Correlation between the fear of falling and fall risk assessment tools in the community-dwelling frail elderly in Korea

Original Article
Yun-Seob Lee1 and *Seong-Gil Kim2
1Department of Physical Therapy, Youngsan University, Yangsan, Gyeongnam, Republic of Korea
2Department of Physical Therapy, Uiduk University, Gyeongju, Gyeongbuk, Republic of Korea
DOI:http://dx.doi.org/10.24816/jcgg.2017.v8i4.04

  • Abstract
  • Full Text
  • References

Abstract

Background/Objectives

This study analyzed the correlations between the FES and fall risk assessment tools in the frail elderly.

Methods

This study was conducted with 44 female elderly residing in the nursing facility in Y city, Korea. Subjects conducted fall risk assessment tools such as 10 meter walk test (10MWT), functional reach test (FRT), short form berg balance scale (SFBBS) and timed up & go test (TUG). Tinetti Falls Efficacy Scale (FES) was used to measure fear of falling. Correlations between the FES and fall risk assessment tools and among the tools were accessed through Pearson correlation coefficient.

Results

FES had positive linear correlation with TUG (p <0.05) and negative linear correlation with 10MWT and SFBBS (p <0.05). There were linear correlations among fall risk assessment tools (FRT, TUG, 10MWT, and SFBBS) (p <0.05).

Conclusions

Activities with higher risk of falling are greatly affected by fear of falling because of increased posture instability during movement.

Keywords:

accidental falls, frail elderly, postural balance

 

Article Outline

  1. Introduction
  2. Material methods
  3. Results
  4. Discussion
  5. Conclusions
  6. Conflict of interest statement
  7. References

Abstract

Background/Objectives

This study analyzed the correlations between the FES and fall risk assessment tools in the frail elderly.

Methods

This study was conducted with 44 female elderly residing in the nursing facility in Y city, Korea. Subjects conducted fall risk assessment tools such as 10 meter walk test (10MWT), functional reach test (FRT), short form berg balance scale (SFBBS) and timed up & go test (TUG). Tinetti Falls Efficacy Scale (FES) was used to measure fear of falling. Correlations between the FES and fall risk assessment tools and among the tools were accessed through Pearson correlation coefficient.

Results

FES had positive linear correlation with TUG (p <0.05) and negative linear correlation with 10MWT and SFBBS (p <0.05). There were linear correlations among fall risk assessment tools (FRT, TUG, 10MWT, and SFBBS) (p <0.05).

Conclusions

Activities with higher risk of falling are greatly affected by fear of falling because of increased posture instability during movement.

Keywords:

accidental falls, frail elderly, postural balance

1. Introduction

People generally, the organs and tissues of human body regress due to aging causing overall decrease in body function. Durability and flexibility in musculoskeletal system and exercise capacity decrease.1,2 Functions related to balance ability such as tactile and visual sense and vestibule reduce due to a decrease in sensory function. Therefore, when the elderly experience an increase in postural sway and instable postural reactions they show slow reaction and gait with wide base of support (BOS) to increase stability.3,4

Such functional decreases related to balance control due to aging accelerate risk of falling while conducting activities that generate temporary postural instability such as gait.5,6 Generally, balance control ability is clinically evaluated with tools that estimate task performance ability to perceive and predict risk of falling. These tools are widely used since performance ability can be simply quantificated through duration, velocity, distance, etcetera in task performance. Among these tools, timed up & go test (TUG), 10 meter walk test (10MWT), berg balance scale (BBS), functional reach test (FRT), etcetera with tested reliability and validity are mainly used.7,8,9,10,11

Previous studies show that falls can be largely affected by not only physical but also mental part. Particularly, fear of falling reduces range of motion and if this problem persists, functional ability decrease causing more increased risk for falling and the vicious circle continues.12,13,14 Thus, if fear of falling can increase risk for falling, it would also affect task performance ability for fall risk assessment and there may be some correlation between fear of falling and fall risk assessment tools.

Therefore, the purpose of this study was to access how fear of falling affects evaluation for prediction of falls. This study assumed that fear largely affects activities in the frail elderly who have dependent lifestyle and analyzed the correlation between the fear of falling and fall risk assessment tools in the frail elderly.

2. Material methods

2.1. Participants

This study was conducted with 44 female elderly residing in the nursing facility in Y city, Korea and selection criteria for the subjects were are as follows: 1) at least 65 years old; 2) fall experiences within the past year more than once; 3) no severe visual or somatosensory impairment that might affect the experiment; 4) ability to walk independently for more than 10 m; 5) no pains that may affect gait; and 6) enough level of consciousness to conduct the experiment. This study was conducted with the female elderly rather than male elderly because of a larger proportion of the older female population in Korea. In addition, the subject with disease with high risk of injury or on medication that affects gait or posture stability was excluded after consulting with a doctor in charge of the facility. Information on the study and written informed consent according to the ethical standards of the Declaration of Helsinki were provided to all subjects prior to their participation, and all agreed to participate in the project (Table 1).

Table 1. General characteristics of subjects

 

Age (year) 76.26±8.49a
Height (cm) 159.41±8.41
Weight (kg) 54.18±10.05
TUG (seconds) 22.59±10.05
10MWT (m/s) 0.52±0.19
SFBBS (score) 20.63±3.97
FRT (cm) 20.63±3.97
Falls Efficacy Scale (score) 50.54±27.72

Mean±SDa

2.2. Measurement

Height, age, and weight of subjects were measured before the test and then tools for prediction of falls related to balance control ability was measured. FRT, TUG, 10MWT, and SFBBS were measured in order and Falls Efficacy Scale was analyzed in the form of questionnaire after all those measurements. FRT, TUG, and 10MWT were measured for three times and the average was used. All measurements were conducted in a confined space in the laboratory in order to reduce risk of falling under therapist’s supervision. Subjects took enough rest when fatigued and then get back to the test.

2.2.1. Functional Reach Test (FRT)

FRT is a tool that measures balance and stability when a subject stretches his arm as far as possible in fixed standing position. The subject spread legs at shoulder width with closed fists and held up his arm in parallel with the ground at 90˚ shoulder flexion without moving feet off the ground. Starting and finishing point using the head of the 3rd metacarpal bone are measured. FRT has been used to measure static balance ability in the elderly with high reliability: its test-retest reliability is ICC=0.92 and inter-rater reliability is r=0.98.7

2.2.2. Timed Up & Go Test (TUG)

TUG is a tool that can quickly measure basic mobility, balance, and gait ability. It measures the time it takes a subject to stand up from a standard armchair, walk 3 m, turn around, walk back to the chair and sit down.8 TUG has been used to predict risk of falls by evaluating balance and mobility in the elderly with high reliability: its test-retest reliability is ICC=0.98.9

2.2.3. Timed 10-meter Walk Test (10MWT)

10MWT is a tool that measures gait ability in various patient populations. It measures the time it takes a subject to walk 10 m without any aids. The time a subject walks through the middle 6 m section is recorded except 2 m acceleration and deceleration distances at each end. A subject walks at a comfortable speed or as fast as he can. Gait velocity was measured for three times and data is gathered by calculating average. 10MWT has high reliability: its test-retest reliability is ICC=0.93 – 0.91.10

2.2.4. Short form Berg Balance Scale (SFBBS)

SFBBS is an efficient tool and shorter version of BBS (berg balance scale) with reduced number of tested items from 14 items to 7 core items. It turned out to be more efficient than the original BBS because it is simple and quick and generates same results with the original BBS. Seven items can be divided into 3 sections: standing, sitting, and change in posture. The item level scores range from 0 to 4 and the maximum score is 28. Higher scores indicate better balance ability. SFBBS has high reliability: its test-retest reliability is ICC=0.95.11

2.2.5. Tinetti Falls Efficacy Scale (FES)

FES is a questionnaire that measures confidence in ability to perform 10 tasks without falling and rates fear of falling. It consists of 10-items, each item is rated from 1 (very confident) to 10 (not confident at all) and the maximum score is 100. Higher scores indicate lower confidence and greater fear of falling. FES has acceptable reliability: its test-retest reliability is r=0.71.15

2.3. Statistics Analysis

This study used SPSS for Windows 20.0 (IBM Corp., Armonk, NY, USA) to analyze the data. Pearson correlation coefficient was used to examine correlation between the Falls Efficacy Scale and fall risk assessment tools. The statistical significance level was set to α=0.05.

3. Results

In correlation between the Falls Efficacy Scale and fall risk assessment tools, Falls Efficacy Scale has no significant correlation with age and FRT (p >0.05), moderate positive linear correlation with TUG (r=0.316), and moderate negative linear correlation with 10MWT (r= -0.346), and SFBBS (r= -0.412) (p <0.05) (Table 2).

In correlation between the fall risk assessment tools, there was negative linear correlation between TUG and 10MWT, between TUG and SFBBS, and between TUG and FRT (p <0.05), and particularly, strong negative linear correlation between TUG and 10MWT. There was moderate positive linear correlation between 10MWT and SFBBS, between 10MWT and FRT, and between SFBBS and FRT. (p<0.05) (Table3).

Table 2. Correlation and significance between Falls Efficacy Scale and tools for prediction of falls
Falls Efficacy Scale
Correlation ( r ) Significance ( p )
Age (years) -0.179 0.244
TUG (seconds) 0.316 0.037*
10MWT (m/s) -0.346 0.021*
SFBBS (score) -0.412 0.006**
FRT (cm) -0.004 0.982
*p <0.05, **p <0.01, 10MWT: Timed 10-meter walk test, FRT: functional reach test, SFBBS: Short form berg balance scale, TUG: Timed Up & Go test.

 

  Table 3. Correlations among tools for prediction of falls
TUG

(seconds)

10MWT

(m/s)

SFBBS

(score)

10MWT (m/s) -0.730**
SFBBS (score) -0.450** 0.597**
FRT (cm) -0.409** 0.561** 0.571**
*p <0.05, **p <0.01, 10MWT: Timed 10-meter walk test, FRT: functional reach test, SFBBS: Short form berg balance scale, TUG: Timed Up & Go test.

4. Discussion

This study measured fear of falling and tools for prediction of falls and analyzed correlation between them and between the fall risk assessment tools to access whether fear of falling increases risk of falling in community dwelling frail elderly or not. As a result, there was an association between Falls Efficacy Scale in TUG, SFBBS, and 10MWT but not with FRT.

TUG evaluates dynamic balance ability and mobility in the elderly at the same time by measuring the time it takes a subject to walk 3 m and walk back. Longer time indicates lower balance ability (8). There was moderate positive negative linear correlation between TUG and Falls Efficacy Scale (r= 0.316) in this study. This result indicates that fear of falling was associated with TUG time. Therefore, fear of falling can be considered to slower TUG time. Cakt et al.’s study with multiple sclerosis patients showed similar result that correlation between Falls Efficacy Scale and TUG was r= 0.535.16

10MWT evaluates dynamic balance ability measuring gait ability by walking 10 m without aids. The time of the middle 6 m was recorded, 2 m acceleration and deceleration distances at each end were excluded, and gait velocity was measured. Lower velocity and time indicate lower balance ability.10 There was small to moderate negative linear correlation between 10MWT and Falls Efficacy Scale (r=-0.346) in this study. This result indicates that fear of falling was associated with 10MWT speed. Therefore, fear of falling can be considered to lower gait velocity. However, Cakt et al.’s study showed that correlation between Falls Efficacy Scale and 10MWT was r= 0.826 and this result comes because correlation was analyzed using time instead of using velocity.16

SFBBS objectively evaluates static and dynamic balance ability and a short version of BBS which is the most reliable balance evaluation tool. It is an efficient and simple tool because it has short measuring time and generates same result with BBS. Higher scores indicate better balance ability.11 There was moderate negative linear correlation between SFBBS and Falls Efficacy Scale (r= -0.412). This result shows that fear of falling is associated with SFBBS scores and can be considered to limit balance ability. Wirz et al.’s study with spinal cord injury patients showed similar result that there was negative linear correlation in correlation between BBS and Falls Efficacy Scale.17

However, age and FRT have no correlation with Falls Efficacy Scale. The reason why age came to have no correlation seems that fear of falling is more affected by personal conditions than by age. FRT is a tool for static balance measurement rather than dynamic balance assessing balance and stability when stretching an arm as far forward as possible in standing position.7 It is a safer tool than the others because both feet are kept fixed on the ground while testing. This shows that FRT has less possibility to take instable posture and relatively less risk of falling during the test than the other tools such as TUG and 10MWT. The reason why FRT came to have no correlation seems that activities with higher risk increase fear of falling.

This study analyzed correlation to access correlation among the tools for prediction of falls. There were significant correlations in all tools; TUG, 10MWT, SFBBS, and FRT. TUG and 10MWT showed the strongest correlation (r=-0.730). This result proved that all tools have correlations among each other because they predict risk of falling reflecting balance ability. Previous studies with dependent community dwelling frail elderly showed that correlation between FRT and gait velocity was r= 0.7118 and between TUG and BBS was r= -0.66,9 which are similar to the results of this study.

5. Conclusions

To summarize this study, there were correlations among FRT, TUG, SFBBS, and 10MWT and Falls Efficacy Scale showed correlation with TUG, SFBBS, and 10MWT but not with FRT. When a task has greater risk of falling and activities with higher instability, fear of falling largely affects conducting task.

A limitation of this study is that study population was relatively small and fear of falling wasn’t analyzed with various tools. Effect of fear of falling on movement of body should be investigated specifically in various ways through follow-up testing.

Conflict of interest statement

All authors have no conflicts of interest to declare.

Acknowledgement

This study was financially supported by the research fund of Youngsan University in 2017.

References

  1. Hannan MT, Felson DT, Dawson‐Hughes B, Tucker KL, Cupples LA, Wilson PW, et al. Risk factors for longitudinal bone loss in elderly men and women: the Framingham Osteoporosis Study. J Bone Miner Res 2000;15:710-20.
  2. Kim SG, Nam CW, Yong MS. The effect of increase in baggage weight on elderly women’s lower extremity muscle activation during gait. Arch Gerontol Geriatr 2014; 59: 574-76.
  3. Lajoie Y, Gallagher S. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr 2004;38:11-26.
  4. EdD MJE. Physical change and aging: A guide for the helping professions: Springer Publishing Company; 2009, p. 74-88.
  5. Bergland A. Fall risk factors in community-dwelling elderly people.Nor Epidemiol 2012;22: 151-64.
  6. O’Loughlin JL, Robitaille Y, Boivin J-F, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993;137:342-54.
  7. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol 1990;45:192-7.
  8. Podsiadlo D, Richardson S. The timed” Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.
  9. Hofheinz M, Schusterschitz C. Dual task interference in estimating the risk of falls and measuring change: a comparative, psychometric study of four measurements. Clin Rehabil 2010;24:831-42.
  10. Bohannon RW. Comfortable and maximum walking speed of adults aged 20—79 years: reference values and determinants. Age Ageing. 1997;26:15-9.
  11. Karthikeyan G, Sheikh SG, Chippala P. Test-retest reliability of short form of berg balance scale in elderly people. Glo Adv Res J Med Med Sci 2012;1, 139-44.
  12. Hill K, Schwarz J. Assessment and management of falls in older people. Intern Med J 2004;34:557-64.
  13. Hwang HF, Lee HD, Huang HH, Chen CY, Lin MR. Fall mechanisms, bone strength, and hip fractures in elderly men and women in Taiwan. Osteoporos Int 2011;22:2385-93.
  14. Sylliaas H, Idland G, Sandvik L, Forsen L, Bergland A. Does mortality of the aged increase with the number of falls? Results from a nine-year follow-up study. Eur J Epidemiol 2009;24:351-5.
  15. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol 1990;45:239-43.
  16. Cakit BD, Nacir B, Genç H, Saraçoglu M, Karagöz A, Erdem HR, et al. Cycling progressive resistance training for people with multiple sclerosis: a randomized controlled study. Am J Phys Med Rehabil 2010;89:446-57.
  17. Wirz M, Müller R, Bastiaenen C. Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale. Neurorehabil Neural Repair. 2009.
  18. Weiner D, Duncan P, Chandler J, Studenski S. Functional reach: a marker of physical frailty. J Am Geriatr Soc 1992;40:203-7.

References

  1. Hannan MT, Felson DT, Dawson‐Hughes B, Tucker KL, Cupples LA, Wilson PW, et al. Risk factors for longitudinal bone loss in elderly men and women: the Framingham Osteoporosis Study. J Bone Miner Res 2000;15:710-20.

  2. Kim SG, Nam CW, Yong MS. The effect of increase in baggage weight on elderly women’s lower extremity muscle activation during gait. Arch Gerontol Geriatr 2014; 59: 574-76.


  3. Lajoie Y, Gallagher S. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr 2004;38:11-26.


  4. EdD MJE. Physical change and aging: A guide for the helping professions: Springer Publishing Company; 2009, p. 74-88.


  5. Bergland A. Fall risk factors in community-dwelling elderly people.Nor Epidemiol 2012;22: 151-64.


  6. O’Loughlin JL, Robitaille Y, Boivin J-F, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993;137:342-54.


  7. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol 1990;45:192-7.


  8. Podsiadlo D, Richardson S. The timed” Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.


  9. Hofheinz M, Schusterschitz C. Dual task interference in estimating the risk of falls and measuring change: a comparative, psychometric study of four measurements. Clin Rehabil 2010;24:831-42.


  10. Bohannon RW. Comfortable and maximum walking speed of adults aged 20—79 years: reference values and determinants. Age Ageing. 1997;26:15-9.


  11. Karthikeyan G, Sheikh SG, Chippala P. Test-retest reliability of short form of berg balance scale in elderly people. Glo Adv Res J Med Med Sci 2012;1, 139-44.


  12. Hill K, Schwarz J. Assessment and management of falls in older people. Intern Med J 2004;34:557-64.


  13. Hwang HF, Lee HD, Huang HH, Chen CY, Lin MR. Fall mechanisms, bone strength, and hip fractures in elderly men and women in Taiwan. Osteoporos Int 2011;22:2385-93.


  14. Sylliaas H, Idland G, Sandvik L, Forsen L, Bergland A. Does mortality of the aged increase with the number of falls? Results from a nine-year follow-up study. Eur J Epidemiol 2009;24:351-5.


  15. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol 1990;45:239-43.


  16. Cakit BD, Nacir B, Genç H, Saraçoglu M, Karagöz A, Erdem HR, et al. Cycling progressive resistance training for people with multiple sclerosis: a randomized controlled study. Am J Phys Med Rehabil 2010;89:446-57.


  17. Wirz M, Müller R, Bastiaenen C. Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale. Neurorehabil Neural Repair. 2009.


  18. Weiner D, Duncan P, Chandler J, Studenski S. Functional reach: a marker of physical frailty. J Am Geriatr Soc 1992;40:203-7.