Fear of Falling: Assessment & Intervention

How to identify in clinic

• Ask directly: "Are you afraid of falling?" — patients rarely volunteer this
• Falls Efficacy Scale – International (FES-I) — validated, 16 items
• Short FES-I (7 items) for clinic screening
• Look for activity avoidance: stopped going out, won't walk alone, holds furniture
• Reduced social activity due to mobility anxiety
• Deconditioning cycle: fear → inactivity → weakness → more fear

Key questions

• "Have you stopped doing things because you're worried about falling?"
• "Do you hold onto furniture or walls when walking at home?"
• "Have you fallen in the past year?" (even if fear exists without falls)

Non-pharmacologic (first-line)

• PT referral — balance and gait retraining is the primary intervention
• Tai Chi or Otago Exercise Program — both reduce falls and fear of falling
• Cognitive-behavioral therapy (CBT) — addresses catastrophic thinking about falls
• Gradual activity exposure — supported walking, community programs
• Assistive device assessment — proper cane/walker fitting reduces fear
• Home safety modifications (grab bars, lighting, rugs removed)

Medications

• Vitamin D 1000–2000 IU daily if deficient
• Treat underlying anxiety or depression if present — avoid benzodiazepines
• Review and reduce fall-risk medications

Avoid in older adults

• Benzodiazepines — worsen balance and increase fall risk
• Overprotection / bed rest — accelerates deconditioning

When to refer

• PT — all patients with fear of falling, regardless of fall history
• OT — home safety evaluation if high-risk or lives alone
• Psychology/behavioral health — if fear is disabling despite PT
• Community exercise programs (Tai Chi, Matter of Balance)

Documentation must include

• Screening result (FES-I score or clinical assessment)
• Activity restrictions due to fear
• Medication review completed
• Interventions ordered (PT, home safety, exercise program)
• Follow-up plan — reassess in 4–6 weeks