March/April 2016

Tai Chi Intervention Reduces Fear of Falling
By Abby Bennett, RN, BSN, and Nancy Bredenkamp, PhD, APRN
Today's Geriatric Medicine
Vol. 9 No. 2 P. 24

The fear of falling in itself is a risk factor for falling. Specialized interventions can help to reduce the fear of falling and, in turn, limit the incidence of falls.

The elderly population has expanded and continues to grow, representing 14.1% of the United States population in 2013, a number that is expected to increase to 21.7% by 2040, according to a 2014 US Department of Health and Human Services (HHS) estimate. Among the elderly's unique health care concerns is their increased risk for falls.

Elderly adults are the population segment most likely to experience falls; each year one in three elderly adults falls, according to the Centers for Disease Control and Prevention (CDC). Falls, of course, negatively impact the elderly in various ways including physical injury, psychological distress, and death. A 2012 World Health Organization report cited falls as the second leading cause of accidental or unintentional injury deaths worldwide. According to the Emergency Nurses Association, up to one-half of older adults who are hospitalized following a fall do not survive another year. The loss of independence and the increased risk of death following a fall also lead to an increased financial burden for the nation.

In 2012, falls among older adults cost the United States health care system $30 billion in direct medical costs. The CDC estimates costs will reach $54.9 billion in direct and indirect costs by the year 2020. Therefore, the health burden of falls in the elderly must be more thoroughly evaluated.

Despite these daunting statistics, the CDC estimates that fewer than one-half of the elderly population have ever discussed the issue of falls with their health care providers. In a 2004 systematic review by the World Health Organization (WHO), it was suggested that prevention strategies for falls in the elderly have yet to be properly studied. Therefore it is vital to identify individuals who are at the greatest risk of falling to maximize the effectiveness of any proposed intervention.

Combating Fear of Falling
Falls are the second leading cause of accidental injury deaths worldwide. The impact of a fall can result in outcomes ranging from minor injury to death. Fear of falling is among the risk factors identified as placing elderly individuals at increased risk of falling. Having a fear of falling can lead to older adults' activity avoidance, reduced mobility, and loss of physical activity. Strategies to decrease the fear of falling include exercise-based interventions, home-modifications, education, and tai chi exercises.

The purpose of a recent pilot project was to decrease the fear of falling in the elderly population residing in an assisted living facility in a rural Midwestern region through the use of a tai chi program. The assisted living facility utilized for this project had completed one fall risk assessment on residents' admission to the facility, but no further assessments related to falling were performed throughout the residents' time in the facility. Tai chi classes were offered for eight weeks in one-hour biweekly sessions. Both before and after the intervention, volunteer participants completed the Falls Efficacy Scale-International (FES-I) to determine whether changes occurred in the participants' fear of falling. The pilot project found that while a quantitative decrease in the fear of falling was not achieved, the small group of participants enjoyed tai chi classes and wanted them to continue; the majority felt the classes had exerted some impact on their balance.

Fear of Falling
Numerous factors that increase the risk of falling have been identified. The WHO broadly classifies fall risk factors into the following three categories: intrinsic, extrinsic, and exposure to risk (see Table 1).

Having a fear of falling has been identified as an intrinsic risk factor for actually falling. It is defined as a lasting concern about falling that can lead to an individual's avoiding activities that he or she remains capable of performing.1 According to the American Nurses Association (ANA), an increasing body of evidence suggests that falls can cause psychological problems in many older adults, whether they have fallen in the past of have never fallen. Furthermore, the ANA notes an estimate among elderly individuals who have fallen that between 29% and 92% fear they will suffer another fall; and among those who have not fallen, between 12% and 65% fear they will fall in the future. This fear of falling causes a decrease in activity, which leads to reduced mobility and the loss of physical activity, and increases the individual's actual risk of falling, according to the CDC. Furthermore, elderly adults who develop a fear of falling limit their travel outside of their homes and their enjoyment of life experiences.2 Fear of falling was the risk factor of interest for the project described in this article.

Screening for Fear of Falling
The fear of falling has been identified in the literature for many years and has been referred to by various names, such as postfall syndrome and self-efficacy. In addition, many different scales have been developed and utilized in an attempt to quantify an individual's fear of falling. Some of the common scales include the Falling Efficacy Scale (FES), the FES-I, Activities-Specific Balance Confidence Scale, and the Geriatric Fear of Falling Measurement. The FES-I was utilized to measure fear of falling for this project. The FES-I, adapted from the FES to include six additional questions regarding outdoor activities not covered in the original FES, was designed to be suitable for use in a range of languages and cultural contexts to permit direct comparison between studies and populations in different countries and settings. The FES-I was found to have excellent internal and test-retest reliability (Cronbach's a=0.96; ICC=0.96) and excellent psychometric properties. It assesses concerns relating to basic and more demanding physical and social activities.3 Delbaere et al evaluated the FES-I in a comprehensive longitudinal validations study and found that it had acceptable structure, good validity, and reliability, and its internal consistency as a whole was acceptable (Cronbach's a=0.79).4 The authors recommended it for further studies exploring the FES-I's responsiveness to change during intervention studies.

Reducing the Fear of Falling
Screening for the fear of falling is one of the first steps to reduce older adults' fear. Implementing evidenced-based strategies for decreasing the fear of falling is the second step. Numerous evidence-based interventions aimed at reducing the fear of falling have been studied. A few of the more frequently referenced interventions include exercise-based programs, education, home modification, and the use of tai chi.

In a literature review of interventions to reduce the fear of falling, it was found that six of nine studies utilizing exercise-based interventions showed a statistically significant reduction in the fear of falling.5-10 Of the three remaining studies, one demonstrated that group exercise was effective at reducing the risk factors related to falling in the elderly in an ambulatory care setting.11 Buttery et al found that 95% of the elderly were satisfied to very satisfied with participation in therapeutic exercise groups.12 Finally, McCormack et al concluded that there was no statistical significance between fear of falling and exercise interventions; however, this was a pilot study with a relatively small sample size.13

Rucker et al conducted a controlled pilot study in an emergency department aiming to reduce fear of falling in individuals aged 50 and older who had sustained a fracture postfall.14 The intervention included educational leaflets and postdischarge telephone counseling regarding fall prevention strategies. The researchers found that at three months postfall 48% of participants reported an increase in fear of falling and 11% had fallen again. Four studies were found to actually reduce falls in the elderly population through home modification interventions; however, there is limited research regarding whether they reduce the fear of falling.15-18

Tai Chi Intervention
Tai chi, a martial art that uses a mind-body connection and is practiced in complementary and alternative medicine, involves moving the body slowly, gently, and with awareness while breathing deeply. There are many benefits to practicing tai chi, including aerobic exercise, coordination, flexibility, improved balance, decrease in the risk of falls, and easing pain and stiffness, according to the HHS.

Methods and Materials
The purpose of this project was to decrease the fear of falling in the elderly population residing in a Midwestern assisted living facility. The facility screened entering residents regarding previous falls during an initial assessment on admission to the facility; no subsequent screenings were completed throughout a resident's stay. The facility's exercise regimen involved one-hour sessions five days per week conducted by the activities director in the exercise room. Three days per week residents were led through stretching and light weight-lifting exercises. The other two days of the week, the residents utilized age-appropriate exercise equipment. The equipment remained available throughout the week for residents to use as they wished. The facility housed 48 residents at the onset of the project. All residents were notified of the project and were invited and encouraged to participate in the new tai chi exercises.

The project offered tai chi classes twice per week for one-hour sessions over a period of eight weeks. The tai chi program for the elderly was developed and instructed by an American Council on Exercise-certified fitness trainer with a degree in fitness management, sports management, and health. Classes were conducted in the exercise room of the facility. Residents were provided two chairs, placed on either side, allowing them to hold on to the chairs for balance if they felt unsteady during any exercise. The fitness instructor, project leader, and activities director were present at all sessions to observe residents for any safety concerns. Prior to beginning and at the completion of the tai chi program, all participants completed the FES-I to assess their fear of falling.

Results
The range of ages among all residents of the facility during the time of the pilot study was 66 to 101, with an average age of 84. There were 15 participants, ranging in age from 65 to 91, who completed the initial FES-I, indicating their interest in participating in the study. Only residents who completed the pre- and post-FES-I and who participated in at least 75% or 12 of the 16 classes offered were included in the results. All were women whose average age was 84. All participants used assistive devices for ambulating prior to beginning the project.

Statistical Results
The FES-I consists of 16 questions regarding activities of daily living, including inside and outside activities. The participants were asked to rank answers on a scale from 1 to 4 (1: not at all concerned about falling; 2: somewhat concerned; 3: fairly concerned; and 4: very concerned). The scores for each answer are added and then categorized within the following spans: 16 to 19 (low concern of falling); 20 to 27 (moderate concern); and 28 to 64 (high concern).

The FES-I scores increased after the eight weeks of tai chi (see Table 2).

The small number of participants strictly limits any statistical inference. However, this indicates that fear of falling increased postintervention. However, four qualitative questions asked at the end of the project demonstrated positive outcomes from the tai chi program.

Qualitative Feedback
To better understand the significance of the FES-I results, participants who completed the study were asked four questions. The first question inquired whether participants enjoyed doing tai chi. All the participants answered in the affirmative. The second question asked whether participants would like to continue with tai chi classes at the facility. All replied in the affirmative and two added that they were working on tai chi outside of the class in their own rooms. The third question was directed at whether participants felt that tai chi had had any effect on their balance. Three of the participants replied that tai chi had had a positive effect on their balance, and one participant replied that she felt that it had little effect on her balance. The final question addressed participants' least favorite thing about tai chi. The responses included trying to keep up and various chronic musculoskeletal complaints.

The project leader and the tai chi instructor noted that as the classes continued, the balance and the activity of the residents appeared to improve. Increased participation with movements was noted by week three and continued throughout the remainder of the project. Likewise, by week five, the leaders noted a decrease in the need to hold on to chairs for balance.

Conclusion
Tai chi can be a difficult exercise to learn and perform even for the nonelderly. A modified version of tai chi could be designed so that elderly participants could reap the benefits of the martial art that has been shown in the literature to generate many benefits including better balance.

The FES-I has been shown to have good validity, reliability, and internal structure in research studies. However, these studies were performed with elderly community-dwelling participants. The CDC places assisted living facilities collectively in the category of long term care facilities, along with nursing homes and skilled nursing facilities. Furthermore, the CDC reports that each year between one-half and three-quarters of nursing home residents fall; this is twice the rate of falls among older adults living in the community. The effectiveness of the FES-I should be specifically tested in an assisted living facility to determine whether it remains reliable and valid in this population, especially with individuals who use assistive devices for ambulation but are not completely dependent on others.

The facility personnel recommended that the pre-tai chi exercise program continue with the addition of simple tai chi exercises. In addition, screening for the risk of falls and the fear of falling beyond the initial screening when residents move in to the facility to extend to an annual assessment for all residents was encouraged. A better understanding of the effect of tai chi exercises on the fear of falling would be gained with increased participation and continuation of the program for a longer period. Organizers discussed ideas to increase participation in the tai chi exercises. Suggestions included such things as reminding residents on the days of the tai chi exercises, giving recognition in the weekly newsletter to the residents for their participation, displaying pictures of participants engaged in tai chi, and offering incentives for consistent participation.

Falls in the elderly present a significant health care burden. With the elderly population expected to increase to 21.7% by the year 2040, it is an issue that will continue to be a concern until the completion of further research on falls, including the development of interventions to decrease older adults' fear of falling. More research must be undertaken to examine individual risk factors for falls and to determine the effectiveness of interventions to help reduce risk factors for falls.

— Abby Bennett, RN, BSN, is a DNP candidate at Creighton University in Omaha, Nebraska, with a clinical focus as a family practice nurse practitioner.

— Nancy Bredenkamp, PhD, APRN, is an assistant professor of nursing at Creighton University.

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