Determinants of Balance Confidence in Community - Dwelling Eldery People.pdf

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Determinants of Balance Confidence
in Community-Dwelling
Elderly People
Background and Purpose. The fear of falling can have detrimental
effects on physical function in the elderly population, but the relation-
ship between a person’s confidence in the ability to maintain balance
and actual balance ability and functional mobility is not known. The
extent to which balance confidence can be explained by balance
performance, functional mobility, and sociodemographic, psycho-
social, and health-related factors was the focus of this study. Subjects.
The subjects were 50 community-dwelling elderly people, aged 65 to 95
years (X 81.7, SD 6.7). Methods. Balance was measured using the
Berg Balance Scale. Functional mobility was measured using the Timed
Up & Go Test. The Activities-specific Balance Scale was used to assess
balance confidence. Data were analyzed using Pearson correlation,
multiple regression analysis, and t tests. Results. Fifty-seven percent of
the variance in balance confidence could be explained by balance
performance. Functional mobility and subject characteristics exam-
ined in this study did not contribute to balance confidence. Discussion
and Conclusion. Balance performance alone is a strong determinant of
balance confidence in community-dwelling elderly people. [Hatch J,
Gill-Body KM, Portney LG. Determinants of balance confidence in
community-dwelling elderly people. Phys Ther . 2003;83:1072–1079.]
Key Words: Balance, Balance confidence, Falling, Fear of falling, Geriatric.
Janine Hatch, Kathleen M Gill-Body, Leslie G Portney
1072
Physical Therapy . Volume 83 . Number 12 . December 2003
aging. Thirty percent of people over the age of
65 years fall annually, with that number rising to
40% for people over the age of 80 years. 1
Although serious injuries such as hip fractures and wrist
fractures are a well-recognized consequence of falls, the
fear of falling is thought to be a more pervasive problem
in the elderly population. When compared with other
common fears, fear of falling ranked first among elderly
people living in the community. 2 Recent studies have
shown that more than half of community-dwelling
elderly people over the age of 62 years report a fear of
falling. 3 Developing a fear of falling is more prevalent
with increasing age and fall history, 3,4 but is not limited
to individuals with a history of falls. Tinetti et al 5 found
that 48% of people over age 75 years who had fallen in
the previous year were afraid of falling, while 27% of
those who had not fallen admitted having a fear of
falling. The impact of fear of falling is far-reaching
because it can lead to activity restriction and diminished
mobility, 3,6,7 with as many as 56% of elderly people
curtailing activities due to this fear. 3 Individuals without
a history of falls who have a fear of falling have an
increased risk for admission to an aged care institution. 8
Fear of falling was originally conceptualized and mea-
sured as a dichotomous variable (present/absent). The
simple presence or absence of fear of falling was used
extensively in early research studies, 2–12 but is limited in
its ability to determine whether different degrees of fear
exist across different circumstances or have a varying
effect on function. Furthermore, some researchers 9,10
have suggested that many people expressing a concern
about their balance during functional tasks do not
necessarily categorize themselves as “fearful,” even when
they have modified their behavior to avoid falling.
Consequently, efforts to measure fear of falling have
focused on using the concept of “self-efficacy” in place of
“fear.” 13,14 Self-efficacy , a concept based in the field of
psychology, refers to an individual’s perceived capability
within a specific domain of activities. 15 Assessing falls-
related self-efficacy in performing specific activities or
tasks, rather than global fear of falling, should reveal the
extent to which a person believes he or she is able to
participate in specific activities without falling.
In an effort to measure fear of falling based on the
concept of self-efficacy, 2 measurement tools have been
developed: the Falls Efficacy Scale (FES) 13
and the
J Hatch, PT, DPT, MS, was Physical Therapist, Department of Physical Therapy, Harvard Vanguard Medical Associates, West Roxbury, Mass, when
this study was conducted. Address all correspondence to Dr Hatch at 282 Nepas Rd, Fairfield, CT 06430 (USA) (hatchjowd@yahoo.com).
KM Gill-Body, PT, DPT, MS, NCS, is Adjunct Clinical Associate Professor, Graduate Programs in Physical Therapy, MGH Institute of Health
Professions, and Clinical Associate, Massachusetts General Hospital, Boston, Mass.
LG Portney, PT, DPT, PhD, FAPTA, is Professor and Director, Graduate Programs in Physical Therapy, MGH Institute of Health Professions.
All authors provided concept/idea/research design, writing, and data analysis. Dr Hatch provided data collection, project management, and fund
procurement. Dr Gill-Body and Dr Portney provided consultation (including review of manuscript before submission). The authors thank Susan
K Bade for research assistance.
The Spaulding Rehabilitation Hospital Institutional Review Board and the Elder Rights Review Committee of the Commonwealth of Massachusetts
Executive Office of Elder Affairs approved this study.
This study was funded, in part, by a grant from the Marjorie K Ionta Fund.
This article was received August 1, 2002, and was accepted July 2, 2003 .
Physical Therapy . Volume 83 . Number 12 . December 2003
Hatch et al . 1073
F alling is a common problem associated with
Activities-specific Balance Confidence (ABC) Scale. 14
Although the FES scale is often referred to as a measure
of “falls-related self-efficacy” and the ABC Scale is a
measure of “balance confidence,” both scales measure
the same construct of perceived balance ability (ie, a
person’s level of confidence in the ability to maintain
balance while performing specific daily activities). 14 The
FES, developed by Tinetti et al, 13 is a 10-item question-
naire, either self-administered or administered through
interview, that asks respondents to rate their level of
confidence in performing common activities such as
“taking a shower or bath,”“getting dressed,” and “reach-
ing into cabinets” without falling. Each item is rated on
a 10-point scale, with 1 indicating “extreme confidence”
and 10 indicating “no confidence at all.” The FES has
been widely used in studies examining the effect of fear
of falling on physical function. However, some investiga-
tors 8,10 have noted that FES scores in community-
dwelling elderly people can be skewed toward the max-
imum score of 100, suggesting a ceiling effect for higher-
functioning individuals. As a result, Powell and Myers 14
developed the ABC Scale, which includes functional
activities with a wider continuum of activity difficulty.
mental activities of daily living (ADL) status and physical
function and moderately associated with level of social
activity. 9 Prospective studies have shown that low base-
line FES scores are associated with greater declines in
self-report ADL status, deterioration of health-related
quality of life, and an increased risk for falling in
community-dwelling elderly people. 16,17 Cumming and
colleagues 8 reported that low baseline FES scores in
community-dwelling elderly people were associated with
greater declines in self-reported ADL performance over
a 12-month period. Mendes de Leon and colleagues 17
examined the role of falls-related self-efficacy on
changes in physical functioning in community-dwelling
elderly people in an effort to determine if self-efficacy
would be protective of self-care behaviors. Physical func-
tioning was measured using a self-report of ADL status.
Subjects’ physical performance capacity was also mea-
sured using timed tests of balance and gait, including
chair stands, turning 360 degrees, and walking 20 ft
(6.1 m). Over the 18-month study period, ADL perfor-
mance was preserved in subjects with high baseline FES
scores, despite declines in physical performance capaci-
ty. 17 The ADL performance levels in these subjects were
similar to those in subjects who experienced no physical
decline. The results of these studies suggest that confi-
dence in being able to perform activities without falling
may have a powerful buffering effect on preserving
function despite declining physical capacity.
The ABC Scale is a 16-item questionnaire that asks
respondents to score their level of confidence in per-
forming situation-specific activities such as “reaching at
eye level,”“reaching on tiptoes,”“picking up slipper
from floor,” and “walking in crowded mall”“without
losing...balance or becoming unsteady.” 14 Each item is
scored from 0% to 100%, with 0% being no confidence
and 100% being full confidence in the ability to perform
the activity without losing balance. The total ABC Scale
score is the average sum of the individual item scores.
The ABC Scale was found to yield data with strong
test-retest reliability ( r
.92), and good convergent valid-
ity with the physical activity subscale of the Physical
Self-Efficacy Scale ( r
A few investigators have explored the relationship
between balance ability and both fear of falling and
balance confidence. Maki et al 10 found that elderly
people with a fear of falling demonstrated poorer per-
formance of one-legged standing balance and anterior-
posterior platform sway measures as compared with
nonfearful subjects. A trend toward poorer clinical bal-
ance scores as measured by the Performance-Oriented
Mobility Assessment of Balance (POMA) 18 also was
noted in fearful subjects, although this relationship did
not reach statistical significance. A prospective 2-year
study examining fear of falling and restriction of mobil-
ity in community-dwelling elderly people showed that
fear of falling was associated with a decline of balance
and gait scores (POMA) at follow-up in those who did
not have abnormalities at baseline. 7 Individuals who
were prone to falling who initially reported a fear of
falling also were found to have more balance and gait
disorders at baseline than persons who were prone to
falling but had no fear of falling. 7 Myers and colleagues 16
investigated the association between balance confi-
dence, as measured by the ABC Scale, and balance
performance, as measured by static posturography, in
elderly people. They reported a strong relationship
between balance confidence and performance on
mediolateral sway, with subjects with higher balance
.63). 14 Discriminant validity of
data obtained with the ABC Scale in elderly people was
supported by the low correlation of ABC Scale scores
with overall scores on the Positive and Negative Affectiv-
ity Scale ( r
.12), which assesses emotionality. 14 Further-
more, the ABC Scale has been shown to have better scale
responsiveness than the FES when used with community-
dwelling elderly people aged 65 to 95 years. 14 When
compared in a group of community-dwelling elderly
people, the FES and the ABC Scale have both been
found to be able to discriminate between fearful and
nonfearful subjects and between those who avoided
activity due to fear of falling and those who did not avoid
activity. 16
Several studies have demonstrated a strong link between
falls-related self-efficacy as measured by the FES and
physical function. Scores on the FES have been found to
be highly correlated with self-reports of basic and instru-
1074 . Hatch et al
Physical Therapy . Volume 83 . Number 12 . December 2003
confidence demonstrating less postural sway in standing
than subjects with lower balance confidence. 16
be able to see well enough to read, and have had no
lower-extremity fracture, surgery, or joint replacement
within the past year. Eligible participants were then
scheduled for a single study session. Informed consent
was obtained immediately prior to data collection.
Although the results of these studies suggest that indi-
viduals who have a concern about their ability to avoid
falling may have impaired balance, our understanding of
the relationship between balance confidence and actual
balance ability is quite limited. The use of static posturo-
graphy as a measure of balance ability by Myers et al 16
provides little information about a person’s ability to
maintain upright postural control while performing
functional activities that challenge balance through multi-
directional self-initiated perturbations, such as reaching,
lifting, bending, and ambulatory transfers. Thus, it
remains unclear whether the ability to perform typical
balance and mobility tasks is impaired in people who
report diminished balance confidence. In addition, we
need to investigate how health-related, psychosocial, and
sociodemographic factors previously reported as corre-
lates of fear of falling 3,4 may influence balance confi-
dence in an effort to gain a better understanding of this
phenomenon. Understanding the extent to which each
of these factors plays a role in determining balance
confidence is an important prerequisite to the develop-
ment of interventions that effectively address balance,
falling, and diminished balance confidence and their
impact on physical function in elderly people.
Demographic information regarding subject character-
istics and medical history is summarized in Table 1. Fifty
percent of the subjects reported a fear of falling. Of
those subjects reporting a fear of falling, 63% experi-
enced a fall in the past year, and 30% had no history of
falls. Of those subjects with a history of falls, 25 (63%)
required medical attention for falls; only 7 (18%) of
those subjects required hospitalization or surgery. Forty-
one subjects (82%) knew someone who had a serious fall
requiring medical attention. Thirty-six subjects (72%)
were independent with self-care and homemaking tasks,
while 14 (28%) required some level of assistance with
ADL (meals, bathing, homemaking tasks). Thirty-nine
subjects (78%) exercised on a regular basis; 4 of these
subjects regularly participated in high-level activities
(heavy housework, outdoor gardening, skating, skiing).
All subjects participated in weekly social activities; most
participated greater than 3 times per week. When asked
if they could rely on friends and family for support in the
event of an injurious fall, 13 subjects (26%) were com-
pletely confident that they would have support, 25
(50%) were somewhat confident, and 12 subjects (24%)
were not at all confident that they would have help.
The purposes of this study were: (1) to explore whether
a relationship exists among balance confidence, balance
performance, and functional mobility and (2) to exam-
ine the extent to which balance confidence can be
explained by clinical measures of balance and functional
mobility, as well as sociodemographic, health-related,
activity-level, and fall-related characteristics. We hypoth-
esized that balance performance and functional mobility
would be strongly associated with balance confidence in
elderly individuals.
Procedure
Interviews and subject testing were each performed in
separate designated common areas (to ensure tester
masking) in the senior housing sites and the senior
center where recruitment took place. A research assis-
tant gathered sociodemographic data (subject character-
istics, living situation, and subject’s level of confidence in
social support in the event of an injurious fall), health-
related information (past medical history, use of assistive
device, amount of daily assistance required, activity level,
and use of medication and alcohol), and fall-related
information (fear of falling [yes/no], fall history and
frequency, the need for medical attention due to falls,
and knowledge of someone who had sustained a serious
fall) using a standardized interview protocol. The selec-
tion of questions to include in the interview was based on
clinical experience as well as correlates of fear of falling
identified in the literature. 3,4,6,7 Fall history was consid-
ered to be the number of falls in the past year, with a fall
defined as an episode of unintentionally coming to rest
on the ground or lower surface that was not the result of
dizziness, fainting, sustaining a violent blow, loss of
consciousness, or other overwhelming external factors.
The ABC Scale standardized questionnaire was then
administered through interview by the research assistant.
Method
6.7), with and without a
history of falls, residing in the greater Boston area.
Subjects were enrolled on a volunteer basis in response
to informative lectures in senior centers and senior
housing sites. The primary author ( JH) contacted inter-
ested people by telephone to review the format of the
study, address any questions, and screen potential sub-
jects for study eligibility. In order to participate in the
study, subjects needed to be English speaking, be able to
walk at least 20 ft (6.1 m) without human assistance, be
able to follow 3-step commands, have no history of
clinical depression or progressive neurological disorder,
81.7, SD
Physical Therapy . Volume 83 . Number 12 . December 2003
Hatch et al . 1075
Subjects
Participants were a convenience sample of 50
community-dwelling elderly people between 65 and 95
years of age (X
Table 1.
Subject Characteristics (N
50)
the primary author in random order as determined by a
coin toss. The BBS is a 14-item balance assessment tool
that is scored on a 5-point ordinal scale (0 – 4), measur-
ing levels of ability in performing each task (4
Characteristic
N
%
safe and
Age (X
SD)
81.7
6.7 y
unable). 19 The BBS includes tasks such
as standing with eyes closed, reaching, standing on one
foot, and picking up objects from the floor. The BBS has
been shown to yield data with high interrater reliability
(intraclass correlation coefficient [ICC]
Sex
Female
46
92
Male
4
8
Marital status
Married
.98) and high
8
16
.99) 19 and to be highly spe-
cific in identifying elderly people who are not prone to
falling (cutoff score
Widowed
35
70
Single
7
14
45). 20 The TUG is a measure of
basic functional mobility. The time it takes for a subject
to rise to stand, walk 10 ft (3 m), walk back to the chair,
and sit is recorded (in seconds). 21 The TUG can be used
as a screening tool because its measurements have been
shown to be well correlated to function. 21 It has been
shown to yield measurements with good interrater and
intrarater reliability (ICC
Assistive device
Walker
8
16
Cane
12
24
None
30
60
Sociodemographic
Living situation
Private house
13
26
Assisted living
14
28
.99) in patients with various
neurological disorders 21 and is predictive for fall risk in
community-dwelling elderly people using a cutoff score
of 14 seconds. 11 The tester was masked to the results of
the ABC Scale as well as to information regarding fear of
falling and fall history to avoid bias. Subjects also were
asked not to reveal this information during testing.
Senior housing
23
46
Living alone
40
80
Confidence in availability of support in
event of injurious fall
Yes
38
76
No
12
24
Activity level
Participation in social activities
50
100
Prior to testing, each subject was informed that the
therapist would closely guard him or her to minimize the
risk for falls. Each new task was explained and demon-
strated, and the subject asked if he or she felt safe
performing that task. Subjects who did not feel safe
performing a task were reassured that they could
attempt to complete as much of the task as possible while
they were being closely guarded for safety. If the subject
still did not feel safe attempting the task, the examiner
entered the lowest possible score for the task and
continued to the next item. For the TUG and the last 3
items on the BBS, each subject was allowed one practice
trial before scoring to ensure that these more difficult
tasks were understood. Intermittent rest periods were
given between tasks at intervals that were standard across
all subjects. Subjects were allowed to take more frequent
rest periods as needed. The majority of subjects required
no additional rest periods. Time to complete the inter-
view and testing procedures ranged from 40 to 60
minutes.
Participation in regular physical exercise
39
78
Requires assistance for daily activities
14
28
Health related
Reported medical conditions
Diabetes
7
14
Cancer
9
18
Osteoporosis
13
26
Osteoarthritis
23
46
Vertigo
6
12
Joint replacement
9
18
Rheumatoid arthritis
4
8
Fracture
19
38
Cardiac
28
56
Stroke
4
8
Visual problems
37
74
Coumadin a use
6
12
Alcohol use
23
46
7 or more medications
5
10
Fall related
Fear of falling
25
50
History of falls
40
80
Requires medical attention for falls
25
50
Data Analyses
Descriptive analyses were performed on all subject char-
acteristic variables and test scores. The Pearson product
moment coefficient of correlation was used to examine
the relationship among the BBS, TUG, and ABC Scale
scores.
Hospitalization/surgery
7
14
Knows someone who sustained serious fall
41
82
a Bristol-Myers Squibb Co, PO Box 4500, Princeton, NJ 08543-4500.
Following the interview, 2 physical performance mea-
sures were used to assess balance performance and
functional mobility. The Berg Balance Scale (BBS) and
the Timed Up & Go Test (TUG) were administered by
To analyze the determinants of balance confidence, a
stepwise multiple regression analysis was performed with
1076 . Hatch et al
Physical Therapy . Volume 83 . Number 12 . December 2003
independent, 0
intrarater reliability (ICC
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