Effects of a Multicomponent Cognitive Behavioral Group Intervention on Fear of Falling and Activity Avoidance in Community‐Dwelling Older Adults: Results of a Randomized Controlled Trial

Zijlstra, G. A. Rixt; Haastregt, Jolanda C. M. van; Ambergen, Ton; Rossum, Erik van; Eijk, J.T.M. van; Tennstedt, Sharon L.; Kempen, Gertrudis I. J. M.

doi:10.1111/j.1532-5415.2009.02489.x

Cited by 225 publications

(224 citation statements)

References 41 publications

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“…This approach has shown improvement in fear of falling and falls efficacy, although mixed results in preventing falls and increasing activity levels. 81,82 Unfortunately, there have not been any studies examining the effect of these interventions on concurrent depressive symptoms. Given the fact that antidepressant medications have been associated with an increased risk of falls, and the depression associated with fear of falling is often of mild-moderate severity, further research in psychotherapeutic interventions is warranted.…”

Section: Depression Fear Of Falling Falls Prevention and Exercisementioning

confidence: 99%

The Complex Interplay of Depression and Falls in Older Adults: A Clinical Review

Iaboni

Flint

2013

The American Journal of Geriatric Psychiatry

227

178

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Depression and falls have a significant bidirectional relationship. Excessive fear of falling, which is frequently associated with depression, also increases the risk of falls. Both depression and fear of falling are associated with impairment of gait and balance, an association that is mediated through cognitive, sensory, and motor pathways. The management of depression in fall-prone individuals is challenging, since antidepressant medications can increase the risk of falls, selective serotonin reuptake inhibitors may increase the risk of fragility fractures, and data are lacking about the effect of fall rehabilitation programs on clinically significant depression. Based on the current state of knowledge, exercise (particularly Tai Chi) and cognitive-behavioral therapy should be considered for the first-line treatment of mild depression in older fallers. Antidepressant medications are indicated to treat moderate to severe depression in fall-prone individuals, but with appropriate precautions including low starting dose and slow dose titration, use of psychotropic monotherapy whenever possible, and monitoring for orthostatic hypotension and hyponatremia. To date, there have been no recommendations for osteoporosis monitoring and treatment in individuals prescribed antidepressant medications, beyond the usual clinical guidelines. However, treatment of the older depressed person who is at risk of falls provides the opportunity to inquire about his or her adherence with osteoporosis and fracture-prevention guidelines. KeywordsAntidepressants; depression; falls; fear of falling; fractures One-third of community-dwelling seniors fall each year, with half of these individuals falling more than once. Ten percent of all falls result in a major injury, which can lead to institutionalization and death. 1 Falls often result in a fear of further falls, leading to fearrelated restriction of activities: this activity restriction has been associated with subsequent impairment in balance, mobility, and disability. 2,3 Send correspondence and reprint requests to Alastair

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Section: Depression Fear Of Falling Falls Prevention and Exercisementioning

confidence: 99%

The Complex Interplay of Depression and Falls in Older Adults: A Clinical Review

Iaboni

Flint

2013

The American Journal of Geriatric Psychiatry

227

178

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“…27 There was a 31% reduction in the number of falls [relative risk 0.69, 95% confidence interval (CI) 0.50 to 0.96; p = 0.025] in the intervention group, although, interestingly, there was no corresponding change in FES scores. 27 More recently, Zijlstra et al 28 conducted a RCT of a multicomponent cognitive-behavioural group intervention in older community-dwelling elders. Five hundred and forty participants were drawn from a random sample of 7431 individuals sent questionnaires who reported 'at least some fear of falling', although the method of assessment was not specified.…”

Section: Psychological Treatments For Fear Of Fallingmentioning

confidence: 99%

“…The beginning of the trial predates widespread use of the FES-International version (FES-I) 29 (advocated by the same group as the most appropriate measure for such studies), 8 instead using a single-item question on fear of falling as well as an unspecified scale, probably the original FES from the description and reference supplied. 28 Other outcomes included perceived control over falling and daily activity as well as falls. There were no measures of physical function despite the prior evidence base suggesting improvement in fear of falling with the exercise-related interventions as described above.…”

Section: Psychological Treatments For Fear Of Fallingmentioning

confidence: 99%

“…We estimated a 25% dropout rate on the basis of previous experience with older fallers in RCTs 83 and data from a previous study of CBT in fear of falling in which 30% of the intervention group and 25% of the usual care group failed to complete the study. 28 Accordingly, to allow for 25% dropouts, we aimed to recruit 412 participants.…”

Section: Sample Size Calculationmentioning

confidence: 99%

“…There was a 30% attrition rate in the intervention group and 19.6% attrition rate in the control group. 28 The study intervention was carefully developed and grounded in cognitive-behavioural theory, but interpretation of findings is hampered considerably by the lack of clarity on sample size calculation and outcome measures, and the absence of generic quality-of-life measures and measures of physical functioning. The same research group later reported a before-and-after design study 20 implementing a similar protocol into routine health care in 125 community-living older people, with significant improvements in concerns about falling.…”

Section: Psychological Treatments For Fear Of Fallingmentioning

confidence: 99%

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Cognitive–behavioural therapy-based intervention to reduce fear of falling in older people: therapy development and randomised controlled trial – the Strategies for Increasing Independence, Confidence and Energy (STRIDE) study

Parry

Bamford

Deary

et al. 2016

Health Technol Assess

122

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BackgroundFalls cause fear, anxiety and loss of confidence, resulting in activity avoidance, social isolation and increasing frailty. The umbrella term for these problems is ‘fear of falling’, seen in up to 85% of older adults who fall. Evidence of effectiveness of physical and psychological interventions is limited, with no previous studies examining the role of an individually delivered cognitive–behavioural therapy (CBT) approach.ObjectivesPrimary objective To develop and then determine the effectiveness of a new CBT intervention (CBTi) delivered by health-care assistants (HCAs) plus usual care compared with usual care alone in reducing fear of falling.Secondary objectives To measure the impact of the intervention on falls, injuries, functional abilities, anxiety/depression, quality of life, social participation and loneliness; investigate the acceptability of the intervention for patients, family members and professionals and factors that promote or inhibit its implementation; and measure the costs and benefits of the intervention.DesignPhase I CBTi development.Phase II Parallel-group patient randomised controlled trial (RCT) of the new CBTi plus usual care compared with usual care alone.SettingMultidisciplinary falls services.ParticipantsConsecutive community-dwelling older adults, both sexes, aged ≥ 60 years, with excessive or undue fear of falling per Falls Efficacy Scale–International (FES-I) score of > 23.InterventionsPhase I Development of the CBTi. The CBTi was developed following patient interviews and taught to HCAs to maximise the potential for uptake and generalisability to a UK NHS setting.Phase II RCT. The CBTi was delivered by HCAs weekly for 8 weeks, with a 6-month booster session plus usual care.Main outcome measuresThese were assessed at baseline, 8 weeks, 6 months and 12 months.Primary outcome measure Fear of falling measured by change in FES-I scores at 12 months.Secondary outcome measures These comprised falls, injuries, anxiety/depression [Hospital Anxiety and Depression Scale (HADS)], quality of life, social participation, loneliness and measures of physical function. There were process and health-economic evaluations alongside the trial.ResultsFour hundred and fifteen patients were recruited, with 210 patients randomised to CBTi group and 205 to the control group. There were significant reductions in mean FES-I [–4.02; 95% confidence interval (CI) –5.95 to –2.1], single-item numerical fear of falling scale (–1.42; 95% CI –1.87 to 1.07) and HADS (–1; 95% CI –1.6 to –0.3) scores at 12 months in the CBTi group compared with the usual care group. There were no differences in the other secondary outcome measures. Most patients found the CBTi acceptable. Factors affecting the delivery of the CBTi as part of routine practice were identified. There was no evidence that the intervention was cost-effective.ConclusionsOur new CBTi delivered by HCAs significantly improved fear of falling and depression scores in older adults who were attending falls services. There was no impact on other measures.Further workFurther work should focus on a joint CBTi and physical training approach to fear of falling, more rational targeting of CBTi, the possibility of mixed group and individual CBTi, and the cost-effectiveness of provision of CBTi by non-specialists.Trial registrationCurrent Controlled Trials ISRCTN78396615.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 56. See the NIHR Journals Library website for further project information.

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Interventions to Prevent Falls in Community-Dwelling Older Adults

Grossman

Curry

Owens

et al. 2018

JAMA

257

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The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences. (C recommendation) The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older. (D recommendation) These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.

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Effects of a Multicomponent Cognitive Behavioral Group Intervention on Fear of Falling and Activity Avoidance in Community‐Dwelling Older Adults: Results of a Randomized Controlled Trial

Cited by 225 publications

References 41 publications

The Complex Interplay of Depression and Falls in Older Adults: A Clinical Review

The Complex Interplay of Depression and Falls in Older Adults: A Clinical Review

Cognitive–behavioural therapy-based intervention to reduce fear of falling in older people: therapy development and randomised controlled trial – the Strategies for Increasing Independence, Confidence and Energy (STRIDE) study

Interventions to Prevent Falls in Community-Dwelling Older Adults

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