Case Study: Fear of Falling: A Structured Group Intervention

Fear of falling is a recognized public health problem that impacts 30-50% of older adults. A structured group intervention applied cognitive-behavioral theory through activities designed to improve participants’ falls self-efficacy (i.e. confidence in ability to engage in activities of daily living without falling).

NERI's Role

The effectiveness of the CBT intervention was evaluated in a randomized controlled trial with 434 subjects at 20 community sites (senior housing and senior centers). This project addressed a largely unrecognized problem that is now called a major public health concern. Early research indicated that older adults are reluctant to reveal their fear of falling because falls are considered a sentinel event leading to nursing home admission. Therefore, we used focus groups to determine if older adults would talk about this problem in a group setting and would attend an intervention program. These sessions also explored their concerns and issues to ensure inclusion of relevant content. The subsequent ease of recruitment of older adults in these community settings was notable and underscored the interest in and need for such an intervention.

It was recognized that older adults who had restricted activities due to fear of falling would be less likely to travel to a central site for the intervention. Therefore, the intervention was offered in locations such as senior housing to facilitate their attendance. The sample size required a large number of such community sites and sufficient time on site to obtain access, inform potential participants about the program, and then screen and enroll them. Referrals and references from early involved sites facilitated access to and involvement of subsequent sites.

Critical to the evaluation was standardized implementation of the intervention program. The professional facilitators (social workers or nurses) were trained and certified with a highly structured intervention manual, and QC observations were completed at regular intervals. Additionally, the facilitators played an important function in minimizing attrition by personal contact with participants who missed a session and offering support to attend the next session.

Results

Here are some of the immediate and long-term intervention effects, which were most noticeable among those who attended the majority of group sessions:

• Increased falls efficacy
• Perceived ability to better manage falls
• Fewer mobility restrictions
• Increased social functioning
• Increased mobility range

What began as a behavioral intervention trial is now a significant evidence-based program that has been replicated and implemented internationally. A Matter of Balance has been implemented throughout the US in a wide range of settings – hospitals, home health care agencies, senior housing and retirement communities, senior centers, churches and other community settings. The program has been modified for administration by peer facilitators and has been culturally adapted and evaluated in randomized trials in the Netherlands, Germany, Canada and Australia. This ground-breaking work remains the single most important intervention study to date to specifically address fear of falling.