Healthy living

A program against the fear of falling did no better than a well-matched comparison class

In a randomized trial with 160 people aged 70 and over in Germany, four months of strength and balance training plus coaching against the fear of falling reduced that fear, but no more than a comparison program of health talks and light stretching did. Eight months later, both groups were still doing about equally well.

Being afraid of falling is common in old age, and it can become a trap: people who worry about falling move less, lose strength, and become more likely to fall. A randomized trial from the University of Erlangen-Nürnberg in Germany tested a four-month program designed to break this circle. People in the program did become less worried, but so did people in a comparison group who only attended health talks and stretched lightly. The program gave no extra benefit, either right after it ended or eight months later.

Concerns about falling are widespread: the paper cites a review estimating that about half of older adults have them. The researchers also wanted to know whether such worry behaves like chronic stress in the body. Long-lasting stress changes the daily rhythm of cortisol, a stress hormone, and is thought to feed low-grade inflammation, which in turn is linked to the loss of muscle with age. So besides questionnaires and fitness tests, the team measured stress hormones in saliva and inflammation markers in blood.

What they did

The trial enrolled 160 people aged 70 or older who lived at home and scored at least moderately high on a standard questionnaire about fear of falling. People with memory problems (a low score on a standard memory test) or who took anti-inflammatory drugs were excluded. They were randomly assigned to one of two 16-week programs:

  • The real program (87 people): progressive strength, balance and walking training, combined with cognitive-behavioral training, a form of coaching that changes how people think about and react to a fear. It was adapted from an existing program called "A Matter of Balance" and covered setting goals, avoiding less, and building confidence.
  • The comparison program (73 people): the same number of sessions, each with a 40-minute health lecture and 20 minutes of light stretching for the upper body.

Participants were told that two programs were being compared, and the people who measured the results were kept separate from the people who ran the sessions. Everyone was assessed at the start, right after the program, and eight months later.

What they found

  • No difference between the groups. On none of the 31 measures did the real program beat the comparison program, at either time point. This held both for people who attended the sessions as planned and in an analysis of everyone who was randomized.
  • Both groups improved. Fear of falling, avoidance of activities, anxiety and perceived stress went down in both groups after the program, and stayed down eight months later. People also felt more in control of their risk of falling.
  • Small physical changes. Walking speed rose by 0.05 metres per second, about half of what is usually considered a meaningful change. Grip strength rose too, but stayed below the gain considered clinically meaningful, and the authors note that people may simply have got used to the test. The number of steps per day, measured with a sensor, fell over the year.
  • Mixed biology. Daily cortisol output fell over the year, while a marker of the "fight or flight" nervous system rose. Inflammation markers moved in different directions: two rose, one fell, and two did not change. The authors call this pattern inconsistent. Muscle mass and body weight did not change.

Attendance was high in both groups: more than three quarters of the sessions.

What to keep in mind

  • The comparison was not a "do nothing" group. The authors' main explanation is that the comparison program was itself helpful: regular meetings, social contact and some movement may reduce fear of falling. They suggest it should be seen as an active control rather than a placebo. So the trial does not show that nothing works, only that this program did not beat a well-matched alternative.
  • Smaller than planned. The trial aimed for 200 people and reached 160, and its statistical power was designed for the short-term comparison. Small differences between the groups, especially at eight months, could have been missed.
  • A fairly fit group. Participants lived independently, had no memory problems and could get to the study center on their own. The authors think the program may not have been intense or long enough to show a difference in such a group. The results may not apply to frailer people or to those without fear of falling.
  • Being watched. The improvements in both groups may partly reflect taking part in a study (the "Hawthorne effect"), and things like diet were not measured.

Why it matters

Many studies of programs against the fear of falling compare them with usual care or with nothing. This trial used a comparison group that met just as often, and the difference disappeared. That is a useful lesson for how such programs are tested, and it hints that regular contact and gentle activity may do much of the work. The authors call for programs that are more intensive and better tailored to the individual, tested against equally demanding comparisons.

Sources