Older Adults’ Psychosocial Responses to a Fear of Falling: A Scoping Review to Inform Occupational Therapy Practice

Abstract

Falls in older adults are a major health concern, yet the “fear of falling”, a common psychosocial response that can occur post-fall, has seldom been investigated. A scoping review was conducted to identify and map interventions that occupational therapists can use to manage the fear of falling psychosocial response (FoFPR) among older adults. Thirteen electronic databases were searched and 22 studies were retrieved. Cognitive behavioral therapy, guided imagery, and Tai Chi were interventions found to help older adults deal with their FoFPRs. Occupational therapists assisting older adults in this area can play a significant role.     

The Effect of External and Internal Focus of Attention on Gait Variability in Older Adults

Internal focus of attention on a movement or focusing on an external target are both strategies that can affect motor performance. The authors explored whether manipulating subjects' focus of attention while walking would alter gait variability, a measure reflecting consistency of gait and associated with the risk of falling in older adults. Twenty community-living older adults participated in the study and were tested while focusing their attention on (a) gait consistency (internal focus) or (b) metronome beats (external focus). In both conditions gait variability increased (i.e., worsened p < .05) or did not change. No benefit was found in instructing subjects to focus on gait consistency or metronome beats. Such instructions may actually have distracted and interfered with the execution of gait.     

Performance of Faller and Nonfaller Older Adults on a Motor–Motor Interference Task

Typically, falls in older adults occur when 2 tasks are performed simultaneously, due to the increased motor demand required to maintain stability and attention to perform the other task. The authors' purpose was to investigate walking while grasping, transporting, and placing a dowel on a predetermined target while manipulating difficulty levels of the manual task. Faller and nonfaller older adults performed a walking block (manual tasks combined with gait) and a stationary block (upright stance combined with manual tasks). The manual task involved grasping, transporting, and placing the dowel over a target. The results showed that fallers underperformed when compared with nonfallers in the task of placing the dowel over the target. The main difference observed between the groups was found in the condition that required allocation of attention between tasks and greater accuracy in the final placement of the object. Fallers showed gait stability similar to the nonfallers, but fallers were less accurate than nonfallers in the object placement task, especially for the highest level of difficulty. Thus, fallers seem to use a stability-first strategy. Fallers had problems in executing the manual tasks, which suggests a more global change in motor behavior rather than specific changes to balance control.     

The effect of a non-steroidal anti-inflammatory drug on two important predictors for accidental falls: Postural balance and manual reaction time. A randomized, controlled pilot study

Accidental falls in older individuals are a major health and research topic. Increased reaction time and impaired postural balance have been determined as reliable predictors for those at risk of falling and are important functions of the central nervous system (CNS). An essential risk factor for falls is medication exposure. Amongst the medications related to accidental falls are the non-steroidal anti-inflammatory drugs (NSAIDs). About 1-10% of all users experience CNS side effects. These side effects, such as dizziness, headaches, drowsiness, mood alteration, and confusion, seem to be more common during treatment with indomethacin. Hence, it is possible that maintenance of (static) postural balance and swift reactions to stimuli are affected by exposure to NSAIDs, indomethacin in particular, consequently putting older individuals at a greater risk for accidental falls. The present study investigated the effect of a high indomethacin dose in healthy middle-aged individuals on two important predictors of falls: postural balance and reaction time. Twenty-two healthy middle-aged individuals (59.5 ± 4.7 years) participated in this double-blind, placebo-controlled, randomized crossover trial. Three measurements were conducted with a week interval each. A measurement consisted of postural balance as a single task and while concurrently performing a secondary cognitive task and reaction time tasks. For the first measurement indomethacin 75 mg (slow-release) or a visually identical placebo was randomly assigned. In total, five capsules were taken orally in the 2.5 days preceding assessment. The second measurement was without intervention, for the final one the first placebo group got indomethacin and vice versa. Repeated measures GLM revealed no significant differences between indomethacin, placebo, and baseline in any of the balance tasks. No differences in postural balance were found between the single and dual task conditions, or on the performance of the dual task itself. Similarly, no differences were found on the manual reaction time tasks. The present study showed that a high indomethacin dose does not negatively affect postural balance and manual reaction time in this healthy middle-aged population. Although the relatively small and young sample limits the direct ability to generalize the results to a population at risk of falling, the results indicate that indomethacin alone is not likely to increase fall risk, as far as this risk is related to abovementioned important functions of the CNS, and not affected by comorbidities.     

Intraindividual Variability of Neuromotor Function Predicts Falls Risk in Older Adults and those with Type 2 Diabetes

This study was designed to examine the effect of increasing age and type 2 diabetes on the average responses and inter- and intraindividual variability of falls risk, reaction time, strength, and walking speed for healthy older adults and older persons with type 2 diabetes (T2DM). Seventy-five older individuals (controls) and 75 persons with T2DM aged between 50 and 79 years participated in the study. Assessments of falls risk, reaction time (RT), knee extension strength, and walking speed were conducted. The results revealed that advancing age for both control and T2DM groups was reflected by a progressive increase in falls risk, decreased leg strength and a decline (i.e., slowing) of reactions and gait speed. Conversely, the level of intraindividual variability for the RT, strength and gait measures increased with increasing age for both groups, with T2DM persons tending to be more variable compared to the healthy controls of similar age. In contrast to the intraindividual changes, measures of interindividual variability revealed few differences between the healthy elderly and T2DM individuals. Taken together, the findings support the proposition that intraindividual variability of neuromotor measures may be useful as a biomarker for the early detection of decline in physiological function due to age or disease.     

Response inhibition and avoidance of virtual obstacles during gait in healthy young and older adults

Adjustments of preplanned steps are essential for fall avoidance and require response inhibition. Still, inhibition is rarely tested under conditions resembling daily living. We evaluated the ability of young and older adults to modify ongoing walking movements using a novel precision step inhibition (PSI) task combined with an auditory Stroop task.Healthy young (YA, n = 12) and older (OA, n = 12) adults performed the PSI task at 4 individualized difficulty levels, as a single and dual task (DT). Subjects walked on a treadmill by stepping on virtual stepping stones, unless these changed color during approach, forcing the subjects to avoid them. OA made more failures (40%) on the PSI task than YA (16%), but DT did not affect their performance. In combination with increased rates of omitted Stroop task responses, this indicates a “posture first” strategy. Yet, adding obstacles to the PSI task significantly deteriorated Stroop performance in both groups (the average Stroop composite score decreased by 13% in YA and 27% in OA). Largest deficit of OA was observed in rates of incorrect responses to incongruent Stroop stimuli (OA 35% and YA 12%), which require response inhibition. We concluded that the performance of OA suffered specifically when response inhibition was required.     

Characteristics of older cyclists (65+) and factors associated with self-reported cycling accidents in the Netherlands

Cycling supports the mobility, health and independency of the ageing population. However, older cyclists have an increased injury risk. On average, the risk of older people to sustain an injury in a cycling accident is three times higher per cycling kilometre than for middle-aged people and the injury risk increases with age. In comparison with middle-aged cyclists (<65 years), the risk of hospitalization is more than four times as high for older cyclists (≥65 years). The aim of this study was to reveal characteristics of older cyclists in general and to explore which of these characteristics are associated with self-reported cycling accidents from age 59. More than eight hundred older cyclists (>65 years) filled out a questionnaire, which included questions on demographics, bicycle specifications and personal characteristics. By means of a logistic regression, the relationship between personal factors and self-reported bicycle falls were studied. The univariate models showed that age, physical and mental impairments, bicycle model, living environment, feelings of uncertainty of the cyclist and changed cycling behaviour (such as more patience, lower speed) were related to falling off a bicycle. From the multivariate model we can conclude that several factors are associated with falling off a bicycle in the older population: (1) every year the cyclists becomes one year older (from the age of 65), the chance they have fallen increases with 7.3%, (2) If cyclists have mental impairments, the chance they have fallen increases with a factor 2.5, (3) if cyclists were less than completely confident the chance they have fallen increases with factor 1.8, (4) if cyclists live in a rural environment compared to an urban environment the chance they have fallen increases with a factor 2.1. In conclusion, demographic, cycling and personal factors can be related to increased self-reported fall risk. It is advised to take these factors into account when implementing new cycling related safety measures.     

Predicting incident falls: Relationship between postural sway and limits of stability in older adults

BackgroundWe have previously shown that objective measurements of postural sway predicts fall risk, although it is currently unknown how limits of stability (LOS) might influence these results.Research question: How integrated postural sway and LOS measurements predict the risk of incident falls in a population-based sample of older adults.Methods:The sample for this prospective observational study was drawn from the Healthy Ageing Initiative cohort and included data collected between June 2012 and December 2016 for 2396 men and women, all 70 years of age. LOS was compared to postural sway with measurements during eyes-open (EO) and eyes-closed (EC) trials, using the previously validated Wii Force Plate. Fall history was assessed during baseline examination and incident falls were collected during follow-up at 6 and 12 months. Independent predictors of incident falls and additional covariates were investigated using multiple logistic regression models.Results:During follow-up, 337 out of 2396 participants (14%) had experienced a fall. Unadjusted regression models from the EO trial revealed increased fall risk by 6% (OR 1.06, 95% CI 1.02–1.11) per each centimeter squared increase in sway area and by 16% (OR 1.16, 95% CI 1.07–1.25) per 1-unit increase in Sway-Area-to-LOS ratio. Odds ratios were generally lower when analyzing EC trials and only slightly attenuated in fully adjusted models.Significance:Integrating postural sway and LOS parameters provides valid fall risk prediction and a holistic analysis of postural stability. Future work should establish normative values and evaluate clinical utility of these measures.     

Traumatic Incident Reduction

Abstract

Traumatic Incident Reduction (TIR) is a person-centered, yet intensely focused approach to trauma resolution, based on the principle that the very act of trying to repress painful memories is what holds them in place and gives them power over the individual. TIR consists of a safe and structured method for reviewing the contents of a past trauma repeatedly at a pace and with a degree of exposure determined by the client. By applying the TIR technique to a traumatic memory in a one-on-one setting with a trained facilitator, the client can discover what he or she needs to know in order to achieve a permanent reduction or elimination of the memory's traumatic aftereffects.