International Journal of Nursing Studies 46 (2009) 13131319

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International Journal of Nursing Studies

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Comparison of three established measures of fear of falling in community-dwelling older adults: Psychometric testing
Tzu-Ting Huang *, Woan-Shyuan Wang
School of Nursing, Chang-Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, TaoYuan, 333, Taiwan ROC

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 November 2008 Received in revised form 23 February 2009 Accepted 20 March 2009 Keywords: Fear of falling Psychometric evaluation Responsiveness to change

Background: Several approaches have emerged for measuring self-reported fear of falling. A comparison of measurement scales psychometric properties is needed for researchers to choose the proper scale for their study. Objectives: To compare the psychometric properties of the Falling Efcacy Scale (FES), the Activities-Specic Balance Condence Scale (ABC) and the Geriatric Fear of Falling Measurement (GFFM). Design: Secondary analysis using baseline and 8-week data from a randomized, controlled trial on fall and fear of falling prevention. Settings: Rural area northeast of Taiwan with assessments conducted in participants homes. Participants: Population-based sample of 168 community-dwelling older adults aged 60 and older. Methods: During a home visit, a nurse administered the Tinetti Mobility Scale, and asked about the FES, ABC, GFFM, WHOQOL, falls, chronic illnesses and medicines taken. Results: Baseline internal consistency measured using Cronbachs alpha was 0.98 for the FES, 0.96 for the ABC and 0.88 for the GFFM. Baseline concurrent validity between the FES, ABC and GFFM measured using a correlation coefcient was 0.88 (FES vs. ABC), 0.55 (FES vs. GFFM), and 0.57 (ABC vs. GFFM), respectively, p < .001. All three instruments scores were signicantly correlated at baseline with physical performance tests and WHOQOL. The GFFM demonstrated responsiveness to change at 8 weeks. Conclusions: The FES, ABC and GFFM demonstrated strong internal consistency reliability. The GFFM had stronger associations with physical and psychosocial functioning and may be more appropriate for studies focused on improving all aspects of fear of falling. Both FES and ABC instruments demonstrated ceiling effects, which may explain the lack of responsiveness to change in relatively non-frail older community-dwelling adults. Instruments sensitive to measuring lower levels of fear of falling are needed to capture the full range of this phenomenon in this population. 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic?  Fear of falling among older adults has been investigated using several of measurement scales.

 Studies comparing measurement scales psychometric properties are needed so researchers can select appropriate measures for their given population and study design. What this paper adds

* Corresponding author. Tel.: +886 3 2118800x5321; fax: +886 3 2118700. E-mail address: thuang@mail.cgu.edu.tw (T.-T. Huang). 0020-7489/$ see front matter 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2009.03.010

 The GFFM may be more appropriate for interventions focused on improving on all dimensions of function, and

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is able to response to change for the fear of falling management intervention.  Possible ceiling effects and the potential for a lack of responsiveness to change for the FES and ABC should be kept in mind when new studies are planned among lessfrail community-dwelling elders. 1. Introduction Fear of falling has been identied not only as an important psychological consequence of falling, but also in those who have not fallen, warranting its inclusion as an outcome variable in fall prevention trials (Huang, 2006; Lamb et al., 2005). Fear of falling can be assessed by several instruments with differing theoretical denitions. To enable researchers to select appropriate instruments for their target population and study design, studies are needed comparing their psychometric properties (Jorstad et al., 2005; Scheffer et al., 2008; Talley et al., 2008). Three conceptually different measures of fear of falling are the Falling Efcacy Scale (FES), the Activities-specic Balance Condence Scale (ABC), and the Geriatric Fear of Falling Measurement (GFFM). The FES assesses fear of falling within a self-efcacy framework and is based on the operational denition of this fear as low perceived selfefcacy at avoiding falls during essential, non-hazardous activities of daily living (Tinetti et al., 1990). The ABC, also based on Banduras theory of self-efcacy, denes fear of falling as balance condence, or condence in the ability to maintain balance while performing selected activities (Powell and Myers, 1995). The GFFM was derived from a framework for managing fear of falling (Huang, 2005), and denes fear of falling as concern about falling during daily life. The GFFM includes three domains (psychosomatic symptoms, adopting an attitude of risk prevention, and modifying behavior) and assumes that a lower level of fear may increase awareness to prevent falling (Huang, 2006). Knowledge of the psychometric properties of the FES, ABC, and GFFM is limited by the small number of studies investigating these properties, convenience sampling, and small samples. The FES was validated in 56 communityliving elderly persons (Tinetti et al., 1990) and 60 community seniors (Powell and Myers, 1995), which are non-representative samples and may limit use of the FES to small samples. Recent validation of the FES in new longterm care enrollees (N = 112) (Gillespie and Friedman, 2007) and patients after stroke (N = 140) (Andersson et al., 2008) may misrepresent older adults from broader health backgrounds. The ABC was validated in ve samples consisting of high- and low-mobility community-dwelling seniors, vigorous older adults enrolled in research projects and community exercise programs, retirement home residents enrolled in a fall prevention program, elderly people undergoing hip and knee replacement surgery, and women at least 70 years old (Myers et al., 1996, 1998; Talley et al., 2008). Although these samples represent a wide spectrum of community-dwelling older adults, their small size, selection by convenience, and/or older age limit generalizability of the ABC. The GFFM was shown to have good

content and factorial validity in two community-dwelling samples (N = 100, N = 384) in northern Taiwan (Huang, 2006). Determining whether these instruments have acceptable psychometric properties is desirable so that researchers can reliably use them in studies. Studies are needed to establish the psychometric properties in large, representative samples and to compare the psychometric properties within these samples. Additionally, few studies have examined the responsiveness of these instruments to changes in clinical features such as fall risk and physical abilities, a critical attribute for outcome measures in clinical trials (Jorstad et al., 2005; Talley et al., 2008). The purpose of this study was to compare the internal consistency reliability, concurrent validity, construct validity, and responsiveness to change of the FES, ABC, and GFFM for a population-based sample of communitydwelling older adults. Drawing from previous research ndings, the authors hypothesized that FES, ABC, and GFFM scores representing greater fear of falling would be associated with older age (Andersson et al., 2008; Myers et al., 1998; Talley et al., 2008), female gender (Andersson et al., 2008), gait (Li et al., 2005; Sattin et al., 2005; Sihvonen et al., 2004), balance disturbance (Devereux et al., 2005; Li et al., 2005; Sattin et al., 2005), mobility impairment (Andersson et al., 2008; Bula et al., 2008; Gillespie and Friedman, 2007), more medical conditions and medications taken (Sattin et al., 2005), falls history (Andersson et al., 2008; Bula et al., 2008; Sattin et al., 2005), activity restriction (Bula et al., 2008; Lachman et al., 1998), self-reported health status (Brouwer et al., 2003; Zijlstra et al., 2005), and health-related quality of life (QOL) (Devereux et al., 2005; Lachman et al., 1998; Suzuki et al., 2002). The authors also hypothesized that all instruments would demonstrate responsiveness to change for participants completing a multi-factorial fall prevention program. 2. Methods 2.1. Design Secondary analysis was used for data that was collected during a randomized, controlled, single-blind trial known as the Fear of Falling Intervention Program (FOFIP), which compared a home-based, multi-factorial fall prevention program (exercise, cognitive behavioral education, and risk-reduction counseling) with a health education program (control) in a population-based sample of community-dwelling older adults. This secondary analysis used data collected at baseline and after the 8-week, homebased, fall prevention intervention. Registered nurses delivered the FOFIP during home visits each week. The Chang-Gung University institutional review board approved the study protocol, and all participants gave informed consent before data collection. 2.2. Sample The sample included 174 community-dwelling adults aged 60 and older, who were randomized to the

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experimental (n = 88) or control (n = 89) group. Participants were recruited by mailed invitation and a follow-up call to a randomly selected sample of 600 residents of registered households in a rural community of Yi-Lan County, northeast Taiwan. Of the 600 individuals invited to participate, 18% did not respond, 28% were ineligible, 16% refused participation, and 9% had died or moved. Registered nurses screened potential participants over the telephone. Inclusion criteria required participants to be 60 years or older, be mentally intact (Short Portable Mental Status Questionnaire [SPMSQ] score >6 if illiterate, >7 for 6 years of education, >8 for >6 years of education; Pfeiffer, 1975), reside in the community, and be able to communicate in Mandarin or Taiwanese. Participants were excluded if they had an articial leg or leg brace, had unstable health problems, or were terminally ill. 2.3. Measures Data were collected during home visits by a research assistant (RA), who was blind to group assignment, at baseline and immediately after the 8-week, home-based intervention. At baseline, data were collected on participants age, the number of falls experienced in the previous year, and the number and types of chronic illnesses and medicines taken. At baseline and 8 weeks, data were collected on gait and balance, balancing condence, and using the Tinetti Mobility Scale (Tinetti et al., 1986), and World Health Organization QOL-BREF questionnaire (WHOQOL-BREF, Yao, 2002), respectively. Data on fear of falling were collected using the FES, ABC and GFFM. The FES asks participants to rate their condence in conducting 10 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 condence in maintaining daily living activities. The total score is calculated by summing all item responses and can range from 0 to 100. The ABC asks participants to rate their condence in maintaining their balance and remaining steady when engaging in 16 non-hazardous activities of daily living that require transferring, bending, reaching, or walking (Powell and Myers, 1995). Responses range from 0 to 100%, with higher scores indicating greater condence in maintaining balance. The total score is calculated by averaging all the item responses and can range from 0 to 100. The GFFM asks respondents to rate their concern while engaged in 15 situations within 3 domains: psychosomatic symptoms (4 items), adopting an attitude of risk prevention (5 items), and modifying behavior (6 items). Responses range from 1 (not at all concerned) to 5 (very concerned). Higher scores indicate greater concern. The total score is the sum of all item responses and can range from 15 to 75 (Huang, 2006). The WHOQOL-BREF is a widely used, reliable, valid, and self-administered measure of QOL in terms of physical health, psychological health, social relationships, and environment (Yao, 2002). The WHOQOL-BREF includes 4 subscales with 28 items that measure different health concepts. Responses are rated from 1 (very poor/very

dissatised/not at all) to 5 (very good/very satised/ completely). The total score is calculated by averaging all item responses. Higher scores indicate better quality of life. The Tinetti Mobility Scale (Tinetti et al., 1986) is a simple scale that requires no equipment to quickly and conveniently identify and quantify an individuals balance and gait. Subjects take approximately 5 min to perform the whole series of activities. Higher scores indicate better performance. The maximum score for balance is 16 and for gait is 12. The balance and gait scores are summed to give an overall mobility score. Mobility scores <14 are associated with recurrent falling; gait scores <9 and balance scores <10 are independent predictors for recurrent falls (Tinetti et al., 1986). 2.4. Statistical analysis Descriptive statistics were used to describe the mean, range, and distribution of total FES, ABC and GFFM scores. Cronbachs coefcient a was used to measure internal consistency reliability at baseline and 8 weeks. Concurrent validity between the FES, ABC and GFFM at baseline and 8 weeks was determined by calculating Pearson correlation coefcients. Construct validity was determined by correlating FES, ABC and GFFM scores with age, mobility (gait and balance), number of chronic illnesses, medicines taken, prior falls, self-reported health status, and selfreported WHOQOL-BREF subscale scores. Pearson correlation coefcients were calculated to determine the degree to which constructs were related. Responsiveness to change was measured by signicant differences in scores under two conditions (paired t-test) and standardizedresponse mean (SRM). The SRM is computed by dividing the mean change score by the standard deviation in the change score. Small, medium, and large response effects are reected by values of 0.20, 0.50, and 0.80 (Cohen, 1988), respectively. SPSS version 13.0 was used for all data analyses (SPSS Inc., Chicago, IL). 3. Results Baseline characteristics of the participants are listed in Table 1. Six participants withdrew from the study before the 8-week follow-up assessment, leaving 168 participants for the 8-week analysis. Reasons for withdrawal included new or worsening health condition (n = 3), moving from home (n = 2), and time commitment (n = 1). The mean (S.D.) FES score at baseline was 91.85 (16.89), with scores ranging from 11 to 100 and skewed toward condence (2.71). The majority of participants (n = 96, 57.1%) scored 100, indicating complete condence in feeling free from falling. The mean (S.D.) FES score at 8 weeks was 91.67 (17.42) and scores were skewed toward more condence (2.52). The mean (S.D.) ABC score at baseline was 79.89 (20.59), with scores ranging from 11.25 to 100 and skewed toward higher balance condence (1.67). Only 8 participants (4.8%) scored 100, the highest level of condence possible, but 70 (41.7%) scored >90. The mean ABC score at 8 weeks was 79.38 (21.04) and scores were skewed toward higher balance condence (1.73).

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Table 1 Baseline participant characteristics (N = 168). Characteristic Demographic Age, mean (S.D., range) Gender, % Male Female Primary school education, % Married, % Live with other people, % Functional Balance test score, mean (S.D., range) Gait, mean (S.D., range) Tinetti mobility Clinical Number of medicines taking, mean (S.D., range) Medical conditions, % Number of falls in previous year, mean (S.D., range) Self-rated health status, % Worse Average Better WHOQOL subscale, mean (S.D., range) Physical health Psychological Social relationships Environment Fear of falling, mean (S.D., range) FES Activity-specic balance condence scale GFFM S.D. = standard deviation. Value

ABC, and 0.88 for the GFFM. At 8 weeks, these values were 0.98 for the FES, 0.98 for the ABC, and 0.90 for the GFFM. 3.2. Concurrent validity
70.96 (6.91, 6093)

72 (42.86%) 96 (57.14%) 63.10 79.76 51.19

Scores on the FES, ABC, and GFFM were signicantly correlated at baseline (p < .001) (correlation coefcient, g = 0.88 [FES vs. ABC], 0.55 [FES vs. GFFM], 0.57 [ABC vs. GFFM]) and at 8 weeks (g = 0.89, 0.64, and 0.61, respectively, p < .001). As condence in performing activity decreased (FES and ABC scores), concern about falling increased (GFFM score). 3.3. Construct validity Scores on the FES, ABC, and GFFM were related to demographic, functional, and clinical variables (Table 2). Lower ABC and FES scores were signicantly correlated with older age, lower balance score, lower gait score, lower mobility score, more falls in the previous year, greater number of chronic illnesses, and worse self-rated health status. Higher GFFM scores were signicantly correlated in the same direction as all of these variables. However, only lower ABC and higher GFFM scores were signicantly correlated with greater number of medicines taken. Signicant correlations were found between scores on the FES, ABC, GFFM, and self-rated WHOQOL-BREF subscales, except for scores between the ABC and social relationships subscale. Lower FES and ABC scores and higher GFFM scores were signicantly correlated with lower scores on self-rated health status and WHOQOLBREF subscales (Table 3). Also, scores on the FES, ABC, and GFFM had similar correlations with the total WHOQOLBREF score. 3.4. Responsiveness to change Participants who received the Fear of Falling Intervention Program had mean (S.D.) change scores for the GFFM, FES, and ABC of 0 (.41), 2.16 (7.93), and 3.58 (6.61), respectively. The GFFM scores differed signicantly over 8 weeks (paired t = 3.76, p = .000), but the FES and ABC scores did not change signicantly (t = 0, p = 1.0 and t = 1.894, p = .07, respectively). The standardized-response means for the FES, ABC, and GFFM were 0, 0.27, and 0.54, respectively. When participants were grouped according to mobility improvement, the FES, ABC, and GFFM SRMs were 0.78, 0.23, and 0.60, respectively. When participants were grouped according to mobility deterioration, the FES, ABC, and GFFM SRMs were 0, 0.66, and 1.29, respectively.

13.21 (3.75, 116) 9.89 (2.87, 012) 23.11 (6.39, 128)

2.9 (1.74, 05) 60.7 1.26 (5.4, 03)

22.62 38.10 39.28

14.14 12.92 13.79 13.59

(2.62, (2.44, (1.90, (1.92,

620) 720) 1018) 920)

91.85(16.89, 11100) 79.89 (20.59, 11.25100) 36.60 (11.44, 1572)

The mean (S.D.) GFFM score at baseline was 36.6 (11.44), with scores ranging from 15 to 72, and skewed toward less concern about falling (0.89). Two participants (2.4%) scored 15, indicating no concern about falling, but only 6 participants (3.6%) scored <21 (90th percentile). The mean GFFM score at 8 weeks was 34.5 (11.72), with scores ranging from 15 to 70 and skewed toward less concern (0.84). 3.1. Internal consistency reliability The internal consistency reliability measured at baseline by Cronbachs alpha was 0.98 for the FES, 0.96 for the

Table 2 Baseline correlations between fear of falling measures and other characteristics. Fear of falling measure FES ABC GFFM
* ** ***

Age 0.23** 0.17* 0.20**

Balance 0.66*** 0.70*** 0.65***

Gait 0.67*** 0.70*** 0.67***

Mobility 0.71*** 0.73*** 0.69***

# of medications taken 0.13 0.23** 0.26**

Fall history 0.47*** 0.51*** 0.44***

Medical conditions 0.18* 0.32*** 0.27***

Self-rated health status 0.36*** 0.36*** 0.33***

p < .05. p < .01. p .001.

T.-T. Huang, W.-S. Wang / International Journal of Nursing Studies 46 (2009) 13131319 Table 3 Baseline correlations between fear of falling measures and WHOQOL. Fear of falling measure WHOQOL subscale Physical health FES ABC GFFM
** ***

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Psychological 0.45*** 0.48*** 0.36***

Social relationships 0.15 0.23** 0.22**

Environment 0.29** 0.25** 0.30**

Total 0.46*** 0.48*** 0.46***

0.58*** 0.61*** 0.63***

p < .01. p .001.

4. Discussion This study provides new information comparing the psychometric properties among the FES, ABC, and GFFM in community-dwelling older adults. These ndings can be used by researchers and clinicians to inform their selection of the most appropriate fear-of-falling instrument for their study design or population, in accordance with current fall prevention guidelines recommending assessment of fear of falling (Lamb et al., 2005). The unique contribution of this study is its ndings on how these three fear-of-falling instruments responded to changes in participants clinical characteristics. The GFFM showed a medium response to change, and the ABC had a small response to change, but the FES was unresponsive to change. This psychometric failing of the FES is likely related to participant characteristics and not to the intervention performed, because similar interventions have reduced fear of falling (Li et al., 2005; Sattin et al., 2005; Zijlstra et al., 2005). The participants in this study were less frail (as evidenced by 77.4% of participants rating their health status average or above) than participants of other studies (Li et al., 2005; Sattin et al., 2005; Zijlstra et al., 2005). These less-frail participants demonstrated ceiling effects on both the FES and ABC instruments, similar to a previous report that participants scoring above 80 on the ABC were unlikely to improve their balance condence after completing physical activity programs (Myers et al., 1998). Ceiling effects were also found for less-frail older women tested with the ABC and another instrument that assesses the role of fear of falling in activity restriction (Survey of Activities and Fear of Falling in the Elderly) (Talley et al., 2008). On the other hand, the FES demonstrated that when participants mobility improved, the SRM approached large response effects, but could not respond when older adults mobility deteriorated. In addition, the ABC showed that when participants mobility improved, the SRM reected small response effects, with medium effect responses only when older adults mobility declined. The lack of responsiveness of the FES instrument to change may reect its inability to detect changes in fear of falling among community-dwelling older adults whose mobility deteriorated. The GFFM may be a better choice instrument to detect changes in fear of falling among communitydwelling older adults. All three instruments in this study showed strong relationships with age, mobility (including balance and gait), fall history, and self-rated health status. The FES and ABC, based on self-efcacy theory (Bandura, 1982), assess condence in specic physical abilities necessary to perform daily activities without falling. The strong

relationships between both instruments (the FES and ABC) and measures of mobility (balance and gait), and selfreported physical health (subscale of WHOQOL-BREF) are consistent with predictions of self-efcacy theory. Behavior is related to perceived ability, and individuals with lower condence (perceived ability) had lower physical functioning and greater activity restrictions (behaviors). The GFFM, which was developed from a conceptual model based on qualitative study ndings, is concerned not only with restriction of activity, but also with psychological and social concerns (Huang, 2006). Fear of falling has been associated with traits unrelated to physical ability, such as neuroticism (Mann et al., 2006), anxiety, depressive symptoms, loneliness, social support interactions (Zijlstra et al., 2005), and social embarrassment upon falling (Yardley and Smith, 2002). Moreover, the term concern used in the GFFM, instead of worry may be an advantage. Worry connotes a higher level of emotional distress than may be reected in a participants personal awareness or concern about falling (Talley et al., 2008). This study also conrms prior ndings on reliability and concurrent validity and addresses previous limitations by using a representative population-based sample. All instruments demonstrated acceptable internal consistency reliability, consistent with prior reports (Powell and Myers, 1995; Lachman et al., 1998; Huang, 2006). Among these instruments, the FES and ABC had Cronbach a values !0.96 at both measurement times. However, very high alphas (>.90) may suggest a high level of item redundancy (several items asking the same question in slightly different ways) (Streiner and Norman, 1989). Regarding construct validity, this study found that lower FES scores were signicantly associated with increased age, previous falls, lower mobility, and more chronic illnesses, consistent with a previous report (Andersson et al., 2008). Similarly, lower ABC scores have been related to older age, greater number of chronic illnesses, lower mobility, and lower perceptions of physical ability (Powell and Myers, 1995; Myers et al., 1998). The GFFM was derived from a framework for managing fear of falling (Huang, 2005) developed in a purposive sample of 25 community-dwelling elders in Taiwan. The GFFM includes three domains, and is not limited to activity restriction. The outcomes of managing fear of falling are impacted by three factors: the level at which management strategies are used, elders satisfaction with outcomes of strategies, and whether strategies are supported by the elders family. The Fear of Falling Intervention Program in which participants were enrolled contained exercise, cognitive behavioral education, and risk-reduction counseling that may signicantly help the elderly manage their fear of falling. Both the FES and ABC were developed for

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T.-T. Huang, W.-S. Wang / International Journal of Nursing Studies 46 (2009) 13131319 istics. International Journal of Rehabilitation Research 31 (3), 261 264. Bandura, A., 1982. Self-efcacy mechanism in human agency. American Psychologist 37 (2), 122147. Brouwer, B.J., Walker, C., Rydahl, S.J., Culham, E.G., 2003. Reducing fear of falling in seniors through education and activity programs: a randomized trial. Journal of the American Geriatrics Society 51 (6), 829 834. Bula, C.J., Martin, E., Rochat, S., Piot-Ziegler, C., 2008. Validation of an adapted falls efcacy scale in older rehabilitation patients. Archives of Physical Medicine & Rehabilitation 89 (2), 291296. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Science. Lawrence Erlbaum, Hillsdale, NJ. Devereux, K., Robertson, D., Briffa, N.K., 2005. Effects of a water-based program on women 65 years and over: a randomized controlled trial. Australian Journal of Physiotherapy 51 (2), 102108. Gillespie, S.M., Friedman, S.M., 2007. Fear of falling in new long-term care enrollees. Journal of the American Medical Directors Association 8 (5), 307313. Huang, T.T., 2005. Managing fear of falling: Taiwanese elders perspective. International Journal of Nursing Studies 42 (7), 743750. Huang, T.T., 2006. Geriatric fear of falling measure: development and psychometric testing. International Journal of Nursing Studies 43 (3), 357365. Jorstad, E.C., Hauer, K., Becker, C., Lamb, S.E., ProFaNE Group, 2005. Measuring the psychological outcomes of falling: a systematic review. Journal of the American Geriatrics Society 53 (3), 501 510. Lachman, M.E., Howland, J., Tennstedt, S., Jette, A., Assmann, S., Peterson, E.W., 1998. Fear of falling and activity restriction: The Survey of Activities and Fear of Falling in the Elderly (SAFE). Journals of Gerontology Series B: Psychological Sciences & Social Sciences 53 (1), 43 50. Lamb, S.E., Jorstad-Stein, E.C., Hauer, K., Becker, C., 2005. Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus. Journal of the American Geriatrics Society 53 (9), 16181622. Li, F., Harmer, P., Fisher, K.J., McAuley, E., Chaumeton, N., Eckstrom, E., Wilson, N.L., 2005. Tai Chi and fall reductions in older adults: a randomized controlled trial. Journals of Gerontology Series A: Biological Sciences & Medical Sciences 60 (2), 187194. Mann, R., Birks, Y., Hall, J., Torgerson, D., Watt, I., 2006. Exploring the relationship between fear of falling and neuroticism: a cross-sectional study in community-dwelling women over 70. Age & Ageing 35 (2), 143147. Myers, A.M., Fletcher, P.C., Myers, A.H., Sherk, W., 1998. Discriminative and evaluative properties of the Activities-specic Balance Condence (ABC) Scale. Journals of Gerontology Series A: Biological Sciences & Medical Sciences 53 (4), M287M294. Myers, A.M., Powell, L.E., Maki, B.E., Holliday, P.J., Brawley, L.R., Sherk, W., 1996. Psychological indicators of balance condence: relationship to actual and perceived abilities. Journals of Gerontology Series A: Biological Sciences & Medical Sciences 51 (1), M37M43. Pfeiffer, E., 1975. A short portable mental status questionnaire for the assessment of organic brain decit in elderly patients. Journal of the American Geriatrics Society 23 (10), 433441. Powell, L.E., Myers, A.M., 1995. The Activities-specic Balance Condence (ABC) Scale. Journals of Gerontology Series A: Biological Sciences & Medical Sciences 50A (1), M28M34. Sattin, R.W., Easley, K.A., Wolf, S.L., Chen, Y., Kutner, M.H., 2005. Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults. Journal of the American Geriatrics Society 53 (7), 11681178. Scheffer, A.C., Schuurmans, M.J., van Dijk, N., van der Hooft, T., de Rooij, S.E., 2008. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing 37 (1), 1924. Sihvonen, S., Sipila, S., Taskinen, S., Era, P., 2004. Fall incidence in frail older women after individualized visual feedback-based balance training. Gerontology 50 (6), 411416. Streiner, D.L., Norman, G.R., 1989. Health Measurement Scales: A Practical Guide to their Development and Use. Oxford University Press, New York. Suzuki, M., Ohyama, N., Yamada, K., Kanamori, M., 2002. The relationship between fear of falling, activities of daily living and quality of life among elderly individuals. Nursing & Health Sciences 4 (4), 155161. Talley, K.M., Wyman, J.F., Gross, C.R., 2008. Psychometric properties of the activities-specic balance condence scale and the survey of activities and fear of falling in older women. Journal of the American Geriatrics Society 56 (2), 328333.

American subjects (Tinetti et al., 1990; Powell and Myers, 1995). The expression of fear may differ according to social cultural background. For example, a survey of fear of falling using the FES and ABC in Taiwan may be affected by traditional barriers to some living routines (for example, males elderly in Taiwan seldom cook or do housekeeping) and weather issues (an icy or snowy oor is rare in Taiwan). This study found that the likely reason for the lack of responsiveness to change in both the FES and ABC instruments is the ceiling effect. For community-dwelling elders, the GFFM appears to be a better choice for detecting changes in fear of falling. The reliability and validity of fearof-falling instruments still needs investigating among elders who are living in the community, long-term care facility residents, and hospitalized. Selecting the most accurate screening tool and appropriate outcome measures is helpful to evaluate the effect of specic interventions for fear of falling among the elderly with various health conditions. This study had two limitations. First, results should not be generalized beyond a population of rural, less-frail community-dwelling older adults. Second, because many elderly participants had a low educational level and were visually impaired, all scales were completed through interview by a RA. The FES, ABC, and GFFM are meant to be self-report instruments. In conclusion, possible ceiling effects and a potential lack of responsiveness to change for the FES and ABC should be kept in mind when planning new studies. Consideration should be given to participants characteristics, because neither the FES nor the ABC might adequately measure fear of falling in rural community-dwelling older adults who are less frail. Also, the GFFM can respond to changes evoked by interventions to manage fear of falling. Instruments with sufcient sensitivity to measure lower levels of fear of falling are needed to capture the full range of this phenomenon. However, all three scales are appropriate for interventions focused on improving all dimensions of physical, psychosocial, and environmental functions, because their scores were signicantly correlated with scores on the WHOQOLBREF subscales. Acknowledgment This study was supported by National Science Council, Taiwan (Grant number: NSC96-2314-B-182-033). I would like to thank all the study participants for sharing their experiences. Ethical approval: This study had approved by the Institutional Review Board of Chung-Gung University (No. 95-1363B).

Funding: This study was supported by National Science Council, Taiwan (Grant Number: NSC96-2314-B-182-033).

Conict of interest: None declared. References

Andersson, A.G., Kamwendo, K., Appelros, P., 2008. Fear of falling in stroke patients: relationship with previous falls and functional character-

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