Fear-of-Falling... Or Falling-From-Fear?
How can fall-related anxiety increase the likelihood of a fall occurring?
Posted March 8, 2017
As illustrated in the previous blog-post , performing motor skills under conditions of anxiety – whether the performer is an athlete worried about missing an important shot, or an older adult anxious about falling – can cause behavioral adaptations which increase the likelihood of a breakdown in performance occurring (i.e., a missed shot or a trip/fall). Research demonstrates that older adults who are anxious about falling are more likely to experience subsequent falls (Friedman, Munoz, West, Rubin, & Fried, 2002). Traditional conceptualizations of the relationship between fear-of-falling and increased falls are based on the notion that individuals anxious about falling are more likely to avoid activities where they could fall, such as leaving their house. These conceptualizations propose that it is then this activity avoidance which increases the likelihood of falling, with these individuals becoming de-conditioned to walking outside and, as a result, developing poorer balance. However, longitudinal research has challenged these traditional notions (i.e., Hadjistavropoulos, Delbaere, & Fitzgerald, 2011). Instead, recent research suggests that fall-related anxiety can lead directly to behavioral adaptations which may increase the likelihood of a fall occurring.
But what are these behavioral adaptations? And how can they increase the likelihood of a fall occurring?
Anxious individuals will display a ‘stiffening strategy’ during walking, whereby they reduce the motion of their lower limbs, resulting in shorter strides and reduced gait speed (Brown, Gage, Polych, Sleik, & Winder, 2002; Staab, Balaban, Furman, 2013). It is possible that this stiffening strategy is caused by the direction of attention inwards in an attempt to consciously control movement (Masters & Maxwell, 2008; Young & Williams, 2015). Indeed, research demonstrates a causal relationship between fall-related anxiety during walking and this internal focus of attention (Young et al., 2016), suggesting that anxious individuals will direct conscious cognitive processes towards controlling their gait in an attempt to avoid a fall occurring. While walking requires some degree of cognitive input, it can occur with largely automatic, lower-level processing. However, consciously attending to the processing of walking may impair the efficiency of the movement by disrupting the automaticity and reducing movement fluidity (Masters & Maxwell, 2008).
These stiffening strategies may be effective in enhancing balance during static tasks (such as standing on a bus or train). However, they are likely to increase the possibility of falling during dynamic tasks (such as walking along an uneven pavement), where rapid, fluid movements are required to maintain safety. For example, stiffening the lower limbs may reduce the individual’s ability to make the rapid reactionary step necessary to regain their balance following a trip. As a result, it is possible that adopting this conscious control of movement in an attempt to prevent a fall may in fact increase the likelihood of a fall occurring.
Maladaptive visual-search behavior
This internal focus of attention may increase the likelihood of falling through mechanisms other than simply reducing movement automaticity. During walking, we rely on visual information to identify trip-hazards and navigate safely through the environment. The way we shift our gaze and scan the environment (our visual-search behavior) may also be affected by attempting to consciously control our movement. It has been argued that this conscious movement processing requires cognitive resources. As a result, this may then limit the resources available for carrying out other processes, such as the visual-search necessary for detecting trip-hazards and obstacles. Indeed, results indicate that older adults who consciously process their walking will often do so at the expense of attending to their environment (Uiga, Capio, Wong, Wilson, & Masters, 2015). Research from our lab also demonstrates less-effective patterns of visual-search in individuals reporting higher levels of movement processing (Ellmers, Cocks, Doumas, Williams, & Young, 2016). It has been proposed that this internal focus may, therefore, increase fall-risk by enhancing the likelihood that these individuals will miss identifying external information necessary for successful locomotion, such as trip-hazards (Uiga et al., 2015).
Research illustrates that anxiety may also influence visual-search behavior in other ways. It has been suggested that anxious individuals may have a gaze-bias for potential threats to their balance. For example, under conditions of greater anxiety, older adults at a high risk of falling will transfer their gaze away from a stepping target earlier in order to fixate on an upcoming threat to their balance (in this instance, an obstacle over which they had to step; Young, Wing, & Hollands, 2012). This threat-related bias is likely to be problematic during complex walking environments where the individual has to identify numerous potential threats to their balance (such as a busy street). Adopting this threat-related gaze bias, whereby the individual prioritizes a salient threat at the expense of proactively scanning their environment, is likely to increase the risk of falling by limiting the individual’s ability to perceive and identify any other upcoming threats to their balance, such as an oncoming cyclist.
Young and Williams (2015) additionally propose that focusing on anxiety-related thoughts/worries about falling may reduce balance safety during complex gait tasks (such as obstacle avoidance) by impairing an individual’s ability to store a ‘spatial map’ of their surroundings. If individuals are unable to store this spatial map, they may be less likely to proactively scan their environment, given that they would be unable to store any visual information they may acquire from doing so (Young & Williams, 2015). This may explain why during the navigation of a series of stepping constraints, older adults at a high-risk of falling will adopt a less-variable pattern of visual-search, whereby their gaze is fixated predominately on the initial stepping target, at the expense of upcoming obstacles or targets (Young, Wing & Hollands, 2012). Failing to acquire this visual information is likely to impair an individual’s ability to effectively plan future actions, such as identifying an uneven paving stone and then planning the necessary adjustments required to safely navigate this obstacle.
As this post illustrates, fall-related anxiety can lead to behavioral adaptations which may increase the likelihood of falls in the elderly. It appears that fear-of-falling can have an almost paradoxical effect: By changing their behavior in an attempt to avoid falling, these anxious individuals actually increase the likelihood that a fall will occur.
So what can be done?
Thankfully, it’s not all doom and gloom. Research demonstrates the positive effect that carefully designed interventions can have at enhancing balance confidence in older adults at risk of falling.
Tune into part 4 of this series to learn exactly how research from the domain of rehabilitation is giving hope to those afflicted by fear-of-falling.
Brown, L. A., Gage, W. H., Polych, M. A., Sleik, R. J., & Winder, T. R. (2002). Central set influences on gait. Experimental Brain Research, 145(3), 286–296.
Ellmers, T. J., Cocks, A. J., Doumas, M., Williams, A. M., & Young, W. R. (2016). Gazing into thin air: The dual-task costs of movement planning and execution during adaptive gait. PLoS ONE, 11(11), e0166063.
Friedman, S. M., Munoz, B., West, S. K., Rubin, G. S., & Fried, L. P. (2002). Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. Journal of the American Geriatrics Society, 50(8), 1329–1335.
Hadjistavropoulos, T., Delbaere, K., & Fitzgerald, T. D. (2011). Reconceptualizing the role of fear of falling and balance confidence in fall risk. Journal of Aging and Health, 23(1), 3–23.
Masters, R. & Maxwell, J. (2008). The theory of reinvestment. International Review of Sport and Exercise Psychology, 1(2), 160–183.
Staab, J. P., Balaban, C. D., & Furman, J. M. (2013). Threat assessment and locomotion: clinical applications of an integrated model of anxiety and postural control. Seminars in Neurology, 33(3), 297–306.
Uiga, L., Capio, C. M., Wong, T. W. L., Wilson. M. R., & Masters, R. S. W. (2015). Movement specific reinvestment and allocation of attention by older adults during walking. Cognitive Processing, 16, 421–4.
Young, W. R., Olonilua, M., Masters, R. S. W., Dimitriadis, S., & Williams, A. M. (2015). Examining links between anxiety, reinvestment and walking when talking by older adults during adaptive gait. Experimental Brain Research, 234, 161–172.
Young, W. R. & Williams, A. M. (2015). How fear of falling can increase fall-risk in older adults: Applying psychological theory to practical observations. Gait & Posture, 41(1), 7–12.
Young, W. R., Wing, A. M., & Hollands, M. A. (2012). Influences of state anxiety on gaze behavior and stepping accuracy in older adults during adaptive locomotion. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 67, 43–51.