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A 70-year-old man is brought to the emergency department by his daughter, who is concerned about his increasing loss of mobility. He is using a wheelchair, and is no longer able to get up from a seated position or walk without assistance. They explain that until about a month ago, the patient was not experiencing any gait disorders or neurological signs and symptoms.

The patient's mobility problem developed after he experienced a traumatic fall 1 month prior to admission. He was in a busy hospital lobby when he tripped on his cane and spilled his coffee. Although he was not injured in his fall, a false cardiac arrest code was called, and he was quickly surrounded by a rush of hospital staff.

Before this occurred, the patient had been living on his own. He was shopping, cooking, and dressing himself independently, and had good mobility with a cane.

At admission, the patient is receiving treatment for hyperlipidemia, high blood pressure, and chronic hiccups. In addition, his past medical history includes diabetes mellitus type 2 (controlled through dietary measures), asymptomatic bradycardia, and chronic kidney disease stage IV.

His daily medication regimen includes:

• 40 mg atorvastatin
• 20 mg lisinopril
• 10 mg baclofen

His family history is unremarkable. The family reports that he was a heavy drinker in the past, although they were not able to quantify that claim.

Physical exam results

Notable findings include a blood pressure of 190/60 mm Hg without orthostatic changes, and a pulse of 52. He is friendly and cooperative. His describes his mood as "okay." His affect is appropriate to context, and his cognition is normal.

A cardiac exam notes a 4/6 systolic crescendo-decrescendo murmur in the right upper sternal border. Neurological exam results are normal in terms of facial expressions, speech, and tone. On assessment of his strength, he scores 5/5 in all extremities, with no evidence of tremor, bradykinesia, or abnormal muscular tone. The patient has normal proprioception, vibration, and pain and temperature sensations.

His reflexes are 2+ and he has flexor plantar reflexes (negative Babinski sign). However, he requires two-person assistance to stand. He insists repeatedly that he is too "wobbly" to stand or to walk without assistance.

Evaluation of his mobility finds that while walking with the assistance of four people, he grips the four-legged walker very tightly. Notably, the patient repeatedly seeks reassurance that he is being held and will not be released.

Clinicians assessing his gait note that he takes slower and shorter steps with a broad-based stance. He takes each step with great caution, but he is not shuffling – he lifts his feet to the appropriate height.

The patient's test results are within normal range for hepatic function, blood glucose, metabolic panel, urinalysis, complete blood count with coagulation studies, thyroid function tests, vitamin B12 (545 ng/L), cardiac (including EKG), and pre-albumin tests.

Assessment of the patient's comorbidities results in treatment with lisinopril and furosemide, which stabilizes his blood pressure to baseline. Evaluation of the patient's chronic kidney disease by a nephrologist rules out diabetes-related exacerbations.

The patient has a long-term suprapubic catheter for his obstructive uropathy, so it is not possible to assess him for urinary incontinence. Given the patient's slightly broad-based gait, self-described "wobbliness," and recent memory problems reported by the family, clinicians decide to check him for normal pressure hydrocephalus. A formal neurology consult is negative for evidence of any neurologic deficit.

MRI reveals dilated ventricles without cerebellar degeneration or evidence of prior cerebrovascular accident. That his condition does not improve after removal of cerebrospinal fluid through lumbar puncture makes normal pressure hydrocephalus unlikely; however, clinicians note that the tap test does not rule out normal pressure hydrocephalus.

The patient undergoes the , with a score of 41/64. On further discussion of what might be causing his mobility problem, he explains that he does not think he has a physical problem, but rather that he is simply afraid of falling, saying "no one in the world has a greater fear of falling than I do." He requests psychiatric help to overcome his fears.

Treatment

To help manage his anxiety, clinicians prescribe a daily bedtime dose of escitalopram 5 mg. He is discharged and continues with this treatment, under the care of an appropriate outpatient provider. In addition to skilled physical therapy 5–6 times per week, he receives daily cognitive behavioral therapy and encouragement to address his fear of falling.

After just 3 days of treatment, he is improved to the extent that he needs only single-person assistance for ambulatory support. At the end of day 5, he can stand on his own and his walking distance using a walker is significantly increased with minimal single-person assistance.

Importantly, clinicians also educated the patient's family about FOF gait and the required treatment regimen. Clinicians explained that FOF is a legitimate disorder, and that the patient is not malingering, but could recover with appropriate treatment.

Case follow-up

The patient plans to start tai chi group exercises for older adults upon his discharge to a sub-acute rehabilitation facility. Unfortunately, the skilled nursing facility where he is admitted does not offer the recommended cognitive behavioral therapy with skilled physical therapy.

Three months later, when he is readmitted to the hospital for a urinary tract infection, he has regressed to the state he was in at the time of prior admission.

Discussion

Clinicians reporting this note that fear of falling is a debilitating and commonly missed new-onset gait abnormality which, when detected, can be rapidly reversed.

Missed diagnosis of this pervasive and serious problem in the elderly often results in inappropriate treatment as a medical emergency, making it important to assess "fall history" and fear of falling in older adults, case authors note.

The fear of falling gait often goes undetected, mistaken for organic neurologic conditions. FOF was first reported in 1982 in a cohort of 36 patients who were unable to walk unsupported after experiencing a fall. These patients also presented with a significant tendency to clutch and grab, and had increased short-term mortality.

Fear of falling syndrome (FOF) is now characterized as the psychological trauma endured after a fall, which results in perpetual anxiety about falling or loss of confidence in balance abilities, leading to reduced activity and loss of physical capabilities, case authors report.

FOF does not necessarily involve a fall, authors write; it may be caused by the interplay of physical, psychological, and functional influences. About one in three adults ages 65 years or older in the U.S. report being moderately or very afraid of falling. Women, people ages 75 years or older, single individuals, and those with lower income are more likely to be affected. Research suggests that FOF may be under-reported by men, due to the stigma associated with reporting fears.

A temporal relationship with a recent fall has been widely noted, with 29%–92% of older adults developing FOF following a fall. Notably, injury from a fall does not increase risk of FOF. However, an individual who develops FOF is then at greater risk of a subsequent fall, due to the increasing self-limited functionality that results from a fear of standing or walking.

Assessment of fear of falling

As in this patient's case, initial workup involves ruling out organic causes of gait instability based on history and physical exam, including a comprehensive neurological exam. Potential organic causes include alcoholic cerebellar degeneration, vascular dementia, and normal pressure hydrocephalus.

The Falls Efficacy Scale-International

This instrument's target population is older adults, either with or without FOF. Patients are objectively assessed using 16 questions regarding their concerns of falling during physical and social activities. Answers are graded on a 4-point scale, from 1 (not at all concerned) to 4 (very concerned).

Total scores range from 16 to 64: cut-points differentiate between low, moderate, and high concern about falling (low 16–19, moderate 20–27, and high 28–64), with the mean score and standard deviation being 22.6±6.4 for older adults, irrespective of falling history.

Case authors note that with a score of 41, their patient was approximately 3 standard deviations above the mean and in the category of high concern for falling.

In addition to accurately predicting future falls, the FES-I accurately predicts physiological fall risk, muscle weakness, overall disability, and depressive symptoms.

Recognizing the fear of falling gait

The FOF gait, or "cautious gait," involves several specific patterns of ambulation including those noted in this patient – a slightly lowered center of mass (crouched posture), broader base, and shorter stride – as well as shuffling of feet and diminished foot-floor clearance, which were not observed in this case, case authors note.

They cite a recent controlled study which reported that patients with FOF have a slower walking gait velocity, yet other balance and gait parameters were unaffected (e.g., stride-length variability, stride-time variability, mediolateral angular displacement, and mediolateral angular velocity). Based on their observations, researchers concluded that patients with FOF adapted their gait mechanism to enhance balance, without demonstrating decreased balance control.

One theory that accounts for the balance adaptation suggests that the anxiety that accompanies FOF taxes the cognitive demands required for gait and balance control. However, the same study reported that performance of dual tasks in FOF gait were unaffected, thus contradicting the hypothesis, case authors observe.

In contrast, for static patients, several studies have noted decreased balance and postural control, such as increased postural sway and stiffness. Another study suggested that the most common features of FOF patients are retropulsion in stance and anxiety about movement.

FOF management and treatment

As this case report demonstrates, appropriate and timely can alleviate FOF-related morbidity and mortality. There have been few clinical trials assessing intervention efficacy. Generally, the goal of treatment is to establish the patient's confidence and perceived control over falls through patient education with reassurance, physical therapy, and psychological and pharmacological treatment of the underlying anxiety.

Randomized controlled trials have shown that appropriate cognitive-behavioral changes can reverse patients' cycle of activity restriction and gait abnormalities.

A home safety checklist and a home assessment with appropriate safety modifications have also been shown to improve patients' sense of environmental control.

Consolidation of medications, either by switching the patient to a safer alternative or reducing the medication to the lowest effective dose, can also reduce the risk of drug-induced falls.

Classes of medications associated with falls include:

• Anticonvulsants
• Benzodiazepines
• Opioids
• Antipsychotics
• Sedative-hypnotics
• Anticholinergics
• Antihistamines
• Muscle relaxants
• Antihypertensives
• Antidepressants (tricyclics, fluoxetine, paroxetine, sertraline, fluvoxamine)

When accompanied by the support and encouragement of family/friends, assertiveness training that teaches the patient to ask for assistance when they are in a fearful situation, and to openly discuss their fear also promotes better outcomes.

In one study, patients who are able to openly discuss their FOF with family, friends, and healthcare providers were found to more likely remain physically active.

Case authors emphasize that for optimal results, community or home-based interventions should be continued for at least 4 months. Physical therapy transitioning to long-term group fitness programs has significantly improved balance and mobility and decrease fall risk; daily group tai chi or chair exercises have also been found to be helpful. Medical comorbidities contributing to falls should also be addressed, along with mental health problems such as anxiety and depression.

Overall, case authors conclude that FOF gait can be reversed using a multidimensional and multidisciplinary approach focused on confidence building, cognitive-behavioral changes, education, assertiveness training, and environmental modification. However, as uniquely noted in this case, patients are at significant risk for regression without treatment follow-through.

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