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Review
. 2023 Nov 15;11(11):CD014666.
doi: 10.1002/14651858.CD014666.pub2.

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

Eric Lenouvel  1   2 , Phoebe Ullrich  3   4 , Waldemar Siemens  5   6 , Dhayana Dallmeier  7   8 , Michael Denkinger  9   10 , Gunver Kienle  11 , G A Rixt Zijlstra  12   13   14 , Klaus Hauer  3   15 , Stefan Klöppel  1
Affiliations
Review

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

Eric Lenouvel et al. Cochrane Database Syst Rev. .

Abstract

Background: 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.

Objectives: 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.

Search methods: 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.

Selection criteria: 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.

Data collection and analysis: 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.

Main results: 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.

Authors' conclusions: 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.

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Conflict of interest statement

EL: was granted funding from the Age Stifung (Kirchgasse 42, 8001 Zürich, Switzerland) during the process of this review for developing a cognitive behavioural therapy (CBT) intervention for reducing fear of falling in nursing home residents, which when the study is conducted, due to a different population would not fulfil the inclusion criteria of this review.

PU: none.

WS: none.

DD: none.

MD: none.

GK: none.

GARZ: was involved in conducting a study that was included in the review (Zijlstra 2009). She was independent of the study selection decision, risk of bias assessment, and data extraction for this study.

KH: none.

SK: was granted funding from the Age Stifung (Kirchgasse 42, 8001 Zürich, Switzerland) during the process of this review for developing a CBT intervention for reducing fear of falling in nursing home residents, which when the study is conducted, due to a different population would not fulfil the inclusion criteria of this review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for fear of falling outcomes of each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages for fear of falling outcomes across all included studies.
1.1
1.1. Analysis
Comparison 1: Fear of falling: immediate postintervention, Outcome 1: Fear of falling: subgrouped according to intervention approach
1.2
1.2. Analysis
Comparison 1: Fear of falling: immediate postintervention, Outcome 2: Fear of falling: subgrouped according to mean age
1.3
1.3. Analysis
Comparison 1: Fear of falling: immediate postintervention, Outcome 3: Fear of falling: subgrouped according to control
1.4
1.4. Analysis
Comparison 1: Fear of falling: immediate postintervention, Outcome 4: Fear of falling: subgrouped according to "A Matter of Balance" (AMB) versus non‐AMB based interventions
1.5
1.5. Analysis
Comparison 1: Fear of falling: immediate postintervention, Outcome 5: Fear of falling: subgrouped according to group versus individual interventions
2.1
2.1. Analysis
Comparison 2: Fear of falling: sustainability of effects, up to 6 months' postintervention, Outcome 1: Fear of falling: subgrouped according to intervention approach
2.2
2.2. Analysis
Comparison 2: Fear of falling: sustainability of effects, up to 6 months' postintervention, Outcome 2: Fear of falling: subgrouped according to control
2.3
2.3. Analysis
Comparison 2: Fear of falling: sustainability of effects, up to 6 months' postintervention, Outcome 3: Fear of falling: subgrouped according to AMB versus non‐AMB based interventions
2.4
2.4. Analysis
Comparison 2: Fear of falling: sustainability of effects, up to 6 months' postintervention, Outcome 4: Fear of falling: subgrouped according to group versus individual interventions
3.1
3.1. Analysis
Comparison 3: Fear of falling: sustainability of effects, more than 6 months' postintervention, Outcome 1: Fear of falling: subgrouped according to intervention approach
3.2
3.2. Analysis
Comparison 3: Fear of falling: sustainability of effects, more than 6 months' postintervention, Outcome 2: Fear of falling: subgrouped according to "A Matter of Balance" (AMB) versus non‐AMB based interventions
3.3
3.3. Analysis
Comparison 3: Fear of falling: sustainability of effects, more than 6 months' postintervention, Outcome 3: Fear of falling: subgrouped according to group versus individual interventions
4.1
4.1. Analysis
Comparison 4: Secondary outcomes, Outcome 1: Activity avoidance: immediate postintervention
4.2
4.2. Analysis
Comparison 4: Secondary outcomes, Outcome 2: Occurrence of falls: immediate postintervention
4.3
4.3. Analysis
Comparison 4: Secondary outcomes, Outcome 3: Depression: immediate postintervention
4.4
4.4. Analysis
Comparison 4: Secondary outcomes, Outcome 4: Anxiety: immediate postintervention
4.5
4.5. Analysis
Comparison 4: Secondary outcomes, Outcome 5: Quality of life: immediate postintervention
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