“Fear of falling is a gradual, insidious spiral,” said Julie Varno, Physical Therapist – Case Manager with Lifespark Home Health. “It might start with a fall, but not necessarily. Either way, you become less active, which leads to weaker muscles and stiffer joints which, in turn, affect your balance and your ability to react. Then an uneven sidewalk, a misplaced area rug, or an excited puppy can put you at risk for a fall.”
Research suggests, and Julie’s experience confirms, that both those who fall and even those who haven’t fallen can be fearful and therefore at greater risk of falling. “According to some studies, having the fear without the fall is actually more limiting than having multiple falls,” she said.
Admittedly, that fear is not completely irrational. According to the National Safety Council, 38,742 adults aged 65 and older died from preventable falls in 2021, and nearly 2.9 million were treated in emergency departments. But there is good news. “While it’s true that falls are more common in older people, falling is not a normal part of aging, which means we can do something about it,” Julie said.
How to identify fear of falling
As a Home Health PT, Julie often works with clients who’ve been discharged from the hospital after a fall, illness or injury. But if there’s no history of falls, how can family members detect whether a loved one has developed a fear of falling?
“The biggest clues are if they’re walking more and more slowly and if they start shuffling their feet,” Julie said. “Shuffling can be a sign that they’re uncomfortable walking out of midline, meaning actively shifting all their weight to one foot while the other steps forward.”
Another, more subtle, clue is if an older loved one has stopped participating in activities they used to enjoy, like going out to restaurants or joining friends to play cards. There could be other factors involved, Julie said, so it might take a little more investigating.
She suggests that family members gently ask their loved one whether something is going on with them. “They might answer honestly that they’re afraid of falling, but it’s more likely they won’t be able to articulate why they no longer want to leave the house,” Julie said. “They might also be worried that if they admit to being afraid of falling or having falls, their family will force them to move.”
Medically cleared for PT or OT
Julie also recommends that family members make sure that a physician has evaluated their older loved one to rule out other possible reasons for balance issues. “Many of the medications prescribed for older people have dizziness as a side effect, but other possible explanations include electrolyte imbalance and low blood pressure,” she said. “Once they’re cleared medically, ask their doctor to prescribe PT and OT.”
Julie said she relies heavily on Lifespark’s senior-savvy medical experts and on outside subspecialists to give her as much information as possible about her clients. She continues to keep them in the loop, and if there’s a change in a client’s health status, she refers back to them for more evaluation. “Those relationships are extremely important, both to us and to the physicians who appreciate having ‘boots on the ground,’” she said.
Maintaining the ‘cone of stability’
When working with a new client, Julie focuses on the cone of stability, which refers to a person’s ability to move forward, backward, or sideways without losing their balance. “The cone of stability allows you to safely reach for a tissue or step backward to allow someone to pass without falling down,” she explained. But when people become less active, their cone of stability shrinks, leading to abnormal balance reactions.
“It’s a classic case of ‘use it or lose it,’” she said. “Fortunately, with agility and flexibility work, strengthening exercises, and balance drills, people can regain a greater sense of balance and ability to feel safe in their activities.” If standing feels too unstable, Julie might have the client begin the exercises seated in a chair. Once the chair becomes too easy, she moves them to standing, and then to moving more dynamically, progressing from reaching to stepping to dancing.
One of the tools Julie uses to identify fear of falling is the Activities-specific Balance Confidence (ABC) Scale. The test asks the client to rate their confidence on a scale of 1 to 100 while imagining themselves doing certain activities, such as sweeping the floor, walking on an icy sidewalk, riding an escalator, getting in and out of the car, and walking in a crowded mall.
“If they rate themselves lower than 67%, they’re at an increased risk of falls,” she said. “The test gives us a starting point, and then, after 30 or 60 days of intervention, we can reassess their confidence level to measure progress.”
What the intervention looks like will vary from client to client, depending on the degree of muscular weakness, joint stiffness, or pain. “If the client has a bum knee, for example, they’re not going to feel very confident walking upstairs,” Julie said. “In addition to strengthening exercises, we can suggest different interventions to reduce the pain, like Kinesio tape, manual therapy, or braces. We can also ask their primary care physician for further evaluation to determine whether interventions like medication or injections might be helpful.”
Sometimes, the treatment involves making adjustments to how daily activities are done. This might include learning how to safely use an assistive device, like a cane, walker, or wheelchair, so the client can continue to participate actively in their lives.
Tips for family members
When coaching family members, Julie said that it’s important how we as caregivers talk to our loved ones about our concerns. “I’ve learned over the years that telling someone you just want them to be safe really doesn’t resonate,” she said. “To them, feeling ‘safe’ means they aren’t afraid that someone is going to break into their apartment.”
She also cautions against telling older family members they need to start exercising and doing strength training. Instead, she suggests asking questions, such as: What can I do to make you want to participate more in your life? and How can I help you be more active in doing what you like to do?
As Julie mentioned earlier, older people might not want to disclose their history of falls or their fear of falling because they think they’ll be removed from their home and placed in a long-term care facility. “We have to be careful how we address these issues so we can have an open, honest discussion,” she said. “If clients know that their family members and caregivers want them to succeed, that’s a great place to start.”