Exposure Therapy for Fear of Falling in Older Adults

描述(由申请人提供)：大约7%-14%的老年人独立生活在社区，包括超过5%的从未摔倒的人，经历过中度到重度的摔倒恐惧(FF)，并因此避免多项活动。至少有3%的人因为害怕而避免离开家或院子。过量的FF会导致体力活动减少、残疾、丧失独立性、抑郁、焦虑、社交参与度降低，以及生活质量下降。它也是跌倒的一个主要独立风险因素。针对FF的干预措施，通常以小组形式提供，并结合认知结构调整、教育和锻炼，增加与跌倒相关的自我效能。然而，回避对治疗具有抵抗力，参加这些干预的患者中几乎有40%退出了治疗。与自然减员相关的因素包括高水平的FF，这表明最需要此类计划的人是那些最有可能过早退出的人。这些数据表明，治疗中应该有针对性地避免，干预措施应该设计成接触到那些有严重恐惧和回避的人，他们最有可能退出传统的FF计划。然而，尽管FF和焦虑症之间有相似之处，而且大多数焦虑症最有效的行为治疗是暴露疗法，但到目前为止，FF干预还没有纳入暴露成分。总体而言，现有研究表明，需要一种将暴露疗法与其他已被证明有效减少FF的元素相结合的干预措施。这样的干预还必须对患者安全问题敏感。拟议的项目旨在开发一种由物理治疗师提供的居家干预措施--“活动、平衡、学习和暴露”(ABLE)，将暴露疗法和认知结构调整与运动、关于跌倒风险的教育、家庭安全评估以及对患有过量和残疾的FF的老年人的药物审查结合在一起。在开发这一新的干预措施并对20名患有FF的老年人进行试点测试后，我们建议进行一项可行性研究，其中40名患者被随机分配到能够或教育控制的条件下。通过开发和测试一种新的干预措施来解决普遍存在的老年焦虑状况，并具有潜在的破坏性公共健康后果，这一研究路线有望填补知识和临床实践中的一个重大空白。 公共卫生相关性：对跌倒的过度恐惧会导致老年人体力活动减少、残疾、丧失独立性、抑郁、焦虑、社交参与度降低、生活质量下降和跌倒风险增加。然而，尽管FF和焦虑症之间有相似之处，而且大多数焦虑症最有效的行为治疗是暴露疗法，但到目前为止，FF干预还没有纳入暴露成分。这个R34应用程序建议开发一种由物理治疗师提供的居家干预，将暴露疗法和认知重建与运动、关于跌倒风险的教育、家庭安全评估以及针对患有过度和致残跌倒恐惧的老年人的药物审查结合在一起。

DESCRIPTION (provided by applicant): Approximately 7-14% of older adults living independently in the community, including more than 5% of those who have never fallen, experience moderate to severe fear of falling (FF) and avoid multiple activities as a result. At least 3% avoid leaving their homes or yards due to fear. Excessive FF leads to decreased physical activity, disability, loss of independence, depression, anxiety, reduced social engagement, and poor quality of life. It is also a major independent risk factor for falls. Interventions targeting FF, typically delivered in groups and incorporating cognitive restructuring, education, and exercise, increase fall-related self-efficacy. Avoidance is resistant to treatment, however, and almost 40% of patients enrolled in these interventions drop out. Factors associated with attrition include high levels of FF, indicating that the individuals most in need of such programs are those most likely to withdraw prematurely. These data suggest that avoidance should be targeted in treatment, and that interventions should be designed to reach those with severe fear and avoidance who are most likely to drop out of traditional FF programs. Yet despite the similarities between FF and anxiety disorders, and the fact that the most effective behavioral treatment for most anxiety disorders is exposure therapy, no FF interventions to date have incorporated an exposure component. Overall, the existing research suggests the need for an intervention that combines exposure therapy with other elements that have proven effective for reducing FF. Such an intervention must also be sensitive to issues of patient safety. The proposed project aims to develop an in-home, physical therapist-delivered intervention, "Activity, Balance, Learning, and Exposure" (ABLE), that integrates exposure therapy and cognitive restructuring with exercise, education about fall risks, a home safety evaluation, and a medication review for older adults with excessive and disabling FF. After developing and pilot testing this new intervention with 20 older adults with FF, we propose to conduct a feasibility study in which 40 patients are randomly assigned to ABLE or an education control condition. By developing and testing a new intervention to address a prevalent geriatric anxiety condition with potentially devastating public health consequences, this line of research has the promise to fill a major gap in knowledge and clinical practice. PUBLIC HEALTH RELEVANCE: Excessive fear of falling (FF) leads to decreased physical activity, disability, loss of independence, depression, anxiety, reduced social engagement, poor quality of life, and increased fall risk in older adults. Yet despite the similarities between FF and anxiety disorders, and the fact that the most effective behavioral treatment for most anxiety disorders is exposure therapy, no FF interventions to date have incorporated an exposure component. This R34 application proposes to develop an in-home, physical therapist-delivered intervention integrating exposure therapy and cognitive restructuring with exercise, education about fall risks, a home safety evaluation, and a medication review for older adults with excessive and disabling fear of falling.