SAVANNAH, GA. – An innovative intervention combining exercise and exposure therapy addresses the outsized fear of falling that limits many seniors' activities.
Fear of falling, a debilitating but undertreated condition, is generally correlated more with anxiety than with physical disability. However, the proposed intervention called ABLE – Activity, Balance, Learning, and Exposure – might help solve the problem.
A quarter of the elderly report moderate to severe fear of falling; about 10% of those avoid activities as a result of that fear, Julie Wetherell, Ph.D., reported during a symposium on anxiety at the meeting. She noted that fear of falling has been described in many epidemiologic studies.
Fear of falling actually increases the risk of falls, she reported. In fact, those with no falls but high fear have a nearly fivefold increased risk of nursing home admission, even after controlling for age and disability. It also increases the risk of depression.
The condition often goes undetected and therefore untreated. Seniors are reluctant to discuss concerns about falling and they may be unwilling to seek help for the anxiety because of the stigmas related to mental health issues.
That the fear is rooted in an objective risk also makes identification and treatment more challenging. Nevertheless, Dr. Wetherell, who is with the department of psychiatry at the University of California, San Diego, noted that fear of falling is more closely correlated with symptoms of anxiety than with physical symptoms.
Community-based exercise and fall-education programs are available, but seniors who are unwilling to leave their homes as a result of their fear don't have access to them. Moreover, families often reinforce the avoidant behavior.
Dr. Wetherell offered a case study to illustrate some of these issues. An 85-year-old woman who had fallen twice in the past 3 years, once in the last year, was diagnosed with osteoporosis. The intervention consisted of her doctor telling her “don't fall.” She went online to find balance exercises, but she won't leave the house alone. Her daughter pays someone to accompany her when she goes out, which is reinforcing the avoidant behavior.
When Dr. Wetherell tried to discuss treatment, the woman turned her down because she was a psychologist. “My problem isn't in my head, it's real,” the woman said.
The woman did not receive an intervention.
Dr. Wetherell's proposed ABLE plan addresses several of those barriers. It includes exercise, a medication review, and a home safety evaluation. The intervention is delivered in the home by a physical therapist, not a mental health professional. Families and caregivers are encouraged to participate.
Delivery by the physical therapist is key: It helps avoid the “it's not in my head” reaction illustrated by the first case study. As part of the intervention, the patient creates a hierarchy of activities, such as walking to the driveway alone, walking with a full cart of groceries through a parking lot, getting in and out of a car alone, and so on. Then the patient rates, on a scale of 0-10, which of the activities are the most anxiety provoking.
The therapy starts with situations rated 5-6. The patient is asked to perform one of the activities in the presence of the therapist and then with a friend or family member between sessions. This is continued until the anxiety is only mild; then the process begins with the next items on the list.
Dr. Wetherell presented another case, this time one in which the ABLE intervention seemed to have been effective. A 79-year-old man had multiple medical problems and in addition to his fear of falling, he had symptoms of generalized anxiety disorder and depression. He wouldn't leave his home, nor would he use an assistive device.
After four sessions over 4 months, he showed marked improvement. (Sessions should be more frequent, but medical issues interfered in the case of this particular patient, Dr. Wetherell noted.) The man had fallen 10 times in past year, but fell only twice during treatment. His exercise capacity doubled, and his gait and balance improved. Moreover, he eventually started going out of his home.
As a result of the exposure therapy, the man, a 30-year Marine veteran, resumed a task he once loved: speaking to Marine recruits at Camp Pendleton. He now agrees to use a cane and let two younger Marines (“his honor guard”) escort him to and from the podium.
In an interview, Dr. Wetherell said that, pending funding, she hopes to start recruiting for a larger pilot soon.
Dr. Wetherell has received research support from Forest Laboratories.