A randomized trial comparing Tai Chi with and without cognitive-behavioral intervention (CBI) to reduce fear of falling in community-dwelling elderly people
Introduction
The prevalence of a fear of falling among community-dwelling elderly people varies between 21% and 85%, regardless of their fall history, health status and mobility levels (Scheffer, Schuurmans, van Dijk, van der Hooft, & de Rooij, 2008). The concept of the fear of falling is multi-dimensional and strongly correlated, and includes the perceived threat of falling, perceived risk of falling, concern about consequences of falls, and fall-related self-efficacy (Yardley, Donovan-Hall, Francis, & Todd, 2007). Tinetti, Liu, and Claus (2003, p. 36) defined fear of falling as “a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing”. As a consequence, this fear causes a loss of self-confidence in performing certain activities. This can be viewed as protective behavior in response to the threat of falls, discouraging elderly people from undertaking activities involving a high risk of falling and concomitant injury. Risk factors that contribute to the fear of falling include physical factors (such as balance and gait), social factors (such as participation in social events) and psychological factors (such as self-perceived wellbeing) (Gagnon and Flint, 2003, Gagnon et al., 2005, Scheffer et al., 2008). When people become more concerned about falls, they tend to self-impose restrictions on their normal activities. This explains their increased social restriction (Bruce et al., 2002, Fletcher et al., 2010, Jang et al., 2007): having few social contacts is common in people with this fear (Howland et al., 1998). Consequently, it affects sufferers’ self-perceived personal wellbeing and their health (Bruce et al., 2002, Jang et al., 2007), leading them to have decreased life satisfaction (Arfken et al., 1994, Zijlstra et al., 2007a). Fear of falling seems to be an important psychological issue that may have negative impacts on their physical, mental and psychosocial wellbeing.
The high incidence and negative impacts of the fear of falling show the importance of developing effective strategies to reduce this unnecessary concern among elderly people. The growth of this fear is partly associated with unsuitable and unhelpful automatic thoughts and emotions about falling (Fletcher et al., 2010, Jang et al., 2007). The effectiveness of cognitive behavioral therapy in modifying people's faulty thinking and faulty beliefs tied to their faulty behavior have been demonstrated in many randomized controlled trials (Allen et al., 2010, Kushner et al., 2009, Stanley et al., 2009). Tennstedt et al. (1998) is one of a few pioneers who have developed, implemented and evaluated CBIs to reduce the fear of falling among community-dwelling elderly people. Compared with participants in the control group, the intervention participants showed a significantly increased level of intended activity, greater mobility control, and improved social function and mobility range. Zijlstra et al. (2009) adopted Tennstedt et al.’s interventions and used them in Dutch elderly populations. Zijlstra et al. (2009) also reported a positive effect of the Dutch version of CBI in reducing the fear of falling in community-dwelling elderly people.
Besides faulty beliefs about falling, impaired balance, gait and mobility are also common among elderly people with the fear of falling. Empirical evidence shows that this fear can be reduced significantly after exercise interventions, although the original aim of the exercise was to improve participants’ mobility. Tai Chi emphasizes precise body movement while maintaining tranquil, relaxed, periodic breathing and a concentrated mind. Its performance relies more on image recollection than memorization of instructions (Bottomly, 1997). Tai Chi has postulated effects on balance, mental outlook and stress that might directly affect fear of falling (Sattin, Easley, Wolf, Chen, & Kutner, 2005). Continually practicing Tai Chi can build the confidence necessary to counteract the fear of falling (Li et al., 2005). Empirical evidence shows that Tai Chi has benefits in both physical and psychological wellbeing (Sattin et al., 2005, Li et al., 2008, Zhang et al., 2006). Additionally, it was found to reduce fear of falling significantly more than other exercise programs for older adults (Sattin et al., 2005). The result of a meta-analysis of six studies concluded that the most appropriate form of intervention to address the problem of fear of falling should be a combined intervention including both exercise and education components (Jung, Lee, & Lee, 2009). In this regard, Huang, Yang, and Liu (2011) evaluated the effects of a combined Tai Chi with CBI intervention on reducing the fear of falling. The findings showed that the combined intervention demonstrated the largest effects in helping community-dwelling elderly people to enhance their mobility, reduce their fear of falling and increase their quality of life. However, Huang's study did not have an experimental group that received purely the Tai Chi intervention. Therefore, it was impossible to distinguish whether the effectiveness of their interventions was due to the Tai Chi alone or its combination with CBI.
The aim of this study was to compare the effects of Tai Chi exercise with and without CBI on a primary outcome, reducing the fear of falling, and on the secondary outcomes of encouraging better social engagement, improving self-perceived personal wellbeing and achieving better overall mobility (i.e. balance and gait) among community-dwelling elderly people who were afraid of falling. We hypothesized that participants receiving both interventions would reduce their fear of falling and improve other physio-psychosocial aspects, but that the improvements for those who received both Tai Chi and CBI would be greater than for those who received the Tai Chi intervention only.
Section snippets
Study design
A prospective, randomized comparison trial was used to compare the effects of two interventions (i.e. Tai Chi only versus Tai Chi plus CBI) in four elderly community centers in Wing Tai Sin district in Hong Kong (HK) between May 2011 and January 2013.
Ethical considerations
Ethical approval was obtained from the Human Subjects Ethics Committee of The Hong Kong Polytechnic University. Permission to perform the study was also sought from the person in-charge of each district community center. All participants were asked
Participant
Four hundred and fifty-one members aged 65 or above in the four district elderly community centers were assessed by an RA based on the sample selection criteria. Fig. 1 shows the number of elderly people assessed for eligibility and the progress of participants throughout the study. Of the 451 elderly people assessed, 66 (14.63%) did not respond to the invitation, 58 (12.86%) chose not to participate, and 42 (9.31%) had died or moved to another district. In addition, 157 (34.81%) were excluded
Discussion
The main conclusions from the findings are (1) Tai Chi both with and without CBI has a similar effect on reducing community-dwelling elderly people's fear of falling, (2) but only the Tai Chi plus CBI intervention had a positive effect on participants’ self-perceived personal wellbeing; and (3) Tai Chi both with and without CBI has no effect on participants’ self-perceived social participation and mobility.
Originally, we hypothesized that the combined intervention of Tai Chi plus CBI would
Conclusion
This study provides preliminary evidence that combining CBI has no effect on modifying Tai Chi's effect on reducing fear of falling in community-dwelling older adults. This finding raises a question about the additive effects of a combined intervention over Tai Chi alone. In view of the resource constraints in most community settings, more evidence is required to support the additional benefits of the combined intervention of CBI with Tai Chi before the implementation of combined interventions
Conflicts of interest statement
None.
Funding
This study was funded by The Hong Kong Polytechnic University, Department General Research Fund (Grant number: A-PL32).
Acknowledgements
We would like to thank the cognitive behavioral therapist, Annie Yip, for her advice in designing the CBI in this study. She also worked as an instructor before and during the implementation of the CBI in this study. We would also like to think the statistician, Kenny Chin, for his excellent advice during the data analysis.
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