Systematic Review of the Effects of Cognitive and Behavioral Interventions on Fall-Related Psychological Concerns in Older Adults

in Journal of Aging and Physical Activity
Restricted access

Purchase article

USD  $24.95

Student 1 year subscription

USD  $76.00

1 year subscription

USD  $101.00

Student 2 year subscription

USD  $144.00

2 year subscription

USD  $189.00

This systematic review aims to evaluate the efficacy of cognitive and behavioral interventions for improving fall-related psychological concerns. A systematic search yielded eight randomized controlled trials eligible for inclusion. All studies compared a cognitive and behavioral intervention with a control. The meta-analysis showed that cognitive and behavioral treatments had beneficial effects on fear of falling outcomes (lower score better) immediately after treatment (random-effects standardized mean difference [SMD]: −0.3, 95% confidence interval [CI] [−0.50, −0.10]) and at the longer term follow-up (random-effects SMD: −0.29, 95% CI [−0.49, −0.09]). Cognitive and behavioral treatments also showed a positive effect on falls efficacy outcomes (higher score better) immediately after treatment (fixed-effects SMD: 0.19, 95% CI [0.04, 0.34]) and over the longer term (fixed-effects SMD: 0.13, 95% CI [−0.00, 0.25]). However, the clinical significance of these effects on fear of falling and falls efficacy was unclear. Further work is required with best-practice comparators over a longer follow-up period.

Papadimitriou is with Health & Social Sciences Cluster, Singapore Institute of Technology, Singapore, Singapore. Perry is with National Guideline Centre, Royal College of Physicians, London, United Kingdom.

Papadimitriou (angela.papadimitriou@singaporetech.edu.sg) is the corresponding author.
  • Azizan, A., & Justine, M. (2015). Elders’ exercise and behavioral program: Effects on balance and fear of falls. Physical & Occupational Therapy in Geriatrics, 33(4), 346362. doi:10.3109/02703181.2015.1093060

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Barban, F., Annicchiarico, R., Melideo, M., Federici, A., Lombardi, M.G., Giuli, S., … Caltagirone, C. (2017). Reducing fall risk with combined motor and cognitive training in elderly. Brain Sciences, 7, 19. doi:10.3390/brainsci7020019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Batra, A., Melchior, M., Seff, L., Frederick, N., & Palmer, R.C. (2012). Evaluation of a community-based falls prevention program in South Florida, 2008–2009. Preventing Chronic Disease, 9, E13. PubMed ID: 22172180

    • Search Google Scholar
    • Export Citation
  • Brouwer, B.J., Walker, C., Rydahl, S.J., & Culham, E.G. (2003). Reducing fear of falling in seniors through education and activity programs: A randomized trial. Journal of the American Geriatrics Society, 51, 829834. PubMed ID: 12757571 doi:10.1046/j.1365-2389.2003.51265.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Büla, C.J., Monod, S., Hoskovec, C., & Rochat, S. (2011). Interventions aiming at balance confidence improvement in older adults: An updated review. Gerontology, 57, 276286. doi:10.1159/000322241

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Chen, T.Y., Edwards, J.D., & Janke, M.C. (2015). The effects of the A Matter of Balance Program on falls and physical risk of falls, Tampa, Florida, 2013. Preventing Chronic Disease, 12, E157. Retrieved from www.cdc.gov/pcd/issues/2015/15_0096.htm

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Clemson, L., Cumming, R.G., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Geriatrics Society, 52, 14871494. PubMed ID: 15341550 doi:10.1111/j.1532-5415.2004.52411.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Dorresteijn, T.A., Zijlstra, G.A., Ambergen, A.W., Delbaere, K., Vlaeyen, J.W., & Kempen, G.I. (2016). Effectiveness of a home-based cognitive behavioral program to manage concerns about falls in community-dwelling, frail older people: Results of a randomized controlled trial. BMC Geriatrics, 16, 2. PubMed ID: 26739339 doi:10.1186/s12877-015-0177-y

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Finch, T.L., Bamford, C., Deary, V., Sabin, N., & Parry, S.W. (2014). Making sense of a cognitive behavioural therapy intervention for fear of falling: Qualitative study of intervention development. BMC Health Services Research, 14, 436. Retrieved from http://www.biomedcentral.com/1472-6963/14/436

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Freiberger, E., Häberle, L., Spirduso, W.W., & Zijlstra, G.A. (2012). Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: A randomized controlled trial. Journal of the American Geriatric Society, 60(3), 437446. doi:10.1111/j.1532-5415.2011.03859.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M., & Lamb, S.E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 9, CD007146. doi:10.1002/14651858.CD007146.pub3

    • Search Google Scholar
    • Export Citation
  • Greenberg, S.A. (2012). Analysis of measurement tools of fear of falling for high-risk, community-dwelling older adults. Clinical Nursing Research, 21(1), 113130. PubMed ID: 22373731 doi:10.1177/1054773811433824

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Hagovska, M., & Olekszyova, Z. (2016). Impact of the combination of cognitive and balance training on gait, fear and risk of falling and quality of life in seniors with mild cognitive impairment. Geriatrics & Gerontology International, 16, 10431050. PubMed ID: 26338465 doi:10.1111/ggi.12593

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Hallford, D.J., Nicholson, G., Sanders, K., & McCabe, M.P. (2017). The association between anxiety and falls: A meta-analysis. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 72(5), 729741. PubMed ID: 26791279

    • Search Google Scholar
    • Export Citation
  • Healy, T.C., Peng, C., Haynes, M.S., McMahon, E.M., Botler, J.L., & Gross, L. (2008). The feasibility and effectiveness of translating A Matter of Balance into a volunteer lay reader model. Journal of Applied Gerontology, 27(1), 3451. doi:10.1177/0733464807308620

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Higgins, J.P.T., & Green, S. (Eds). (2011). Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration. Retrieved from www.cochrane-handbook.org

    • Search Google Scholar
    • Export Citation
  • Hofmann, S.G., Asnaani, A., Imke, J.J.V., Sawyer, A.T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427440. PubMed ID: 23459093 doi:10.1007/s10608-012-9476-1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Huang, T.T. (2006). Geriatric fear of falling measure: Development and psychometric testing. International Journal of Nursing Studies, 43(3), 357365. PubMed ID: 15961091 doi:10.1016/j.ijnurstu.2005.04.006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Huang, T.T., Chung, M.L., Chen, F.R., Chin, Y.F., & Wang, B.H. (2016). Evaluation of a combined cognitive-behavioural and exercise intervention to manage fear of falling among elderly residents in nursing homes. Aging & Mental Health, 20(1), 212. PubMed ID: 25791743 doi:10.1080/13607863.2015.1020411

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Huang, T.T., & Wang, W.S. (2009). Comparison of three established measures of fear of falling in community-dwelling older adults: Psychometric testing. International Journal of Nursing Studies, 46(10), 13131319. PubMed ID: 19394017 doi:10.1016/j.ijnurstu.2009.03.010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Huang, T.T., Yang, L.H., & Liu, C.Y. (2011). Reducing the fear of falling among community-dwelling elderly adults through cognitive-behavioural strategies and intense Tai Chi exercise: A randomised controlled trial. Journal of Advanced Nursing, 67(5), 961971. PubMed ID: 21214623 doi:10.1111/j.1365-2648.2010.05553.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Jaeschke, R., Singer, J., & Guyatt, G.H. (1989). Measurement of health status: Ascertaining the minimal clinically important difference. Controlled Clinical Trials, 10, 407415. PubMed ID: 2691207 doi:10.1016/0197-2456(89)90005-6

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Jayasinghe, N., Sparks, M.A., Kato, K., Wilbur, K., Ganz, S.B., Chiaramonte, G.R., … Difede, J. (2014). Exposure-based CBT for older adults after fall injury: Description of a manualized, time-limited intervention for anxiety. Cognitive and Behavioral Practice, 21(4), 432445. doi:10.1016/j.cbpra.2014.01.003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Jørstad, E.C., Hauer, K., Becker, C., & Lamb, SE. (2005). Measuring the psychological outcomes of falling: A systematic review. Journal of the American Geriatrics Society, 53(3), 501510. doi:10.1111/j.1532-5415.2005.53172.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Jung, D., Lee, J., & Lee, SM. (2009). A meta-analysis of fear of falling treatment programs for the elderly. Western Journal of Nursing Research, 31(1), 616. doi:10.1177/0193945908320466

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Kane, R.L., & Radosevich, D.M. (2011). Conducting health outcomes research. Burlington, MA: Jones and Bartlett Learning.

  • Kempen, G.I.J.M., Oude Wesselink, S.F., van Haastregt, J.C., & Zijlstra, G.A. (2011). Long-term effect on mortality of a multicomponent cognitive behavioural group intervention to reduce fear of falling in older adults: A randomised controlled trial. Age and Ageing, 40(4), 519523. PubMed ID: 21551460 doi:10.1093/ageing/afr041

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Kumar, A., Delbaere, K., Zijlstra, G.A., Carpenter, H., Iliffe, S., Masud, T., … Kendrick, D. (2016). Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis. Age and Ageing, 45(3), 345352. PubMed ID: 27121683 doi:10.1093/ageing/afw036

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Liu, Y.W.J., & Tsui, C.M. (2014). A randomized trial comparing Tai Chi with and without cognitive-behavioral intervention (CBI) to reduce fear of falling in community-dwelling elderly people. Archives of Gerontology and Geriatrics, 59, 317325. PubMed ID: 24953768 doi:10.1016/j.archger.2014.05.008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Meulen, E., Zijlstra, G.A., Ambergen, T., & Kempen, G.I. (2014). Effect of fall-related concerns on physical, mental, and social function in community-dwelling older adults: A prospective cohort study. Journal of the American Geriatrics Society, 62(12), 23332338. PubMed ID: 25438609

    • Search Google Scholar
    • Export Citation
  • Moreland, J.D., Richardson, J.A., Goldsmith, C.H., & Clase, C.M. (2004). Muscle weakness and falls in older adults: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 52(7), 11211129. PubMed ID: 15209650 doi:10.1111/j.1532-5415.2004.52310.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Morgan, M.T., Friscia, L.A., Whitney, S.L., Furman, J.M., & Sparto, P.J. (2013). Reliability and validity of the Falls Efficacy Scale-International (FES-I) in individuals with dizziness and imbalance. Otology & Neurotology, 34(6), 11041108. PubMed ID: 23542134 doi:10.1097/MAO.0b013e318281df5d

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Muse, K., & McManus, F. (2013). A systematic review of methods for assessing competence in cognitive-behavioural therapy. Clinical Psychology Review, 33, 484499. PubMed ID: 23454222 doi:10.1016/j.cpr.2013.01.010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ory, M.G., Smith, M.L., Wade, A., Mounce, C., Wilson, A., & Parrish, R. (2010). Implementing and disseminating an evidence-based program to prevent falls in older adults, Texas, 2007–2009. Preventing Chronic Disease, 7(6), A130. PubMed ID: 20950537

    • Search Google Scholar
    • Export Citation
  • *

    Parry, S.W., Bamford, C., Deary, V., Finch, T.L., Gray, J., MacDonald, C., & McColl, E.M. (2016). Cognitive behavioural therapy-based intervention to reduce fear of falling in older people: Therapy development and randomised controlled trial the strategies for increasing independence, confidence and energy (STRIDE) study. Health Technology Assessment, 20(56), 1206. PubMed ID: 27480813 doi:10.3310/hta20560

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Parry, S.W., Deary, V., Finch, T., Bamford, C., Sabin, N., McMeekin, P., & McColl, E. (2014). The STRIDE (Strategies to Increase confidence, InDependence and Energy) study: Cognitive behavioural therapy-based intervention to reduce fear of falling in older fallers living in the community—Study protocol for a randomised controlled trial. Trials, 15, 210. PubMed ID: 24906406 doi:10.1186/1745-6215-15-210

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Parry, S.W., Finch, T.L., & Deary, V. (2013). How should we manage fear of falling in older adults living in the community? British Medical Journal, 346, f2933. PubMed ID: 23714190 doi:10.1136/bmj.f2933

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Payette, M.C., Bélanger, C., Léveillé, V., & Grenier, S. (2016). Fall-related psychological concerns and anxiety among community-dwelling older adults: Systematic review and meta-analysis. PLoS ONE, 11(4), e0152848. PubMed ID: 27043139 doi:10.1371/journal.pone.0152848

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Peterson, E.W. (2002). Using cognitive behavioural strategies to reduce fear of falling: A matter of balance. Generations, 24, 5359.

  • Schünemann, H.J., Jaeschke, R., Cook, D.J., Bria, W.F., El-Solh, A.A., Ernst, A., & Guyatt, G. (2006). An official ATS statement: Grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations. American Journal of Respiratory and Critical Care Medicine, 174, 605614. doi:10.1164/rccm.200602-197ST

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Segev-Jacubovski, O., Herman, T., Yogev-Seligmann, G., Mirelman, A., Giladi, N., & Hausdorff, J.M. (2011). The interplay between gait, falls and cognition: Can cognitive therapy reduce fall risk? Expert Review of Neurotherapeutics, 11(7), 10571075. PubMed ID: 21721921 doi:10.1586/ern.11.69

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Smith, M.L., Jiang, L., & Ory, M.G. (2012). Falls efficacy among older adults enrolled in an evidence-based program to reduce fall-related risk: Sustainability of individual benefits over time. Family and Community Health, 35(3), 256263. PubMed ID: 22617416 doi:10.1097/FCH.0b013e318250bdb8

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Sullivan, G.M., & Feinn, R. (2012). Using effect size—Or why the P value is not enough. Journal of Graduate Medical Education, 4(3), 279282. PubMed ID: 23997866 doi:10.4300/JGME-D-12-00156.1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 53B(6), P384P392. doi:10.1093/geronb/53B.6.P384

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Tennstedt, S., Lawrence, R.H., & Kasten, L. (2001). An intervention to reduce fear of falling and enhance activity: Who is most likely to benefit? Educational Gerontology, 27, 227240. doi:10.1080/036012701750194969

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ullmann, G., Williams, H.G., & Plass, C.F. (2012). Dissemination of an evidence-based program to reduce fear of falling, South Carolina, 2006–2009. Preventing Chronic Disease, 9, E103. PubMed ID: 22632740

    • Search Google Scholar
    • Export Citation
  • Vendrely, A., Messmer, E., & Moseley, J. (2012). Integration of cognitive-behavioral therapy with gait training for a 58-year-old male with a fear of falling: A case report. Physiotherapy Theory and Practice, 28(3), 232237. PubMed ID: 21929323 doi:10.3109/09593985.2011.598221

    • Crossref
    • Search Google Scholar
    • Export Citation
  • van Haastregt, J.C., Zijlstra, G.A., van Rossum, E., van Eijk, J.T., de Witte, L.P., & Kempen, G.I. (2007). Feasibility of a cognitive behavioural group intervention to reduce fear of falling and associated avoidance of activity in community-living older people: A process evaluation. BMC Health Services Research, 7(7), 156. doi:10.1186/1472-6963-7-156

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van Haastregt, J.C., Zijlstra, G.A., Hendriks, M.R., Goosens, M.E., van Eijk, J.T., & Kempen, G.I. (2013). Cost-effectiveness of an intervention to reduce fear of falling. International Journal of Technology Assessment in Health Care, 29(3), 219226. PubMed ID: 23778198 doi:10.1017/S0266462313000275

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Wetherell, J.L., Johnson, K., Chang, D., Ward, S.R., Bower, E.S., Merz, C., & Petkus, A.J. (2016). Activity, balance, learning, and exposure (ABLE): A new intervention for fear of falling. International Journal of Geriatric Psychiatry, 31(7), 791798. PubMed ID: 26729564 doi:10.1002/gps.4393

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age and Ageing, 34(6), 614619. PubMed ID: 16267188 doi:10.1093/ageing/afi196

    • Crossref
    • Search Google Scholar
    • Export Citation
  • You, J.H., Shetty, A., Jones, T., Shields, K., Belay, Y., & Brown, D. (2009). Effects of dual-task cognitive-gait intervention on memory and gait dynamics in older adults with a history of falls: A preliminary investigation. NeuroRehabilitation, 24(2), 193198. PubMed ID: 19339758 doi:10.3233/NRE-2009-0468

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Young, W.R., & Hollands, M.A. (2012). Newly acquired fear of falling leads to altered eye movement patterns and reduced stepping safety: A case study. PLoS ONE, 7(11), e49765. PubMed ID: 23185432 doi:10.1371/journal.pone.0049765

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zidén, L., Häggblom-Kronlöf, G., Gustafsson, S., Lundin-Olsson, L., & Dahlin-Ivanoff, S. (2014). Physical function and fear of falling 2 years after the health-promoting randomized controlled trial: Elderly persons in the risk zone. The Gerontologist, 54(3), 387397. doi:10.1093/geront/gnt078

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zijlstra, G., van Haastregt, J.C., van Eijk, J.T., & Kempen, G.I. (2005). Evaluating an intervention to reduce fear of falling and associated activity restriction in elderly persons: Design of a randomised controlled trial [ISRCTN43792817]. BMC Public Health, 5, 26. doi:10.1186/1471-2458-5-26

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zijlstra, G.A. (2007). Managing concerns about falls: Fear of falling and avoidance of activity in older people (PhD thesis). Retrieved from http://digitalarchive.maastrichtuniversity.nl/fedora/get/guid:7c82d48e-765f-4f22-9742-956405c2dd1c/ASSET1

    • Search Google Scholar
    • Export Citation
  • Zijlstra, G.A., Tennstedt, S.L., van Haastregt, J.C., van Eijk, J.T., & Kempen, G.I. (2006). Reducing fear of falling and avoidance of activity in elderly persons: The development of a Dutch version of an American intervention. Patient Education and Counseling, 62(2), 220227. doi:10.1016/j.pec.2005.07.005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • *

    Zijlstra, G.A., van Haastregt, J.C., Ambergen, T., van Rossum, E., van Eijk, J.T., Tennstedt, S.L., & Kempen, G.I. (2009). Effects of a multicomponent cognitive behavioral group intervention on fear of falling and activity avoidance in community-dwelling older adults: Results of a randomized controlled trial. Journal of the American Geriatrics Society, 57, 20202028. doi:10.1111/j.1532-5415.2009.02489.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zijlstra, G.A., van Haastregt, J.C., Du Moulin, M.F., de Jonge, M.C., van der Poel, A., & Kempen, G.I. (2013). Effects of the implementation of an evidence-based program to manage concerns about falls in older adults. The Gerontologist, 53(5), 839849. PubMed ID: 23135419 doi:10.1093/geront/gns142

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zijlstra, G.A., van Haastregt, J.C., & Kempen, G.I. (2012). “A matter of balance--Netherlands”: An effective intervention to reduce concerns about falls and related avoidance of activity in older people. Tijdschrift voor Gerontologie en Geriatrie, 43(4), 164174. PubMed ID: 23082409 doi:10.1007/s12439-012-0026-9

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zijlstra, G.A., van Haastregt, J.C., van Eijk, J.T., de Witte, L.P., Ambergen, T., & Kempen, G.I. (2011). Mediating effects of psychosocial factors on concerns about falling and daily activity in a multicomponent cognitive behavioral group intervention. Aging & Mental Health, 15(1), 6877. PubMed ID: 20924813 doi:10.1080/13607863.2010.501054

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Zijlstra, G.A., van Haastregt, J.C., van Rossum, E., van Eijk, J.T., Yardley, L., & Kempen, G.I. (2007). Interventions to reduce fear of falling in community-living older people: A systematic review. Journal of the American Geriatrics Society, 55(4), 603615. doi:10.1111/j.1532-5415.2007.01148.x

    • Crossref
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 452 452 64
Full Text Views 29 29 5
PDF Downloads 18 18 4