FEAR OF FALLING
Ways to help the person in your care conquer this very real concern.
Las Vegas resident Esther Kahn, 81, has mixed feelings about her front yard. "The small rocks are good for water conservation but bad for me," she says. "I used to take a shortcut to my mailbox across the rocks, but I don't do that anymore. I'm afraid of falling."
She's not alone. The fear of falling is a significant concern among older adults, says Elizabeth Walker Peterson, MPH, OTR/L, clinical associate professor of occupational therapy at the University of Illinois, Chicago. In a study that she and her team conducted, 26 percent of the respondents admitted to a fear of falling compared to only 17 percent who were afraid of being robbed.
Chevy Chase and Charlie Chaplin notwithstanding, falls are no laughing matter. They are the leading cause of injuries—including fatal ones—for people over the age of 65. Further, because mobility and independence are intertwined like the strands of a double helix, a fall can mean the beginning of a downward slide into dependency. "This fear is not limited to those who have already fallen," says Peterson. "In fact, it is sometimes greater in those who have had only the vicarious experience of a fall."
Healthy prudence—like thinking twice before going out on an icy, rainy or windy day—is one thing. But, in extreme cases, the fear of falling may actually trigger a fall. "Increased anxiety leads to decreased activity and then physical de-conditioning," says Debra Rose, PhD, professor in the division of kinesiology and health promotion and co-director of the Center for Successful Aging at California State University, Fullerton. "So when the person has to walk someplace or go down a flight of stairs, he or she may actually be more prone to a fall."
Falling is a complex phenomenon that involves interplay of physical, environmental and emotional factors. Diabetes, stroke, Parkinson's disease, multiple sclerosis—and simply aging—can lead to changes in posture and gait, as well as weakened bones and muscles. Side effects of certain prescriptions, particularly sedatives and antidepressants, or a mixture of medications can cause balance problems. And environmental factors—such as slippery floors, throw rugs and poor lighting—can make the home a danger zone. Individually or combined, these factors can increase not only the risk for falls but also the fear of falling.
Communicate, Assess and Encourage
"If a person is paralyzed by a fear of falling, the burden on the caregiver can be that much harder," explains Dr. Rose. So what do you do if you're taking care of someone whose fear of falling has reached this level?
Communicate. Many at-risk people will not admit to a fear of falling and sometimes not even to having had a fall, so it is the caregiver's responsibility to sensitively initiate the discussion. "Give reassurance that having this fear is perfectly normal, and doesn't automatically mean a fall [is imminent] or loss of independence," says Roberta Newton, PhD, PT, professor of physical therapy and professor of medicine at Temple University in Philadelphia and associate director of the Institute on Aging. Dr. Newton also suggests:
Be direct but non-confrontational. "Gee, Dad, I was wondering if wearing an emergency alert device on your wrist would make you feel more secure."
Treat your parent as an equal. Avoid scolding your parent as if she were a child. This is a lesson Dr. Newton learned for herself when her 89-year old mother fell time and again.
Speak for yourself. "Mom, I'm worried that you don't use your walker when you go to the bathroom. I'm afraid you might fall."
Once the subject is out in the open, you can help your loved one feel less afraid by taking these steps to reduce the risk for falls:
Assess Physical Risks. Ask the primary-care physician to check balance, gait and muscle strength as part of a falls-risk assessment involving the performance of simple tasks like reaching, getting out of a chair, or walking a few steps and returning to the chair. "It's especially important to insist on this if the person is experiencing balance and mobility problems or has already fallen," says Dr. Rose. "Then make sure to follow up if a referral is given to an occupational or physical therapist, or to another doctor."
Sometimes local health fairs provide fall-risk screenings for free. Dr. Newton, who is also director of the federally funded Fall Prevention in Older Adults Project, suggests contacting your local agency on aging to locate such programs so that you can schedule such a screening.
Also, take all medications to the doctor and ask if any, singly or in combination, might cause poor balance. If you are a caregiver to an older adult, make sure his or her vision is checked regularly. Conditions like glaucoma or cataracts-or simply the wrong prescription for glasses-can increase the risk for falls.
Assess Environmental Risks. When it comes to the home environment, do your own initial assessment. Some steps to take are obvious: clear away clutter, use nightlights and put grab bars in the bathroom. You can download a fact sheet on fall prevention in the home from the National Safety Council website. "Enlist your grandchildren or local school kids to be what I call ‘Inspector Detectors,'" says Dr. Newton. "Give them a sheriff's badge and have them keep an eye out for situations that might be dangerous, like toys on the floor or wet spots in the kitchen."
But a more thorough home assessment can be done by an occupational therapist, who, says Dr. Rose, can identify hazards and watch how the adult interacts with the home environment. Sometimes things may just need to be rearranged to, for example, make a clear path to the kitchen.
Assess the Need for Assistive Devices. An occupational therapist, physical therapist or visiting nurse can evaluate the need for an assistive device and advise on the proper use of a device. "To be effective," Dr. Newton notes, "a cane has to be the correct height." When standing with shoes on and the elbow slightly bent, the top of the cane's handle should be level with the wrist. A cane can be held in either hand, unless there is weakness on one side as from a stroke, and then it should be held in the hand opposite the weaker extremity. "Be aware that the person is actually learning a new task when beginning to walk with a cane," Dr. Newton advises, "and until they become comfortable, may be at greater risk for a fall."
Encourage Activity. Perhaps the most important thing you, as a caregiver, can do is make sure the person in your care stays active despite his or her fear of falling. And it's never too late to get started. "I use the word ‘activity' as opposed to ‘exercise' because activity encompasses a whole range of behavior," Dr. Newton says. "Ask the person what they like to do. Maybe it's dancing or swimming or gardening." Tai Chi, an ancient Chinese exercise, has been shown to strengthen muscles and improve balance (for more on this, click here).
Poor balance can be blamed for many falls, but the underlying causes may differ. Those with diabetes, for example, may experience gradual numbness in their feet. "It's like wearing several pairs of heavy socks," says Dr. Newton, "and we need to have information from our feet in order to maintain balance." This is one reason she recommends wearing lighter tennis shoes for walking exercise; athletic shoes often are too heavy.
Group-based programs work well because they incorporate the social aspect, but they aren't absolutely necessary. Dr. Newton's 89-year-old mother, Ann, who has had two mild strokes, walks daily with her caregiver and does a simple exercise routine at home by herself.
"Balance exercises don't have to be complex and can easily be incorporated into daily activities," says Michael E. Rogers, PhD, CSCS, an exercise physiologist at Wichita State University in Kansas. "Simply standing on one foot while washing the dishes or brushing your teeth can improve balance," he says. But, cautions Dr. Rogers, who is also director of the Center for Physical Activity and Aging, there should be a sturdy counter or table nearby, just in case.
"The message we need to get across is that there are resources and professionals who can help," says Elizabeth Peterson. "No one—neither the caregiver nor the person afraid of falling—has to manage this alone."