Physical or psychological change? Which is the most important rehabilitation outcome for older people who fall?

SIR—The National Institute for Clinical Excellence is currently preparing clinical guidelines on 'the assessment and prevention of falls in older people'. It is timely, therefore , to consider just what such programmes should really be trying to achieve. Are they only about preventing falls, all falls, in ambulant older people? Clearly this is unrealis-tic. Not all falls are preventable and not all old people who fall are bothered enough about doing so to attend a 'falls group'. Many consider that they have more interesting things to do [1]. On the one hand the increasing incidence of hip fractures needs to be controlled but the usual culprit, osteoporosis, is most successfully prevented earlier in life. In any case only about 10% of non-fatal falls result in serious injury [2]. On the other hand anxiety about falling and its consequences 'profoundly threaten' many older peoples' quality of life [3]. But even people who are concerned about falling are not necessarily prepared to take preventive measures other than 'taking care' [4]. Thus the most likely participants in 'falls prevention' programmes, and those most likely to adhere, are older people who are seriously concerned about falling. At present, however, published 'falls prevention' programmes, focus on achieving physical change in participants by encouraging them to exercise in order to improve their postural stability through increased lower limb extensor power and ankle joint mobility. Like others before us [5], we suggest that psychological change, in terms of decreased anxiety about, or fear of, falling with increased balance conWdence, is an even more important outcome. Anxiety about falling is commonly attributed simply to having fallen yet four groups of older people have been revealed [6]: fallen and afraid, not fallen and afraid, fallen and not afraid, not fallen not afraid. An alternative, cognitive psychological explanation is suggested: anxiety about falling arises from the interplay of people's belief about how likely they are to fall and their awareness of what might happen to them if a fall occurs [7]. The more anxious people are about falling the lower will be their conWdence in their capability to move about without falling and do what they want to do i.e. their balance conWdence [8, 9]. Whereas anxiety is an emotion, conWdence (or self-efWcacy) is a cognitive construct, concerned with people's beliefs in their capabilities to produce results and accomplish designated types of performance [10]. Good balance conWdence is the most …