AMELIORATION OF FEAR OF FALLING USING A GROUP APPROACH IN A

GERIATRIC DAY HOSPITAL SETTING: EVALUATION AND IMPLICATIONS FOR

BEST PRACTICE

Maureen Gorman, Ph.D. Dept of Psychology, Queen Elizabeth II Health Sciences Centre (QEII), Halifax, NS &

Jaime Williams, M.A. Dept of Psychology, QEII, Halifax, NS; Department of Psychology, University of Regina, Regina, SK

disclosure declaration

• There is no apparent conflict(s) of interest that may have a direct bearing on the subject matter of this presentation

• We acknowledge Cathy Burton, M.A., in assisting to design and conduct the program.

Falls and Seniors

Can result in • serious injury

– 40% result in hip factures

• death– 20% of seniors’ “injury-related deaths” traced to a fall

• severe pain• developing fears about falling in the future

(Cumming et al., 2000; Health Canada, 2005)

Fears about falling in the future

Associated with negative outcomes:

(1) psychological difficulty– loss of independence – avoidance of activities > social isolation, poor self-rated health, and

reduced quality of life

(2) activity restriction > postural instability and physical deconditioning – Deconditioning > reductions in endurance, muscle strength, and

coordination

(3) a risk factor for future falls

(e.g., Brummel-Smith, 1989; Delbaere et al., 2005; Franzoni et al., 1994; Howland et al., 1993; Maki et al., 1991; Murphy et al., 2002; Powell & Myers, 1995; Vellas et al., 1997; Zijlstra et al., 2007).

Fear of Falling Group Proposal To decrease older adults’ fear and anxiety

related to falling

Secondarily to improve quality of life : self-confidence in relation to daily activities, self-efficacy related to managing conditions

placing them at risk for falls, physical activity, and social interaction.

• based on previous work conducted in different contexts (i.e., Tennstedt et al., 1998; Zijlstra et al., 2005)

Setting: A Multidisciplinary Geriatric Day Program

Geriatric Day Hospital and Falls Clinic

Centre for Health Care of the Elderly at the QEII Health Sciences Centre

“Provides rehabilitative and other services to help the elderly reach a higher level of

function or maintain their present level so they can stay in their home”

Geriatric Day Hospital (GDH)

• A comprehensive, interdisciplinary assessment and rehabilitative outpatient treatment program

• For seniors who need at least two of the

following services: geriatric medicine, nursing, occupational therapy, physiotherapy and social work. (Psychology, Seniors MH, etc: prn)

• A Falls Clinic is a component of the GDH.

Services Provided by the GDH

• Medical assessment and care • Nursing care and supervisions • Diagnostic testing • Physiotherapy • Occupational therapy • Social work services • Medication monitoring and counselling • Psychological testing (NP), therapy and counselling • Diet therapy and counseling • Speech therapy • Family conferences/consultation • Home visits by various team members

GDH Admission Criteria (Inclusion)

Referred patients must

• Be 65 years + (considers those 50-64 yrs)

• Have multiple physical/psychosocial problems re: at least two GDH disciplines

• Be willing to participate in the program

• Have access to appropriate transportation to ensure consistent participation in their individualized program

GDH Criteria (Exclusion)

• Psychiatric illness as primary reason for referral

• Acute illness requiring inpatient admission

• Behaviors disruptive to a group setting

• Requiring constant supervision

GDH Attendance

• Averages 2 days (am or pm) per wk for approximately 2 mos between Mon and Thurs.

• Free service (travel subsidized prn)

Referral

• By any health professional

• Family Physician must be aware of and in agreement with the referral

Falls Clinic Referral

• 65 years and over

• require a team assessment

• mobility, balance and/or falls is the main concern.

Fear of Falling Group

Focused on cognitive and behavioural strategies to address

– beliefs about falling – anxiety reduction– perceived and actual loss of independence

Participants: max 12; min 4Inclusion Criteria: (meets criteria for GDH) plus:

(1) Self-reported fear, concern, or worry about falling (2) Self-reported restriction or avoidance of activity due to fear of

falling: (3) Fluency in English or auditory comprehension of spoken English

(1) & (2) assessed at pre-admission assessment, GDH staff ask

“On a scale of 1 – 10 how worried or concerned are you about falling?” (1 = not concerned at all and 10 = worst fear you can imagine)

“On a scale of 1 – 10 how restricted are your activities due to worries or concerns about falling?” (1 = not restricted at all and 10 = completely restricted)

Exclusion Criteria

– Permanent use of a wheelchair– Diagnosis of dementia but on a case-by-case

basis, as deemed appropriate by GDH staff (i.e., if staff believe they may be able to benefit from the group).

Checklist for Referral to Fear of Falling Group

Please complete and fax to: (902) 473-4878

Patient Name: Date of Assessment: Unit Number: Referral Source:

Is the Patient 65 years of age or older? YES NODoes the patient speak English fluently? YES NODoes the patient have an MMSE score 24 or higher? YES NO SCORE: ___________If no, is referral still appropriate? Please comment on whether you believe the patient would be able to benefit from the group:

______________________________________________________________

Checklist for Referral to Fear of Falling Group CON’D

Please ask: On a scale of 1 – 10 (with 1 being not concerned at all and 10 being worst fear you can imagine), how worried or concerned are you about falling?

RATING: ___________

Please ask: On a scale of 1 – 10 (with 1 being not restricted at all in any of your activities and 10 being completely restricted in all of your activities), how restricted are your activities due to worries or concerns about falling?”

RATING: ___________

Please indicate any additional concerns or conditions that may affect optimal participation in group:

_____________________________________________________________________________________________________________________________________________

Signature of Referral Source Date

Group Format

• COMPONENTS: Psychoeducational and Therapeutic– General information about fear of falling– Opportunity to share their own experiences and fears related to falls,

to normalize their experiences and reactions. – Cognitive-behavioural framework to explore the impact of thoughts

and beliefs on emotions such as fear, anxiety. – Information on general coping & feedback on assessed coping styles.– Adaptive coping strategies and anxiety management techniques. – Relapse-prevention.

– Information and handouts; in particular, material from A Matter of Balance: Managing Concerns About Falls (Tennstedt et al., 1998)

• TIME: One hour per week: Thursday, 12 am to 1 pm to maximize patient population from am & pm GDH programs; for 4 weeks

Initial Psychology Pre-group Assessment

• To determine appropriateness for group, • Obtain consent to participate in the group,

program evaluation data collection, &

a follow-up assessment to administer outcome measures (see below “Measures” section).

• About 60 minutes in length, including administration of measures

Group Outline

• Pre-group individual assessment• Session 1 – General introduction to fear of falling• Session 2 – Thoughts & beliefs about falling and

the impact on anxiety• Session 3 – Exploration of general coping styles• Session 4 – Anxiety management and coping

skills • Post-group individual assessment

ASSESSMENT: State Measure

• State anxiety measured weekly, at the conclusion of each session – Time estimate is 5 minutes

– State-Trait Anxiety Scale (Spielberger et al., 1970) – Time estimate is 15 minutes

Outcome Measures

Pre- and post-group assessment: fear of falling, anxiety, depression, coping, &

life satisfaction

– Survey of Activities and Fear of Falling in the Elderly (SAFFE; Lachman et al., 1998) – 15 minutes (Estimated)

– Geriatric Depression Scale (Yesavage et al., 1982)• Pre-group scores obtained from initial GDH assessment

– Coping with Health Injuries and Problems (CHIP; Endler & Parker, 2000) –15 minutes

– Life Satisfaction Scale (Salamon & Conte, 1984) –15 minutes

Program Evaluation Plan

To evaluate the efficacy of the group: • The fear of falling group (Falls Group)

compared to a wait-list control group (patients who also meet the inclusion/exclusion criteria & are interested in participating in the group).

• Both groups pre-post the initial Falls Group • The wait-list control group also complete the

measures following their Falls Group series.

Pilot Project SchedulePLANNED

1. Develop Project Proposal and present to GDH staff in May 2007

2. GDH staff identify potential group members and Psychology staff conduct pre-group interviews in June 2007

3. Begin first group in early July 2007

4. Begin second group, perhaps on a Wednesday, in late July 2007

5. Conduct post-group assessments in August 2007

6. Write up report for GDH staff

7. Write up paper for presentation at CCSMH Sept. 24/07

ACTUAL1. Hard copy: May; Presentation: June

28

2. 4 patients ID’d & interviewed, 2nd wk July

3. 3rd wk July. N=2; 1 learned of vision problem; 1 time not convenient

4. First Group: 3rd session 1 ½ hr; 4th session of first group not held- 1 group member had fall; have 2 referrals for Next Group

5. n=1

N= 1 Pre-Post

Male Age 78 Married Anxiety Problems

Pre Post Change

SAFFE: Activity Level 6/11 7/11 =

Fear of Falling 7 2 +

Activity Restriction 4 8 - Because other reasons 1 0

“Other” + fear of falling 2 1 +

N= 1 Pre-Post, cont’d

Pre%ile Post%ileCoping with Health Injuries & Problems (CHIP)

Distraction coping 45 47 = Palliative coping 46 32 -

Instrumental coping 55 48 - Emotional Preoccupation 67 51 *

Pre-Post CHIP for M

0

20

40

60

80

1 2 3 4

Coping Style

Per

cen

tile

pre

post

References• Brummel-Smith, K. (1989). Falls in the aged. Primary Care, 16, 377-393.• Cumming et al., 2000 • Delbaere, K., Willems, T. & Cambier, D. (2005). Devastating influence of fear of

falling in the elderly. Gait & Posture, 21, Suppl 1, p. S114.• Endler, N.S., & Parker, J.D.A. (2000). Coping with Health, Injuries and

Problems (CHIP): Manual. Toronto, ON: Multi-Health Systems.• Franzoni et al. 1994• Howland, J., Peterson, E.W., Levin, W.C., Fried, L., Pordon, D., & Bak, S.

(1993). Fear of falling among the community-dwelling elderly. Journal of Aging and Health, 5, 229-243.

• Lachman, M.E., Howland, J., Tennstedt, S., Jette, A., Assmann, S., & Peterson, E.W. (1998). Fear of falling and activity restriction: The survey of activities and fear of falling in the elderly (SAFFE). The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 53, P43-50.

• Maki, B.E., Holliday, P.J., Topper, A.K. (1991). Fear of falling and postural performance in the elderly. Journal of Gerontology: Medical Sciences, 46, M123-M131.

• Murphy, S.L., Williams, C.S., & Gill, T.M. (2002). Characteristics associated with fear of falling and activity restriction in community-living older persons. Journal of the American Geriatrics Society, 50, 516-520.

• Powell, L.E., & Myers, A.M. (1995). The Activities-Specific Balance Confidence Scale. Journal of Gerontology: Medical Sciences, 50A, M28-M34.

References Con’t• Salamon, M.J., & Conte, V.A. (1984).  Manual for the Salamon-Conte Life

Satisfaction in the Elderly Scale (LSES).  Psychological Assessment Ressources, Inc.

• Spielberger, C.D., Gorsuch, R.L., & Lushene, R.E. (1970). Manual for State–Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologist Press.

• Tennestedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. The Journals of Gerontology: Series B Psychological Sciences and Social Sciences, 53, P384-P392.

• Tombaugh, T.N., & McIntyre, N.J. (1992). The mini-mental state examination: A comprehensive review. Journal of the American Geriatrics Society, 40, 922-935.

• Vellas et al., 1997 • Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M., &

Leirer, V.O. (1982-1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.

• Zijlstra, G.A., van Haastregt, J.C., van Eijk, J.T., van Rossum, E., Stalenhoef, P.A., & Kempen, G.I. (2007). Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age & Aging, 36, 304-309