Conquering the Fear of Falling: How Occupational Therapy Makes The Difference
By Lauren Reynolds, MS, OTR/L
occupational therapist
The last time I fell down was when I was 16 years old, carrying my marching band instrument across an icy parking lot. Fortunately, I got right back up. Unfortunately, I fell right back down. The last time an older adult fell down and was treated in the emergency room was approximately 11 seconds ago, probably the time you started reading this article.
In fact, the CDC estimates that approximately one out of four older adults will fall each year, and only half will report the fall.
When I slipped on ice, though my ego was bruised for a minute, I cannot say I thought much about it thereafter. That is not the case with older adults. Approximately 41 percent of community-dwelling older adults have a fear of falling. This fear is reported more commonly by females, those with decreased cognition, and those with a history of falling.
Without properly understanding, identifying, and treating this fear of falling, older adults are at significant risk for decreased quality of life. As occupational therapists, we can utilize our unique psychosocial background to identify and treat the fear linked to falling in order to increase older adults’ quality of life and participation in meaningful and necessary occupations.
OCCUPATIONAL THERAPY TIPS TO IDENTIFY A FEAR OF FALLING
When gathering information on a patient’s fall history, including when and where a fall occurred, the most direct way to identify a fear is to simply ask. I always follow up after asking about the basics of the fall and ask if they have any fear of falling since their last fall. Even if a patient is comfortable reporting a fall, not all are comfortable reporting a continued fear of falling.
When I meet a patient, the conversation typically doesn’t go like this:
“Hi, Ms. Smith. I’m Lauren. I’m your new occupational therapist. I understand you fell recently.”
“Nice to meet you. I fell about a month ago, and I have a fear of falling.”
Instead, they often sound like:
“Hi, Ms. Smith. I’m Lauren. I’m your new occupational therapist. I understand you fell recently.”
“Nice to meet you. I fell about a month ago, but I get along just fine now. I manage.”
Unless a patient directly tells you about a fear, it can take some digging, clinical observations, and a good heart-to-heart conversation to identify a fear of falling. As occupational therapy practitioners, we begin to build an occupational profile as soon as we meet a patient. This occupational profile tells us the history and experiences of a patient, what activities and roles are meaningful to them, and how the environment and context around them impact their occupations. I find that, through a thorough occupational profile, I can identify what occupations a patient has stopped doing, too.
Sometimes, what a patient does not do reveals more than what a patient does do. One indication of fear of falling is the withdrawal from meaningful occupations that were previously done with joy and ease. Have a conversation with your patient about those occupations. Ask why they stopped working on their car, going out to eat, or dancing with their spouse. As human beings, we want to do. We want to occupy our time with purposeful, meaningful activities. There is likely a good reason if we are inactive.
Let’s use Ms. Smith again as our example. Ms. Smith tells you that she fell but is managing just fine. You start asking her more questions about herself, her hobbies, and what a typical day is like for her. She tells you she does not do much now but used to spend a lot of time in her garden.
When you ask her to show you her garden, she hesitates at first but then have you follow her to the back door. The whole way there she holds on to her couch, counter, door handle, or wall. Her cane bumps a doorframe and she startles for a second, stops walking, and holds her arms out as if to brace herself. When she arrives at the back door she points out the window without opening the door and says, “You can see it from here. There it is.”
Without directly telling us, we can see that Ms. Smith is resistant to take an initial step after standing. Additionally, her use of furniture to walk around her home tells us that she is likely feeling unsteady or as if she may fall. Lastly, her refusal to walk outside onto the uneven ground of her garden indicates that she may be more fearful of walking long distances, on uneven terrains, or without the support of furniture. Using our clinical judgment, we can begin to identify a potential fear of falling in Ms. Smith that would warrant additional conversation and education.
The same can be said for patients who have difficulty communicating, such as those with cognitive impairment. The use of nonverbal behavior including hesitation or resistance to activity, uncomfortable vocalizations such as screaming, facial expressions and tearfulness during tasks, and the use of nearby items for steadying assistance can all indicate a fear of falling in patients with cognitive impairment. This can also apply to those with difficulty communicating their fear to us.
Lastly, in addition to interviewing and clinical observations, functional outcome measures, such as the Activity-Specific Balance Confidence (ABC) Scale or the FES-I, can assist clinicians not only identifying a fear of falling in our patients but also quantifying the fear in order to guide treatment and goal planning. The ABC Scale is a self-report scale in which patients rate their confidence in percentages as it relates to balance when performing certain occupations or activities. This may include getting into or out of a car, sweeping the floor, or picking up a slipper from a closet floor. A higher percentage relates to higher balance confidence. Likewise, the FES-I is a self-report, 10-item measure that addresses a fear of falling in relation to performing activities of daily living such as taking a bath or shower and reaching into cabinets. Both the ABC Scale and FES-I scales are simple, self-report measures that can help identify fear of falling in older adults.
Keep in mind that additional functional outcome measures that address functional reach, balance, and gait speed can assist clinicians in identifying deficits that may increase a patient’s risk of falls. But these may not directly indicate a fear of falling.
LEARN THE REASONING BEHIND YOUR PATIENTS’ FEAR OF FALLING
Part of our role as occupational therapy practitioners is to understand the “why” of our patients through a unique lens that allows us to look at both physical and psychological well-being. It is not enough to just say a patient is fearful of falling; we must also understand why a patient is fearful in order to appropriately treat that fear.
As previously mentioned, older adults who have a history of falling are more likely to develop a fear of falling. However, it is important to also note other physical and emotional causes that can result in a fear of falling. Consider the impact physical deficits, such as poor balance or low vision, can make when navigating through the home and community, performing ADLs such as putting on pants and showering, or standing to prepare a meal. Additionally, consider changes in blood pressure and fatigue or decreased activity tolerance when understanding the fear of falling.
Our physical abilities or deficits have the potential to affect our confidence when performing routine, meaningful activities. Emotional, environmental, and psychological factors also contribute to a fear of falling. The fears of family members finding out about falls, no longer being able to independently live at home, or transitioning to an assisted living facility due to falling are all realistic concerns that older adults may have regarding falling.
Therapeutic use of self is powerful when discussing why fear is present. Therapeutic listening and empathizing with a patient who is fearful of falling is an important part of allowing our patients to feel support, trust, and capable of working through a fear of falling.
Again, let’s revisit Ms. Smith. After she walks with you to her back door, you compliment her garden and ask when the last time she gardened was. She tells you it has been a few months. You offer a smile and tell her that you would love to work with her outside sometime and that maybe she could offer some “green thumb” tips. She smiles back and mentions that she does not think she will ever feel comfortable enough to get back out to her garden. You ask her what is stopping her and she mentions that she “just doesn’t feel steady” and that if she falls again she is fearful she may not be able to stay at home. You listen to her concerns and validate how she is feeling—telling her that her fear is understandable but that already she is taking some good first steps by working with you as a clinician.
PATIENTS CAN CONQUER THE FEAR OF FALLING WITH OCCUPATIONAL THERAPY
Establishing an action plan for conquering the fear of falling should always involve the patient and be realistic and attainable. As OTs, we have the opportunity to establish and implement a variety of strategies to assist patients in overcoming the fear of falling.
One way to address this is working with your patient to create a thorough plan of action to address falls. Include components such as training about how to get up from a fall and contact information for whom to call if a fall occurs. Education on the use of emergency alert buttons to call 911 or ask for help is also necessary for making sure our patients feel safe in their homes. Addressing home modifications and safety strategies can decrease the risk of falling and make our patients feel more confident in navigating their homes.
Helpful home modifications to address the fear of falling include:
- increasing lighting
- removing throw rugs
- changing the route of travel through the home if a safer route is available
- using contrast-colored tape to mark changes in surfaces
- placing commonly used items within reach
- using non-slip surfacing, and installing grab bars to assist in the bathroom during ADLs
Using our OT training in activity analysis can break down the movements, skills, and demands of an activity to help us target specific interventions to address when treating fear of falling. Again, consider physical and psychological causes of the fear and start slowly toward your patient participating in a full activity or occupation to assure they are comfortable with each step of the activity.
Lastly, consider using a fall log with patients who fall frequently. In this log, the patient can mark the date, time, and area that a fall occurred. This will allow you to track common patterns to address strategies to combat the falls. For example, say a patient has a pattern of falling when reaching overhead in the kitchen and bathroom. We can implement modifications to bring items within reach, use non-slip surfacing on the tile flooring, and practice the use of durable medical equipment during kitchen and bathroom activities to increase safety.
Most importantly, while treating patients with fear of falling, you must stay tuned into the patients’ response to activity, need for support, and validation of fear.
KEEP A LONG-TERM PERSPECTIVE FOR FALLS REDUCTION
My personal motto is “practice makes progress.” That is to say, no fear will be changed overnight. For our patients with fear of falling it may take time to identify and work through the fear with a realistic and comfortable plan. Continued support and positive feedback on patients’ progress, success, and hard work will pave the way for reduced fear and improved participation.
Our psychosocial lens allows us to address the fear and anxiety surrounding falling to constructively and creatively conquer it. Integrating the psychosocial frame of reference can help us adopt a wider perspective on our patients’ quality of life and occupational engagement as it relates to fear of falling.
Remember that with all things, teamwork makes the dream work, so communicating and working with physical therapy and speech-language pathology to carry over strategies and interventions to combat the fear of falling is necessary in providing optimal care for our patients.
Let’s take one last look at Ms. Smith. Imagine it’s been a few weeks now and you are noticing she is wearing the emergency alert bracelet you recommended. She has stopped using furniture as support to walk around and has mentioned how much the physical therapist has helped her to feel comfortable walking around her home. She tells you how her speech-language pathologist has been helping her remember all the components of her fall action plan. She feels more comfortable problem solving through what to do if a fall happens.
Most importantly, she mentions how she feels safer carrying her garden supplies in and out of her home. She has received a lot of compliments on the flowers she has planted using the raised garden bed you have been working with her on. She thanks you by independently reaching outside her base of support to hand you some bright, well-cared-for flowers.