Abstract
In an effort to understand the multifactorial etiology of falls among the well elderly, the interrelationships among anxiety, depression, worry about falling, and falls self-efficacy were explored. A sample of convenience of 61 elders attending senior centers was interviewed to obtain the information necessary to explore the extent to which depression and anxiety were associated with worry about falling and concerns about falling while performing specific activities of daily living. Results indicate a need for clinicians to inquire into the mood states of elderly persons in their care. Variables of anxiety and depression should be included in every falls history, with in-depth follow-up when indicated. Secondary prevention measures should include referral for all appropriate interventions in order to reduce the substantial public health burden that falls and worry about falling imposes.
FALLS in the elderly are a major public health problem with serious medical, psychosocial, and economic sequelae. 1-3 However, falls often go undetected by health care professionals (HCPs). This is because (1) many older adults do not spontaneously report their falls or near-falls, (2) the aftereffects of a fall are not always obvious, and (3) HCPs may not include questions about falls in their initial evaluation. 1 The multifactorial nature of falls necessitates a thorough, comprehensive evaluation of older adults to identify specific, salient fall risk factors and the ability to intervene effectively. The more risk factors individuals have the greater their risk of falling. 2,4,5
Fear of falling has been identified as both a cause and consequence of falls. 6,7 It has been defined "as a lasting concern about falling that leads to an individual's avoiding activities that he/she remains capable of performing." 8 The fear has been described as greater than warranted based on objective gait or balance difficulties or other physical incapacities. Because of the subjective nature of expressed fear and the psychiatric conditions the term could suggest, Tinetti and colleagues stated that "defining fear of falling as low self-efficacy has advantages." 6,8 In keeping with Bandura's conceptual model of self-efficacy, Tinetti and colleagues developed a falls self-efficacy instrument, the "Falls Efficacy Scale," that operationalizes fear of falling by measuring individuals' concerns about falling in relation to performing specific, nonhazardous activities of daily living. 6 One advantage of using low self-efficacy as a gauge of fear of falling is that interventions can focus on specific concerns about falling in relation to specific activities, an approach that can be useful in changing dysfunctional behaviors to more functional ones, thereby increasing activity levels, while reducing fall risks. 9
Very few studies have demonstrated correlations between depressive syndromes and/or anxiety disorders and fear of falling or falls efficacy, although several articles and book chapters suggest such relationships. 2,7,9-11 In this article, the complex etiology of fear of falling (operationalized as worry about falling) is explored further.
The prevalence of clinically significant symptoms of depression and anxiety in community-dwelling elders ranges from 8% to 15% and 3.5% to 10%, respectively. 1,12 The etiology of both conditions is complex, requiring a biopsychosocial approach to evaluation. 2,9 The similarities in signs and symptoms of those older adults with a seemingly circumscribed fear of falling and those adults with depression and/or anxiety disorders can make for a difficult differential diagnosis in community-dwelling elders.
Minor depression and subthreshold anxiety in older adults are receiving increasing attention as these disorders have been shown to result in significant distress and impairment. 13Minor depression is defined "as the presence of at least two but fewer than five depressive symptoms, including depressed mood or loss of interest or pleasure in normal daily activities during the same two-week period with no history of major depressive episode or dysthymic disorder but with clinically significant impairment or distress." 14,15 Other symptoms of minor depression include, but are not limited to, psychomotor changes, decreased energy, fatigue, and impaired concentration. 15
"Subthreshold anxiety is a less severe, but even more prevalent form of the late-life anxiety disorders that are associated with decreased activity, poorer perceptions of health, reduced quality of life and satisfaction and frequent coexistent diagnoses." 13 Older adults, especially those with medical illnesses, often have comorbid anxiety and depressive symptoms that are difficult to separate diagnostically. 16
This investigation was designed to explore the extent to which the psychological variables of depression and anxiety were associated with "worry about falling" and concerns about falling while performing various activities of daily living in community-dwelling elders.
To study this overarching question, the following specific questions were addressed:
* Are objective criteria of gait and balance related to (a) worry about falling and (b) falls efficacy?
* What is the association between scores on a screen for depression and (a) worry about falling and (b) falls efficacy?
* What is the association between scores on a screen for anxiety and (a) worry about falling and (b) falls efficacy?
* Which activities of daily living are most commonly associated with (a) low self-efficacy, (b) worry about falling, (c) depression, and (d) anxiety?
* Which items on the screening tool for anxiety are associated most closely with (a) worry about falling and (b) falls efficacy?