SHELLEY JONES looks at recent research on actual risk of falling and perceived risk, and the implications for older people.

Readers would advise this lady that her trousers pose a risk of tripping and that she needs to be wearing well-fitting, flat shoes or slippers with non-slip soles.

Fear of falling ranks higher than other fears, such as burglary or financial trouble, according to several studies of older people(1),(2). Fear of falling can be protective if it prompts a positive or proactive response(3) – or it can create a downward spiral of physical inactivity and social withdrawal that actually increases the risk of falling(4).

Commonly cited findings in research on falls in older people are that fear of falling can exist even in those who haven’t had a fall, and that 12 to 65 per cent of older people living in their own homes have a fear of falling, with higher rates in women than in men(4).

What we know about falls and fall-related injuries confirms that falls are a fact of life in older age and that there are indeed reasons to fear falling:

  • Over the course of a year, among generally healthy people aged 65-plus living in their own homes, approximately one in three will take a tumble. Although most will not have a serious injury, about one in 20 of those who fall will have a fracture or other injury requiring hospital admission, with the likelihood of injury increasing with age(5).
  • People living in age-related residential care fall more often than those in their own homes and their falls are more likely to result in harm. The severity of fall-related injuries is higher, with up to one in four falls resulting in serious injuries such as lacerations, fractures or head injuries(5).
  • People living with dementia fall twice as often as those who are cognitively intact, and are more likely to have injurious falls(6).
  • After age 75, hip fractures are the most common fracture – and the most unfortunate. Figures from the New Zealand Health Information Service tell us that within a year, 27 per cent of people who’ve had a hip fracture will have died (and just under two-thirds wouldn’t have died if they hadn’t fractured their hip)(7).

However, since it’s generally held that falls are not an inevitable part of ageing, and considering the extensive publicity about ways to prevent falls in older people, these figures are less a losing score than a challenge to do the right thing by those in our care. A significant part of that challenge is not to cause anxiety or avoid the issue, but to encourage older people to take relevant and practical actions for themselves to prevent falls(8),(9).

Being concerned about falling, or worrying about possible outcomes of a fall, is functional if it means taking appropriate actions to reduce one’s personal risk of falling. Fear of falling is by definition a dysfunctional “ongoing concern that ultimately limits the performance of daily activities”, according to falls researchers Tinetti and Powell(10).

Limiting activity to reduce the risk of falling makes sense on one level, but unintended consequences can actually increase the risk of falling. For example, inactivity leads to a loss of strength and condition; avoiding or dropping activities that involve being ‘out and about’ reduces social interaction and quality of life(4).

A shift in perspective

The opposite of fear of falling – rather than an absence of fear – is a sense of confidence in being able to undertake everyday activities without falling. This ‘fall-related self-efficacy’ allows an older person to maintain the participation and activity that helps prevent falling(11). One study showed that improvement in depressive symptoms is associated with increased falls efficacy(12).

A recent study followed the number of falls (with and without injury) in 500 men and women aged between 70 and 90 over a year. It measured actual physiological risk of falling (through a series of physical tests and questionnaires) and perceived risk of falling (according to the falls efficacy scale). Almost a third of the sample overestimated or underestimated their risk of falling, and the researchers suggested that attention to the disparity between physiological and perceived risk would be useful in preventing falls(13).

Drawing from this study, the framework below matches possibilities of actual risk and perceived risk, and identifies relevance for different sub-groups in the retirement village and aged residential care populations. Actions for organisations, professionals, families and carers to take in supporting older people are also suggested.

Low actual risk and high perceived risk

About 10 per cent of the study sample had perceived their falls risk as high – inappropriately in relation to their actual physiological risk. However, they had performed poorly in a dynamic balance task and were classified as ‘anxious’. Although they weren’t less active than the group with low actual risk and low perceived risk, just under half of this anxious group had multiple falls or injurious falls in the follow-up year.

What we can do

  • Be aware that a small proportion of older people will have a high level of concern about falling (not related to actual risk), and are also quite likely to fall.
  • Respond in ways that acknowledge and allay concerns about falling, rather than heightening anxiety.
  • Involve these older people in activities targeted to improving balance and confidence in performing daily activities.

High actual risk and high perceived risk

The frail older person and those with one or more risk factors for falling (such as problems with mobility or balance and strength, painful feet, medical conditions predisposing to falls) have realistic concerns about the possibility of falling, perhaps because they have already fallen.

What we can do

  • Shift the focus from ‘preventing falls’ to involving the older person and their family/carers in positive confidence-building actions for ‘moving around safely’, keeping physically active, and staying as independent as possible.
  • Support older people who have risk factors for falling in practical preparation for the possibility of a fall (such as having a personal alarm, and learning how to get up after a fall or what to do if they face a ‘long lie’).

Low actual risk and low perceived risk

Older people living in their own homes usually agree falls are a problem in their age group, but believe that falls happen to other people – even when they themselves have had a fall-related injury requiring hospital admission(14). Those living in their own homes (including in retirement villages) may benefit from a reality check: ‘One in three people over the age of 65 falls each year… it could be me’. Keeping active, improving balance, attending to hazards around the home (indoors and outdoors), choosing safe footwear, checking eyesight and taking extra care when getting used to updated glasses are all effective ‘fall-proofing’ actions:‘If I do these things, I reduce the chance of it being me that has a fall’.

What we can do

  • Heighten awareness that normal ageing processes increase the risk of falling in even generally healthy, active people.
  • Promote ‘fall-proofing’ actions(15) and support uptake through motivational interviewing(16).

High actual risk and low perceived risk

Older people living with cognitive impairments have higher rates of falling – perhaps related to lack of insight into their own capabilities, risk-taking and impulsivity. Global cognitive impairment has been found to be strongly associated with low levels of concern about falling, despite these people also having low levels of physical functioning(17).

What we can do

  • Make the care environment as safe as possible for those who are unaware of their actual falls risk and unable to compensate for it.
  • Consider technologies that alert staff or carers to assist with mobilising safely.
  • Provide tailored prompts for using mobility aids where needed.
  • Using a person-centred approach, support physical activities that are meaningful and motivating(18), and encourage involvement in exercise programmes tailored to risks.

Common sense tells us to ensure hazard-free environments that enable everyone to get about safely, irrespective of falls risk(19),(20). Evidence for effective falls prevention directs us to identify and address an older person’s modifiable risk factors for falling, and to facilitate involvement in exercise programmes and activities targeted particularly to improving balance and strength(21),(22),(23),(24).

Moving on from thinking that ‘fear of falling’ is something that many older people have, to a more nuanced understanding of what their concerns are – or should be – helps us to find a point of motivation that can lead to positive action. While fear of falling may be a ‘foe’ to those whose actual risk of falling is low, for many older people, a shift in perspective could make their concerns about falling a useful ‘friend’.

Shelley Jones RN BA MPhil works independently in training and development and has an advisor role in the Health Quality & Safety Commission’s national programme, Reducing Harm from Falls.

My thanks to the colleagues who provided peer review: Associate Professor Clare Robertson, Judith Johnson (General Manager Clinical, Arvida), and Gina Langlands (independent healthcare consultant).

  1. Howland J, Peterson EW, Levin WC et al. 1993. Fear of falling among the community-dwelling elderly. Journal of Aging and Health 5(2): 229-43.
  2. Physiotherapy New Zealand. 2014. Falls Prevention Survey. Grown Ups website. Physiotherapy New Zealand: Wellington.
  3. Kwan MM, Tsang WW, Lin SI et al. 2013. Increased concern is protective for falls in Chinese older people: the Chopstix Fall Risk Study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 68: 946–53
  4. Delbaere K, Crombez G, Vanderstraeten G et al. 2004. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age and Ageing 33(4): 368-73.
  5. Rubenstein LZ. 2006. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 35-S2:ii37-41.
  6. Taylor ME, Delbaere K, Close JC et al. 2012. Managing falls in older patients with cognitive impairment. Aging Health 8(6): 573-88.
  7. New Zealand Health Information Service. 2002. Fractured Neck of Femur Services in New Zealand Hospitals 1999–2000. Ministry of Health: Wellington.
  8. Bunn F, Dickinson A, Barnett-Page E et al. 2008. A systematic review of older people’s perceptions of facilitators and barriers to participation in falls-prevention interventions. Ageing and Society (28): 449-72.
  9. Child S, Goodwin V, Garside R. 2012. Factors influencing the implementation of fall-prevention programmes: a systematic review and synthesis of qualitative studies. Implementation Science 7(91): 1–14.
  10. Tinetti ME, Powell L. 1993. Fear of falling and low self-efficacy: a case of dependence in elderly persons. Journal of Gerontology, 48(S):35–38.
  11. Schepens S, Sen A, Painter JA et al. 2012. Relationship between fall-related efficacy and activity engagement in community-dwelling older adults: a meta-analytic review. The American Journal of Occupational Therapy 66(2): 137–48.
  12. Iaboni A, Banez C, Lam R et al. 2015. Depression and outcome of fear of falling in a falls prevention program. The American Journal of Geriatric Psychiatry (in press).
  13. Delbaere K., Close JC, Brodaty H et al. 2010. Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study. BMJ 341: c4165.
  14. Dollard J, Barton C, Newbury J et al. 2012. Older community-dwelling people’s comparative optimism about falling: A population-based telephone survey. Australasian Journal on Ageing 32(1): 34-40.
  15. Accident Compensation Corporation. 2012. Standing up to falls. Your guide to preventing falls and protecting your independence ACC 2383. ACC: Wellington.
  16. Emmons KM, Rollnick S. 2001. Motivational interviewing in health care settings: opportunities and limitations. American Journal of Preventive Medicine 20(1): 68-74.
  17. Uemura K, Shimada H, Makizako H. 2014. Effects of mild and global cognitive impairment on the prevalence of fear of falling in community-dwelling older adults. Maturitas 78(1): 62-6.
  18. See Scotland’s ‘Care…about physical activity’ resources as an example of promoting physical activity.
  19. Health Quality & Safety Commission. 2013. Topic 4 Safe environment and safe care: essential in preventing falls. HQSC: Wellington.
  20. Accident Compensation Corporation. 2009. ACC Home safety checklist ACC 5128. ACC: Wellington.
  21. Gillespie LD, Robertson MC, Gillespie WJ et al. 2012. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews (9): CD007146.
  22. Cameron ID, Gillespie LD, Robertson MC et al. 2012. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews (12): CD005465.
  23. Health Quality & Safety Commission. 2014. Topic 3 Falls risk assessment and care planning: what really matters? HQSC: Wellington.
  24. Health Quality & Safety Commission. 2013. Topic 9 Improving balance and strength to prevent falls. HQSC: Wellington.


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