– Cognitive behavioural therapy (CBT) with and without exercise probably reduces fear of falling in older people living in the community, when measured once treatment has ended. Improvements may be sustained during the first six months after treatment finished, and probably last beyond six months.
– As a consequence of these interventions, people may be less likely to avoid activities after treatment and their level of depression may be reduced.
– It is unclear if the frequency of falls is reduced following treatment.
– We do not know if there are any adverse effects (harms) caused by CBT with and without exercise for reducing fear of falling, as none of the studies measured this as one of their outcomes. We need more studies looking at adverse effects.
What is fear of falling?
Fear of falling is a lasting concern about falling that leads to a person avoiding activities that he/she remains capable of performing. Fear of falling is common among older adults. They may be warned by healthcare professionals, family, and friends of the dangers of falls, as well have witnessed directly or indirectly the consequences of a fall. This is significant as up to 34% of older adults fall each year, with 5% experiencing bone fractures. Furthermore, they may recognise that their body is not as strong as it was when they were younger, adding to concern that they may not be able to protect themselves from a fall, and must, therefore, take preventive measures to avoid falling. People with fear of falling can experience physical, psychological, and social consequences. Treating fear of falling is therefore important to reduce dysfunctional cognitions and behaviours leading to these consequences.
How is the condition treated?
There are several treatment approaches: cognitive behavioural therapy (CBT) (a talking therapy that helps change thoughts and behaviour), exercise (a planned, structured, and repetitive physical activity to help keep the body healthy), or a combination of both. These treatments are usually given in group settings by trained therapists.
What did we want to find out?
We wanted to find out if CBT with and without exercise in older adults living in the community (who live in places without additional support, such as assisted living centres) were better than usual care or dummy treatments in reducing fear of falling. We also wanted to see how CBT with and without exercise affected activity avoidance, falls, and depression, or if it caused any harm.
What did we do?
We searched several electronic databases and consulted experts for studies that compared interventions to reduce fear of falling using CBT alone and CBT with exercise.
We combined and summarised the results across the studies. We rated our confidence in the evidence based on factors such as study design, methods, and numbers of participants.
What did we find?
We found 12 relevant studies, of which 11 studies were included for statistical analyses with a total of 2383 people, with a mean age varying from 73 to 83 years. The therapy (CBT or dummy treatment) was given at a frequency from three times per week to once per month, for eight to 48 weeks. Added up, the treatments lasted between six and 156 hours. Most interventions were given in groups of between five and 10 participants, and in one study up to 25. The primary aim of 10 studies was to reduce fear of falling.
We found that CBT with and without exercise interventions probably reduces fear of falling in older people living in the community once treatment has ended. Improvements may be sustained during the first six months after treatment finished, and probably last beyond six months. Additionally, we found that people may be less likely to avoid activities, and may reduce their level of depression. It remains unclear if the frequency of falls improves after treatment.
What are the limitations of the evidence?
Our confidence in the evidence was limited because the results may have been influenced by the participants in the studies knowing which treatment they received and the studies used different ways of delivering the interventions.
To improve our certainty of the evidence, we would need more studies, with more similarity in how they treated and measured fear of falling.
How up to date is this evidence?
This evidence is up to date to 11 January 2023.
CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months.
Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects.
Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.
Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.
To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.
This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.
Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.
We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias.
CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD −0.23, 95% CI −0.36 to −0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD −0.24, 95% CI −0.41 to −0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD −0.28, 95% CI −0.40 to −0.15; 5 studies, 1185 participants; moderate-certainty of evidence).
CBT interventions for reducing FoF may reduce activity avoidance (MD −2.57, 95% CI −4.67 to −0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD −0.41, 95% CI −0.60 to −0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence).
All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article.
No studies reported adverse effects due to their interventions.