Psychology after stroke: The fear
of falling
Dr Ian Kneebone, Consultant Clinical Psychologist
& Visiting Reader
Mr T






Referral from Day Hospital
83 year old man
Approx 14 falls last 3 ½ yrs
Peripheral neuropathy, TIAs (heavy
smoker)
Ca prostate
AMT 9/10
Fear of Falling and Stroke





Provide an overview of falls and stroke
Consider fear of falling (FoF) and
provide an heuristic model
Review methods to assess FoF
Consider the opportunities for
management in individual and group
settings
Practical trial a relaxation exercise
Falls & Stroke
In-patients as high as 39% ( Nyberg & Gustafson, 1995)
10 years post event fall twice as often as matched
controls (Jorgensen et al., 2002).
Associated with greater medication usage, hemi
neglect, reduced physical function (Mackintosh et al.,
2006), reduced upper limb function (Ashburn et al., 2008),
executive change (Liu-Ambrose et al., 2007) and
depression (Jorgensen et al., 2002)
Falls & Stroke

Falls associated with subsequently being
lower in mood, less socially active and
carer stress (Forster & Young, 1995)

4% experience a fracture within two
years of a stroke (Dennis et al., 2002)
Fear of Falling
‘Le meiller secret pour ne jamais tomber
c’est rester toujours assis.’
‘The best way never to fall is to remain
seated at all times.’
Stendhal, Journal 1814
Stroke & Fear of Falling

FoF has been described as ‘a lasting concern
about falling that leads to an individual
avoiding activities’ (Tinetti & Powell, 1993).

Limited prevalence data but likely 48% in those
with stroke who have fallen (Watanabe, 2005)

20% of those with stroke who have not fallen
report low fall related self-efficacy, 11% who
have fallen, high falls related self-efficacy
(Andersson et al., 2008)
Stroke & Fear of Falling

Associated with poor physical function
(Andersson et al., 2008)

Falls related self-efficacy, not balance or
mobility performance is related to
accidental falls in stroke patients with
low bone density (Pang & Eng, 2008).
Fear of Falling

- generally has been indicated to be a
predictive, independent risk factor for
poorer quality of life (Lachman et al,
1998), functional decline and/or loss of
independence (Tinetti et al, 1990).
FoF as a risk factor for future falls
Immediate risk
Longer term risk
Low falls self-efficacy
Negative
thoughts
Distraction
Bodily
awareness
Stiffening
Negative
beliefs
Poor selfperception
Increased risk of falling
Reduced activity
/avoidance
Lowered body
strength
FoF Assessment

FOF may be hard to recognize in some
clients as they may already have cut out
all the activities that demonstrate the
problem by the time they are referred for
intervention.

Some clients may also lack awareness
or avoid discussion of their fear.
FoF Assessment


-
-
-
Important to differentially identify post fall
PTSD
Characterised by:
Intrusive recollection: e.g., dramatic re-experiencing,
dreams etc
Avoidance: e.g., of associated stimuli, numbing of
responsiveness
Hyperarousal: hypervigilance, irratibility
FoF Assessment Scales

‘Falls Efficacy Scale-International’ FES-I
(Tinetti, Richman & Powell, 1990) or the
‘Survey of Activities and Fear of Falling in
the Elderly’ (SAFE; Lachman, Howland,
Tennstedt, Jette, Assman & Peterson, 1998).

These scales ask individuals about how
confident or afraid they feel about carrying out
a number of specific activities of daily living.
Falls Efficacy Scale - International

‘Now we would like to ask some questions about how
concerned you are about the possibility of falling. Please reply
thinking about how you usually do the activity. If you currently
don’t do the activity (e.g. if someone does your shopping for
you), please answer to show whether you think you would be
concerned about falling IF you did the activity. For each of the
following activities, please tick the box which is closest to your
own opinion to show how concerned you are that you might fall
if you did this activity.’
FES-I

1
2
3
4
Not at all concerned
Somewhat concerned
Fairly concerned
Very concerned

1

2
Cleaning the house (e.g. sweep, vacuum or dust)
1􀂆 2􀂆 3􀂆 4􀂆
Getting dressed or undressed
1􀂆 2􀂆 3􀂆 4􀂆



FES-I




Scores range from 16 to 64
The higher the score the greater is
the concern about falling
Low: 16-22, High 23-64
Low 16-19, Moderate 20-27, High 28-64
(Delbaere et al., 2010)
Other Measures

Activity-specific Balance Confidence
Scale
‘balance confidence’ with respect to
specific activities (Powell & Meyers, 1995)

Consequences of Falling Scale ‘outcome
expectancy’ with respect to falls
(Yardley & Smith, 2002)
FoF Observations

Observation of the client during physical
therapy sessions and discussion with the
client’s relatives to gain their opinions as
to whether an individual has tended to
increasingly avoid activities.
FoF Multi-factorial Treatment



cognitive therapy to change attitudes
about the risk of falling
education about the fear of falling and
that it is controllable
goal setting to increase relative activity
levels of participants and to manage a
graduated exposure to fearful situations
FoF Multi-factorial Treatment



environmental modification to
reduce the risk of falling
increasing physical exercise
and maximising strength and
balance
FoF Treatments
Systematic review of treatments for
community living older people.
-multi-factorial
-tai chi interventions,
-exercise interventions
-hip protector intervention.
(Zijlstra, et al., 2007)
Realistic Goals and Fear of Falling
- allowing open discussion of the client’s valid
fears; and give the client ‘permission’ to admit
to falls, without feeling they will be blamed for a
preventable incident
-assists staff to conceptualise realistic goals, thus
maintaining
their
motivation
for
the
intervention.
Realistic Goals and Fear of Falling
-ensure a reality base to intervention, that is
facilitate the adoption of a philosophy of falls
reduction, rather than falls prevention.
-assurance the programme has face validity with
clients who may be skeptical falls can be
prevented
Individual Treatment
Steps

1.
acknowledge the validity of their
fear, whilst reminding them that there are
factors in their control that can reduce
the risk of them falling.
Individual Treatment Steps

2. Motivational interviewing (Prochaska
& DiClemente, 1982) may help in the
establishment of a commitment to
proceed with therapy.
Acknowledge their choice to proceed,
however you inform that choice…
Decisional Balance




AVOIDANCE +
-feel safe, relaxed
-easier
-tasks done for me




AVOIDANCE -weak, frail
-constipation
-dependence (care
risk)
Individual Treatment Steps

3. Initial
education
can
involve
presenting the heuristic model.

4. Control, management, not eradication
of fear is the goal of intervention.
Individual Treatment Steps
5.
Physical arousal associated with anxiety is
contained using relaxation.
6.
Helpful attitudes for use during mobilization
trials are achieved through motivational
interview and cognitive disputation. Attention
is directed away from anxiety provoking
thoughts to behaviours that will potentiate
success
CBT Structure

Physical
Relaxation and
breathing

Cognitive
Pre-prepared responses
to negative thoughts

Behavioural
What I need to do to
walk well
Relaxation & Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training
Cognitive

‘Sure, there is a risk of falling, but if I
concentrate well and relax its less likely’

Can be based on motivational interview
Behavioural

How to look ahead, breathe properly, lift
their frame etc.
Case example Mrs W





In-patient referral
86 year old woman
L hemi, AF, CCF, Hi BP, f UTI, #L NOF
99, OA, Recent further #L DHS & leg
shortening
Commenced on sertraline (anti –
depressant)
MMSE 21/30
Jack

Client: 80 years of age, poor mobility,
increasingly frail, mild stroke/small vessel
disease, heart failure, glaucoma, postural
hypotension

Referral: Day hospital concerned about
general anxiety and marked fear of falling that
was interfering with rehabilitation progress,
Jack

Assessment: Adjustment reaction with mixed
features of anxiety and depression.
Precipitated by physical decline and difficulty
with falls. Reaction included insomnia, suicidal
ideas (without planning or action). Fear of
falling evident on account of a falls history and
conviction the next fall would be a bad one that
would leave him ‘worse off’. ‘I’ll do it wrong, I’ll
fall and it will be a bad one’
Jack

Reinforced by relief he feels at
discontinuing efforts to mobilise.
Jack



Intervention: 10 sessions
1. Decision to focus on FoF because so
prominent
2. Motivational interview: safe from falls
v’s loss of independence, decline in
health, increased constipation etc.
Jack




3. Relaxation general and specific
4. Cognitive coping self-statements
5. Physio goal setting and instructions
‘What is it I have to do to walk well’
6. Home visits X 2 Physio. Plus followup by H/V elderly
Jack
Relaxation general and specific
Autogenic and 3 part breathing
Cognitive coping self-statements:
‘OK I might fall, but if I relax and think about what
I need to do its less likely’ ..‘Breathe’
‘Its important I do this to stay independent and
keep the bowels from seizing up completely!’
Jack

Now, what is it I have to do to walk
well…’

‘Head up, bottom in, lift the frame..off I
go’
Jack

Outcome: Mobilised to goal level set
with Physiotherapist. Mood
improvement. Sleep remained impaired
? bladder difficulty.
Case Study: Mary
CASE STUDY 1: Fear of Falling
Client: Female 79 years of age, stroke 3 years
prior to #NOF. Painful experience. History of 3
– 5 falls prior to fall that resulted in #.
Referral: Physiotherapy very concerned,
complete refusal to mobilise stand or attempt
walking when ‘clearly’ physical ability was in
place.
Mary
Assessment: Psychological assessment
confirmed FoF.
99% convinced if she attempted to stand or walk
she would fall and experience a further painful
event.
Clear negative adversarial interaction between
physios and patient, characterised by repeated
entreaties and refusals
‘Ya will, ya will, ya will’.
Mary
Intervention:
Took the pressure off completely.
-Physio (or student) would come and just
talk
-Clarified the decision to participate in
recommended rehabilitation tasks was
entirely hers
Mary
Intervention
Discussion with physios were centred around
what they were doing and why
- -Mapped out programme in detail),
- -Considered the potential consequences of
non participation (dependence, institutional
accommodation)
Mary
Outcome:
After 2-3 sessions agreed to start initial stage of
intervention. Subsequently she progressed in
line with normal expectation. Discharged to
own home.
Major aspects leading to change. Changed
nature of interaction from adversarial to
collaborative, gave control, choice to patient
Fear of falling after stroke
 Questions?
i.kneebone@nhs.net