The Activities-Specific Balance Confidence (ABC) Scale is another tool used to examine confidence in balance, as it relates to fear of falling (Powell & Myers, 1995). Like the FES-I, the ABC is also a brief self-report tool; it asks respondents to indicate on a scale of 0% to 100% their confidence in maintaining their balance while performing a progressively more challenging list of life activities. In contrast to the FES-I, however, this tool targets higher-level balance activities performed while standing, and its sensitivity makes it most appropriate for higher-functioning, ambulatory older adults. Substance abuse According to the Substance Abuse and Mental Health Services Administration (SAMHSA), substance abuse is pervasive among older adults, affecting 1.7 million adults over the age of 50 (2009). Primary substances abused by older adults include alcohol and prescription drugs. A 2011 survey revealed that about 40% of adults age 65 and older consume alcohol (SAMHSA, 2012). Alcohol abuse among older adults is associated with an increased risk of functional difficulties, depression, and memory impairment (Perreira & Sloan, 2002). Drinking alcohol can also compound the effects of prescription and over-the-counter (OTC) medicines, leading to adverse drug interactions (Lynskey, Day, & Hall, 2003). This synergistic effect is particularly problematic for seniors, who typically consume multiple prescription and OTC drugs. Spirituality Spirituality plays an important role in the lives of many older adults (Nelson-Becker, Nakashima, & Canda, 2007), and their spiritual beliefs may impact beliefs about illness and coping with chronic conditions and other life circumstances. Though often viewed interchangeably with religion, spirituality connotes a broader quest for meaning that transcends the human experience and formalized religious affiliations. Spirituality should be explored with older adults whenever it is identified as significant in their lives and relevant to the goals of the helping process (Nelson-Becker et al., 2007). Although he is able to meet the ADL activity demands in the home, there are time issues and convenience issues involved in remaining independent. His personal factors include issues with his self-perception and fears of using the ramp. There is no evidence that his gender, education, or past life experiences are affecting his home management. At this time, the fear of the environment (a personal factor affecting his navigation of the environment) is restricting his participation in his IADLs. This is a personal factor possibly related to a previous mishap on a ramp using his rollator or it may be his natural method of coping, which is to avoid an activity unless someone will support him. It is clear that the decisions he makes with regard to his health condition are influenced by his personal factors and by environmental demands. Physical environment in relation to home safety Although the environment can affect all areas of functioning for older adults, the physical environment is a common area of focus in home safety and falls prevention (Turner et al., 2011). The physical environment includes both structures in the home, such as lighting and design of the bathroom, and factors outside of the home, including entranceways, sidewalks, and railings. Although the physical environment has always been an area of interest for physical therapy practitioners, home modifications have more recently become a focus of the rising population of older adult consumers who are aware of the critical dangers associated with falls. Despite the increased focus and attention on changing physical environments, research suggests that general changes alone do not yield significant results in falls prevention (Lord, Menz, & Sherrington, 2006). However, evidence does suggest that client-centered, person-specific modifications to the physical environment can produce positive outcomes for high-risk older adult populations (Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008;
Anxiety disorders in older adults are more likely to occur in the presence of physical medical conditions, depression, and cognitive impairment. Old age, being female, lower educational levels, and living alone have been identified as risk factors for anxiety disorders (Blay & Marinho, 2012; Gum et al., 2009). Recognizing symptoms of anxiety in older adults is important in physical therapy practice, as the condition impedes participation in daily activities even in the absence of physical performance barriers. If anxiety appears to be hampering the patient’s ability to participate in physical therapy, a referral should be made to a mental health professional, and the referring physician should Over the past two decades, a significant amount of research has led to the recognition that falls in older adults are caused by a complex interaction of both internal and external factors that reflect medical, social, and environmental considerations (Chang & Ganz, 2007; Leland, Elliott, O’Malley, & Murphy, 2012). Fear of falling is a psychological symptom of falls risk and is described as a concern about falling that leads to activity avoidance or reduction (Tinetti et al., 1990). With 35% to 55% of older adults reporting this fear, the implications of fear of falling on participation in ADLs and IADLs become critically important to physical therapy practitioners (Painter et al., 2012; Schepens, Sen, Painter, & Murphy, 2012). While fear of falling may be most quickly confirmed through direct questioning with older adults, other factors, such as balance, confidence, and falls self-efficacy, can be explored to determine the cause and intervention for fear of falling (Schepens et al., 2012). The Falls Efficacy Scale – International (FES-I) is a brief self-report instrument that examines the intensity of concern about falling for both easy and difficult physical and social activities (Peterson & Clemson, 2008; Yardley et al., 2005). Using a four-point Likert scale, the tool assesses confidence for activities such as getting dressed and walking in crowded places. be contacted. Fear of falling Environmental factors Functional performance in older adults is heavily dependent on context and the environment (Bonder, 2009; Talley, 2008). The ICF model includes the consideration of environment as a general term. It is important for physical therapy practitioners to remember that the environment has several attributes. Naturally there is the physical environment in which the patient dwells and functions, but there are also the elements of personal factors such as social and cultural aspects that relate to the patient. The following example illustrates how critical the environment and personal factors may be to functioning in older adults: Sam is a 78-year-old man with type 2 diabetes, neuropathy, and hypertension. He has just been discharged home from subacute rehabilitation after a below-the-knee amputation. Due to poor vision and small length of the residual limb, he has a cosmetic prosthesis only and is non-ambulatory. Sam no longer considers himself a “whole” person. Prior to this episode, Sam was able to independently get out of the building and into the community using a rollator. Currently he is independent at the wheelchair level inside his apartment. He has to deal with the following environmental issues: his bathroom door is too narrow for his wheelchair, so he must hop from the doorway to use the bathroom; also, the carpets in the bedroom make it difficult to propel his wheelchair. It takes much longer to do all of his ADLs than prior to his surgery. His apartment building has a ramp at the entrance and an elevator, but Sam is afraid of the ramp. He is worried that the wheelchair will roll out of control when descending. He is not willing to venture out of the apartment by himself, thus limiting his participation in the community In this example, Sam’s day-to-day functioning is directed or guided by the things he wants, needs, and is expected to do.
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