Academic journal article Generations

Using Cognitive Behavioral Strategies to Reduce Fear of Falling: A Matter of Balance

Academic journal article Generations

Using Cognitive Behavioral Strategies to Reduce Fear of Falling: A Matter of Balance

Article excerpt

Several population-based surveys indicate that one-third to one-half of community-living older adults acknowledge fear of falling (Peterson, 2001). For some older adults, especially those who have experienced an injurious fall, concerns about falls can be protective. Frail older adults, for example, use good judgment when they avoid activities beyond their physical capability because of the fear that they might fall. The situation becomes more problematic when older adults curb involvement in activities they remain capable of performing in an effort to avoid a fall. Studies indicate that between 35 percent and 56 percent of community-dwelling older adults curtail activities because of fear of falling (Howland, Peterson, and Ohayon, 2000). While further studies are needed to better understand the prevalence of activity curtailment that occurs independent of physical limitations, it is safe to say that activity curtailment associated with fear of falling is common.

Fear of falling is a clinically relevant concern. A number of cross-sectional studies have shown consistent associations between fear of falling and compromised physical and psychosocial status (Howland et al., 1993; Arfken et al., 1994; Tinetti et al., 1994a; Peterson et al., 1999). Results from a prospective study by Gumming and colleagues (2000) provide compelling evidence that fear of falling may be a predictor of falls. In that study, compared to older adults with high fall-related self-efficacy (i.e., confidence in their ability to perform everyday tasks without falling), older adults with low fall-related self-efficacy had an increased risk of falling and greater declines in their ability to perform activities of daily living (ADLS). Additionally, nonfallers who said they were afraid of falling had an increased risk of admission to a care institution. Fortunately, randomized trials evaluating diverse intervention strategies have now demonstrated that fear of falling can be mitigated among older adults (Tinetti et al., i994b; Wolf et al., 1996; Tennstedt et al., 1998a; Cameron et al., 2000). This evidence strengthens the rationale for including fear of falling as a component of geriatric care.

Recognizing the negative impact that fear of falling has on quality of life for many older adults, the Boston University Roybal Center for the Enhancement of Late-Life Function undertook a five-year, randomized, controlled trial to evaluate the efficacy of a group-based program designed to reduce fear of falling and increase activity levels among older adults (Tennstedt et al., 1998b). That program, A Matter of Balance, is unique in at least two ways. First, the program is specifically directed to community-dwelling older adults who curtail their activity as a result of the fear of falling. Second, the intervention is solidly based upon principles of cognitive-behavioral theory. This article reviews the principles of cognitive-behavioral theory and describes how those principles are put into practice through the A Matter of Balance program.

COGNITIVE-BEHAVIORAL MODEL

The aim of cognitive-behavioral therapy (CBT) is to identify, evaluate, and change maladaptive, distorted belief systems and dysfunctional styles of information processing (Beck, 1979). Recognizing that attitudes and beliefs affect behavior, cognitive-behavioral therapists work with clients to help them correct habitually negative ways of thinking. Traditional cognitive-behavioral therapy is, in essence, psychoeducational because the cognitive processes themselves are the focus of treatment (Abraham et al., 1991). CBT begins with identification of dysfunctional thoughts (e.g., over-generalizing, self-blame, unrealistic expectations). Once erroneous beliefs and methods of processing information are exposed, the client attempts to examine and alter the problematic cognitions (Beck, 1979). This shifting from maladaptive, "task-interfering" thoughts to motivating, "strategy-relevant" thoughts is viewed as the basis for improved emotional functioning and adaptive behavior change. …

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