No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Fear of falling impairs spatiotemporal gait parameters, mobility, and quality of life in Parkinson's disease: a cross-sectional study
Abstract
Fear of Falling (FOF) significantly affects Parkinson's Disease (PD) patients by limiting daily activities and reducing quality of life (QoL). Though common in PD, the relation between FOF, mobility, and QoL remains unclear. This study examines the connections between FOF, gait, daily motor activity, and QoL in PD patients.
Fifty PD patients on stable levodopa therapy were enrolled, excluding those with dementia or walking impairments. Assessments included UPDRS-III, Hoehn and Yahr, MoCA, Berg Balance scale, Geriatric Depression Scale and Fall Efficacy Scale International (FES-I). QoL was evaluated using PDQ39. The Timed-Up-and-Go (TUG) test was performed at regular and fast paces, with data collected via smartphone apps for TUG gait parameters and for 24-h quantity of movement monitoring (Activity Index, AIX). A subgroup of 10 patients also underwent 24-h gait monitoring.
FOF was found in 38% of patients, correlating with worse motor scores and QoL (UPDRS-III, 26 vs 17, p < 0.0001; PDQ39 36 vs 14, p < 0.0001). FOF patients showed slower walking (0.73 m/s vs 1.13 m/s, p < 0.001), reduced step length (0.151 vs 0.220 m, p < 0.001), and poorer adaptation to fast walking and environment (being unable to vary their speed and frequency). FOF and sex were both associated with a reduced mobility QoL, with a significant contribution of AIX only in women (r -0.648, p = 0.012).
This study supports the existence of a significant correlation between FOF, motor activity and QoL in PD, especially in women, emphasize the need for targeted interventions, early rehabilitation and prospective studies focusing on gender.
ResearchGate has not been able to resolve any citations for this publication.
Introduction
The Fear of Falling Avoidance Behavior Questionnaire (FFABQ) has good psychometric properties. However, we have recently modified the FFABQ (mFFABQ) to improve the clarity of the questions and Likert responses. This study aimed to examine the reliability and validity of this modified version in older adults and people with Parkinson’s disease (PD).
Methods
A total of 88 participants, 39 with PD (age = 72.2 ± 9.5; 29 males, 10 females) and 49 older adults (age = 72.8 ± 5.0; 13 males, 36 females), answered the mFFABQ twice, separated by 1 week, for test-retest reliability. Construct validity was evaluated through correlational analyses with fall history, Activities-Specific Balance Confidence Scale (ABC), Berg Balance Scale (BBS), Timed Up and Go, 30-Second Sit to Stand, Sensory Organization Test, Zung Anxiety Scale, Beck Depression Inventory, Consequences of Falling Questionnaire (CoFQ), and average daily activity levels using an activity monitor.
Results
The mFFABQ had good overall test-retest reliability (intraclass correlational coefficient [ICC] = 0.822; older adult ICC = 0.781, PD ICC = 0.806). The mFFABQ correlated with fall history (r = −0.430) and exhibited high correlation with the ABC (rho = −0.804) and moderate correlations with CoFQ (rho = 0.582) and BBS (rho = −0.595). The mFFABQ also correlated with time stepping (rho = −0.298) and number of steps (rho = −0.358).
Conclusion
These results provide supportive evidence for the reliability and validity of the mFFABQ in older adults and people with PD, which supports its suitability as a clinical and research tool for the assessment of fear of falling avoidance behavior.
Daily steps could be a valuable indicator of real-world ambulation in Parkinson’s disease (PD). Nonetheless, no study to date has investigated the minimum number of days required to reliably estimate the average daily steps through commercial smartwatches in people with PD. Fifty-six patients were monitored through a commercial smartwatch for 5 consecutive days. The total daily steps for each day was recorded and the average daily steps was calculated as well as the working and weekend days average steps. The intraclass correlation coefficient (ICC) (3,k), standard error of measurement (SEM), Bland–Altman statistics, and minimum detectable change (MDC) were used to evaluate the reliability of the step count for every combination of 2–5 days. The threshold for acceptability was set at an ICC ≥ 0.8 with a lower bound of CI 95% ≥ 0.75 and a SAM < 10%. ANOVA and Mann–Whitney tests were used to compare steps across the days and between the working and weekend days, respectively. Four days were needed to achieve an acceptable reliability (ICC range: 0.84–0.90; SAM range: 7.8–9.4%). In addition, daily steps did not significantly differ across the days and between the working and weekend days. These findings could support the use of step count as a walking activity index and could be relevant to developing monitoring, preventive, and rehabilitation strategies for people with PD.
Background: Fear of falling (FOF) is common in Parkinson’s disease (PD) and associated with distinct gait changes. Here, we aimed to answer, how quantitative gait assessment can improve our understanding of FOF-related gait in hospitalized geriatric patients with PD. Methods: In this cross-sectional study of 79 patients with advanced PD, FOF was assessed with the Falls Efficacy Scale International (FES-I), and spatiotemporal gait parameters were recorded with a mobile gait analysis system with inertial measurement units at each foot while normal walking. In addition, demographic parameters, disease-specific motor (MDS-revised version of the Unified Parkinson’s Disease Rating Scale, Hoehn & Yahr), and non-motor (Non-motor Symptoms Questionnaire, Montreal Cognitive Assessment) scores were assessed. Results: According to the FES-I, 22.5% reported low, 28.7% moderate, and 47.5% high concerns about falling. Most concerns were reported when walking on a slippery surface, on an uneven surface, or up or down a slope. In the final regression model, previous falls, more depressive symptoms, use of walking aids, presence of freezing of gait, and lower walking speed explained 42% of the FES-I variance. Conclusion: Our study suggests that FOF is closely related to gait changes in hospitalized PD patients. Therefore, FOF needs special attention in the rehabilitation of these patients, and targeting distinct gait parameters under varying walking conditions might be a promising part of a multimodal treatment program in PD patients with FOF. The effect of these targeted interventions should be investigated in future trials.
Objective:
To synthesize recent empirical evidence for the prevention and management of falls and fear of falling in patients with Parkinson's disease (PD).
Data source:
Database from PubMed, Cochrane Library, and EMBASE.
Study design:
Systematic review.
Data collection:
We searched the PubMed, Cochrane Library, and EMBASE databases for studies published from inception to February 27, 2021. Inclusion criteria were nonreview articles on prevention and management measures related to falls and fall prevention in Parkinson's disease patients.
Principal findings:
We selected 45 articles and conducted in-depth research and discussion. According to the causes of falls in PD patients, they were divided into five directions, namely physical status, pre-existing conditions, environment, medical care, and cognition. In the cognitive domain, we focused on the fear of falling. On the above basis, we constructed a fall prevention model, which is a tertiary prevention health care network, based on The Johns Hopkins Fall Risk Assessment Tool to provide ideas for the prevention and management of falling and fear of falling in PD patients in clinical practice CONCLUSIONS: Falls and fear of falls in patients with Parkinson's disease can be reduced by effective clinical prevention and management. Future studies are needed to explore the efficacy of treatment and prevention of falls and fear of falls.
In chronic disorders such as Parkinson's disease (PD), fear of falling (FOF) is associated with falls and reduced quality of life. With inertial measurement units (IMUs) and dedicated algorithms, different aspects of mobility can be obtained during supervised tests in the lab and also during daily activities. To our best knowledge, the effect of FOF on mobility has not been investigated in both of these settings simultaneously. Our goal was to evaluate the effect of FOF on the mobility of 26 patients with PD during clinical assessments and 14 days of daily activity monitoring. Parameters related to gait, sit-to-stand transitions, and turns were extracted from IMU signals on the lower back. Fear of falling was assessed using the Falls Efficacy Scale-International (FES-I) and the patients were grouped as with (PD-FOF+) and without FOF (PD-FOF−). Mobility parameters between groups were compared using logistic regression as well as the effect size values obtained using the Wilcoxon rank-sum test. The peak angular velocity of the turn-to-sit transition of the timed-up-and-go (TUG) test had the highest discriminative power between PD-FOF+ and PD-FOF− (r-value of effect size = 0.61). Moreover, PD-FOF+ had a tendency toward lower gait speed at home and a lower amount of walking bouts, especially for shorter walking bouts. The combination of lab and daily activity parameters reached a higher discriminative power [area under the curve (AUC) = 0.75] than each setting alone (AUC = 0.68 in the lab, AUC = 0.54 at home). Comparing the gait speed between the two assessments, the PD-FOF+ showed higher gait speeds in the capacity area compared with their TUG test in the lab. The mobility parameters extracted from both lab and home-based assessments contribute to the detection of FOF in PD. This study adds further evidence to the usefulness of mobility assessments that include different environments and assessment strategies. Although this study was limited in the sample size, it still provides a helpful method to consider the daily activity measurement of the patients with PD into clinical evaluation. The obtained results can help the clinicians with a more accurate prevention and treatment strategy.
Objective: To evaluate the feasibility of a smartphone remote patient monitoring approach in a real-life Parkinson's disease (PD) cohort during the Italian COVID-19 lockdown.
Methods: Fifty-four non-demented PD patients who were supposed to attend the outpatient March clinic were recruited for a prospective study. All patients had a known UPDRS-III and a modified Hoehn and Yahr (H&Y) score and were provided with a smartphone application capable of providing indicators of gait, tapping, tremor, memory and executive functions. Different questionnaires exploring non-motor symptoms and quality of life were administered through phone-calls. Patients were asked to run the app at least twice per week (i.e., full compliance). Subjects were phone-checked weekly throughout a 3-week period for compliance and final satisfaction questionnaires.
Results: Forty-five patients (83.3%) ran the app at least once; Twenty-nine (53.7%) subjects were half-compliant, while 16 (29.6%) were fully compliant. Adherence was hindered by technical issues or digital illiteracy (38.7%), demotivation (24%) and health-related issues (7.4%). Ten patients (18.5%) underwent PD therapy changes. The main factors related to lack of compliance included loss of interest, sadness, anxiety, the absence of a caregiver, the presence of falls and higher H&Y. Gait, tapping, tremor and cognitive application outcomes were correlated to disease duration, UPDRS-III and H&Y.
Discussion: The majority of patients were compliant and satisfied by the provided monitoring program. Some of the application outcomes were statistically correlated to clinical parameters, but further validation is required. Our pilot study suggested that the available technologies could be readily implemented even with the current population's technical and intellectual resources.
Gait disorders and falls are common in elders and in many clinical conditions, yet they are typically infrequently and subjectively evaluated, limiting prevention and intervention. Completion-time of the Timed-Up-and-Go (TUG) test is a well-accepted clinical biomarker for rating mobility and prediction of falls risk. Using smartphones’ integral accelerometers and gyroscopes, we already demonstrated that TUG completion-time can be accurately measured via a smartphone app. Here we present an extended app, EncephaLogTM, which provides gait analysis in much more detail, offering 9 additional gait biomarkers on top of the TUG completion-time. In this pilot, four healthy adults participated in a total of 32 TUG tests; simultaneously recorded by EncephaLog and motion sensor devices used in movement labs: motion capture cameras (MCC), pressure mat; and/or wearable sensors. Results show high agreement between EncephaLog biomarkers and those measured by the other devices. These preliminary results suggest that EncephaLog can provide an accurate, yet simpler, instrumented TUG (iTUG) platform than existing alternatives, offering a solution for clinics that cannot afford the cost or space required for a dedicated motion lab and for monitoring patients at their homes. Further research on a larger study population with pathologies is required to assess full validity.
Objective: To analyze the multivariate associations between self-rated level of physical activity and demographic characteristics, self-efficacy for physical activity, fall-related self-efficacy, fear of falling, enjoyment from participation in physical activity, social support, fatigue, and health-related quality of life in persons with PD with a focus on gender.
Method: Participants were persons with PD (n = 285, mean age 69.1 ± 7 years). Self-reported scales measuring level of physical activity (Physical Activity Disability Survey–Revised), enjoyment of physical activity (study- specific questions), self-efficacy for physical activity (Exercise Self-Efficacy Scale), fall-related self-efficacy (Falls Efficacy Scale), social support (Social Influences on Physical Activity), fatigue (Fatigue Severity Scale) and health-related quality of life (Parkinson’s Disease Questionnaire-39) were used. The response rate was 58.2%.
Results: Multiple regression analyses showed that 54.5% of the level of physical activity was explained by low-degree limitations in mobility and activities of daily life (ADL), being younger, higher self-efficacy for physical activity, communication limitations, bodily discomfort, social support and shorter time since diagnosis. Enjoyment of physical activity explained the level of physical activity for women, whereas self-efficacy for physical activity explained the level of physical activity for men.
Conclusion: Implementing strategies to increase functional mobility, self-efficacy for physical activity, social support, and enjoyment of physical activity might facilitate persons with PD beginning and/or maintain different physical activities.
Increasing evidence points to biological sex as an important factor in the development and phenotypical expression of Parkinson’s disease (PD). Risk of developing PD is twice as high in men than women, but women have a higher mortality rate and faster progression of the disease. Moreover, motor and nonmotor symptoms, response to treatments and disease risk factors differ between women and men. Altogether, sex-related differences in PD support the idea that disease development might involve distinct pathogenic mechanisms (or the same mechanism but in a different way) in male and female patients. This review summarizes the most recent knowledge concerning differences between women and men in PD clinical features, risk factors, response to treatments and mechanisms underlying the disease pathophysiology. Unraveling how the pathology differently affect the two sexes might allow the development of tailored interventions and the design of innovative programs that meet the distinct needs of men and women, improving patient care.
Purpose: Since fear of falling may be one of the main problems in people with Parkinson’s disease (PD), its assessment with valid tools is necessary in both drug phases. This study was carried out to investigate the psychometric attributes of the Fall Efficacy Scale-International (FES-I) in people with PD, both in On and Off phases.
Methods: One hundred twenty-four patients with PD (mean age±standard deviation, 60.33±12.59 years) were assessed with the FES-I, both in On- and Off-drug phases. Dimensionality, internal consistency, and test-retest reliability were respectively explored by means of factor analysis, Cronbach’s alpha, and Intraclass Correlation Coefficient. Convergent validity of FES-I was established with Visual Analog Scale-Fear of Falling, Berg Balance Scale, Functional Reach Test. Parkinson’s Disease Questionnaire-39 and Unified Parkinson Disease Rating Scale-Activities of Daily Living were also applied. Discriminative validity was tested between patients with and without a history of falling.
Results: Factor analysis showed two factors for On- and one factor for Off-drug phase. Internal consistency (α=0.96, On phase; 0.98, Off phase) and test-retest reliability (0.94; 0.91) were satisfactory in both drug phases. A moderate/high correlation (rS=|0.50-0.70|) between FES-I and Visual Analog Scale-Fear of Falling, Berg Balance Scale, Functional Reach Test. Parkinson’s Disease Questionnaire-39 and Unified Parkinson Disease Rating Scale-Activities of Daily Living was achieved in both drug phases too. The sensitivity of FES-I to discriminate Parkinson’s disease with and without falls showed moderate effect size in both phases.
Conclusion: This study verified that FES-I is unidimensional, reliable and valid to measure the Fear of Falling during On- and Off- drug phases in people with PD.
Keywords: Fall Efficacy Scale-International, Parkinson’s disease, On- and Off- drug phases
In Parkinson’s disease (PD), concurrent declines in cognitive and motor domain function can severely limit an individual’s ability to conduct daily tasks. Current diagnostic methods, however, lack precision in differentiating domain-specific contributions of cognitive or motor impairments based on a patients’ clinical manifestation. Fear of falling (FOF) is a common clinical manifestation among the elderly, in which both cognitive and motor impairments can lead to significant barriers to a patients’ physical and social activities. The present study evaluated whether a set of analytical and machine-learning approaches could be used to help delineate boundary conditions and separate cognitive and motor contributions to a patient’s own perception of self-efficacy and FOF. Cognitive and motor clinical scores, in conjunction with FOF, were collected from 57 Parkinson’s patients during a multi-center rehabilitation intervention trial. Statistical methodology was used to extract a subset of uncorrelated cognitive and motor components associated with cognitive and motor predictors, which were then used to independently identify and visualize cognitive and motor dimensions associated with FOF. We found that a central cognitive process, extracted from tests of executive, attentional, and visuoperceptive function, was a unique and significant independent cognitive predictor of FOF in PD. In addition, we provide evidence that the approaches described here may be used to computationally discern specific types of FOF based on separable cognitive or motor models. Our results are consistent with a contemporary model that the deterioration of a central cognitive mechanism that modulates self-efficacy also plays a critical role in FOF in PD.
Background
The 10-m walk test (10MWT) is a widely used measure of gait speed in Parkinson’s disease (PD). However, it is unclear if different standardizations of its conduct impact test results. Aim of the studyWe examined the clinical significance of two aspects of the standardization of the 10MWT in mild PD: static vs. dynamic start, and a single vs. repeated trials. Implications for fall prediction were also explored. Methods151 people with PD (mean age and PD duration, 68 and 4 years, respectively) completed the 10MWT in comfortable gait speed with static and dynamic start (two trials each), and gait speed (m/s) was recorded. Participants then registered all prospective falls for 6 months. ResultsAbsolute mean differences between outcomes from the various test conditions ranged between 0.016 and 0.040 m/s (effect sizes, 0.06–0.14) with high levels of agreement (intra-class correlation coefficients, 0.932–0.987) and small standard errors of measurement (0.032–0.076 m/s). Receiver operating characteristic curves showed similar discriminate abilities for prediction of future falls across conditions (areas under curves, 0.70–0.73). Cut-off points were estimated at 1.1–1.2 m/s. Conclusions
Different 10MWT standardizations yield very similar results, suggesting that there is no practical need for an acceleration distance or repeated trials when conducting this test in mild PD.
Background: Parkinson’s disease (PD) is a neurodegenerative movement disorder associated with gait and balance problems and a substantially increased risk of falling. Falls occur often during complex movements, such as turns. Both fear of falling (FOF) and previous falls are relevant risk factors for future falls. Based on recent studies indicating that lab-based and home assessment of similar movements show different results, we hypothesized that FOF and a positive fall history would influence the quantitative turning parameters differently in the laboratory and home.
Methods: Fifty-five PD patients (43 underwent a standardized lab assessment; 40 were assessed over a mean of 12 days at home with approximately 10,000 turns per participant; and 28 contributed to both assessments) were classified regarding FOF and previous falls as “vigorous” (no FOF, negative fall history), “anxious” (FOF, negative fall history), “stoic” (no FOF, positive fall history) and “aware” (FOF, positive fall history). During the assessments, each participant wore a sensor on the lower back.
Results: In the lab assessment, FOF was associated with a longer turning duration and lowered maximum and middle angular velocities of turns. In the home evaluations, a lack of FOF was associated with lowered maximum and average angular velocities of turns. Positive falls history was not significantly associated with turning parameters, neither in the lab nor in the home.
Conclusion: FOF but not a positive fall history influences turning metrics in PD patients in both supervised and unsupervised environments, and this association is different between lab and home assessments. Our findings underline the relevance of comprehensive assessments including home-based data collection strategies for fall risk evaluation.
Background
There is limited knowledge concerning fall-related activity avoidance in people with Parkinson’s disease (PD); such knowledge would be of importance for the development of more efficient PD-care and rehabilitation. This study aimed to examine how fall-related activity avoidance relates to a history of self-reported falls/near falls and fear of falling (FOF) as well as to disease severity in people with PD.
Methods
Data were collected from 251 (61 % men) participants with PD; their median (min-max) age and PD duration were 70 (45–93) and 8 (1–43) years, respectively. A self-administered postal survey preceded a home visit which included observations, clinical tests and interview-administered questionnaires. Fall-related activity avoidance was assessed using the modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE) as well as by using a dichotomous (Yes/No) question. Further dichotomous questions concerned: the presence of FOF and the history (past 6 months) of falls or near falls, followed by stating the number of incidents. Disease severity was assessed according to the Hoehn and Yahr (HY) stages.
Results
In the total sample (n = 251), 41 % of the participants reported fall-related activity avoidance; the median mSAFFE score was 22. In relation to a history of fall, the proportions of participants (p < 0.001) that reported fall-related activity avoidance were: non-fallers (30 %), single fallers (50 %) and recurrent fallers, i.e. ≥ 2 falls (57 %). Among those that reported near falls (but no falls), 51 % (26 out of 51) reported fall-related activity avoidance. Of those that reported FOF, 70 % reported fall-related activity avoidance. Fall-related activity avoidance ranged from 24 % in the early PD-stage (HY I) to 74 % in the most severe stages (HY IV-V).
Conclusions
Results indicate that fall-related activity avoidance may be related to a history of self-reported falls/near falls, FOF and disease severity in people with PD. Importantly, fall-related activity avoidance is reported among those that do not fall and already in mild PD-stages (HY I-II). Although further studies are needed, our findings indicate that fall-related activity avoidance needs to be addressed early in order to prevent sedentary behavior and participation restrictions.
Purpose:
To investigate associations between fear of falling (FOF) and recurrent falls among women and men, and gender differences in FOF with respect to International Classification of Functioning (ICF).
Methods:
Community-dwelling people (n = 230, 75-93 years, 72% women) were included and followed 1 year regarding falls. Data collection included self-reported demographics, questionnaires, and physical performance-based tests. FOF was assessed with the question "Are you afraid of falling?". RESULTS were discussed with a gender relational approach.
Results:
At baseline 55% women (n = 92) and 22% men (n = 14) reported FOF. During the follow-up 21% women (n = 35) and 30% men (n = 19) experienced recurrent falls. There was an association between gender and FOF (p = 0.001), but not between FOF and recurrent falls (p = 0.79), or between gender and recurrent falls (p = 0.32). FOF was related to Personal factors and Activity and Participation. The relationship between FOF and Personal factors was in opposite directions for women and men.
Conclusions:
Results did not support the prevailing paradigm that FOF increases rate of recurrent falls in community-dwelling people, and indicated that the answer to "Are you afraid of falling?" might be highly influenced by gendered patterns.
Postural instability, recurrent falls and fear of falling are common in advanced Parkinson's disease (PD). We examined the impact of fall frequency, fear of falling, balance confidence and objectively measured balance impairment (using Tinetti's Mobility Index) on health-related quality of life (HrQoL) in PD. In 74 subjects HrQoL was assessed using the 39-item Parkinson's disease Quality of Life Questionnaire [PDQ-39]. Patients were interviewed using a validated falls questionnaire, addressing fall history, consequences of falls and fear of falling. Neurological examination included Hoehn and Yahr scale, the Unified Parkinson's disease Rating Scale and Tinetti's Mobility Index. Disease severity, age and gender explained 43% of the differences in HrQoL across patients (R² = 0.43). The combination of these factors and each of the factors fear of falling, balance confidence and fall frequency lead to 55%, 50% and 45% of explained variation, respectively. The standardised regression coefficients of these risk factors were 0.34 (fear of falling), 0.28 (balance confidence) and 0.13 (fall frequency). This suggests that fear of falling is a more important determinant of HrQoL than actual falling. These results emphasise the importance of addressing fear of falling in the clinical management of PD, and the need for development of strategies to reduce fear of falling in intervention programs.
In the elderly, fear of falling (FoF) can lead to activity restriction and affect quality of life (QoL). Our aim was to identify the characteristics of FoF in Parkinson's disease and assess its impact on QoL. We assessed FoF in 130 patients with Parkinson's disease (PD) on scales measuring perceived self-efficacy in performing a range of activities (FES), perceived consequences of falling (CoF), and activity avoidance (SAFFE). A significant difference was found in FoF between PD patients who had previously fallen and those who had not and between frequent and infrequent fallers. Patient-rated disability significantly influenced FoF. Difficulty in rising from a chair, difficulty turning, start hesitation, festination, loss of balance, and shuffling were the specific mobility problems which were associated with greater FoF in PD. Disability was the main predictor of FoF, additionally depression predicted perceived consequences of falling, while anxiety predicted activity avoidance. The FoF measures explained 65% of the variance of QoL in PD, highlighting the clinical importance of FoF. These results have implications for the clinical management of FoF in PD.
We assessed the influence of gait disorders (GD) on quality of life (QOL) in Parkinson's disease (PD). In a survey including the PDQ-39 and a new 8-item questionnaire of GD (8-QGD), 491 PD patients estimated their gait at the worst state, the effect of their GD on activities of daily living, compared the severity of GD with the other PD symptoms, evaluated the occurrence of freezing of gait (FOG), levodopa-resistant FOG, falls, activity limitation due to fear of falling (FOF), and the occurrence of injuries. Significant differences in PDQ-39 scores were found between three groups of patients divided with respect to the severity of GD. Linear multiple regression analysis showed that FOF had the highest impact on PDQ-39 scores (r=0.32, p<0.001). These results confirm that GD have a substantial impact upon the QOL in PD and suggest that FOF plays a major role in QOL deterioration.
fear of falling (FOF) is a major health problem among the elderly living in communities, present in older people who have fallen but also in older people who have never experienced a fall. The aims of this study were 4-fold: first, to study methods to measure FOF; second, to study the prevalence of FOF among fallers and non-fallers; third, to identify factors related to FOF; and last, to investigate the relationship between FOF and possible consequences among community-dwelling older persons.
several databases were systematically searched, and selected articles were cross-checked for other relevant publications.
a systematic review identified 28 relevant studies among the community-dwelling elderly. Due to the many different kinds of measurements used, the reported prevalence of FOF varied between 3 and 85%. The main risk factors for developing FOF are at least one fall, being female and being older. The main consequences were identified as a decline in physical and mental performance, an increased risk of falling and progressive loss of health-related quality of life.
this review shows that there is great variation in the reported prevalence of FOF in older people and that there are multiple associated factors. Knowledge of risk factors of FOF may be useful in developing multidimensional strategies to decrease FOF and improve quality of life. However, the only identified modifiable risk factor of FOF is a previous fall. In order to measure the impact of interventions, a uniform measurement strategy for FOF should be adopted, and follow-up studies should be conducted.
Introduction: The wearing-off phenomenon is characterized by the recurrence of motor and non-motor symptoms of Parkinsonism during a period free from levodopa. It is a pivotal aspect marking the end of the pharmacological "honeymoon" period in Parkinson's disease (PD). A growing body of literature is connecting sex with the likelihood of developing fluctuations. We investigated such an association in a post-hoc analysis of the large WORK-PD study. Methods: WORK-PD analyzed the usability of the wearing-off questionnaire 19 (WOQ19) in clinical practice and included cross-sectional data on age, disease duration, time on levodopa, Hoehn and Yahr stage, and WOQ19 scores of 532 PD patients. In the present study, we selected patients with an exposure time to levodopa of at least 1 year. Results: A total of 380 patients were included. Women reported a higher number of wearing-off symptoms than men (6.09 ± 3.39 vs 4.96 ± 3.11, p = 0.0006). Sex groups also differed in non-motor symptoms (2 ± 1.9 vs 1.5 ± 1.5, p = 0.021), particularly behavioral wearing-off scores being higher in women (p < 0.001). The latter were primarily featured by anxiety-related phenomena. Finally, there was a significant interaction between behavioral symptoms, sex, and age at onset (df = 2, F = 9.79, p < 0.0001), whereas no such interaction was observed with levodopa exposure and motor impairment, unlike motor symptoms. Discussion: Women showed a greater propensity than men to experience wearing-off, particularly non-motor fluctuations on the anxiety spectrum. The latter may demonstrate a lesser reliance on dopamine compared to motor symptoms. This observation could be underpinned by biological variances between genders at the neu-rotransmitter level.
Fear of falling (FOF) is highly prevalent in people with Parkinson's disease (PwPD) and contributes to high fall risk. Studies reporting on the relationship between falls, FOF, and non-motor factors such as cognitive function and sleep quality in Parkinson's disease are limited. This study aimed to investigate (1) the relationship of cognitive function and sleep quality with FOF, and history of falls in PwPD; (2) differences in cognitive function and sleep quality between Parkinson's disease fallers and non-fallers; and (3) a cut-off score for cognitive function and sleep quality to discriminate Parkinson's disease fallers from non-fallers. Fifty PwPD were assessed for FOF [Falls Efficacy Scale-International (FES-I)], cognition [Montréal Cognitive Assessment (MOCA)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], and falls history. The MOCA is significantly associated with FES-I scores (R2 = 0.429, P < 0.0001). Both MOCA (P = 0.012) and PSQI (P = 0.027) were associated with falls history even after adjusting for confounding factors (age, sex, L-dopa use, Parkinson's disease severity). Both MOCA and PSQI scores were able to distinguish fallers from non-fallers with cut-off scores of 15.5 and 7.5, respectively. Although our findings revealed that both cognitive function and sleep quality are important factors influencing falls and FOF in PwPD, it remains to be determined if addressing cognitive impairments and poor sleep quality may favorably impact balance before integrating such screenings into fall prevention programs.
Purpose
The purpose of this study was to examine the relationship between psychological factors (depression, anxiety, and catastrophizing) and fear of falling avoidance behavior (FFAB) among individuals with Parkinson’s disease (PD).
Methods
A secondary analysis of cross-sectional data from 59 individuals with PD using hierarchical multiple regression.
Results
Disease severity (Movement Disorder Society - Unified PD Rating Scale) and catastrophizing (Consequences of Falling Questionnaire (CoF)) explained approximately 48.2% of the variance in the FFAB Questionnaire scores ( P < .001). Catastrophizing was the only significant psychological variable ( P < .001). The damage to identity subscale of the CoF was significant in the final model ( P < .001).
Conclusions
Catastrophizing about the consequences of falls explained the largest portion of variability in FFAB after controlling for disease severity. Catastrophizing about the immediate consequences of falling may play a prominent role in FFAB and may be a potential treatment target for mitigating FFAB.
Background:
Fear of falling avoidance behavior (FFAB) is common in parkinsonisms and results in potentially mitigable downstream consequences.
Objective:
Determine the characteristics of individuals with parkinsonisms most associated with FFAB.
Methods:
A retrospective, cross-sectional study was conducted from medical records data of 142 patients with parkinsonisms. These data included: demographics (age, sex), disease severity (Movement Disorders Society -Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS III), years since diagnosis), fall history (number of fall injuries in previous year), and gait and balance function (five times sit to stand, MiniBESTest, Timed Up and Go (TUG), dual-task TUG, ten-meter walk test (10MWT), observed freezing of gait (FOG) (MDS-UPDRS III item 11)).
Results:
10MWT (p < .001) and MDS-UPDRS III item 11 (p < .014) were significantly associated with FFAB above and beyond disease severity, which also contributed significantly to the overall model (ps < .046). Fall history was not associated with FFAB.
Conclusion:
Our findings suggest that the largest portion of variability in FFAB is explained by gait velocity and FOG; however, disease severity also explains a significant portion of the variability of FFAB. Further investigation into factors predictive of FFAB and mitigation of downstream consequences, using more robust designs, is warranted.
Background:
Fear of falling (FOF) is a serious problem in Idiopathic Parkinson's Disease (IPD) which increases mortality and affects Health Related Quality of Life (HRQoL).
Objective:
To evaluate the effect of FOF on HRQoL in IPD.
Methods:
84 controls and 87 IPD patients were compared by means of Fall Efficacy Scale (FES), Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC Scale), Impact Of Events Scale-Revised (IES-R), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Parkinson Disease Specific Quality of Life Scale (PDQ-39). Then, patients were divided into two subgroups such as patients with FOF (Group 2a) and patients without FOF (Group 2b) by FES. Groups were compared in terms of BBS, ABC Scale, IES-R, BDI, BAI, PDQ-39. Independent factors affecting HRQoL were measured.
Results:
FOF was higher in IPD patients than controls. Female sex, previous falls, off periods, hallucinations, urge incontinence were significantly higher in Group 2a. However, RBD, dyskinesia, daytime somnolence and FOG were not different in IPD patients whether they have FOF or not. FOF was mostly correlated to disability level and disease severity. In addition, UPDRS and FOF were found to be independent factors affecting HRQoL in IPD.
Conclusions:
Clinicians should be aware that FOF can be detected in IPD patients, who are female, depressed or anxious, who had more severe disease with off periods, urge incontinence, hallucinations and previous falls. FOF should be questioned in every IPD patients because it is an independent factor which affects HRQoL of IPD patients.
Background
Falls could be serious events in Parkinson’s disease (PD). Patient remote monitoring strategies are on the raise and may be an additional aid in identifying patients who are at risk of falling. The aim of the study was to evaluate if balance and timed-up-and-go data obtained by a smartphone application during COVID-19 lockdown were able to predict falls in PD patients.MethodsA cohort of PD patients were monitored for 4 weeks during the COVID-19 lockdown with an application measuring static balance and timed-up-and-go test. The main outcome was the occurrence of falls (UPDRS-II item 13) during the observation period.ResultsThirty-three patients completed the study, and 4 (12%) reported falls in the observation period. The rate of falls was reduced with respect to patient previous falls history (24%). The stand-up time and the mediolateral sway, acquired through the application, differed between “fallers” and “non-fallers” and related to the occurrence of new falls (OR 1.7 and 1.6 respectively, p < 0.05), together with previous falling (OR 7.5, p < 0.01). In a multivariate model, the stand-up time and the history of falling independently related to the outcome (p < 0.01).Conclusions
Our study provides new data on falls in Parkinson’s disease during the lockdown. The reduction of falling events and the relationship with the stand-up time might suggest that a different quality of falls occurs when patient is forced to stay home — hence, clinicians should point their attention also on monitoring patients’ sit-to-stand body transition other than more acknowledged features based on step quality.
Background
Postural instability (PI) in Parkinson’s disease (PD) is associated with several negative downstream consequences.
Objective
The purpose was to explore the validity of a theoretical model of these downstream consequences arranged in a vicious cycle wherein PI leads to decreased balance confidence, which in turn leads to increased fear of falling (FOF) avoidance behavior, which in turn leads to decreased physical conditioning, which then feeds back and negatively affects PI.
Methods
A path analysis of cross-sectional data from 55 participants with PD was conducted. The four constructs in the model connected in succession were: 1. PI (principal components analysis (PCA) composite of the Unified Parkinson’s Disease Rating Scale PI and Gait Difficulty score, Timed Up and Go test, and Berg Balance Scale); 2. balance confidence (Activities-Specific Balance Confidence Scale); 3. FOF avoidance behavior (PCA composite of the FOF Avoidance Behavior Questionnaire and average number of steps per day); and, 4. physical conditioning (2-Minute Step Test).
Results
The path model was an excellent fit to the data, χ2 (7) = 7.910, p=.341, CFI=.985, TLI=.968, RMSEA=.049 (90% CI: .000 to .179). The moderate to strong and uniformly significant parameter estimates were -.519, -.651, -.653, and -.570, respectively (ps<.01).
Conclusions
PI directly and inversely predicted balance confidence, which in turn directly and inversely predicted FOF avoidance behavior. Furthermore, FOF avoidance behavior directly and inversely predicted physical conditioning, which directly and inversely predicted PI, thereby closing the cycle. These findings highlight the downstream consequences of PI in PD and support the notion of a vicious cycle of FOF avoidance behavior.
Background:
Fear of falling may be significantly associated with falls in Parkinson's disease (PD) and may have a negative impact on quality of life. Nevertheless, there are no valid and reliable tools to examine this condition in PD. The objective of this study was to design and determine the psychometric attributes of an instrument to assess fear of falling in PD.
Methods:
A prospective 1-year, 2-phase study was conducted to validate the Fear of Falling Scale, a self-assessed instrument for assessing fear of falling in PD. During phase 1, we designed a scale to measure the severity of fear of falling and determine its baseline psychometric characteristics, whereas phase 2 was a 1-year follow-up study to assess the frequency of falls and other clinical factors linked to fear of falling. Convergent and discriminant validity were assessed against the Fear of Falling Measure and the Starkstein Apathy Scale, respectively.
Results:
The Fear of Falling Scale showed high internal consistency, test-retest reliability, and strong convergent and discriminant validity. There was a significant association between fear of falling score and the presence of both generalized anxiety disorder and major depression, poor balance-related motor ability, increased nonmotor symptoms of PD, more severe impairments in activities of daily living, and increased motor fluctuations. Finally, generalized anxiety disorder was a significant predictor of number of falls during a 12-month follow-up period.
Conclusions:
The Fear of Falling Scale is a valid and reliable instrument to assess fear of falling in PD. Fear of falling in PD is associated with specific psychiatric and motor disorders and is significantly related to the performance of balance-related motor functions. © 2019 International Parkinson and Movement Disorder Society.
Background
Fear of falling in Parkinson's disease (PD) has been suggested as predictor of future falling. The purpose of this study was to compare fear of falling score after two years of follow-up with those observed at baseline and to assess factors associated with change in fear of falling over time.
Methods
A total of 120 consecutive persons with PD were recruited and followed for two years. Fear of falling was assessed by using the 10-item Falls Efficacy Scale (FES). Occurrence of falling was registered during the first year of follow-up.
Results
After two years, the average FES score statistically significantly changed (p = 0.003) from 30.5 to 37.5 out of 100 (increase of 22.9%). We observed that median scores of all FES items, except for “Preparing a meal, not requiring carrying of heavy or hot objects” and “Personal grooming,” significantly increased after two-year follow-up. After accounting for age, gender, PD duration, levodopa dosage, Hoehn and Yayhr stage, Unified Parkinson's Disease Rating Scale score three, depression, anxiety, and falling, we observed that sustaining greater number of falls in the first year of follow-up was associated with higher increase in FES score after two years (odds ratio 3.08, 95% confidence interval 1.30–4.87).
Conclusion
After two years of follow-up, we observed a decrease in confidence at performing nearly all basic daily activities. Fall prevention programs should be prioritized in management of PD.
To investigate the relationships between falls, fear of falling and activity limitations in individuals with Parkinson's disease (PD).
Cross-sectional study of individuals with mild to moderate PD (N=83). Associations among demographic data, fall frequency, disease severity, motor impairment, ability to perform Activities of Daily Living (ADL), Activities Balance Confidence Scale, Iowa Fatigue Scale, Co-morbidity Index, and Physical Activity Scale for Elders were studied.
Frequent fallers had more ADL limitations than non-fallers (p < .001) and rare fallers (p=.004). Frequent fallers reported a lower percentage of ability to perform ADL than non-fallers (p=.003). Frequent fallers and rare fallers were less physically active than non-fallers (p=.015 and p=.040, respectively). Frequent fallers and rare fallers reported a higher level of fear of falling than non-fallers (p=.031 and p=.009, respectively).
Falls and fear of falling were associated with more ADL limitations and less physical activity after adjusting for physical impairments.
Purpose:
To study the relationship of fear of falling (FoF) with gait characteristics and balance in individuals with Parkinson's disease (PD).
Method:
Seventy-nine non-demented individuals (62 males) with PD were studied. Their mean age was 69.22 ± 8.93 years. The average time since diagnosis was 8.27 ± 5.31 years. FoF was assessed by the Activities-specific Balance Confidence (ABC) Scale in which high scores indicate less FoF. Gait was measured using a computerized walkway. Balance was measured by timed tests including the 5-step test, 360 degree turn, timed sideways walk, and timed up and go test. Participants were divided into two groups based on their ABC score (high FoF, ABC score <69; low FoF, ABC score ≥69). Gait characteristics and balance measures of the two groups were compared.
Results:
Gait speed and stride length for forward walking (p < 0.0005 for both) and backward walking (p = 0.001 and 0.002, respectively) were lower for those with a high level of FoF compared to those with a low level of FoF. The time to take five steps (p = 0.025), time to turn (p < 0.0005), time to walk sideways (p = 0.001), and time to complete the up and go test (p = 0.003) were longer in those with a high level of FoF than in those with a low level of FoF. Number of steps to complete the turn (p = 0.001) and steps to walk sideways (p = 0.002) were greater in those with a high level of FoF than in those with a low level FoF.
Conclusions:
Gait and balance of individuals with PD with a high level of FoF were poorer than those with a low level of FoF, regardless of previous fall history. Implications for Rehabilitation The results demonstrates that fear of falling (FoF) is related to gait and balance in individuals with PD. Clinicians should be aware that FoF has a negative impact on gait and balance in individuals with PD.
this study aimed to perform a comprehensive validation of the 16-item and 7-item Falls Efficacy Scale International (FES-I) by investigating the overall structure and measurement properties, convergent and predictive validity and responsiveness to change.
five hundred community-dwelling older people (70-90 years) were assessed on the FES-I in conjunction with demographic, physiological and neuropsychological measures at baseline and at 12 months. Falls were monitored monthly and fear of falling every 3 months.
the overall structure and measurement properties of both FES-I scales, as evaluated with item response theory, were good. Discriminative ability on physiological and neuropsychological measures indicated excellent validity, both at baseline (n = 500, convergent validity) and at 1-year follow-up (n = 463, predictive validity). The longitudinal follow-up suggested that FES-I scores increased over time regardless of any fall event, with a trend for a stronger increase in FES-I scores when a person suffered multiple falls in a 3-month period. Additionally, using receiver-operating characteristic (ROC) curves, cut-points were defined to differentiate between lower and higher levels of concern.
the current study builds on the previously established psychometric properties of the FES-I. Both scales have acceptable structures, good validity and reliability and can be recommended for research and clinical purposes. Future studies should explore the FES-I's responsiveness to change during intervention studies and confirm suggested cut-points in other settings, larger samples and across different cultures.
A cross-sectional study was performed to investigate the association between fear of falling and postural performance in the elderly. One hundred ambulatory and independent volunteers (aged 62-96) were subjected to five types of balance tests: (a) spontaneous postural sway, (b) induced anterior-posterior sway, (c) induced medial-lateral sway, (d) one-leg stance, and (e) a clinical balance assessment scale. Pseudorandom platform motions were used in the induced-sway tests. The subjects were classified into both "faller"/"nonfaller" and "fear"/"no-fear" categories, to allow the influence of fear of falling and falling history to be separated in the analyses. Subjects who expressed a fear of falling were found to exhibit significantly poorer performance in blindfolded spontaneous-sway tests and in eyes-open, one-leg stance tests. The clinical scale was the only balance measure that showed a significant association with retrospective, self-reported falling history. We could not ascertain whether the fear of falling affected balance-test performance in an artifactual manner, or whether the fear and poorer performance were related to a true deterioration in postural control. Until this issue can be resolved, balance-test performance should be interpreted with caution when testing apprehensive individuals. Furthermore, studies of postural control and falling should allow for the potentially confounding influence of fear of falling.
To assess internal consistency and validity of measures of balance (Berg balance scale, BBS), postural changes (postural changes scale, PCS) and fear of falling (fear of fall measure, FFM) in 70 ambulant Parkinson's disease (PD) persons, these instruments were matched with performance-based balance and mobility tests, and other clinical, functional and quality of life PD-specific measures. The BBS, PCS and FFM showed a good internal consistency, moderate to good inter-correlation, and a significant correlation with measures of both disability (UPDRS-ADL, Schwab and England scale) and--to a lesser extent--impairment/severity of symptoms (UPDRS-ME, Hoehn and Yahr Scale). Tandem Romberg, Single-Limb Stance, Functional Reach, and the Timed Up & Go test correlated slightly better with BBS than with PCS and FFM. This study shows that problems of balance and postural control in PD patients result from complex interactions between motor impairment, functional abilities and fear of falling.
Factors predicting fear of falling avoidance behavior in parkinsonisms
- J K Longhurst
- J V Rider
- K Eckard
- JK Longhurst