Fear of Falling and Its Related Factors in the Older Adults with Heart Failure

Document Type : Short Report

Authors

1 PhD Candidate of Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

2 Ms of Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

3 Research Assistant Professor of Epidemiology, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran

4 Assistant Professor of Cardiology, Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran

5 Associate Professor of Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

6 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.

Abstract

Fear of falling (FOF) acts as an inhibitory factor for the activities of daily living and causes disability and dependence in the elderly suffering from heart failure (HF). This study aimed to determine FOF among the elderly with HF and its related factors. This cross-sectional study was performed on 445 elderly patients with heart failure who were referred to the HF clinic of Tehran Heart Center affiliated with Tehran University of Medical Sciences, Tehran, Iran, from March to July 2018. Participants in this study were selected randomly. Data collection was conducted using demographic characteristics form and Falls Efficacy Scale-International questionnaires. Data were analyzed using STATA software (Version 14). The mean FOF among participants was 36.7 out of 64 scores (ST=0.27 and CI: 95%). The level of FOF was moderate in 61% of the participants. Based on the obtained results, FOF had no statistically significant correlation with gender, education, smoking, and marital status (P>0.05); however, it had a statistically significant correlation with age, HF class, residence, medications, and the history of falls (P<0.05). It is recommended that health caregivers should develop a comprehensive care program that takes into account such factors as age, HF class, residence, medications, and history of falls to prevent and reduce the FOF. Therefore, given the importance of the issue of FOF in older adults with HF, a comprehensive care program and educational, counseling, and welfare interventions should be developed in a way to prevent and reduce FOF.

Keywords


Introduction

Falling during physical activity is one of the most important health issues in elderly people and has a high annual mortality rate and medical costs (1-2). Based on the reports of Centres for Disease Control and Prevention, fall death rates have increased by 30% in the last decade (3). The medical costs attributable to the elderly falls in the United States are estimated at approximately $50.0 billion (4). More than 800,000 elderly people are hospitalized due to falling injuries, and the rate and the costs of falls increase with the growth of the elderly population (5). Research in Iran indicates that 46.9% of the elderly fall at least three times during six months (6). Frequent falls in the elderly can cause FOF, low self-esteem, bone fractures of the skull, pelvis, and femur.  It also increases the chance of recurrence, limits mobility, and decreases life expectancy which disrupts the physical, psychological, and social dimensions of the person’s life (7).

FOF is a hidden risk factor for falling in older adults and means that one does not have confidence in one’s ability to perform daily activities without falling and losing balance (8). FOF is also called a post-fall syndrome (9). FOF reduces daily activity and quality of life and increases the likelihood of falling in the elderly (10). In general, the prevalence of FOF ranges from 25% to 85% in the world, and the range of this prevalence has been reported to be from 36.4% to 76.2% in Iran (6-8). It is worth mentioning that FOF can occur even with no history of falling. Based on the results of some studies, the prevalence of FOF without a positive history of falling is estimated to be more than 50% (6, 11). A significant relationship has been observed between FOF and physical activity (12). The results of a study conducted in Brazil indicated that FOF has led to the reduction of activities in 52% of the elderly population (13). Based on the results of recent research, factors associated with FOF in the elderly include age (11), female gender (14), history of falling (11), physical dysfunction (15), depression, a low education level (11), cognitive impairment, living alone, and having chronic diseases (16).

HF is one of the chronic debilitating diseases in the elderly. Today, life expectancy in patients with HF has increased due to significant advances in the diagnosis and control of diseases which has led to advances in cardiovascular interventions and pharmacotherapy (17). Moreover, it should be noted that HF in the elderly is more important than young population due to the presence of age-related diseases, such as hypertension, atrial fibrillation, a vascular disease especially coronary artery disease, renal failure, and the simultaneous use of several drugs (18). Physical activity is a pillar in the treatment of HF and prevention from the progression of the disease. The patients are at risk of falling during activities due to certain conditions, such as decreased muscle strength, the consumption of medications with neurovascular and volume modulating properties (diuretics, digoxin, ad antihypertensive drugs), as well as drugs for orthostatic hypotension (19-20). A previous experience of falls in the elderly with HF can cause FOF (10). However, FOF may either be a positive reaction in the elderly which makes them more attentive while walking (11), or a disabling factor that causes activity restriction, lower quality of life, and increased hospitalization time (11, 21). Excessive activity restriction in the elderly with HF is of particular importance since it exacerbates the consequences of this disease (22).

Nurses, as health care providers, need to be aware of FOF and its consequences for the elderly in both hospitals, other 24-hour care centers, and/or at patients’ homes. Moreover, their close relationship with patients and their responsibility to maintain and promote patients’ safety and health empowers them to consider the predictors before doing any preventive and control interventions. Based on the review of literature, few studies have addressed FOF in older adults with HF, and there is little information about FOF as a deterrent to physical activity in the elderly with HF. Therefore, the present study was designed with an eye to such major considerations as the growth of the elderly population, the increase in the incidence of chronic diseases including HF, the significance of physical activity as a pillar of treatment regimen in these patients, and the importance of falling as a patient safety index in hospitals. A better understanding of the factors associated with FOF can lead to the better prediction of the effective factors, reduction of FOF, an increase of the physical activity among the elderly with HF, and improvement of the patient’s condition. Moreover, understanding the current level of FOF and its predictors not only increases awareness in this field but also leads to the selection of wise preventive and controlling interventions for the treatment of FOF and the improvement of quality of life in the elderly with HF. Therefore, the present study aimed to evaluate the level of FOF and its related factors in older adults with HF.

Methods

This cross-sectional study was performed on 445 elderly patients with HF who were referred to the HF clinic of Tehran Heart Center affiliated with Tehran University of Medical Sciences, Tehran, Iran, from March to July 2018. The sample size was calculated to be 385 patients based on the highest prevalence (50%) of FOF in the elderly population in previous studies (14), considering type 1 error (a) 5%, type II error (β) 20%, accuracy of 5%, using the formula n= z21-a/2 * p (1− p) / d2. The sample size was increased to 445 participants, considering the design effect of 1.1, and a 5% attrition rate. Participants were selected by the simple randomization method and based on a table of random numbers.

The inclusion criteria included age over 60 years, the ability to move without the use of mobility aids (independence in daily activities), the lack of any known cognitive impairment based on the patients’ self-report, a score of more than 23 in the Mini-Mental Status Examination, such as Alzheimer’s disease, and a definite diagnosis of HF confirmed by a specialist with a HF fellowship. The researcher attended the research environment during the morning work shifts.

The data collection instrument included a demographic characteristics form and FES-I questionnaire.

The demographic characteristics form was used to obtain the participants’ demographic data including age, gender, level of education, marital status, smoking status, residence, history of falls, Ejection Fraction, medications, and HF class.

The FES-I questionnaire was used to assess the level of concern about falling while performing various daily activities, which was developed as a part of the Prevention of Falls Network Europe project from 2003 to 2006 by Todd et al. This questionnaire has been widely used in many studies, especially in geriatric science (23). In a study conducted by Yardley et al., it was reported that the English version of FES-I had excellent internal and test-retest reliability (Cronbach’s α=0.96, ICC= 0.96) (24).

In the present study, the reliability of this questionnaire was evaluated by the test-retest method after 10 elderly living in the community were asked to complete the questionnaires in two stages with a one-week interval. Subsequently, the correlation coefficient of 0.98 obtained in the statistical analysis of the results confirmed the reliability of the questionnaire.

This questionnaire consisted of 16 items for assessing the level of concern about the fall. The scale is scored based on a 4-point Likert scale from 1=not at all concerned to 4=very concerned. The total score of the scale that was obtained by adding the score of each item ranged from 16 to 64 with higher scores indicating higher fear of fall in the person and vice versa.

 The researcher went to the HF clinic during the morning shift to complete the questionnaires. The questionnaires were completed by the researcher after explaining the objectives of the study to the participants and emphasizing the optionality of participation in the study.

The study protocol was approved by the Ethics Committee of the School of Nursing and Midwifery in Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.FNM.REC.1397.074). The special permissions were obtained from the relevant officials and the written informed consent was obtained from participants after explaining the study objectives to them. Participation in the study was voluntary and based on willingness.  It is worth mentioning that the participants’ information and the questionnaires were kept confidential.

Afterward, the data were analyzed using STATA software (Version 14) and descriptive statistics including frequency (percentage), as well as analytical statistics, such as the Pearson Chi-square analysis and logistic regression analysis. A p-value less than 0.05 (P<0.05) was considered statistically significant in the present study. In addition, the Kolmogorov-Smirnov test was used to determine the normality of the distribution of data.

 

Results

Based on the obtained results, the mean age in both genders was about 75 years (the age range of 60-93). The majority of the participants were married (78.15%), male (67.19%), lived in their own homes (44.27%), and were non-smoker (70%). Most of the participants (55.73%) were just able to read and write, were in HF class II (49.4