A multi-component cognitive behavioural intervention for the treatment of fear of falling after hip fracture (FIT-HIP): protocol of a randomised controlled trial.

BACKGROUND: Hip fracture is a common injury in the geriatric population. Despite surgical repair and subsequent rehabilitation programmes, functional recovery is often limited, particularly in individuals with multi-morbidity. This leads to high care dependency and subsequent use of healthcare services. Fear of falling has a negative influence on recovery after hip fracture, due to avoidance of activity and subsequent restriction in mobility. Although fear of falling is highly prevalent after hip fracture, no structured treatment programme is currently available. This trial will evaluate whether targeted treatment of fear of falling in geriatric rehabilitation after hip fracture using a multi-component cognitive behavioural intervention (FIT-HIP), is feasible and (cost) effective in reducing fear of falling and associated activity restriction and thereby improves physical functioning. METHODS/DESIGN: This multicentre cluster randomised controlled trial will be conducted among older patients with hip fracture and fear of falling who are admitted to a multidisciplinary inpatient geriatric rehabilitation programme in eleven post-acute geriatric rehabilitation units. Fifteen participants will be recruited from each site. Recruitment sites will be allocated by computer randomisation to either the control group, receiving usual care, or to the intervention group receiving the FIT-HIP intervention in addition to usual care. The FIT-HIP intervention is conducted by physiotherapists and will be embedded in usual care. It consists of various elements of cognitive behavioural therapy, including guided exposure to feared activities (that are avoided by the participants). Participants and outcome assessors are blinded to group allocation. Follow-up measurements will be performed at 3 and 6 months after discharge from geriatric rehabilitation. (Cost)-effectiveness and feasibility of the intervention will be evaluated. Primary outcome measures are fear of falling and mobility. DISCUSSION: Targeted treatment of fear of falling may improve recovery and physical and social functioning after hip fracture, thereby offering benefits for patients and reducing healthcare costs. Results of this study will provide insight into whether fear of falling is modifiable in the (geriatric) rehabilitation after hip fracture and whether the intervention is feasible. TRIAL REGISTRATION: Netherlands Trial Register: NTR 5695 .

Longitudinal follow-up study on fear of falling during and after rehabilitation in skilled nursing facilities.

BACKGROUND: Fear of falling (FoF) is regarded as a major constraint for successful rehabilitation in older people. However, few studies have investigated FoF in vulnerable older people who rehabilitate in a skilled nursing facility (SNF). Therefore, this study measures the prevalence of FoF during and after rehabilitation and assesses differences between those with and without FoF. The relation between FoF and instrumental activities of daily living (IADL) after discharge was also assessed. METHODS: In this longitudinal follow-up study, patients who rehabilitated in a SNF were assessed at admission and at 4 weeks after discharge. A one-item instrument was used to measure FoF at admission; based on their answer, the patients were divided into groups with no FoF and with FoF. To study FoF after discharge, the one-item instrument and the short Falls Efficacy Scale-International (FES-I) were used. IADL after discharge was assessed with the Frenchay Activities Index (FAI). RESULTS: Of all participants, 62.5 % had FoF at admission. The participants with FoF were older, more often female, and had a higher average number of falls per week, more depressive symptoms and a lower level of self-efficacy. Four weeks after discharge, 82.1 % of the participants had FoF. IADL after discharge was considerably lower in patients with FoF (FAI of 27.3 vs. 34.8; p = 0.001). CONCLUSIONS: FoF is common among older persons who rehabilitate in SNF. FoF seems to be persistent and may even increase after rehabilitation, thereby hampering IADL after discharge. Interventions are needed to reduce FoF to ensure better outcomes in older patients rehabilitating in a SNF.

Reliability and validity of the Falls Efficacy Scale-International after hip fracture in patients aged ≥ 65 years.

PURPOSE: To assess the measurement properties of the Falls Efficacy Scale-International (FES-I) in patients after a hip fracture aged ≥ 65 years. METHODS: In a sample of 100 patients, we examined the structural validity, internal consistency and construct validity. For the structural validity a confirmatory factor analysis was carried out. For construct validity predetermined hypotheses were tested. In a second sample of 21 older patients the inter-rater reliability was evaluated. RESULTS: The factor analysis yielded strong evidence that the FES-I is uni-dimensional in patients with a hip fracture; the Cronbach's alpha was 0.94. When testing the reliability, the intra-class correlation coefficient was 0.72, while the Standard Error of Measurement was 6.4 and the Smallest Detectable Change was 17.7 (on a scale from 16 to 64). The Spearman correlation of the FES-I with the one-item fear of falling instrument was high (r = 0.68). The correlation was moderate with instruments measuring functional performance constructs and low with instruments measuring psychological constructs. CONCLUSIONS: Reliability and structural validity of the FES-I in patients after a hip fracture are good. The construct validity appears more closely related to functional performance constructs than to psychological constructs, suggesting that the concept measured by the FES-I may not capture all aspects of fear of falling. IMPLICATIONS FOR REHABILITATION: The Falls Efficacy Scale-International (FES-I), which is commonly used to measure fear of falling in community-dwelling older persons, can also be used to assess fear of falling in patients after a hip fracture. The reliability and the structural validity of the FES-I for these hip patients are good, whereas the construct validity of the FES-I is not optimal. The FES-I may not capture all aspects of fear of falling and may be more closely related to functional performance than to psychological concepts such as anxiety.

Fear of falling after hip fracture in vulnerable older persons rehabilitating in a skilled nursing facility.

OBJECTIVE: To identify factors that explain differences in patients with high and low levels of fear of falling after a hip fracture. DESIGN: Cross-sectional study in 10 skilled nursing facilities in the Netherlands. PATIENTS: A total of 100 patients aged ≥ 65 years admitted to a skilled nursing facility after a hip fracture. METHODS: Participants were divided into 2 groups; low and high level of fear of falling, based on median Falls Efficacy Score - International. Data relating to factors that might explain fear of falling were collected, including demographic variables, aspects of functioning, psychological factors, and comorbidities. For every factor a univariate logistic regression was conducted. For the multivariate regression model a backward procedure was used in which variables with p < 0.05 were included. RESULTS: Walking ability and activities of daily living before fracture, number of complications, activities of daily living after fracture, anxiety and self-efficacy were significantly associated univariately with fear of falling. Multivariate analysis showed that walking ability before fracture (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.14-0.83), activities of daily living after fracture (OR 0.89, 95% CI 0.80-0.99), and anxiety (OR 1.22, 95% CI 1.05-1.42) were independently associated with fear of falling. CONCLUSION: Impaired walking ability before fracture, impaired activities of daily living after fracture, and increased anxiety help distinguish between older persons with high and low levels of fear of falling after hip fracture. Because the last 2 factors are modifiable, this information enables the development of specific interventions for older persons with a high level of fear of falling.