Background
Falls efficacy has often been conflated with the concept of fear of falling. It is critical to recognise the distinct nature of falls efficacy and fear of falling to properly advance falls prevention and management practice.
Since the late 90s, researchers have acknowledged that the two concepts are related but distinct. For example, Lawrence et al. (1998) distinguished the measurements of falls efficacy and fear of falling. The two scales (Perceived Control Over Falling and Perceived Ability to Manage Falls and Falling) were introduced for falls efficacy. To measure fear of falling, they applied a 4-point scale item to determine the degree of fear that the person might fall and hurt themselves.
Most importantly, Tinetti et al (1994) studied fear of falling and falls efficacy after developing the first Falls Efficacy Scale, the study team found strong independent association between falls efficacy and function. Fear of falling was not significant in the social and physical functioning models! It was explained that falls efficacy, the psychological factor underpinned by the self-efficacy concept, was determinant of function. Tinetti and colleagues posited for more clinical trials showing that efficacy training adds to physical skill training in improving function. The concept of efficacy advances the pursuit of helping older adults to age well in the face of potential comorbidities.
In another study to provide greater insights about the value of focusing on falls efficacy, Li and colleagues (2002) demonstrated that older adults who were fearful of falling, but had high levels of falls efficacy, showed good functional outcomes. In their subsequent work, Li and colleagues (2005) targeted on addressing falls efficacy as a mediator of change in fear of falling using a six-month Tai Chi intervention and demonstrated a significant reduction in the fear of falling in older adults.
However, even today, literature still reports the synonymous interpretation between fear of falling and falls efficacy. This is concerning as fundamental questions would arise. Are we making incorrect conclusions when falls efficacy and fear of falling are viewed to be tautologic? Are studies designed to address fear of falling or falls efficacy? What mechanisms were being targeted to improve individuals’ functional status and their quality of life? Systematic reviews, including Moore (2008), Jorstad (2005), and Soh (2021) have reported significant difficulties in delineating the two concepts because of the interchangeable use of measurement instruments which were conceptually designed to measure fear or falling and falls efficacy.
Potentially, falls efficacy and fear of falling should be working together like accelerator and brake pedals for a cruising car in order to have individuals maintain safe and active lifestyles. In our opinion, it is better to focus on falls efficacy and moderate the levels of falls efficacy to promote greater functional independence rather than reducing fear. Focusing on the brake pads does not get the car moving! Whilst fear of falling should be acknowledged, falls efficacy is a more critical psychological concept to improve individuals’ agency. Nevertheless, more work would be needed to investigate the relationships between falls efficacy and fear of falling and unravel these insights.
Let us collaborate to advance falls prevention and management practice together! For now, it’s time to switch gears. Let us get familiar with some contemporary perspectives about falls efficacy and fear of falling!
Check out this video clip
References
1. Fuzhong, L., McAuley, E., Fisher, K.J., Harmer, P., Chaumeton, N., Wilson, N.L. (2002). Self-efficacy as a mediator between fear of falling and functional ability in the elderly. J Aging Health. 14(4):452-66.
2. Li, F., Fisher, K. J., Harmer, P., McAuley, E. (2005). Falls self-efficacy as a mediator of fear of falling in an exercise intervention for older adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60(1), P34-P40.
3. Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 84(2):191-215.
4. Hughes, C., Kneebone, I., Jones, F., Brady, B. (2015). A theoretical and empirical review of psychological factors associated with falls-related psychological concerns in community-dwelling older people. International Psychogeriatrics, 27(7), 1071-1087.
5. McKenna, S.P., Heaney, A., Wilburn, J. (2019). Measurement of patient-reported outcomes. 2: Are current measures failing us? J Med Econ. 22(6):523-530.
6. Moore, D.S., Ellis, R. (2008). Measurement of fall-related psychological constructs among independent-living older adults: a review of the research literature. Aging Ment Health. 12(6):684-99.
7. Jørstad, E.C., Hauer, K., Becker, C., Lamb, S.E., ProFaNE Group. (2005) Measuring the psychological outcomes of falling: a systematic review. J Am Geriatr Soc. 53(3):501-10. doi: 10.1111/j.1532-5415.2005.53172.x. PMID: 15743297.
8. Soh, S.LH., Lane, J., Xu, T., Gleeson, N., Tan, C.W. (2021). T Falls efficacy instruments for community-dwelling older adults: a COSMIN-based systematic review. BMC Geriatr 21, 21.
9. Image in the website by Freepik
10. Lawrence, R.H., Tennstedt, S.L., Kasten, L.E., Shih, J., Howland, J., Jette, A.M. (1998). Intensity and correlates of fear of falling and hurting oneself in the next year: baseline findings from a Roybal Center fear of falling intervention. J Aging Health. 10(3):267-86.
Falls efficacy
| Present definition | Perceived ability to prevent and manage falls (Soh et al., 2021). |
| Previous definitions | A person with low falls efficacy is considered to be one with a fear of falling (Tinnetti et al., 1990). Balance confidence as perceived ability to perform various activities without losing balance or becoming unsteady (Powell and Myers, 1995). |
| Theoretical concept | Self efficacy theory applied to a multi-dimensional concept of falls efficacy including balance confidence, balance recovery confidence, safe-landing confidence, and fall recovery confidence to address the perceived ability of individuals to overcome different demands of falls across various stages including pre-fall, near-fall, fall-landing, and post fall. |
| Suggested measurement instruments | Multi-dimensional scales Perceived ability to prevent and manage fall risks (PAPMFR) (Yoshikawa et al., 2019). Perceived ability to manage falls and falling (PAMF) (Lawrence et al., 1998). Perceived control over falling (PCOF) (Lawrence et al., 1998). Single-dimensional scales Activities-specific Balance Confidence Scale (Powell and Myers, 1995). Balance Recovery Confidence Scale (Soh et al., 2022). |
For more information, read “Falls efficacy: The self-efficacy concept for falls prevention and management”. Click here.
References
1. Soh, S.L., Tan, C.W., Thomas, J.I., Tan, G., Xu, T., Ng, Y.L., Lane, J. (2021) Falls efficacy: Extending the understanding of self-efficacy in older adults towards managing falls. J Frailty Sarcopenia Falls. 1;6(3):131-138.
2. Soh, S.L.H., Lane, J., Xu, T., Gleeson, N., Tan, C.W. (2021). Falls efficacy instruments for community-dwelling older adults: a COSMIN-based systematic review. BMC Geriatr 21, 21
3. Lawrence, R.H., Tennstedt, S.L., Kasten, L.E., Shih, J., Howland, J., Jette, A.M. (1998). Intensity and correlates of fear of falling and hurting oneself in the next year: baseline findings from a Roybal Center fear of falling intervention. J Aging Health. 10(3):267-86.
4. Yoshikawa, A., Smith, M.L. (2019). Mediating Role of Fall-related Efficacy in a Fall Prevention Program. Am J Health Behav. 1;43(2):393-405.
5. Tinetti, M.E., Richman, D., Powell, L. (1990). Falls efficacy as a measure of fear of falling. J Gerontol. (6):239-243.
6. Powell, L.E., Myers, A.M. (1995). The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 50A(1):M28-34.
7. Hadjistavropoulos, T., Delbaere, K., Fitzgerald, T.D. (2011). Reconceptualizing the role of fear of falling and balance confidence in fall risk. J Aging Health. 23(1):3-23.
8. Soh, S.L.H, Tan, C.W., Xu, T., Yeh, T.T., Bte Abdul Rahman, F., Soon, B., Gleeson, N., Lane, J. (2022). The Balance Recovery Confidence (BRC) Scale. Physiother Theory Pract. 19:1-12.
9. Soh, S.L.H. (2022). Falls efficacy: The self-efficacy concept for falls prevention and management. Front Psychol. 9;13:1011285.
Fear of falling
| Present definition | Refers to a persistent concern about falling (Lee and Tak, 2023). Manifested in four distinct aspects: (1) Apprehension arising from the unpredictability of falls, (2) Unease related to personal vulnerability, (3) Heightened vigilance concerning the environment, (4) Concern about potential harm following fall events. Worries about falling which could be protective or harmful to individuals (Ellmers et al., 2022). An innate fear that is experience when performing activities that one perceives to at risk of falling. This form of fear can be adaptive (protective) or maladapative (over-protective) (Adamczewska and Nyman, 2018) |
| Previous definitions | A phobic reaction to standing or walking due to concerns about falling (Bhala et al., 1982). Low confidence in performing activities of daily living without falling or losing balance (Tinetti et al., 1990). Lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing (Tinetti and Powell, 1993). Considers emotional (i.e., anxiety) and behavioural (i.e., avoidance) elements, psychological factors associated with fear of falling may include emotional states (e.g., anxiety) and behavioural elements (e.g., activity avoidance). (Hughes et al., 2015). |
| Theoretical concept | Behaviourist theory Consequence theory Posttraumatic stress disorder (PTSD) theory |
| Suggested measurement instruments | Falls Efficacy Scale-International (Yardley et al., 2005) Single question about fear of falling (e.g., Are you afraid of falling?) Survey of Activities and Fear of Falling in the Elderly (Lachman et al., 1998) Fear-Avoidance Beliefs Questionnaire (FABQ) (Waddell et al., 1993) Refer to the list of measures for fear of falling (Link) |
References
1. Bhala, R., O’Donnell, J., Thoppil, E. (1982) Ptophobia: phobic fear of falling and its clinical management. Phys Ther. (62)187-190.
2. Tinetti, M.E., Richman, D., Powell, L. (1990). Falls efficacy as a measure of fear of falling. J Gerontol. 45(6):239-243.
3. McGarrigle, L., Yang, Y., Lasrado, R., Gittins, M., Todd, C. (2023). A systematic review and meta-analysis of the measurement properties of concerns-about-falling instruments in older people and people at increased risk of falls. Age Ageing. 1;52(5):afad055.
4. Montero-Odasso, M., van der Velde, N., Martin, F.C., Petrovic, M., Tan, M.P., Ryg, J., Aguilar-Navarro, S., Alexander, N.B., Becker, C., …, Task Force on Global Guidelines for Falls in Older Adults. (2022). World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2;51(9):afac205.
5. Tinetti, M. and Powell, L. (1993). Fear of falling and low self-efficacy: a cause of dependence in elderly persons. Journals of Gerontology, 48, 35–38.
6. Hughes, C.C., Kneebone, I.I., Jones, F., Brady, B. (2015). A theoretical and empirical review of psychological factors associated with falls-related psychological concerns in community-dwelling older people. Int Psychogeriatr. 27(7):1071-87.
7. https://sites.manchester.ac.uk/fes-i/
8. Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 34(6):614-9.
9. Lee, D., Tak, S.H. (2023). A concept analysis of fear of falling in older adults: insights from qualitative research studies. BMC Geriatr 23, 651.
10. Ellmers, T.J., Wilson, M.R., Norris, M., Young, W.R. (2022). Protective or harmful? A qualitative exploration of older people’s perceptions of worries about falling. Age Ageing. 1;51(4):afac067.
11. Adamczewska, N., Nyman, S.R. (2018). A New Approach to Fear of Falls From Connections With the Posttraumatic Stress Disorder Literature. Gerontol Geriatr Med. 27;4:2333721418796238.
12. MacKay, S., Ebert, P., Harbidge, C., Hogan, D.B. (2021). Fear of Falling in Older Adults: A Scoping Review of Recent Literature. Can Geriatr J. 1;24(4):379-394.
13. Lachman, M.E., Howland, J., Tennstedt, S., Jette, A., Assmann, S., Peterson, E.W. (1998). Fear of falling and activity restriction: the survey of activities and fear of falling in the elderly (SAFE) J Gerontol B Psychol Sci Soc Sci. 53(1):P43–P50.
14. Waddell, G., Newton, M., Henderson, I., Somerville, D., Main, C.J. (1993). A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 52(2):157-168.