Catch Me If I Fall: Preventing Fear of Falling in Patients With Rheumatoid Arthritis

In a year, about half of individuals with rheumatoid arthritis (RA) have a fall and, of those, 16% to 62% fall more than once.¹ Some of your patients may have an increased fall risk due to 1 or more physical symptoms such as impaired mobility, balance, lower-limb muscle weakness, swollen and tender joints, pain, fatigue, and postural instability. Someone’s risk for falling is a combination of those things and unique to your patient. What most of your patients will have in common though, is a fear of falling or psychological distress that can exacerbate physical limitations. In fact, more than half of RA patients report significant fear of falling.²

Kim Gorgens, PhD, ABPP

A fear of falling isn’t necessarily a problem in and of itself, however, if unchecked it can limit experiences and contribute to a poorer quality of life. Specifically, a fear of falling is correlated with poorer reported health and physical functioning and more painful joints, all of which contribute to an increased risk of falling.³ Fear of falling is also related to anxiety and depression and, in the same cyclical way, can contribute to or be exacerbated by poor mood. Physical movement operates in the same way. Physical movement is essential to build confidence (ie, muscle strength, endurance, and range of motion) and is directly related to self-esteem, improved mood and sleep quality, and decreased pain perception. Movement can be curbed by worsening fears of falling, which then accelerates a decline in physical function. Of course, the physical deconditioning associated with inactivity increases the fear of falling and the vicious cycle continues.

Devrey Martin, BS

Of course, a realistic amount of fear can be healthy considering the negative long-term repercussions of a serious fall. It is necessary to distinguish what a healthy level of fear looks like and how to determine when it becomes pathological. The DSM-V categorizes a pathological fear of falling as a specific phobia.⁴ To meet this diagnosis, your patient must present with a fear of falling that causes clinically significant distress or impairment, patterns of avoidance for 6 months or longer, and their fear must be out of proportion to the actual danger posed.

Your patient’s history is a helpful way to gauge if their fear is disproportionate to their situation. If a patient had a recent fall, their fear will be greater than was true previously but if they have drastically limited their activity with no basis (no change in function or fall history), you might have identified a potential problem that warrants clinical attention. If a patient has fallen or tells you they feel unsteady while walking, you will consider a full fall risk assessment.⁵ There are best practice guidelines like those from the American Geriatrics Society (AGS) and British Geriatrics Society (BGS).⁶ If, after careful examination, you determine that their risk of falling is relatively low but is accompanied by a disproportionate fear of falling, you might consider a different recommendation: cognitive behavioral therapy (CBT). CBT is remarkably effective in a fall-prevention and anxiety reduction and is regarded as the gold standard in managing fear of falling.⁷ In research with adults with a fear of falling, patients exposed to CBT demonstrated significant reductions in activity avoidance, disability, and actual falls compared to those who received treatment as usual.⁸

Consider bringing in a psychologist colleague for consultation or make a treatment referral for your patients that need psychological support. You can find professionals with expertise in phobias and CBT on APA’s Psychologist Locator or by searching the National Register of Health Service Psychologists for a local referral. In both searches, you just need a zip code, practice area (phobias), and treatment method (CBT) in order to find a mental health professional that is compatible with your patient’s needs. A fear of falling can be a protective factor but should not limit the wellbeing of your patients, especially when the fix is as close as your neighborhood psychologist.

References:

1. Armstrong, C. (2005). Occurrence and risk factors for falls in rheumatoid arthritis. Annals of the Rheumatic Diseases, 64(11), 1602–1604. https://doi.org/10.1136/ard.2004.031195
2. Böhler, C., Radner, H., Ernst, M., Binder, A., Stamm, T., Aletaha, D., Smolen, J. S., & Koller, M. (2012). Rheumatoid arthritis and falls: The influence of disease activity. Rheumatology, 51(11), 2051–2057. https://doi.org/10.1093/rheumatology/kes198
3. Jamison, M., Neuberger, G. B., & Miller, P. A. (2003). Correlates of falls and fear of falling among adults with rheumatoid arthritis. Arthritis & Rheumatism, 49(5), 673–680. https://doi.org/10.1002/art.11383
4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
5. Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and Management of Fall Risk in Primary Care Settings. Medical Clinics of North America, 99(2), 281–293. https://doi.org/10.1016/j.mcna.2014.11.004
6. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157. doi:10.1111/j.1532-5415.2010.03234.x
7. Büla, C. J., Monod, S., Hoskovec, C., & Rochat, S. (2011). Interventions Aiming at Balance Confidence Improvement in Older Adults: An Updated Review. Gerontology, 57(3), 276–286. https://doi.org/10.1159/000322241
8. Zijlstra GA, van Haastregt JC, Ambergen T, et al. Effects of a multicomponent cognitive behavioral group intervention on fear of falling and activity avoidance in community-dwelling older adults: results of a randomized controlled trial. J Am Geriatr Soc. 2009;57(11):2020-2028. doi:10.1111/j.1532-5415.2009.02489.x