Authors: Jung Hyun Park, MD, PhD Hyungpil Cho, MD, MMSc Joon-Ho Shin, MD Taikon Kim, MD, PhD Si-Bog Park, MD, PhD Bo-Youl Choi, MD, PhD Mi Jung Kim, MD, PhD
Aging
ORIGINAL RESEARCH ARTICLE
Affiliations: From the Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, South Korea (JHP); and Department of Rehabilitation Medicine (HC, J-HS, TK, S-BP, MJK) and Department of Preventive Medicine (B-YC), Hanyang University College of Medicine, Seoul, South Korea.
Correspondence: All correspondence and requests for reprints should be addressed to: Mi Jung Kim, MD, PhD, Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul, South Korea.
Disclosures: Both Jung Hyun Park and Hyungpil Cho contributed equally to this work. Supported by the research fund of Hanyang University Institute of Aging Society in 2010 and the grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A112074). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9305-0379 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins
Relationship Among Fear of Falling, Physical Performance, and Physical Characteristics of the Rural Elderly ABSTRACT Park JH, Cho H, Shin J-H, Kim T, Park S-B, Choi B-Y, Kim MJ: Relationship among fear of falling, physical performance, and physical characteristics of the rural elderly. Am J Phys Med Rehabil 2014;93:379Y386.
Objective: The aim of this study was to evaluate the relationship between the fear of falling, physical performance, and physical characteristics in an elderly population.
Design: This study is a cross-sectional study with 883 community dwellers 60 yrs or older from a rural area. They completed surveys and evaluations including demographics, the Korean version of the Falls Efficacy Scale-International, the Short Physical Performance Battery, the timed up and go (TUG) test, grip strength, and bone mineral density.
Results: The subjects who had experienced a fall showed lower physical performance than those who had not experienced a fall. Regardless of a previous experience of a fall, the score on the Korean version of the Falls Efficacy ScaleInternational had a positive correlation with TUG time and negative correlations with the score on the Short Physical Performance Battery, grip strength, and bone mineral density. Compared with the group without the fear of falling, the group with the fear of falling showed a lower score on the Short Physical Performance Battery, longer TUG time, weaker grip strength, and lower bone mineral density. The subjects with osteoporosis showed significantly higher scores on the Korean version of the Falls Efficacy Scale-International.
Conclusions: The experience of falls had a significant relationship with the fear DOI: 10.1097/PHM.0000000000000009
of falling and physical performance, and greater fear of falling was related to poorer physical performance, independent of the experience of falls. This result implies that more attention should be paid to seniors with the fear of falling and the experience of falls, and screening and consequent intervention for fall prevention should be warranted in this population. For this purpose, the TUG test may be recommended as a screening tool because TUG time reflects the fear of falling and the experience of falls as well as physical performance. Key Words:
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Accidental Falls, Geriatric Assessment, Task Performance, Osteoporosis
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Fear of Falling Assessment
T
he fear of falling is defined as Blow perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living.[1 The prevalence of the fear of falling in community senior citizens is reported to range from 25% to 50%2Y5 and is higher in women and those who have experienced falls.4,6 Previous experiences of falls make the fear of falling greater than the fear of other events.7,8 The fear of falling is related to subjective feeling of healthiness and leads to restriction of activities of daily living, deteriorated physical function,7,9,10 limited functional independence, and damaged self-image.11 The fear of falling is not only the immediate result of falls12 but also a risk factor of falls,4,9,13 which creates a vicious cycle between falls and the fear of falling. To reduce the incidence of falls and its related consequences, it is important to expose the relationships among risk factors and the way those factors cause falls. However, there have been few studies investigating the relationship between the fear of falling and other risk factors other than the restriction of physical activities. In this study, the authors aimed to evaluate the relationship between the fear of falling; physical performance; and characteristics including grip strength, bone mineral density (BMD), and body mass index (BMI).
MATERIALS AND METHODS This research was approved by the institutional review board at the Hanyang University Medical Center, and written informed consents were obtained from all participants.
Subjects This study targeted 918 subjects 60 yrs or older among 1534 residents who participated in the Yangpyeong Epidemiological Cohort study in 2010. The exclusion criteria were applied to those who were not able to walk more than 4 m independently, who refused to be tested, or who could not participate in evaluations because of physical or psychologic impairments. A total of 883 participants participated in this study.
METHODS All performance tests were assessed by one experienced physiatrist, and those tests had been demonstrated by the examiner before being tested. The experience of falls was also investigated, and the subjects who had fallen within the year before participation in this study were referred to as Bfaller.[
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The participants were asked to fill out the Korean version of the Falls Efficacy Scale-International (KFES-I). The Falls Efficacy Scale-International was developed by Yardley et al.14 in 2005, and its reliability and validity were proven. A longitudinal validation study for 500 seniors confirmed that the Falls Efficacy ScaleInternational was a recommendable tool in both research and clinical setting,15 and the KFES-I was translated in 2010. It has 16 items that can be scored from 1 to 4 (total score: 16Y64). According to the cut point suggested by Delbaere et al.15 (2010), the subjects with a score of less than 23 on the KFES-I were classified as the group without the fear of falling; and those with a score of 23 or greater, as the group with the fear of falling.
Physical Performance Assessment Physical performance was primarily assessed by using the Short Physical Performance Battery (SPPB). This battery consists of three major items including a balance test, a 4-m walking test (gait speed), and repeated chair stands.16Y18
SPPB, Balance Test The balance test began with a semitandem stand. The subjects who were unable to hold this position tried the side-by-side position. Those who were able to stand in the semitandem position were tested again in the full tandem position. The participants were asked to hold each position for 10 secs. Scoring was as follows: 0, side by side for 0Y9 secs or unable; 1, side by side for 10 secs and semitandem for less than 10 secs; 2, semitandem for 10 secs and tandem for 0Y2 secs; 3; semitandem for 10 secs and tandem for 3Y9 secs; and 4, tandem for 10 secs.
SPPB, 4-m Walking Test For gait speed, the subjects were instructed to walk the course with a distance of 4 m at their usual pace. The time to complete the course was measured twice, and the best times were used. Those who used a cane or other walking aids outside their home were allowed to use them for the test. Scoring was as follows: 0, unable; 1, more than 8.7 secs; 2, 6.21Y8.7 secs; 3, 4.82Y6.20 secs; and 4, less than 4.82 secs.
SPPB, Repeated Chair Stands Repeated chair stands were scored according to the time it took to complete the test. The examiner asked the subjects to stand up straight as quickly as they could and then to sit down while keeping their arms folded across the chest. It was performed five
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times without a break. Scoring was as follows: 0, unable; 1, 16.7 secs or longer; 2, 16.6Y13.7 secs; 3, 13.6Y11.2 secs; 4, 11.1 secs or less. Zero was scored for this item when the participants tried to stand up using their arms.
SPPB, Scoring The examiner aborted the test if there was concern about the subject’s safety and gave a score of 0. Each item was scored on a 4-point scale, and the possible range of total score was 0 (the worst performance) to 12 (the best performance).
Timed Up and Go The timed up and go (TUG) test was also performed as a secondary assessment for physical performance. This test started with the participants sitting down in an armchair. After a verbal signal, the participants stood up and walked to a point 3 m away from the chair. When they arrived at the point, they turned around and walked back to the chair and sat down. The examiner checked the time from the time of verbal signal for starting to the time that the participants were seated again in the correct position. The time (second) to complete the test was used as an outcome of this test.
between the groups according to the experience of falls were compared by Mann-Whitney U test. Independent t test was used to assess the difference of age, TUG time, grip strength, BMI, and BMD between the groups with and without the experience of falls. Comparison of the variables between the groups with and without the fear of falling was performed in the same way. The correlations between the KFES-I and other variables were tested by using the Spearman correlation coefficient. The subjects were classified into four groups according to the current and any previous diagnosis of osteoporosis (current and previous diagnosis, current diagnosis without previous diagnosis, previous diagnosis without current diagnosis, and no diagnosis), and an analysis of variance test was performed to check the differences of KFES-I score among those groups. A P value of less than 0.05 was considered to be significant in all analyses. Data analyses were performed using the Statistical Package for the Social Sciences program for Windows, version 17.0 (Statistical Package for the Social Sciences Inc, United States).
RESULTS
Grip Strength Test The subjects’ grip strength was tested in their dominant hand using a JAMAR hand dynamometer (Sammons Preston Rolyan, Illinois). The examinees kept their shoulder neutral, wrist flexed 90 degrees, forearm neutral, and carpal ulnar deviated from 0 to 15 degrees during the test. The participants were given verbal encouragement to achieve maximal strength. It was measured three times for each individual with 1-min breaks between the tests. The mean of the three trials was taken.
Bone Mineral Density Quantitative ultrasound (Hologic Sahara ultrasound heel bone densitometer, United States) was used to measure BMD in the subject’s right tibia, and an experienced physician conducted this examination, A recent study revealed that a T score of 1.0 showed the highest sensitivity and specificity as a cutoff value to detect osteoporosis using quantitative ultrasound19; therefore, this value was applied to this study.
Statistical Analyses The W2 test was used to check the disparity of the prevalence of the fear of falling according to the experience of falls. The KFES-I and SPPB scores www.ajpmr.com
General Characteristics Of 883 seniors who participated in this study, the mean TSD age was 69.4 T 5.8 yrs (ranging from 60 to 94 yrs), and 520 participants (58.9%) were women. One hundred fifty-five participants (17.6%) were fallers, and the mean T SD KFES-I score was 24.5 T 9.0. Aging was related to higher KFES-I score, lower SPPB score, longer TUG time, weaker grip strength, and lower BMI and BMD (Table 1). Among all variables related to physical performance and characteristics, SPPB score and TUG time had the strongest correlation (correlation coefficient, j0.680, P G 0.001).
TABLE 1 Correlations between age and other variables
KFES-I scorea SPPB scorea TUG timeb Grip strength,b lbs BMI,b kg/m2 BMD,b g/cm2 a b
Coefficient
P
0.295 j0.365 0.333 j0.207 j0.145 j0.187
G0.001 G0.001 G0.001 G0.001 G0.001 G0.001
Spearman correlation coefficient. Pearson correlation coefficient.
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regardless of experience of falls. TUG time also showed a positive correlation with KFES-I score in both groups (Table 3).
TABLE 2 Comparison of physical performance and physical characteristics according to the experience of falling
The Relationship Between KFES-I and Physical Characteristics
Falls in the Past Year Yes (n = 155) Agea SPPB scoreb TUG timea Grip strength,a,b BMI,a kg/m2 BMD,a g/cm2
No (n = 728)
69.9 T 5.7 9.8 T 2.2 (10) 14.2 T 4.4 lbs 23.5 T 8.5 24.5 T 3.2 0.4 T 0.1
KFES-I was negatively correlated with BMD but positively correlated with BMI in the women. Grip strength and BMD were negatively correlated with KFES-I in both sexes. There was only a very weak positive correlation between the KFES-I score and BMI in the women (Table 2). When the fallers and the nonfallers were analyzed separately, KFES-I score was negatively correlated with grip strength and BMD in both groups (Table 3).
P
69.3 T 5.9 0.291 10.3 T 2.0 0.002 (11) 13.3 T 4.4 0.012 28.1 T12.0 G0.001 24.2 T 3.2 0.318 0.4 T 0.1 0.152
Values are given as mean T standard deviation (median). a Compared using the independent t test. b Compared using the Mann-Whitney U test.
The Comparison of Physical Performance and Physical Characteristics Between Higher and Lower Level of Groups About Falling
The Comparison of KFES-I, Physical Performance, and Physical Characteristics According to the Experience of Falls The KFES-I score was higher in the fallers (mean T SD, 27.4 T 10.2; median, 25) compared with the nonfallers (mean T SD, 23.9 T 8.6; median, 21) (P G 0.001). The prevalence of the fear of falling was higher in the fallers (P G 0.001). They showed a lower SPPB score, longer TUG time, and weaker grip strength. However, there were no significant differences in BMI or BMD between the two groups (Table 2).
The Relationship Between KFES-I and Physical Performance The KFES-I score had a negative correlation with the SPPB score and a positive correlation with TUG time in both sexes (Table 3). When the fallers and the nonfallers were compared, the KFES-I score was negatively correlated with the SPPB scores,
The group with the fear of falling showed lower SPPB score, longer TUG time, weaker grip strength, higher BMI, and lower BMD compared with the other group. Regardless of the history of falls, lower SPPB score, longer TUG time, weaker grip strength, and lower BMD were observed in the group with the fear of falling in both the faller and nonfaller groups (Table 4). The nonfallers who have the fear of falling had lower SPPB score, longer TUG time, weaker grip strength, and lower BMD compared with the fallers who have no fear of falling (P G 0.05).
The Comparison of KFES-I According to the Previous and Current Diagnosis of Osteoporosis A total of 448 participants had been tested for osteoporosis before participating in this study. Among them, 253 had been diagnosed with osteoporosis and 195 had not. The mean T SD KFES-I scores were 27.9 T 9.9 in the participants with osteoporosis and 23.5 T 7.9 in the other 195 participants. The difference
TABLE 3 Correlation between the KFES-I and physical performance and physical characteristics Sex Male SPPB TUG time Grip strength BMI BMD
History of Falls Female
b
j0.261 0.320b j0.305b j0.102 j0.147b
Yes
b
No b
j0.355 0.390b j0.304b 0.107a j0.187b
j0.461 0.499b j0.515b 0.100 j0.284b
Total b
j0.356 0.404b j0.421b j0.081a j0.285b
j0.384b 0.425b j0.453b j0.090b j0.288b
Values were tested using the Spearman correlation coefficient. a P G 0.05. b P G 0.01.
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TABLE 4 Comparison of physical performance and physical characteristics between the groups with and without the fear of falling With Falls in the Past Year Fear of Falling a
Age SPPB scoreb TUG timea Grip power,a lbs BMIa BMD,a g/cm2
Without Falls in the Past Year
Total
No (n = 75)
Yes (n = 80)
P
No (n = 465)
Yes (n = 263)
P
No (n = 540)
Yes (n = 343)
P
68.5 10.7 (11) 12.4 27.2 24.1 0.43
71.3 8.9 (9) 16.0 20.0 24.9 0.38
0.000 0.000 0.000 0.000 0.119 0.009
68.5 10.8 (11) 12.2 30.3 24.0 0.44
71.3 9.4 (10) 15.1 24.1 24.5 0.40
0.000 0.000 0.000 0.000 0.117 0.000
68.3 10.9 (11) 12.0 30.5 23.9 0.43
71.3 9.4 (10) 15.1 23.5 24.6 0.40
0.000 0.000 0.000 0.000 0.003 0.000
Values are given as mean (median). a Compared using the independent t test. b Compared using the Mann-Whitney U test.
in the KFES-I score between the two groups was statistically significant (P G 0.01). In this study, BMD was evaluated in 879 participants, and 4 participants refused to take the examination. The KFES-I scores were 25.7 T 9.2 in the subjects with osteoporosis (n = 540) and 22.5 T 8.0 in the subjects without osteoporosis (n = 339). This difference was statistically significant (P G 0.01). When both the previous and the current diagnosis of osteoporosis were considered, those who were diagnosed for osteoporosis both times showed the highest KFES-I score (28.7 T 8.9). On the contrary, the participants without osteoporosis in both evaluations had the lowest KFES-I score (22.7 T 7.9) among the four groups (P G 0.01) (Fig. 1).
DISCUSSION This study evaluated the relationship between the fear of falling, physical performance, and physical characteristics in a rural senior population. The fear
of falling was related to lower physical performance, and this result was confirmed in the individual items of the SPPB and the TUG test. According to research investigating the relationship between an incidence of falls and the fear of falling,9 the fear of falling is regarded as a risk factor of falls, but there have been no known explanations, except that it might cause a restriction of physical activities that leads to actual falls.20 This study suggests that a greater fear of falling is associated with poorer physical performance. This result may be a key to understanding the relationship between falls and the fear of falling. In addition, this might explain why the fear of falling is also common in elders who have not experienced falls.21 A decline of physical performance leads to deterioration in the ability to cope with the given physical circumstances and may increase one’s fear of falling regardless of a previous experience of falls. This study also evaluated the relationship between the fear of falling and grip strength. Grip
FIGURE 1 Comparisons of KFES-I according to previous and present diagnosis of osteoporosis (P G 0.01). Values are given as mean (median). www.ajpmr.com
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strength is known to reflect general muscle power22 and can be used to assess sarcopenia.23 It is also reported that grip strength is easier to perform and is more reliable than measuring muscle strength in the lower limbs.24 When the previous report that poorer physical performance and weaker grip strength were related to falls is considered,24 grip strength may play an important role in understanding the many factors related to falls and the fear of falling. Among the physical characteristics in this study’s evaluation, both lower BMD and a previous diagnosis of osteoporosis were related to a greater fear of falling. In this study, the authors assessed the KFES-I score before the participants were tested for BMD and did not inform them of the BMD test results. It was hypothesized that those previously diagnosed have an increased awareness of having osteoporosis. From this perspective, the results of this study may be interpreted as showing that the fear of falling shows greater differences according to having an awareness of osteoporosis than the actual objective condition of osteoporosis. When the authors analyzed the participants by both the previous diagnosis (awareness) and the current diagnosis (actual objective condition of osteoporosis), having an awareness of osteoporosis was related to a greater fear of falling, independent of the objective severity of the condition. It is also notable that 159 participants stated that they had osteoporosis even though their BMD was normal, and this group (group 3) showed the second highest KFES-I scores among the groups (Fig. 1). According to these results, the authors assume that the diagnosis itself is intimidating and contributes to the fear of falling. BMI had no significant relationship with the experience of falls or the fear of falling in this study, although it has been reported that falls are more frequent in obese populations.25,26 When the participants had experienced falls, they had higher prevalence of the fear of falling and poorer physical performance consistent with previous studies.27Y29 It was reported that an experience of falls is related to impaired physical performance.30Many factors are related to both falls and the fear of falling; thus, the relationship between KFES-I and physical performance in both the faller and nonfaller groups was tested separately to exclude confounding effects. The result showed that SPPB score and TUG time were significantly correlated with KFES-I in both groups. The authors assumed that the fear of falling was related to physical performance regardless of the experience of falls. Another interesting finding of this study was that the participants who had the fear of falling and
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did not experience falls had poorer physical performance compared with the participants who experienced falls but have no fear of falling. This result implies that more attention should be paid to those who have the fear of falling even if they have not experienced falling. Therefore, this result suggests that interventions to enhance physical performance for seniors who seem to have the fear of falling and who had experienced falls should be provided. However, evaluating the fear of falling in addition to a comprehensive physical performance test (such as the SPPB) is time consuming and ineffective as a screening tool for a large community senior population. The TUG test was developed to quantify functional mobility of the senior population and has been used widely as a fall-risk screening in community seniors in terms of gait and balance.31Y34 However, there has been controversy about its ability to screen seniors at risk for falls, especially in a healthy and highly functioning population.35Y37 In this study, TUG time was well correlated with the degree of the fear of falling and was prolonged in the participants with the fear of falling and fallers. TUG time also had a strong correlation with SPPB score, and it took less than 1 min to complete the test in most participants (882/883 cases). Therefore the authors suggest using TUG time instead of assessing the fear of falling, history of falls, and physical performance separately to screen candidates for fall prevention program or intervention in a community setting. The advantage of this study is that it was conducted in a large population, and it evaluated the fear of falling, the experience of falls, physical performance, and physical characteristics simultaneously. It is also significant that the relationship between the fear of falling and other factors was evaluated by using the KFES-I, a valid and reliable tool in assessing the fear of falling. The results of this study help understand how having the fear of falling can cause actual falls and could be applied to develop fall prevention programs.
Study Limitations This study evaluated the degree of correlation but was not able to confirm the causal relationships because this was a cross-sectional study, and prospective studies will be required to investigate cause-effect relationships. Another limitation of this study is that more specified balance tests (such as the Berg balance scale) were not conducted for more accurate correlations among balance, physical performance, and the fear of falling. In addition, the
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authors could not conduct an in-depth interview to take a more detailed history of falls. The authors only surveyed whether they had fallen within the year before participation in this study, regardless of severity or related complications. However, more severe falls causing hospitalization or fracture rather than simple falling without injuries may have a stronger impact on the fear of falling, and this issue should be addressed in a future study.
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13. Friedman SM, Munoz B, West SK, et al: Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc 2002;50:1329Y35 14. Yardley L, Beyer N, Hauer K, et al: Development and initial validation of the Falls Efficacy ScaleInternational (FES-I). Age Ageing 2005;34:614Y9 15. Delbaere K, Close JC, Mikolaizak AS, et al: The Falls Efficacy Scale International (FES-I). A comprehensive longitudinal validation study. Age Ageing 2010; 39:210Y6 16. Guralnik JM, Simonsick EM, Ferrucci L, et al: A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49:M85Y94 17. Ostir GV, Volpato S, Fried LP, et al: Reliability and sensitivity to change assessed for a summary measure of lower body function: Results from the Women’s Health and Aging Study. J Clin Epidemiol 2002;55: 916Y21 18. Freire AN, Guerra RO, Alvarado B, et al: Validity and reliability of the Short Physical Performance Battery in two diverse older adult populations in Quebec and Brazil. J Aging Health 2012;24:863Y78 19. Liu H, Paige NM, Goldzweig CL, et al: Screening for osteoporosis in men: A systematic review for an American College of Physicians guideline. Ann Intern Med 2008;148:685Y701 20. Nevitt MC, Cummings SR, Kidd S, et al: Risk factors for recurrent nonsyncopal falls. A prospective study. JAMA 1989;261:2663Y8
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Aging
ORIGINAL RESEARCH ARTICLE
Affiliations: From the Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, South Korea (JHP); and Department of Rehabilitation Medicine (HC, J-HS, TK, S-BP, MJK) and Department of Preventive Medicine (B-YC), Hanyang University College of Medicine, Seoul, South Korea.
Correspondence: All correspondence and requests for reprints should be addressed to: Mi Jung Kim, MD, PhD, Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul, South Korea.
Disclosures: Both Jung Hyun Park and Hyungpil Cho contributed equally to this work. Supported by the research fund of Hanyang University Institute of Aging Society in 2010 and the grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A112074). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9305-0379 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins
Relationship Among Fear of Falling, Physical Performance, and Physical Characteristics of the Rural Elderly ABSTRACT Park JH, Cho H, Shin J-H, Kim T, Park S-B, Choi B-Y, Kim MJ: Relationship among fear of falling, physical performance, and physical characteristics of the rural elderly. Am J Phys Med Rehabil 2014;93:379Y386.
Objective: The aim of this study was to evaluate the relationship between the fear of falling, physical performance, and physical characteristics in an elderly population.
Design: This study is a cross-sectional study with 883 community dwellers 60 yrs or older from a rural area. They completed surveys and evaluations including demographics, the Korean version of the Falls Efficacy Scale-International, the Short Physical Performance Battery, the timed up and go (TUG) test, grip strength, and bone mineral density.
Results: The subjects who had experienced a fall showed lower physical performance than those who had not experienced a fall. Regardless of a previous experience of a fall, the score on the Korean version of the Falls Efficacy ScaleInternational had a positive correlation with TUG time and negative correlations with the score on the Short Physical Performance Battery, grip strength, and bone mineral density. Compared with the group without the fear of falling, the group with the fear of falling showed a lower score on the Short Physical Performance Battery, longer TUG time, weaker grip strength, and lower bone mineral density. The subjects with osteoporosis showed significantly higher scores on the Korean version of the Falls Efficacy Scale-International.
Conclusions: The experience of falls had a significant relationship with the fear DOI: 10.1097/PHM.0000000000000009
of falling and physical performance, and greater fear of falling was related to poorer physical performance, independent of the experience of falls. This result implies that more attention should be paid to seniors with the fear of falling and the experience of falls, and screening and consequent intervention for fall prevention should be warranted in this population. For this purpose, the TUG test may be recommended as a screening tool because TUG time reflects the fear of falling and the experience of falls as well as physical performance. Key Words:
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Accidental Falls, Geriatric Assessment, Task Performance, Osteoporosis
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Fear of Falling Assessment
T
he fear of falling is defined as Blow perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living.[1 The prevalence of the fear of falling in community senior citizens is reported to range from 25% to 50%2Y5 and is higher in women and those who have experienced falls.4,6 Previous experiences of falls make the fear of falling greater than the fear of other events.7,8 The fear of falling is related to subjective feeling of healthiness and leads to restriction of activities of daily living, deteriorated physical function,7,9,10 limited functional independence, and damaged self-image.11 The fear of falling is not only the immediate result of falls12 but also a risk factor of falls,4,9,13 which creates a vicious cycle between falls and the fear of falling. To reduce the incidence of falls and its related consequences, it is important to expose the relationships among risk factors and the way those factors cause falls. However, there have been few studies investigating the relationship between the fear of falling and other risk factors other than the restriction of physical activities. In this study, the authors aimed to evaluate the relationship between the fear of falling; physical performance; and characteristics including grip strength, bone mineral density (BMD), and body mass index (BMI).
MATERIALS AND METHODS This research was approved by the institutional review board at the Hanyang University Medical Center, and written informed consents were obtained from all participants.
Subjects This study targeted 918 subjects 60 yrs or older among 1534 residents who participated in the Yangpyeong Epidemiological Cohort study in 2010. The exclusion criteria were applied to those who were not able to walk more than 4 m independently, who refused to be tested, or who could not participate in evaluations because of physical or psychologic impairments. A total of 883 participants participated in this study.
METHODS All performance tests were assessed by one experienced physiatrist, and those tests had been demonstrated by the examiner before being tested. The experience of falls was also investigated, and the subjects who had fallen within the year before participation in this study were referred to as Bfaller.[
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The participants were asked to fill out the Korean version of the Falls Efficacy Scale-International (KFES-I). The Falls Efficacy Scale-International was developed by Yardley et al.14 in 2005, and its reliability and validity were proven. A longitudinal validation study for 500 seniors confirmed that the Falls Efficacy ScaleInternational was a recommendable tool in both research and clinical setting,15 and the KFES-I was translated in 2010. It has 16 items that can be scored from 1 to 4 (total score: 16Y64). According to the cut point suggested by Delbaere et al.15 (2010), the subjects with a score of less than 23 on the KFES-I were classified as the group without the fear of falling; and those with a score of 23 or greater, as the group with the fear of falling.
Physical Performance Assessment Physical performance was primarily assessed by using the Short Physical Performance Battery (SPPB). This battery consists of three major items including a balance test, a 4-m walking test (gait speed), and repeated chair stands.16Y18
SPPB, Balance Test The balance test began with a semitandem stand. The subjects who were unable to hold this position tried the side-by-side position. Those who were able to stand in the semitandem position were tested again in the full tandem position. The participants were asked to hold each position for 10 secs. Scoring was as follows: 0, side by side for 0Y9 secs or unable; 1, side by side for 10 secs and semitandem for less than 10 secs; 2, semitandem for 10 secs and tandem for 0Y2 secs; 3; semitandem for 10 secs and tandem for 3Y9 secs; and 4, tandem for 10 secs.
SPPB, 4-m Walking Test For gait speed, the subjects were instructed to walk the course with a distance of 4 m at their usual pace. The time to complete the course was measured twice, and the best times were used. Those who used a cane or other walking aids outside their home were allowed to use them for the test. Scoring was as follows: 0, unable; 1, more than 8.7 secs; 2, 6.21Y8.7 secs; 3, 4.82Y6.20 secs; and 4, less than 4.82 secs.
SPPB, Repeated Chair Stands Repeated chair stands were scored according to the time it took to complete the test. The examiner asked the subjects to stand up straight as quickly as they could and then to sit down while keeping their arms folded across the chest. It was performed five
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times without a break. Scoring was as follows: 0, unable; 1, 16.7 secs or longer; 2, 16.6Y13.7 secs; 3, 13.6Y11.2 secs; 4, 11.1 secs or less. Zero was scored for this item when the participants tried to stand up using their arms.
SPPB, Scoring The examiner aborted the test if there was concern about the subject’s safety and gave a score of 0. Each item was scored on a 4-point scale, and the possible range of total score was 0 (the worst performance) to 12 (the best performance).
Timed Up and Go The timed up and go (TUG) test was also performed as a secondary assessment for physical performance. This test started with the participants sitting down in an armchair. After a verbal signal, the participants stood up and walked to a point 3 m away from the chair. When they arrived at the point, they turned around and walked back to the chair and sat down. The examiner checked the time from the time of verbal signal for starting to the time that the participants were seated again in the correct position. The time (second) to complete the test was used as an outcome of this test.
between the groups according to the experience of falls were compared by Mann-Whitney U test. Independent t test was used to assess the difference of age, TUG time, grip strength, BMI, and BMD between the groups with and without the experience of falls. Comparison of the variables between the groups with and without the fear of falling was performed in the same way. The correlations between the KFES-I and other variables were tested by using the Spearman correlation coefficient. The subjects were classified into four groups according to the current and any previous diagnosis of osteoporosis (current and previous diagnosis, current diagnosis without previous diagnosis, previous diagnosis without current diagnosis, and no diagnosis), and an analysis of variance test was performed to check the differences of KFES-I score among those groups. A P value of less than 0.05 was considered to be significant in all analyses. Data analyses were performed using the Statistical Package for the Social Sciences program for Windows, version 17.0 (Statistical Package for the Social Sciences Inc, United States).
RESULTS
Grip Strength Test The subjects’ grip strength was tested in their dominant hand using a JAMAR hand dynamometer (Sammons Preston Rolyan, Illinois). The examinees kept their shoulder neutral, wrist flexed 90 degrees, forearm neutral, and carpal ulnar deviated from 0 to 15 degrees during the test. The participants were given verbal encouragement to achieve maximal strength. It was measured three times for each individual with 1-min breaks between the tests. The mean of the three trials was taken.
Bone Mineral Density Quantitative ultrasound (Hologic Sahara ultrasound heel bone densitometer, United States) was used to measure BMD in the subject’s right tibia, and an experienced physician conducted this examination, A recent study revealed that a T score of 1.0 showed the highest sensitivity and specificity as a cutoff value to detect osteoporosis using quantitative ultrasound19; therefore, this value was applied to this study.
Statistical Analyses The W2 test was used to check the disparity of the prevalence of the fear of falling according to the experience of falls. The KFES-I and SPPB scores www.ajpmr.com
General Characteristics Of 883 seniors who participated in this study, the mean TSD age was 69.4 T 5.8 yrs (ranging from 60 to 94 yrs), and 520 participants (58.9%) were women. One hundred fifty-five participants (17.6%) were fallers, and the mean T SD KFES-I score was 24.5 T 9.0. Aging was related to higher KFES-I score, lower SPPB score, longer TUG time, weaker grip strength, and lower BMI and BMD (Table 1). Among all variables related to physical performance and characteristics, SPPB score and TUG time had the strongest correlation (correlation coefficient, j0.680, P G 0.001).
TABLE 1 Correlations between age and other variables
KFES-I scorea SPPB scorea TUG timeb Grip strength,b lbs BMI,b kg/m2 BMD,b g/cm2 a b
Coefficient
P
0.295 j0.365 0.333 j0.207 j0.145 j0.187
G0.001 G0.001 G0.001 G0.001 G0.001 G0.001
Spearman correlation coefficient. Pearson correlation coefficient.
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regardless of experience of falls. TUG time also showed a positive correlation with KFES-I score in both groups (Table 3).
TABLE 2 Comparison of physical performance and physical characteristics according to the experience of falling
The Relationship Between KFES-I and Physical Characteristics
Falls in the Past Year Yes (n = 155) Agea SPPB scoreb TUG timea Grip strength,a,b BMI,a kg/m2 BMD,a g/cm2
No (n = 728)
69.9 T 5.7 9.8 T 2.2 (10) 14.2 T 4.4 lbs 23.5 T 8.5 24.5 T 3.2 0.4 T 0.1
KFES-I was negatively correlated with BMD but positively correlated with BMI in the women. Grip strength and BMD were negatively correlated with KFES-I in both sexes. There was only a very weak positive correlation between the KFES-I score and BMI in the women (Table 2). When the fallers and the nonfallers were analyzed separately, KFES-I score was negatively correlated with grip strength and BMD in both groups (Table 3).
P
69.3 T 5.9 0.291 10.3 T 2.0 0.002 (11) 13.3 T 4.4 0.012 28.1 T12.0 G0.001 24.2 T 3.2 0.318 0.4 T 0.1 0.152
Values are given as mean T standard deviation (median). a Compared using the independent t test. b Compared using the Mann-Whitney U test.
The Comparison of Physical Performance and Physical Characteristics Between Higher and Lower Level of Groups About Falling
The Comparison of KFES-I, Physical Performance, and Physical Characteristics According to the Experience of Falls The KFES-I score was higher in the fallers (mean T SD, 27.4 T 10.2; median, 25) compared with the nonfallers (mean T SD, 23.9 T 8.6; median, 21) (P G 0.001). The prevalence of the fear of falling was higher in the fallers (P G 0.001). They showed a lower SPPB score, longer TUG time, and weaker grip strength. However, there were no significant differences in BMI or BMD between the two groups (Table 2).
The Relationship Between KFES-I and Physical Performance The KFES-I score had a negative correlation with the SPPB score and a positive correlation with TUG time in both sexes (Table 3). When the fallers and the nonfallers were compared, the KFES-I score was negatively correlated with the SPPB scores,
The group with the fear of falling showed lower SPPB score, longer TUG time, weaker grip strength, higher BMI, and lower BMD compared with the other group. Regardless of the history of falls, lower SPPB score, longer TUG time, weaker grip strength, and lower BMD were observed in the group with the fear of falling in both the faller and nonfaller groups (Table 4). The nonfallers who have the fear of falling had lower SPPB score, longer TUG time, weaker grip strength, and lower BMD compared with the fallers who have no fear of falling (P G 0.05).
The Comparison of KFES-I According to the Previous and Current Diagnosis of Osteoporosis A total of 448 participants had been tested for osteoporosis before participating in this study. Among them, 253 had been diagnosed with osteoporosis and 195 had not. The mean T SD KFES-I scores were 27.9 T 9.9 in the participants with osteoporosis and 23.5 T 7.9 in the other 195 participants. The difference
TABLE 3 Correlation between the KFES-I and physical performance and physical characteristics Sex Male SPPB TUG time Grip strength BMI BMD
History of Falls Female
b
j0.261 0.320b j0.305b j0.102 j0.147b
Yes
b
No b
j0.355 0.390b j0.304b 0.107a j0.187b
j0.461 0.499b j0.515b 0.100 j0.284b
Total b
j0.356 0.404b j0.421b j0.081a j0.285b
j0.384b 0.425b j0.453b j0.090b j0.288b
Values were tested using the Spearman correlation coefficient. a P G 0.05. b P G 0.01.
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TABLE 4 Comparison of physical performance and physical characteristics between the groups with and without the fear of falling With Falls in the Past Year Fear of Falling a
Age SPPB scoreb TUG timea Grip power,a lbs BMIa BMD,a g/cm2
Without Falls in the Past Year
Total
No (n = 75)
Yes (n = 80)
P
No (n = 465)
Yes (n = 263)
P
No (n = 540)
Yes (n = 343)
P
68.5 10.7 (11) 12.4 27.2 24.1 0.43
71.3 8.9 (9) 16.0 20.0 24.9 0.38
0.000 0.000 0.000 0.000 0.119 0.009
68.5 10.8 (11) 12.2 30.3 24.0 0.44
71.3 9.4 (10) 15.1 24.1 24.5 0.40
0.000 0.000 0.000 0.000 0.117 0.000
68.3 10.9 (11) 12.0 30.5 23.9 0.43
71.3 9.4 (10) 15.1 23.5 24.6 0.40
0.000 0.000 0.000 0.000 0.003 0.000
Values are given as mean (median). a Compared using the independent t test. b Compared using the Mann-Whitney U test.
in the KFES-I score between the two groups was statistically significant (P G 0.01). In this study, BMD was evaluated in 879 participants, and 4 participants refused to take the examination. The KFES-I scores were 25.7 T 9.2 in the subjects with osteoporosis (n = 540) and 22.5 T 8.0 in the subjects without osteoporosis (n = 339). This difference was statistically significant (P G 0.01). When both the previous and the current diagnosis of osteoporosis were considered, those who were diagnosed for osteoporosis both times showed the highest KFES-I score (28.7 T 8.9). On the contrary, the participants without osteoporosis in both evaluations had the lowest KFES-I score (22.7 T 7.9) among the four groups (P G 0.01) (Fig. 1).
DISCUSSION This study evaluated the relationship between the fear of falling, physical performance, and physical characteristics in a rural senior population. The fear
of falling was related to lower physical performance, and this result was confirmed in the individual items of the SPPB and the TUG test. According to research investigating the relationship between an incidence of falls and the fear of falling,9 the fear of falling is regarded as a risk factor of falls, but there have been no known explanations, except that it might cause a restriction of physical activities that leads to actual falls.20 This study suggests that a greater fear of falling is associated with poorer physical performance. This result may be a key to understanding the relationship between falls and the fear of falling. In addition, this might explain why the fear of falling is also common in elders who have not experienced falls.21 A decline of physical performance leads to deterioration in the ability to cope with the given physical circumstances and may increase one’s fear of falling regardless of a previous experience of falls. This study also evaluated the relationship between the fear of falling and grip strength. Grip
FIGURE 1 Comparisons of KFES-I according to previous and present diagnosis of osteoporosis (P G 0.01). Values are given as mean (median). www.ajpmr.com
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strength is known to reflect general muscle power22 and can be used to assess sarcopenia.23 It is also reported that grip strength is easier to perform and is more reliable than measuring muscle strength in the lower limbs.24 When the previous report that poorer physical performance and weaker grip strength were related to falls is considered,24 grip strength may play an important role in understanding the many factors related to falls and the fear of falling. Among the physical characteristics in this study’s evaluation, both lower BMD and a previous diagnosis of osteoporosis were related to a greater fear of falling. In this study, the authors assessed the KFES-I score before the participants were tested for BMD and did not inform them of the BMD test results. It was hypothesized that those previously diagnosed have an increased awareness of having osteoporosis. From this perspective, the results of this study may be interpreted as showing that the fear of falling shows greater differences according to having an awareness of osteoporosis than the actual objective condition of osteoporosis. When the authors analyzed the participants by both the previous diagnosis (awareness) and the current diagnosis (actual objective condition of osteoporosis), having an awareness of osteoporosis was related to a greater fear of falling, independent of the objective severity of the condition. It is also notable that 159 participants stated that they had osteoporosis even though their BMD was normal, and this group (group 3) showed the second highest KFES-I scores among the groups (Fig. 1). According to these results, the authors assume that the diagnosis itself is intimidating and contributes to the fear of falling. BMI had no significant relationship with the experience of falls or the fear of falling in this study, although it has been reported that falls are more frequent in obese populations.25,26 When the participants had experienced falls, they had higher prevalence of the fear of falling and poorer physical performance consistent with previous studies.27Y29 It was reported that an experience of falls is related to impaired physical performance.30Many factors are related to both falls and the fear of falling; thus, the relationship between KFES-I and physical performance in both the faller and nonfaller groups was tested separately to exclude confounding effects. The result showed that SPPB score and TUG time were significantly correlated with KFES-I in both groups. The authors assumed that the fear of falling was related to physical performance regardless of the experience of falls. Another interesting finding of this study was that the participants who had the fear of falling and
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did not experience falls had poorer physical performance compared with the participants who experienced falls but have no fear of falling. This result implies that more attention should be paid to those who have the fear of falling even if they have not experienced falling. Therefore, this result suggests that interventions to enhance physical performance for seniors who seem to have the fear of falling and who had experienced falls should be provided. However, evaluating the fear of falling in addition to a comprehensive physical performance test (such as the SPPB) is time consuming and ineffective as a screening tool for a large community senior population. The TUG test was developed to quantify functional mobility of the senior population and has been used widely as a fall-risk screening in community seniors in terms of gait and balance.31Y34 However, there has been controversy about its ability to screen seniors at risk for falls, especially in a healthy and highly functioning population.35Y37 In this study, TUG time was well correlated with the degree of the fear of falling and was prolonged in the participants with the fear of falling and fallers. TUG time also had a strong correlation with SPPB score, and it took less than 1 min to complete the test in most participants (882/883 cases). Therefore the authors suggest using TUG time instead of assessing the fear of falling, history of falls, and physical performance separately to screen candidates for fall prevention program or intervention in a community setting. The advantage of this study is that it was conducted in a large population, and it evaluated the fear of falling, the experience of falls, physical performance, and physical characteristics simultaneously. It is also significant that the relationship between the fear of falling and other factors was evaluated by using the KFES-I, a valid and reliable tool in assessing the fear of falling. The results of this study help understand how having the fear of falling can cause actual falls and could be applied to develop fall prevention programs.
Study Limitations This study evaluated the degree of correlation but was not able to confirm the causal relationships because this was a cross-sectional study, and prospective studies will be required to investigate cause-effect relationships. Another limitation of this study is that more specified balance tests (such as the Berg balance scale) were not conducted for more accurate correlations among balance, physical performance, and the fear of falling. In addition, the
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authors could not conduct an in-depth interview to take a more detailed history of falls. The authors only surveyed whether they had fallen within the year before participation in this study, regardless of severity or related complications. However, more severe falls causing hospitalization or fracture rather than simple falling without injuries may have a stronger impact on the fear of falling, and this issue should be addressed in a future study.
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