What is fear of falling?

Fear of falling is an ongoing concern about falling. Fear of falling can become a vicious cycle in which a fear of falling becomes a risk for future falls. But there is good news. Keeping active plays a key role in maintaining strength and balance to prevent falls. Help is available to overcome a fear of falling and start enjoying life again.

Fear of falling is common. Half of adults who have fallen before are afraid of falling again. Of those who have never fallen, about 30% have a fear of falling. Fear of falling is even greater in people with conditions that affect their balance. These include vestibular disorders, peripheral neuropathy, Parkinson’s disease and stroke.

Other factors associated with fear of falling include:

• old age
• female gender
• perception of poor health
• functional limitations (such as not being able to walk)
• multiple long-term (chronic) health conditions or diseases
• taking 3 or more medications daily
• having fallen in the past year
• muscle deterioration and stiff joints
• impaired gait (manner of walking)
• vision challenges
• social isolation, anxiety and depression

Falls are a major health risk and a fear of falling is sometimes a realistic appraisal of risk. Adults with some form of inner-ear dysfunction, for example, are up to 12 times more likely to have a serious fall. And falls are the leading cause of hospitalization for Canadian seniors.

Most older people have an accurate idea of their risk of falling. About 20% of seniors overestimate their risk of falling while about 10% underestimate their risk. Between one-third and one-half of seniors are concerned enough about having a fall that they limit or avoid activities that promote good health. Overestimating the risk may lead to reduced physical activity and increased risk of falling.

Fear of falling sometimes results in healthy, safe behaviour. For example, it is wise to avoid walking down icy steps. And fear of falling can be a normal response when your sense of balance is challenged. It might stop you from doing activities that expose you to a risk of falling. For example, it is unwise to climb a ladder if you are dizzy. It is only when this fear becomes exaggerated and unreasonable that problems result.

Fear of falling can increase the risk of having a fall. Someone who is fearful of falling is 50% more likely to fall than someone who is not fearful. A number of studies report that those who fear falling have poorer balance compared with non-fearful adults. A lower level of fear of falling is likely to be protective of falls. Less fearful people tend to have a positive attitude to life and are more likely to be physically active.

What comes first: a fear of falling or a fall? Research suggests both occur – in some cases, falling leads to fear, and in others, fear leads to falls.

The impact of fear of falling

Fear of falling, particularly in older adults, is a major social issue. It is associated with:

• decreased confidence in the ability to balance
• restricted activity
• increased risk of social isolation, depression and anxiety
• decreased quality of life

The more fearful someone is about falling, the less likely they are to keep active. Decreased physical activity leads to premature disability and loss of independence. For example, inactivity leads to less ability to carry out activities of daily living such as bathing and shopping. Reduced activity leads to poor muscle strength and balance. This increases the likelihood of falling.

Causes of fear of falling

Studies suggest fear of falling may alter attention. This can have a negative impact on control of body movements. Fearful individuals often slow and shorten their gait, widen their stance, and make other adjustments that negatively affect their balance. They might:

• Tighten muscles when they feel they are about to fall. This stiffening strategy prevents the brain from gathering information from the muscles and joints needed to plan and carry out a full range of motion.
• Limit head movement. This can limit the ability of the vestibular ocular reflex (VOR) to maintain gaze stability.

The way your brain perceives balance control changes when you are fearful or anxious. More information comes into your brain than under normal conditions. Research suggests this might cause changes in how well you can pay attention and how you take in what is happening around you.

When to talk to the doctor

Have a conversation with a family doctor if you, your friend or loved one are having difficulty managing a fear of falling. This is particularly important if the following is experienced:

• increased fearfulness
• slow or cautious gait (manner of walking)
• avoidance of formerly enjoyed activities
• wider-based gait
• reduced head movement when walking

The doctor can help figure out what is causing the fear and work towards a solution. The doctor may suggest sessions with a physiotherapist. Physiotherapists can help with movement dysfunction, balance and gait retraining.

Treatment and management

Fear of falling can be managed through strategies that help build confidence and a sense of control over falling. These include:

• Increasing physical activity - with approval of your health care team, participate in individualized home-based or group exercise programs combining muscle strengthening, resistance, balance and mobility exercises to increase your confidence. Studies show physical balance training combined with behavioural components to reduce fear of falling is effective.
  Start small and take it slow. A physiotherapist can recommend activities and ways to do them safely.
  Community-based tai chi classes have been shown to be particularly effective at reducing fear of falling.
  Consider activities without a risk of falling, such as riding an exercise bike, swimming or aquafit.
  If you have already had a fall, work with a physiotherapist to help you regain your strength and range of motion as you rebuild confidence.
  Studies show that there is a small to moderate improvement in fear of falling using some type of exercise program. These improvements last at least up to 6 months. The longer-term effectiveness of exercise to improve fear of falling is unclear.
• Gait training with a physiotherapist to improve posture and encourage good walking form to help you move more fluidly.
• Using walking aids such as walking poles and canes to help give you confidence to participate in physical activities that you would otherwise avoid due to fear.
• Reviewing medications with your doctor or pharmacist to make sure prescription or over-the-counter preparations do not increase the risk of falling.
• Doing a home safety assessment, making any necessary alterations.
• Learning fall prevention techniques to give a confident and independent mindset. Fear and anxiety will start to decrease when you know you have actively protected yourself from falling.
• If you have had a fall, asking yourself questions to help figure out the cause. For example: Were you in a hurry? Was the floor slippery? Were you feeling dizzy? Take action as appropriate.
• Taking action to correct vision issues.
• Maintaining good nutrition, including following Canadian guidelines for calcium and vitamin D.
• Practicing healthy sleep habits.
• Using relaxation techniques to calm your mind and reduce muscle tension.
• Wearing suitable footwear.
• Using hip protectors. One study shows that wearing hip protectors increases confidence and decreases fear of falling. They may also help reduce the risk of a hip fracture if you fall.
• If you live alone, installing a personal alarm system to help you feel more confident about being active at home.
• Considering cognitive behavioural therapy (CBT). It aims to change how a person thinks (“cognitive”) and acts (“behaviour”). This approach can help overcome your fear of falling by shifting your focus from pessimistic thoughts to things you can do – such as exercise – to lower your risk of falling. This shift in focus encourages you to safely increase your daily activity level.
  CBT can help with problem-solving issues related to activity avoidance, unsafe behaviour and unsafe environment. It may help you come up with practical solutions, for example installing a handrail next to the bath or asking for help.
  It can also help you come up with a series of small achievable goals to encourage confidence and better anxiety management skills.

More resources

The following can offer more help and support for affected individuals and their families.

Books