Evidence based practice and applied nursing research

Evaluation of a combined cognitive-behavioural and exercise intervention to manage fear of

falling among elderly residents in nursing homes

Tzu-Ting Huang a,b , Meng-Ling Chung

c , Fan-Ru Chen

d , Yen-Fan Chin

a * and Bi-Hwa Wang

a

a School of Nursing, College of Medicine, Chang Gung University, Taiwan;

b Healthy Aging Research Center, Chang Gung University,

Taiwan; c National Taoyuan Special School, Taiwan;

d Mackay Memorial Hospital, Taiwan

(Received 5 April 2014; accepted 10 February 2015)

Objectives: Although the fear of falling is common among elderly residents in long-term care facilities, interventions developed for fear of falling management is very rare. Of these limited interventions, most were exercise interventions with only limited testing. The cognitive-behavioural intervention can decrease the fear of falling; however no intervention of the kind was developed and assessed to decrease fear of falling among the elderly in long-term care facilities. The purpose of this study was to examine the effectiveness of cognitive-behavioural strategies either with or without exercise in reducing fear of falling among elderly residents in nursing homes. Method: A prospective randomized control trial was conducted in six nursing homes in northern Taiwan. Seventy-five elderly participants were randomly assigned to one of the three groups: the comparison group, the cognitive-behavioural strategies with or without exercise group. The fear of falling, falls, depressive inclination, mobility, and muscle strength of extremities were collected at the two-month and five-month follow-up sessions, in which the progress of the patients were assessed. Results: The mixed model analysis revealed that elderly adults in the combination experimental group had significant improvements compared with the other two groups on fear of falling, depressive inclination, mobility, and muscle strength at five months. The incidences of falls, post intervention, in both experimental groups were significantly lower than those in the comparison group. Conclusions: The results suggest that the combination intervention helped elderly residents manage their fear of falling and falls, decrease their depressive inclination, and enhance their mobility and muscle strength.

Keywords: fear of falling; nursing homes; randomize controlled trial

Introduction

Fear of falling (FOF) is a common experience among

elderly adults living in long-term care institutions. Previ-

ous studies have estimated that approximately 40%�75% of this population has an FOF (Lach & Parsons, 2013).

The FOF may result in restriction and avoidance of activi-

ties, which in turn causes a loss of muscular strength,

increased risk of falls, depression, and an interference

with quality of life (Lach & Parsons, 2013). Although

older residents of facilities may be frailer than those who

live in a community or home-based setting, one meta-

analysis revealed that community-based or home-based

setting interventions were more effective than facility-

based interventions in decreasing FOF (Jung, Lee, & Lee,

2009). Most of the decreasing-FOF facility-based inter-

ventions were exercise programmes.

The FOF is impacted not only by physical conditions

but also impacted by psychological and cognitive factors,

therefore Jung et al. (2009) suggested that FOF treatment

interventions should involve cognitive reconstructing and

behavioural changes to reduce FOF amongst the elderly.

However, none of the studies combined cognitive-behav-

ioural (CB) strategies and an exercise programme to

reduce FOF among elderly nursing home residents.

Exercise and fear and falling

Exercise can reduce the number of falls (EI-Khoury,

Cassou, Charles, & Dargent-Molina, 2013), thus reducing

FOF (Huang, Yang, & Liu, 2011). Decreased fitness of

the lower extremities is a potentially modifiable fall risk

factor (Rubenstein, 2006; Shigematsu et al., 2008). The

elderly often have difficulty with controlling their body

effectively while transitioning between different physical

activities, which can interfere with their ability to prevent

themselves from falling (Yo, Jwo, Wu, & Lin, 2007).

Exercise can increase the performance of muscle strength

and mobility (Chen, Huang, & Cheng, 2005; EI-Khoury

et al., 2013).

Based on literature review, only seven intervention

programmes with an exercise treatment component have

been developed for older people in long-term care institu-

tions and assessed for their effects on FOF decrease in

randomized clinical trials (Donat & Ozcan, 2007; Gusi et

al., 2012; Nowalk, Prendergast, Bayles, D’Amico, &

Colvin, 2001; Schoenfelder, 2000; Schoenfelder &

Rubenstein, 2004; Sihvonen, Sipila, Taskinen, & Era,

2004; Southard, 2006). The exercise approaches have

included strengthening ankle muscles and walking train-

ing (Schoenfelder, 2000; Schoenfelder & Rubenstein,

*Corresponding author. Email: [email protected]

� 2015 Taylor & Francis

Aging & Mental Health, 2016

Vol. 20, No. 1, 2�12, http://dx.doi.org/10.1080/13607863.2015.1020411

2004); Tai Chi and resistance/endurance exercise (Now-

alk et al., 2001); using a computerized force platform with

visual feedback for balance training (Sihvonen et al.,

2004); balance-retaining exercise (Southard, 2006); an

exercise programme combining balance training, strength-

ening and stretching of the lower limbs, increasing flexi-

bility, posture exercises and functional activities (Donat

& Ozcan, 2007); as well as focusing on balance/rebalance

and weight changes training with the Biodex Balance

system (Gusi et al., 2012). The frequency of exercise pro-

grammes was two to three times per week for 4 weeks

(Sihvonen et al., 2004; Southard, 2006), 8 weeks (Donat &

Ozcan, 2007), 3 months (Gusi et al., 2012; Schoenfelder,

2000; Schoenfelder & Rubenstein, 2004), or 13�18 months (Nowalk et al., 2001). The duration of each

section lasted approximately 20 minutes (Schoenfelder,

2000; Schoenfelder & Rubenstein, 2004; Sihvonen,

Sipila, Taskinen, & Era, 2004; Southard, 2006) or 50

minutes (Donat & Ozcan, 2007). They were provided by

group-base (Donat & Ozcan, 2007; Schoenfelder, 2000;

Schoenfelder & Rubenstein, 2004) or individual-base

(Nowalk et al., 2001; Sihvonen et al., 2004). Most previous

studies found that the FOF was not significantly decreased

by the exercise programmes (Lach & Parsons, 2013). In

the study of Schoenfelder and Rubenstein (2004), only par-

ticipants using assistive devices for ambulation benefited

from the exercise intervention for decreasing their FOF.

Gusi et al. (2012) demonstrated their exercise intervention

was effective on the decrease of FOF immediately after

the intervention. The subsequent effect was not evaluated.

Further studies are needed for developing more effective

exercise programmes and evaluating their subsequent

effect for ameliorating the FOF for the elderly adults resid-

ing in long-term care facilities.

Cognitive-behavioural therapy and fear of falling

The goal of CB is to attenuate symptoms tied to automatic

thoughts and emotions about the FOF (Haby, Donnelly,

Corry, & Vos, 2006). Counsellors arrange for specific

learning experiences to help those affected by FOF iden-

tify, evaluate, and alter automatic thoughts and emotions

associated with falling (Gitlin et al., 2006; Tennstedt et

al., 1998). When older adults feel comfortable discussing

their fears and ask for assistance in fearful situations

(Brouwer, Walker, Rydahl, & Culham, 2003; Legters,

2002), the healthcare personnel and caregiver can plan

and execute the fall avoidance and fear prevention strate-

gies effectively. Although several studies supported the

effect of CB interventions (Tennstedt et al., 1998; Zijlstra

et al., 2009; Zijlstra et al., 2011; Zijlstra et al., 2013) as

well as interventions combined with CB and exercise

(Huang et al., 2011; Liu & Tsui, 2014) on decreasing the

FOF among community-dwelling elderly, there have no

CB interventions developed for reducing FOF among

elderly nursing home residents. Compared with the com-

munity-dwelling elderly, the nursing-home elderly were

frailer and more had cognitive impairment. The CB inter-

vention developed by Huang et al. (2011) is simple and

designed specifically for older adults; thus, it may also be

effective on reducing FOF among elderly nursing home

residents.

The fear of falling management model

The FOF management model (Huang 2005) illustrates the

process of the FOF management of the elderly. The FOF

occurs when the elderly believe that the falling is inevita-

ble. Such misconception may cause the elderly chose to

withdraw rather than deal with their FOF. When dealing

with the FOF, the elderly may adopt the risk-prevention

attitude, pay attention to environmental safety, and mod-

ify their behaviours. The FOF tends to be relieved when

the elderly adult feels satisfaction with the result and the

strategies supported by their caregivers.

Depression, mobility, muscle strength, and fear of falling

Several studies found that there is a reciprocal relationship

between depression and FOF (Lach & Parsons, 2013), and

both are risk factors of falling among the aged (Sj€osten, Vaapio, & Kivel€a, 2008). People with depressive mood may be pessimistic and view things in a negative aspect.

Thus for frail elderly with depressive mood, their concern

of falling may be higher than those without depressive

mood. The improvement of depressive symptoms may be

associated with the decrease of FOF.

The adequate muscle strength and balance ability are

needed for safe movement, thus preventing falling. The

falling experience is associated with FOF (Lach & Parsons,

2013). Interventions that promote muscle strength and

balance may further decrease the FOF of elderly.

We believed the combination of exercise and CB

interventions could improve the elderly adults’ muscle

strength, mobility, and depressive mood, thus decreasing

the FOF, and the frequency of falls. The FOF interven-

tions implemented in this study used two major strategies:

CB strategies (Huang et al., 2011) and exercise interven-

tion, which are feasible for nursing home residents. We

compared the effectiveness of the designed combined

intervention with comparison and CB only groups on pri-

mary outcomes (FOF and falls), and secondary outcomes

(mobility, depression, and muscle strength) of elderly resi-

dents in nursing homes for over five months.

Methods

Procedure

This study was a prospective; a randomized control trial

conducted in northern Taiwan from July 2008 and June

2009. Participants were recruited from six nursing homes

located in northern Taiwan. A research assistant (RA)

obtained written informed consent for each participant.

The first author used a computer-developed table to ran-

domize patient assignment to each of the three groups in

each nursing home. Allocation was concealed from the

recruiting RA.

The group interventions were conducted at the non-open

area in each nursing home. Participants in all three groups

Aging & Mental Health 3

were assessed and interviewed in their own rooms or the

conference room of the nursing home for outcomes evalua-

tion at baseline, two months, and five months. An RA who

was blinded from the group allocations assessed the test

subjects. All of the staff and participants in the nursing

homes were reminded to not discuss group allocations with

the RA. Data were also collected at baseline on participants’

age, gender, education, marital status, living status, chronic

diseases, falls-related history, and admitted FOF.

Approval for this trial was obtained from the local

Research Ethics Committee (No. 95-1363B). Each partici-

pant was assured of confidentiality and the option to

decline participation or withdraw from the trial at any time.

Sample

Based on the score of the geriatric fear of falling measure-

ment (GFFM, Huang, 2006) of the combined group in this

study, to reach the statistic power of 80%, a sample size

of 24�26 in each group is sufficient. The mean score of the GFFM at the pre-test was 54.04 (SD D 6.98), and at second post-test was 49.54 (SD D 7.24). To detect a between-group difference in GFFM scores at 80% power,

a D .05, and two-sided test, use the model of N D (s) (Z1�a/ 2 C Z1�b) / (m�m0)2 (Pagano & Gauvreau, 2000), 21 participants were needed in each group.

The inclusion criteria included patients who were:

65 years or older, a mini-mental State Examination

(MMSE) �13 (Clark, Tucke, & Whitlatch, 2008), ability to communicate in Mandarin or Taiwanese, and ability to

ambulate independently or with an assistive device. The

exclusion criteria included patients who: had an unstable

physical condition or evidence of an end stage terminal

illness. During the study period, there were 360 nursing

home residents. Among them, 262 were excluded

(Figure 1); therefore, 98 potential subjects remained.

Because of the concerns about physical loads and compli-

cations of exercise, such as falling, most of the elderly res-

idents were hesitant to start an exercise programme. After

explaining the goals and procedure of this study by the

researchers, 18 residents refused to participate. Of the 80

elderly adults recruited for this trial, 5 withdrew during

the five-month study (3 relocated, and 2 were hospital-

ized). Therefore, the final sample consisted of 75 partici-

pants (Figure 1). The dropouts and non-dropouts were

similar in the baseline data. The attendance rate of those

non-dropouts was 100%.

Intervention

At baseline, all three groups received a brochure explain-

ing how to prevent fall incidents.

Comparison group. Participants in the comparison group

received the same routine care before participation and in

the study.

CB alone group. The CB group received an intervention

of a previous study (Huang et al., 2011) which is adapted

from the FOF management model developed by the first

author (Huang, 2005). The CB intervention consisted of

eight weekly sessions lasting 20�25 minutes, with groups of six to eight participants. The main strategy was to

restructure misconceptions to help the elderly adults

understand the risks of falling as well as promote the idea

that fears of falling are controllable. Each session covered

the following topics: (1) introduction (defining falling and

FOF); (2) the risks of falling and FOF; (3) the consequen-

ces of falling and FOF; (4) associations with falls or FOF;

(5) participants’ point of view of FOF (positive and nega-

tive aspects regarding the topic); (6) strategies to manage

FOF and family support; (7) implementation in the partic-

ipants’ daily life; and (8) problem solving (learning how

to fall, stand up, and call for help when falling does

occur). Participants in this group needed to complete all

eight sessions of the CB intervention. Each session was

conducted by a trained facilitator who was a nurse quali-

fied in geriatrics nursing.

CB plus exercise group. Participants of this combina-

tion-intervention group received the same CB intervention

as those in the CB group in addition to exercise training.

Based on the previous studies (Donat & Ozcan, 2007;

Schoenfelder, 2000; Schoenfelder & Rubenstein, 2004),

we developed the exercise programme in this study. The

eight week supervised exercising took place twice a week

for about 30 minutes each time. The objective of the inter-

vention was to improve the participants’ upper and lower

limb strength and endurance. The exercise was performed

in groups of six to eight participants and was supervised

by two geriatric nurses experienced in working with

frailer older people. They were trained by the principal

investigator to safely supervise correct performances of

the exercise intervention.

A description of the exercise intervention is shown in

Table 1. For upper limb exercise participants in the group

used a handgrip Swiss ball (5 seconds) from a sitting posi-

tion then raised plastic bottles filled with water in each

hand (5 seconds). For lower limb exercise, participants in

the group performed ankle-strengthening exercises (ankle

joint dorsiflexor (10 seconds) and plantar flexor) as well

as elevation knee exercise (10 seconds). Lastly, partici-

pants performed a rising-from-chair motion exercise

while gripping parallel bars.

The amount of exercise, i.e. the amount of times or

repetition of the exercise was set using the Borg scale.

Each participant’s perception of the exercise was within

the range of 12 to 13 (somewhat difficult).

Measures

Primary outcomes: FOF and falls. The GFFM (Huang,

2006) and falling efficacy scale (FES) were used to mea-

sure the FOF (Tinetti, Richman, & Powell, 1990). The 15-

item GFFM assesses participants’ FOF in three domains:

psychosomatic symptoms, adopting an attitude of risk pre-

vention, and modifying behaviours. Responses to items

are indicated on a Likert-type scale from 1 (not at all

concerned) to 5 (very concerned), with higher scores

4 T.-T. Huang et al.

indicating greater concern. Cronbach’s a for the GFFM in

this study was 0.88.

The FES assesses respondents’ confidence in conduct-

ing ten non-hazardous activities of daily living that

require transferring, bending, reaching, or walking

(Tinetti et al., 1990). Responses range from 1 to 10, with

higher scores indicating greater confidence in maintaining

daily activities. The Chinese version of the FES had a

two-week, test�retest reliability of 0.90 (Huang & Acton, 2004). Cronbach’s a of the Chinese FES in this study was

0.98.

The number of falls was recorded using the Falls

Record Checklist (Huang & Acton, 2004). Falls are

defined as losing one’s balance such that one’s part of

Enrollment

Allocation

Follow-up

Analysis

Assessed for eligibility (N=360)

Excluded (n=262) MMSE <13 (n=197) Age <65 years old (n=17) Can’t ambulate independently or with

an assistive device (n=43) Hard of hearing or Aphasia (n=5)

Discharge from nursing home before post-test 2 (n=1)

Allocated to CB and Exercise

(n=27)

Allocated to CB alone (n=27)

Discharge from nursing home before post-test 1 (n=1)

Hospitalized at post-test 1 (n=1)

Randomised (n=80)

Analysed (n=26)

Allocated to Comparison

(n= 26)

Analysed (n=25)

Discharge from NH before post-test 1 (n=1)

Hospitalized at post –test 1 (n=1)

Analysed (n=24)

Refused to participate (n=18)

Figure 1. Participant enrolment and flow for this randomised trial.

Table 1. Exercise schedule.

The 1st 4-week The 2nd 4-week

Exercise\stage Time Repetition Set Break between sets Repetition Set Break between sets

Warm-up 50 Stretch and range of motion (ROM) Main 200

Grip ball 10 3 103000 15 3 10

Ankle 10 2 103000 15 2 10

Upper limb elevation 10 3 103000 15 3 10

Knee elevation 10 2 103000 15 2 10

Rising-from-chair 1�5 times 3�10 times Cool-down 50 Deep breath and relax

Aging & Mental Health 5

body touches or hits the ground. To achieve greater accu-

racy in the number of falls during the study period, we

collected data from chart record, accident report, in charge

staff, and participants.

Secondary outcomes: depression, mobility, and muscle

strength. Depression was measured by the Taiwanese

depression questionnaire (TDQ). The TDQ measures

emotional, cognitive, and physical aspects of depression.

The TDQ also meets the diagnostic criteria for major

depressive disorder described in the Diagnostic and Statis-

tical Manual of Mental Disorders, Fourth Edition (DSM-

IV). TDQ is a culturally specific depression self-rating

instrument. Responses are rated from 0 (normal) to 3

(most severe), and range from 0 to 54. Previous studies in

Taiwan revealed that the TDQ had a sensitivity of 0.89

and specificity of 0.92 at a cut-off score of 19 (Lee et al.,

2000). Cronbach’s a was 0.90�0.91 (Lee et al., 2000; Wang, 2004). In the present study, Cronbach’s a was

0.91.

Mobility (gait and balance) was assessed using the

Tinetti Mobility Scale (Tinetti, 1986), which was used in

several Taiwanese studies (Chen et al., 2012; Huang &

Wang, 2009). The relationship between the subject’s per-

formance and the score conveys the participant’s perfor-

mance; if he or she did well, then the score will be high.

The maximum scores for gait and balance were 12 and

16, respectively. Balance and gait scores were summed to

give an overall mobility score. Low mobility scores

(<14§6) have been associated with recurrent falling (Tinetti, 1986). Gait scores < 9 and balance scores < 10

were also independent predictors for recurrent falls. Inter-

rater reliability for assessing differences in balance and

gait scores of 10 subjects was <10% in all cases (Tinetti,

1986). Cronbach’s a of the Tinetti mobility scale in this

study was 0.89.

Muscle strength was measured three times using a

Micro FET2 (Hoggan Co., Ltd.) on all extremities, and

the greatest value (lbf) was recorded as the maximum

muscle strength. A physical therapist that was blind to

group allocations measured both arms and legs of each

participant. The maximum knee extensor muscle strength

was measured since it is related to standing and mobility

(Kato, Izumi, Hiramatsu, & Shogenji, 2006; Nishijima

et al., 2004). Participants were asked to sit on a chair

while the physical therapist placed the transducer on the

anterior surface of the lower leg proximal to the ankle, and

then participants were asked to extend their knee as far as

they could. Maximum shoulder flexion muscle strength

was measured as it is related to arm movement and helps

the body balance (Widmaier, Raff, & Strang, 2008).

Participants were asked to sit on a chair while the physical

therapist placed the transducer on the anterior surface of

the upper arm proximal to the elbow, and then participants

were asked to extend the elbow as much as possible.

Analysis

Statistical analyses were performed using SPSS 18.0

(SPSS Inc., Chicago, IL). Analysis of variance, x 2 test/

Fisher’s exact test, and Kruskal�Wallis statistics were used to test for differences among the three groups at

baseline and subsequent follow-up. Changes in outcome

variables at various follow-up times were predicted using

a mixed model approach with an intent-to-treat approach

whereby all randomised participants were included, and a

mixed model was used to account for missing follow-up

data. The t-test and Mann�Whitney U-test was used for post hoc test.

Results

Comparison of three groups at baseline

Regardless of the change from 80 participants at baseline

to 75 participants at the five-month follow-up, about half

were male, had more than six years education, most had a

history of falling during the past year, were taking medica-

tion that may induce orthostatic hypotension, and admitted

to having an FOF (Table 2). Based on literature review, in

Taiwan, there were no data related to the average age of

residents in the long-term care facility. Thus, we could not

be assured of whether our participants represent the popu-

lation of the long-term care facility residents in Taiwan.

These groups were well balanced for baseline demo-

graphic characteristics, falls-related history (Table 2), an

FOF, depressive symptoms (Table 5), falling (Table 4),

mobility, as well as muscle strength (Table 5).

Impact of experimental programmes on outcomes

Elderly adults in the CB with exercise combination exper-

imental group had significantly better outcomes at five

months than the comparison group for all indicators. Also,

the elderly in the CB only group had significantly better

GFFM at two months, and lower incidence of falling at

five months than the comparison group.

Primary outcomes: fear of falling and falls. In terms of

FOF, the average GFFM scores for the CB with exercise

combination groups decreased from 54.04 (SD D 6.98) at baseline to 49.54 (SD D 7.24) at the five-month follow- up, whereas scores for elderly adults in the CB alone and

comparison group changed over the same period from

52.26 (SD D 4.88) and 55.42 (SD D 8.39) to 52.76 (SD D 5.88) and 54.50 (SD D 6.19), respectively (Table 3, Figure 2). Differences among the three groups were

shown by mixed-model analysis to be significant (interac-

tion effect, F D 10.95, p < 0.001). These results indicate that the decreased FOF of elderly adults in the combina-

tion experimental group was significantly higher at five

months than that of the comparison group (F D 3.80, p < 0.05) (Table 3).

The mean FES scores of elderly adults in the combina-

tion group rose from 24.33 (SD D 6.87) at baseline to 30.31 (SD D 6.19) at the five-month follow-up, whereas scores for the elderly in the CB alone and comparison

group decreased from 25.37 (SD D 8.10) and 26.96 (SD D 8.09) to 22.00 (SD D 8.94) and 22.75 (SD D 8.42), respectively (Table 3, Figure 3). FES among the three

6 T.-T. Huang et al.

groups was shown by mixed-model analysis to be signifi-

cantly different (interaction effect, F D 12.88, p < 0.001). The mean FES score, which indicated the confidence in

maintaining daily activities, of the combination group was

considerably higher than those of the comparison group at

the five-month follow-up (F D 3.74, p < 0.05) (Table 3). The average numbers of falls (during the three-month

period before and after intervention) were shown in

Table 4. The incidences of falls among participants at

post-intervention were lower than those at pre-interven-

tion in the combination (6 vs. 0) and CB alone (3 vs. 0)

groups. Also, the fall rate among the three groups was sig-

nificantly different (by Kruskal�Wallis statistics) during the three-month period after the interventions (x

2 D 16.16, p < 0.001) (Table 4).

Secondary outcomes: depressive symptoms, mobility, and

muscle strength. The three groups were shown by

mixed-model analysis to be significantly different for

depressive symptoms (interaction effect, F D 15.43, p < 0.001). Participants who received the combination inter-

vention reported lower depressive symptoms than those in

Table 2. Participants’ baseline characteristics (N D 80, 75). CB C exercise (n D 27, 26) CB (n D 27, 25) Comparison (n D 26, 24)

Variables Group N mean % SD n mean % SD n mean % SD p-value

Gender �

0.45 (0.28)

Male 14 (14) 51.9 (53.8) 11 (10) 40.7 (40.0) 15 (15) 57.7 (62.5)

Female 13 (12) 48.1 (46.2) 16 (15) 59.3 (60.0) 11 (9) 42.3 (37.5)

Education years �

0.17 (0.11)

�6 years 16 (16) 59.3 (61.5) 11 (10) 40.7 (40.0) 9 (8) 34.6 (33.3) > 6 years 11 (10) 40.7 (38.5) 16 (15) 59.3 (60.0) 17 (16) 65.4 (66.7)

Falls Hx. during past year

� 0.18 (0.28)

Yes 14 (14) 51.9 (53.8) 19 (17) 70.4 (68.0) 12 (11) 46.2 (45.8)

No 13 (12) 48.1 (46.2) 8 (8) 29.6 (32.0) 14 (13) 53.8 (54.2)

Medicines taken induce orthostatic hypotension

��

1.0 (0.99)

Yes 25 (24) 92.6 (92.3) 25 (23) 92.6 (92.0) 24 (22) 92.3 (91.7)

No 2 (2) 7.4 (7.7) 2 (2) 7.4 (8.0) 2 (2) 7.7 (8.3)

Admitted FOF ��

0.40 (0.58)

Yes 25 (24) 92.6 (92.3) 22 (21) 81.5 (84.0) 21 (20) 80.8 (83.3)

No 2 (2) 7.4 (7.7) 5 (4) 18.5 (16.0) 5 (4) 19.2 (16.7)

Age ���

79.1 (79.4) 7.0 (6.9) 77.9 (78.4) 7.3 (7.3) 81.3 (81.0) 5.3 (5.4) 0.18 (0.40)

MMSE ���

24.3 (24.2) 4.3 (4.9) 24.1 (24.0) 4.3 (4.4) 22.2 (22.5) 4.5 (4.5) 0.21 (0.38)

BMI ���

22.3 (22.5) 3.7 (3.7) 23.9 (23.8) 2.7 (2.4) 22.3 (22.2) 2.9 (2.9) 0.10 (0.14)

ADL ���

56.3 (56.5) 23.4 (23.9) 60.4 (60.4) 15.8 (16.3) 58.9 (59.6) 23.2 (24.0) 0.77 (0.80)

No. of chronic diseases ���

3.1 (3.1) 1.0 (1.0) 2.6 (3.0) 0.8 (0.8) 3.1 (3.5) 1.0 (1.5) 0.09 (0.21)

Note: The numbers are based on 80 participants at baseline; the numbers in parentheses are based on 75 participants who completed the trial. p-value: � x 2

test; �� Fisher’s exact test;

��� ANOVA.

Table 3. Effects of interventions on five-month primary outcomes for elderly nursing home residents by group.

CBCexercise a (N D 26) CBb (N D 25) Comparisonc (N D 24) ANOVA Mixed model Variables Mean (SD) Mean (SD) Mean (SD) F Post hoc Time Group TxG

FOF

GFFM 37.87 ���

9.04 ���

10.95 ���

Pre 54.04 (6.98) 52.26 (4.88) 55.42 (8.39) 1.41

Post 1 47.15 (5.48) 47.24 (5.65) 55.71 (9.24) 12.38 ���

a,b<c

Post 2 49.54 (7.24) 52.76 (5.88) 54.50 (6.19) 3.80 �

a<c

FES 4.76 �

2.17 12.88 ���

Pre 24.33 (6.87) 25.37 (8.10) 26.96 (8.09) 0.78

Post 1 26.41 (6.42) 23.64 (9.72) 20.21 (7.38) 8.65 ���

a>b,c

Post 2 30.31 (6.19) 22.00 (9.72) 22.75 (8.42) 3.74 �

a>c

Note: a CB C exercise group, bCognitive-behavioural (CB) group, cComparison group.

GFFM D Geriatric fear of falling measure; FES D falling efficacy scale; TDQ D Taiwanese depression Questionnaire; p � < 0.05;

�� < 0.01;

��� < 0.001.

Aging & Mental Health 7

the CB alone and the comparison group at two-month fol-

low-up, but only approached the significant level (F D 3.05, p D 0.053) at the five-month follow-up (Table 5).

The average mobility scores for the combination and

CB alone groups rose from 11.19 (SD D 7.36) and 9.15 (SD D 5.55) at baseline to 15.23 (SD D 8.49) and 9.68 (SD D 6.77), respectively at the five-month follow-up, whereas scores for elderly adults in the comparison group

over the same period decreased from 13.85 (SD D 6.90) to 10.17 (SD D 6.99). Mobility among the three groups changed significantly over time as demonstrated by the

mixed-model analysis (interaction effect, F D 13.59, p < 0.001) (Table 5). The mean mobility score of the combi-

nation group was higher than that of the CB alone and

comparison groups (F D 4.31, p < 0.05) at the five-month follow-up (Table 5). The gait and balance scores among

the three groups changed significantly over time as dem-

onstrated by mixed-model analysis (F D 9.01 and 15.96, respectively, p < 0.001).

Muscle strength of extremities (right upper limb [RU],

left upper limb [LU], right lower limb [RL] and left lower

limb [LL]) among the three groups changed significantly

over time as demonstrated by the mixed-model analysis

(F D 5.56, 4.57, 5.10 and 5.96, p < 0.001 or 0.01, respec- tively) (Table 5). The muscle strength of the lower

extremities for the three groups was significantly different

after the intervention (F D 4.22 and 3.53, respectively, p < 0.05). However, they were not significantly different at

the five-month follow-up (p > 0.05) (Table 5). The

descriptive data showed that the mean of the muscle

strength of the four extremities (especially for both lower

limbs) were higher at the five-month follow-up for the

combination group than those of the CB alone group and

the comparison group.

Discussion

This study is the first trial that uses a combined CB and

exercise intervention to reduce FOF among nursing home

elderly residents. Previous intervention studies for reduc-

ing FOF targeting nursing home elderly residents included

only exercise interventions, but no CB interventions to

help the participants with cognitive reconstruction and

behavioural changes. The merit of our trial is that it

involved two forms of intervention that could be used in

clinical practice. In this study, participants receiving the

CB only intervention had a lower GFFM score at the two-

month follow-up, and less post-intervention falls com-

pared with the elderly in the comparison group. The effec-

tiveness of the combination intervention was better than

the CB only intervention. The findings from the current

study support our idea that when elderly residents of nurs-

ing homes received the combination intervention, they

had less of a fear for falling, better falls efficacy, less fall-

ing, a decrease in depressive symptoms, better mobility

(gait and balance), and increased muscle strength on

extremities compared with the elderly in the comparison

group.

From our findings, participants in both experimental

groups decreased their GFFM scores after the interven-

tions, but only the elderly participants in the combined

Table 4. The falls among three groups before and after intervention for three months.

CBCexercise a (N D 27, 26) CBb (N D 27, 25) Comparison c (N D 26, 24) Variables Mean SD Mean SD Mean SD x

2 p Post hoc

Pre-intervention falls 0.22 0.42 0.11 0.32 0.15 0.37 1.23 0.54

(incidence) (6) (3) (4)

Post-intervention falls 0.00 0.00 0.00 0.00 0.42 0.78 16.16 <0.001 a,b<c

(incidence) (0) (0) (10)

Note: a CB C Exercise group, bCognitive-behavioural (CB) group, cComparison group.

Pre-intervention falls: one time for each falling subject; Post- intervention falls: among the seven fallers, five of them falling once during the three-month period, another one had two fallings, and the other one had three falls at the same period.

Figure 2. GFFM scores stratified by groups over time. Note: CB D cognitive-behavioural group; pre D baseline; post 1 D three-month follow-up; post 2 D five-month follow-up.

Figure 3. FES scores stratified by groups over time. Note: CB D cognitive-behavioural group; pre D baseline; post 1 D three- month follow-up; post 2 D five-month follow-up.

8 T.-T. Huang et al.

group increased their FES scores. Although the GFFM

and FES are both used for measuring the FOF, the FES

measures the self-confidence on delivery the daily living

activity (Tinetti et al., 1990). Based on the theory of man-

aging FOF (Huang, 2005), when the elderly participants

use the FOF strategies and feel satisfaction with the result

and the strategies supported by caregivers, the elderly

tend to manage their FOF better. The CB intervention

may promote the FOF awareness and the FOF-problem-

solving ability of participants, thus promote their help-

seeking behaviours for avoiding falls, which in turn

decreased the fall accidents and FOF. However, partici-

pants in the CB only group did not improve their mobility,

which can be promoted by the exercise intervention which

is consistent with the previous study (Donat & €Ozcan, 2007; Schoenfelder & Rubenstein, 2004), therefore they

did not improve their daily living activity and in turn

reflected on their self-efficacy on the FES scores

(Bandura, 1984).

The FOF is a risk factor for falls, thus further increas-

ing the risk of falling (Gillespie & Friedman, 2007; Gitlin

et al., 2006). In this study, the frequency of falls was dras-

tically decreased in the two experimental groups. The

results were inconsistent with the previous study (Huang

et al., 2011). Huang et al. (2011) implemented the CB

strategies in the community-dwelling elderly for fall pre-

vention, and the effect of the CB strategies was insignifi-

cant. The possible reason for the effectiveness of CB

strategies in this study is due to the characteristics of nurs-

ing home. In nursing homes, nurse aids are responsible for

the care of residents. The CB strategies promoted the par-

ticipant’s insight of fall prevention and facilitated the

Table 5. Effects of interventions on five-month secondary outcomes for elderly nursing home residents by group.

CB Cexercisea (N D 26) CBb (N D 25) Comparisonc (N D 24) ANOVA Mixed model Variables Mean (SD) Mean (SD) Mean (SD) F Post hoc Time Group TxG

TDQ 3.99 ���

4.26 �

15.43 ���

Pre 17.56 (8.19) 19.59 (12.83) 17.32 (12.00) 0.34

Post 1 3.56 (4.03) 17.24 (11.21) 16.50 (10.81) 18.44 ���

a<b,c

Post 2 14.08 (9.44) 18.60 (9.93) 20.50 (9.06) 3.05 �

a<c

Mobility 5.55 ��

3.32 �

13.59 ���

Pre 11.19 (7.36) 9.15 (5.55) 13.85 (6.90) 1.84

Post 1 16.56 (6.51) 10.20 (7.04) 11.63 (8.88) 5.18 ��

a>b,c

Post 2 15.23 (8.49) 9.68 (6.77) 10.17 (6.99) 4.31 �

a>b,c

Gait 5.09 ��

5.46 ��

9.01 ���

Pre 4.26 (3.29) 3.33 (2.51) 4.81 (3.33) 0.77

Post 1 7.22 (3.33) 3.40 (3.16) 4.17 (3.94) 8.82 ���

a>b,c

Post 2 6.77 (4.25) 3.16 (2.72) 4.17 (3.17) 6.80 ��

a>b,c

Balance 6.66 ��

1.70 15.96 ���

Pre 6.93 (4.37) 6.00 (3.33) 9.03 (3.78) 2.56

Post 1 9.33 (3.55) 6.80 (4.15) 7.46 (5.08) 2.47

Post 2 8.46 (4.36) 6.52 (4.19) 6.00 (3.78) 2.51

Muscle strength

RU 3.33 �

0.01 5.06 ���

Pre 8.58 (3.16) 9.40 (7.51) 9.84 (4.49) 0.38

Post 1 10.97 (3.34) 9.42 (6.14) 9.43 (4.45) 0.92

Post 2 9.68 (3.55) 9.46 (6.89) 9.52 (3.74) 0.01

LU 2.91 0.04 4.57 ��

Pre 6.66 (4.71) 8.31 (5.09) 8.05 (2.53) 1.16

Post 1 9.04 (4.33) 7.90 (4.87) 8.02 (2.98) 0.59

Post 2 7.28 (4.30) 7.71 (5.13) 7.93 (2.84) 0.16

RL 8.42 ���

1.37 5.10 ��

Pre 7.33 (3.14) 7.01 (4.46) 7.89 (1.68) 0.37

Post 1 10.30 (4.15) 7.34 (4.76) 7.92 (2.26) 4.22 �

a>b,c

Post 2 9.12 (3.98) 7.21 (5.73) 7.86 (2.84) 1.27

LL 7.25 ��

1.23 5.96 ���

Pre 7.04 (3.60) 7.54 (3.65) 7.12 (2.76) 0.17

Post 1 9.81 (4.85) 7.65 (3.30) 7.19 (2.85) 3.53 �

a>c

Post 2 8.82 (4.76) 7.44 (3.40) 7.07 (2.91) 1.48

Note: a CB C exercise group, bCognitive-behavioural (CB) group, cComparison group.

p � < 0.05;

�� < 0.01;

��� < 0.001.

LU D left upper limb; RU D right upper limb; LL D left lower limb; RL D right lower limb.

Aging & Mental Health 9

development of their strategies for fall prevention. With

improved CB the elderly participants may ask aggres-

sively and timely for help to prevent the falls.

The elderly participants in the combination group

decreased their depressive symptoms dramatically

(17.56 vs. 3.56) after the intervention in this study.

Although at the five-month follow-up, the average score

of TDQ was almost back to the level at baseline, the score

was consistently lower than the average score of CB only

group. The effect may mainly come from the exercise

itself and the social support from our intervention. Previ-

ous studies have revealed that exercise has an effect on

relieving depressive symptoms of the elderly adults

(Akyol, Durmus, Dogan, Bek, & Canturk, 2010; Hill,

Smith, Fearn, Rydberg, & Oliphant, 2007). The exercise

from the interventions may relieve depression by biologi-

cal mechanisms, self-esteem and mastery increase, and

the distraction (Daley, 2002). The social support also

plays an important role on eliminating the depressive syn-

drome (Schwarzbach, Lupp, Forstmeier, K€onig, & Rie- del-Heller, 2014). In the combined group, the social

interaction, which was three times a week for two months,

may have improved participants’ social support. There-

fore when the group interaction ended, the effect of

depression-decrease halted.

The results of this study showed that the elderly in the

combination group improved their mobility (gait and bal-

ance), whereas those in the other two groups did not. The

finding supports the combined intervention, which includes

the effect exercise, has can increase mobility improvement.

Sharaf and Ibrahim (2008) proposed that FOF is experi-

enced more frequently among older adults who had balance

impairment. The improvement of mobility may be a facili-

tating factor for the relief of FOF or vice versa. Chamberlin,

Fulwider, Standers and Medeiros (2005) found that FOF

can influence the spatial and temporal gait parameter

changes in elderly persons. Reducing the influences of FOF

can improve the physical function (Deshpande et al., 2008).

Liu, Lin, and Tang (2008) mentioned that the elderly in

nursing homes demonstrated poorer balance and gait func-

tions because of the FOF. Our intervention may be benefi-

cial for both the relief of FOF and mobility improvement

for residents in long-term care institutions.

Participants in the combination group improved mus-

cle strength in their extremities during this study. How-

ever, same as the mobility improvement, the muscle-

strength-improvement effect on the two-month follow-up

point was not maintained by the five-month follow-up.

The possible reason for the decrease may be that after the

eight-week group programme, participants did not keep

their practice of managing of FOF and exercise regularly.

Morey et al. (2008) targeted elderly adults and found that

attending physical activities regularly can modify the

decrease in function caused by aging. However, if the bar-

riers were not eliminated, regular physical activities

would not be maintained, thus prohibiting the long-term

goal of exercise intervention among elderly adults (Hong

& Chen, 2006). Further intervention may be needed to

eliminate the barriers of residents to maintain the effect

on mobility and muscle strengths.

Limitations

This trial had several limitations. First, regarding sample

size, participants were relatively older adults (mean D 79.59 years, SD D 6.59) who were frail (mean ADL D 58.80, with 3.07 diagnosed diseases). The condition of the

potential subjects means that they were more hesitant to

start an exercise programme. Attrition was also a limitation

in this study. Most of the attrition was due to relocation to

other nursing homes or extended illnesses. Secondary, at

baseline, the MMSE score, and the number of fall history

of combined group were higher than the other two groups.

Although there were no significant differences among three

groups on the scores of MMSE and fall history, such differ-

ence may have some impacts on the results. Third, partici-

pants were followed up over a relatively short period. A

longer follow-up period would better estimate effects of

intervention on long-term management of FOF. Fourth, In

order to control external validity, we randomly assigned

participants to each of the three groups in each nursing

home separately. However, the interactions and informa-

tion sharing between participants from different groups

may have happened. Fifth, since the two experimental

interventions were significantly different, we can only

make a single-blind design. For preventing the RA from

knowing the group assignment of participants, we

reminded staff and participants in the study to not discuss

with the RA about group assignments. Even so, the RA

may notice the group assignment by interacting with

patients. Sixth, we recruited some cognitive impaired par-

ticipants (40%, MMSE < 24). There were some articles

reported that the accuracy of self-report measurement was

doubtful among cognitive impaired people (Clark et al.,

2008; Whitlatch, Feinberg & Tucke, 2005). Although the

above cognitive impaired participants did not reveal any

difficulties when answering the questions of the self-

reported instruments used in this study, it may be necessary

that when recruiting participants with MMSE < 13, the

observation from their caregivers be collected to further

verify the results. As for their involvement of our CB inter-

vention, since the intervention was simple, concise, and

concrete, we had no difficulties on educating the cogni-

tively impaired participants. Finally, participants were ran-

domly allocated into three different groups, and an

exercise only group was not included.

Conclusion

The findings of this study indicate that the CB with exer-

cise intervention is effective for reducing FOF among

older adults in nursing homes. Health professionals in

nursing homes can use this intervention to decrease older

adults’ FOF, falls, depressive mood, and to promote their

mobility as well as muscle strength. To more precisely

study the effects of the intervention, a longer term follow-

up period will be needed.

Acknowledgements

We would like to thank all the study participants for sharing their experiences.

10 T.-T. Huang et al.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by the National Science Council, Taiwan [grant number NSC97-2314-B-182-031-MY3].

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12 T.-T. Huang et al.

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