Fear of Falling: An Independent Factor Affecting Health-Related Quality of Life in Patients with Parkinson's Disease
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.319225
Source of Support: None, Conflict of Interest: None
Keywords: Fear of falling, health related quality of life, Hoehn–Yahr stage, idiopathic Parkinson's disease, UPDRSKey Message: Fear of Falling should be questioned in every patients with Idiopathic Parkinson's Disease (IPD) because it is an independent factor which affects health related quality of life in IPD.
Idiopathic Parkinson's Disease (IPD) is a chronic, age-related neurodegenerative disease with a prevalence of 2–3% in elderly population. Main pathology in IPD is dopaminergic neuron loss in the compact part of substantia nigra and accumulation of cytoplasmic alpha-synuclein inclusions called Lewy bodies. Cardinal symptoms of IPD such as bradykinesia, resting tremor, rigidity and postural instability are seen after approximately 70–80% of the dopaminergic neurons lost. However, as pathology of IPD firstly starts from the dorsal vagal nucleus and olfactory bulb, non-motor symptoms are seen years before the cardinal ones. The lifespan gets longer and the life expectancy of the IPD patients gets approximately 23 years with new treatment options, as a result main goal of the disease treatment becomes increasing Health related quality of life (HRQoL) by symptomatic healing. HRQoL which encompasses the physical, functional, emotional and social well-being of the patient is an important measurement for the medical outcome of the elderly patients with IPD.
IPD treatment guidelines are adjusted to the severity of the disease, most frequently measured by Hoehn and Yahr (HY) stages ranging from stage I (unilateral involvement) to stage V (bed or wheelchair dependency),, When HY stages increase, balance control which is critical for moving safely in and adapting to the environment, will be disrupted. Postural instability defined as one of the most disabling features of IPD with a prevalence of 35-45%, and it may cause falls and near falls which is defined as a fall initiated but arrested by support from a wall, railing, other person, etc. Fear of falling (FOF) is a person's anxiety towards usual or normal mobilizing, with perception that a fall will occur in the presence or absence of a fall. Prevalence of FoF which is already a major health problem among elderly population, ranges from 37% to 59% in patients with IPD. Although some degree of FOF may be beneficial by avoiding risky activities which can result in falls, it may increase mortality and worsen HRQoL as it is associated with decreased mobility and social activity, increased frailty, problems with gait and balance, modified postural control and anxiety and depression,,, It was found that FOF can induce activity avoidance behavior in an estimated 44% to 70% of IPD patients independently of the HY stage, and 20% of IPD patients develop FOF without a previous fall,,, Therefore, FOF may have a complicated effect on HRQoL both by itself and with association of other motor and non-motor symptoms of IPD.
The aim of the current study was to evaluate whether FoF has an independent effect on HRQoL in patients with IPD or not. The second end-point of the study was to describe the characteristics of IPD which were in relation with FOF.
Patients and controls
The cross-sectional study was performed between July 2017 and January 2019. 87 (34 female, 53 male) neurologist-diagnosed IPD patients were selected consecutively from movement disorders department of neurology outpatient clinics and orthopedics and traumatology outpatient clinics. IPD diagnosis was done according to the UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria. IPD patients who were diagnosed and treated for at least 1 year and who had no cognitive impairment (Mini-Mental State Examination >24/30) were included in the study. Exclusion criteria were atypical Parkinsonism More Details syndromes, dementia (mini-mental state examination (MMSE)<25), apathy, psychosis and other psychiatric disorders, chronic systemic diseases, head trauma, ear diseases, vertigo, neuropathy, osteoarthritis, neuroleptic or antidepressant drug usage, pregnancy or lactation, pathological findings in brain imaging and other medical conditions which may affect balance. 84 (40 female, 44 male) healthy controls were selected randomly from the general population.
All participants were informed about the aims and procedures of the study and provided their written informed consent to participate. Participation in this study was voluntary and patients could withdraw from the study at any time.
Data collection and instruments
Data were collected through face-to-face interviews with the participants by means of questionnaires and clinical examinations. Demographic variables, comorbidities, medicines, disease duration and HY stages and Unified Parkinson's Disease Rating Scale (UPDRS) scores were asked and measured during the examination. HY stages and UPDRS scores were determined when the IPD patients were in “on state”.
After physical and neurological examination, all included participants were questioned for REM sleep disorder (RBD), daytime somnolence, hallucinations, dyskinesia, urge incontinence, previous falls, presence of “off state”, freezing of gait (FOG) and disease duration.
Group 1 and Group 2 were administered Fall Efficacy Scale (FES), Berg Balance Scale (BBS), The Activities-specific Balance Confidence Scale (ABC Scale), Impact Of Events Scale-Revised (IES-R), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Parkinson Disease Specific Quality of Life Scale (PDQ-39). All of the assessments were done when the patients were in the “On state”.
FES is a 10-item, multiple choice, self-reported questionnaire ranging from 1 (complete confidence) to 10 (no confidence) and a score of 70 or higher from 100 points indicates FOF. BBS is a 14-item questionnaire with each item consisting of a five-point ordinal scale ranging from 0 to 4; total score 0–20 refers to wheelchair dependency, 21–40 refers to walking with assistance and 41–56 refers to independency. ABC Scale is a 16-item questionnaire ranging from 0 (no confidence) to 100% (complete confidence) that assesses subjective feeling of balance. Lower ABC Scale score refers to higher subjective imbalance. IES-R assesses distress feeling which is caused by traumatic events with self-reported 22-item questionnaire rated on a 5-point scale ranging from 0 (not at all) to 4 (extremely) and higher score refers to greater stress. BDI measures severity of depression with 21-item questionnaire ranging from 0 to 3. A total score of 17 and above indicates that the patient has depression. BAI is a 21-item questionnaire ranging from 0 to 3. A total score of 0-7 is interpreted as a minimal anxiety, 8-15 as mild anxiety, 16-25 as moderate anxiety, 26-63 as severe anxiety. PDQ-39 is a 39-item questionnaire ranging from 0 to 4 which measures HRQoL by calculating scores for each of the eight scales: mobility, activities of daily living, emotional well-being, stigma, social support, cognition, communications and bodily discomfort.
All participants were supported in case of the need for reading and/or writing assistance. During administration of the questionnaires, any incomprehensible questions and answers were explained without giving any guidance as to the responses they should give. The examinations required for BBS was done under the supervision of a neurologist. Cut-off point for PDQ-39 was determined by ROC analysis.
Group 1 and Group 2 were compared regarding to age, sex and mean levels of the FES scores, depression, anxiety. Then, Group 2 (87 IPD patients) were divided into two subgroups by means of FES scores, such as the patients whose scores were 70 and above points as IPD patients with FOF (Group 2a) and the patients whose scores were below 70 points as IPD patients without FOF (Group 2b). Group 2a and Group 2b were compared in terms of age, HY stage, UPDRS, presence of the symptoms (RBD, daytime somnolence, hallucinations, dyskinesia, urge incontinence, previous falls, off periods, FOG), disease duration, and questionnaires' scores (BBS, ABC scale, IES-R, BDI, BAI, PDQ-39). Correlation analysis in between FES and each variable were measured. Independent factors which affect HRQoL were evaluated with logistic regression analysis.
The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975, as revised in 2000. The protocol was approved by the local ethics committee of the hospital. Informed consent was obtained from patients and individuals in control group before the study.
SPSS (Statistical package for the social sciences) version 22 analysis program was used for data analysis. Chi-square test and Fisher's exact test were used to compare the frequency distribution between groups. Variables between two groups were compared to each other by using Student's t test. One-way ANOVA analysis was used to compare among multiple variables. Nonparametric Spearman correlation analysis was used to evaluate the correlation between two variables. ROC curve analysis was used to identify the cut-off point for PDQ-39. Logistic regression analysis was used for evaluating the independent factors which affect HRQoL of IPD patients. P value <0.05 was determined to be statistically significant and P value <0.001 was determined to be statistically very significant.
Mean age was 67.96 ± 9.83 (minimum: 25, maximum: 84) in Group 1 whereas 68.9 ± 10.7 (minimum: 28, maximum: 87) in Group 2. There was no difference according to age and gender between Group 1 (controls) and Group 2 (IPD patients) (P = 0.16, P = 0.26 respectively). 25.5 point was found to be the cut-off for PDQ-39 and IPD patients were found to have significantly low PDQ-39 results than healthy controls (P < 0.001). Mean FES score was 32.03 ± 25.6 in Group 1 whereas 45.03 ± 30.1 in Group 2 (P = 0.003). According to FES, FOF was significantly higher in Group 2 than Group 1. Comparison of demographic features and mean FES between controls and IPD patients is given in [Table 1]. Comparison of FOF, depression and anxiety between controls and IPD patients is given in [Table 2]. FOF and depression were very significantly, anxiety was significantly higher in Group 2. Comparison of Demographics, IPD symptoms, disease duration, HY stage, UPDRS between Group 2a and Group 2b is given in [Table 3]. Disease duration, HY stage and UPDRS were very significantly higher in IPD patients as expected (P < 0.001). Previous falls, urge incontinence and hallucination were significantly higher (P < 0.05) and off periods was very significantly higher in IPD patients (P < 0.001). Female to male ratio was 2.44 in Group 2a whereas 1.0 in Group 2b (P = 0.04). Age, FOG, RBD, daytime somnolence, dyskinesia were not different between Group 2a and Group 2b (P > 0.05). BDI was significantly (P = 0.002) and other questionnaires were very significantly (P < 0.001) different between Group 2a and Group 2b. Comparison of mean levels of FES, BBS, ABC Scale, IES-R, BDI, BAI, PDQ-39 between Group 2a and Group 2b is given in [Table 4].
Correlation analysis showed that FES was positively correlated to age (P = 0.02, r = +0.24) and BDI (P < 0.001, r = +0.38) and BAI (P < 0.001, r = +0.43) and UPDRS (P < 0.001, r = +0.71), however FES was negatively correlated to BBS (P < 0.001, r = -0.71). UPDRS, depression, previous falls, off periods, urge incontinence and FOF were assessed into logistic regression analysis and it was found that UPDRS (P = 0.004) and FOF (P = 0.04) had independent effects on PDQ-39.
Lifespan of IPD patients gets prolonged and HRQoL became the main target of the disease management. As a result, medical treatment and non-medical interventions have been more helpful in IPD management in recent years.
FOF is an intense fear of standing or walking and is a lack of self-confidence that usual activities can be performed without falling. With normal aging, decreased visual acuity, decreased proprioception, vestibular system difficulties and decreased muscle mass may result in balance problems. Also blood pressure regulation due to renin angiotensin system is impaired in elderly which results in risk of falls and increased FOF. FOF is one of the most serious and disabling features in IPD. IPD patients are more likely to develop FOF as compared with their peers because falls become a major problem in IPD due to increased postural instability and previous falls in addition to depression and anxiety. Posture and balance control are impaired in IPD patients as automatic postural responses are impaired, muscle amplitude scaling of the motor response is altered, and generation of automatic responses owing to rigidity is interfered, especially involving the axial body regions. Strength and aerobic training, tai chi or dance therapy lasting at least 12 weeks can be beneficial in IPD patients with previous falls. However, approximately 75% of IPD patients reported an impaired balance and 70% of IPD patients reported activity limitations due to FOF that results in restricted social participation, sedentary behavior, associated metabolic syndrome and early death,,, Although FOF appears to be associated with increased disease duration, disease severity and previous falls, several studies have reported that patients with IPD have reported FOF from the early stages of the disease, with or without previous falls. However, investigation of FOF in IPD has been limited,, Studies have reported that FOF is not related to age and sex, however is associated with disease progression and psychological comorbidities in IPD,,, FOG, hesitation and festinating gait were reported to be associated with higher FOF. Some studies reported that previous falls or near falls that do not lead to negative results may reduce FOF, while several others reported that increased previous falls and near falls may lead to increased FOF. Although, a reciprocal relationship between mental distress and FOF is thought to be present, depression and anxiety have not been reported as direct causes for FOF,, Furthermore, relationship between FOF and non-motor symptoms is not clearly known yet. As FOF is a risk factor for recurrent falls and is an obstacle to exercise, it has a significant impact on HRQoL. Several studies reported that FOF affects HRQoL more than actual falls.
In the current study, FOF was significantly higher in patients with IPD, especially who had longer disease duration and higher disability levels. It was found that age was not related to FOF, compatible with the literature. However, it is found that females were more likely to experience FOF as compared with males, in contrary to the literature. Previous falls, off periods, hallucinations, urge incontinence were significantly higher in IPD patients with FOF. However, RBD, dyskinesia, daytime somnolence and FOG were not different in between groups. The most important difference between the groups was that “off” period was very significantly higher in IPD patients with FOF than whom without FOF, compatible with the literature.
In our study, correlation analysis showed that most important factors that affect FOF were disease severity and motor disability. Although they were not correlated as strong as that of motor disability, increased depression and anxiety were positively associated with FOF. In our study, HRQoL was significantly worse in IPD patients when compared with healthy individuals. Moreover, HRQoL deterioration increased in IPD patients with FOF when compared to IPD patients without FOF. It showed that FOF was an important factor for worsening HRQoL.
In the current study, there was no correlation between HRQoL and each of age, sex, disease duration and non-motor symptoms such as depression and RBD. Independent factors that affect HRQoL should be identified as early as possible for the management of IPD. UPDRS and FOF were found as independent factors that affect HRQoL in IPD.
IPD patients who experienced FOF should be identified as early as possible because physical therapeutic interventions can be helpful in reducing falls and increasing self confidence in movement. As a result, it is important to question and examine FOF in IPD patients from the early stages of the disease for developing strategies to reduce it. In the current study, HRQoL was worse in IPD patients with FOF as compared with IPD patients without FOF. In addition, FOF was found as an independent factor which affects HRQoL of IPD patients.
In conclusion, our study is a cross sectional research and it is a limitation to demonstrate the effect of FOF on falling However, our results showed that FOF is an independent factor that affects HRQoL in IPD. As a result, we believe that FOF should be questioned in every IPD patient. In addition, clinicians should be aware female gender, depression or anxiety, disease severity, off periods, urge incontinence, hallucinations and previous falls are the predictors for FOF in IPD Future cohort studies can provide additional information.
All authors have seen and approved the final version of the manuscript being submitted. All contributors meet the criteria for authorship (ICMJE: authorship and contributorship). The authors declare no conflict of interest. This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]