercise and making changes to the home environment, she said.

Clinicians should work on the maladaptive cognitions, said Bower. "Their fear may be greater than the actual risk," she noted.

The study was supported by a National Institutes of Health grant. Emily Bower and Dr Wetherell report no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting: Session 205, presented March 18, 2016.

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