Psychology after stroke: The fear of falling

1. Psychology after stroke: The fear of falling Dr Ian Kneebone, Consultant Clinical Psychologist & Visiting Reader

2. 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

3. 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

4. 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) .

5. 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)

6. 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

7. 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)

8. 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).

9. 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).

10. Longer term risk Low falls self-efficacy Reduced activity /avoidance Negative thoughts Bodily awareness Negative beliefs Stiffening Poor self- perception Lowered body strength Distraction FoF as a risk factor for future falls Immediate risk Increased risk of falling

11. 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.

12. 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

13. 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.

14. 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.’

15. FES-I • 1Not at all concerned • 2Somewhat concerned • 3 Fairly concerned • 4 Very concerned • 1 Cleaning the house (e.g. sweep, vacuum or dust) 1 􀂆 2 􀂆 3 􀂆 4 􀂆 • 2 Getting dressed or undressed 1 􀂆 2 􀂆 3 􀂆 4 􀂆

16. 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)

17. 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)

18. 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.

19. 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

20. FoF Multi-factorial Treatment • environmental modification to reduce the risk of falling • increasing physical exercise • and maximising strength and balance

21. 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)

22. 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.

23. 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

24. Individual TreatmentSteps • 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.

25. 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…

26. AVOIDANCE + -feel safe, relaxed -easier -tasks done for me AVOIDANCE - -weak, frail -constipation -dependence (care risk) Decisional Balance

27. Individual Treatment Steps • 3. Initial education can involve presenting the heuristic model. • 4.  Control, management, not eradication of fear is the goal of intervention.

28. 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

29. CBT Structure • Physical Relaxation and breathing • Cognitive Pre-prepared responses to negative thoughts • Behavioural What I need to do to walk well

30. Relaxation & Breathing • 3 Part Breathing • Progressive muscle relaxation • Autogenic training

31. Cognitive • ‘Sure, there is a risk of falling, but if I concentrate well and relax its less likely’ • Can be based on motivational interview

32. Behavioural • How to look ahead, breathe properly, lift their frame etc.

33. 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

34. 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,

35. 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’

36. Jack • Reinforced by relief he feels at discontinuing efforts to mobilise.

37. 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.

38. 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 follow-up by H/V elderly

39. 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!’

40. Jack • Now, what is it I have to do to walk well…’ • ‘Head up, bottom in, lift the frame..off I go’

41. Jack • Outcome: Mobilised to goal level set with Physiotherapist. Mood improvement. Sleep remained impaired ? bladder difficulty.

42. 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.

43. 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’.

44. 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

45. 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)

46. 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

47. Fear of falling after stroke • Questions? i.kneebone@nhs.net