Research Article

Fear of Falling and Balance Confidence in Older Adults with Type 2 Diabetes


Background and Aim: Each year, millions of older people experience falling which can cause serious injuries such as broken bones, head injuries, or even death. Since Diabetes Mellitus can disrupt the balance system and increase falling, and given that fear of falling and balance confidence are critical fall-related psychological concerns that can be the risk factors of falls in the diabetic elderly, this study aimed to compare fear of falling and balance confidence of diabetic and non-diabetic older adults in Iran.
Methods: Participants were 63 diabetic older patients and 59 non-diabetic peers aged 60 years and over. Data were collected using the Persian versions of falling efficacy scale-international and activities-specific balance confidence-short form questionnaires. In addition, modified Romberg and timed up and go tests were performed to assess subjective balance performance.
Results: The scores of falling efficacy scale-international questionnaire and timed up and go test were significantly higher in diabetic group while the scores of activities-specific balance confidence-short form questionnaire were lower (p<0.001). No significant differences were observed in the modified Romberg test scores between two groups.
Conclusion: Fear of falling and low balance confidence are more common in diabetic older adults compared to non-diabetic peers. They have poor performance in timed up and go test and have more falls during the last 12 months.

[1] Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(37):993-8. [DOI:10.15585/mmwr.mm6537a2]
[2] Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50(1):116-9. [DOI:10.1097/00005373-200101000-00021]
[3] Hughes CC, Kneebone II, Jones F, Brady B. A theoretical and empirical review of psychological factors associated with fallsrelated psychological concerns in community-dwelling older people. Int Psychogeriatr. 2015;27(7):1071-87. [DOI:10.1017/S1041610214002701]
[4] Moore DS, Ellis R. Measurement of fall-related psychological constructs among independent-living older adults: a review of the research literature. Aging Ment Health. 2008;12(6):684-99. [DOI:10.1080/13607860802148855]
[5] Dewan N, MacDermid JC. Fall Efficacy Scale-International (FES-I). J Physiother. 2014;60(1):60. [DOI:10.1016/j.jphys.2013.12.014]
[6] Stojanovic Z, Kocic M, Balov B, Milenkovic M, Savic N, Ivanovic S. Fear of falling. Prax Med. 2015;44(3):61-6.
[7] Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50A(1):M28-34. [DOI:10.1093/gerona/50a.1.m28]
[8] Diabetes Canada Clinical Practice Guidelines Expert Committee; Punthakee Z, Goldenberg R, Katz P. Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome. Can J Diabetes. 2018;42 Suppl 1:S10-5. [DOI:10.1016/j.jcjd.2017.10.003]
[9] Bruce D, Hunter M, Peters K, Davis T, Davis W. Fear of falling is common in patients with type 2 diabetes and is associated with increased risk of falls. Age Ageing. 2015;44(4):687-90. [DOI:10.1093/ageing/afv024]
[10] Volpato S, Leveille SG, Blaum C, Fried LP, Guralnik JM. Risk factors for falls in older disabled women with diabetes: the women’s health and aging study. J Gerontol A Biol Sci Med Sci. 2005;60(12):1539-45. [DOI:10.1093/gerona/60.12.1539]
[11] Janghorbani M, Van Dam RM, Willett WC, Hu FB. Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture. Am J Epidemiol. 2007;166(5):495-505. [DOI:10.1093/aje/kwm106]
[12] Tander B, Atmaca A, Ulus Y, Tura C, Akyol Y, Kuru Ö. Balance Performance and Fear of Falling in Older Patients with Diabetes Mellitus: A Comparison with Patients without Diabetes Mellitus. Turk J Phys Med Rehabil. 2016;62(4):314-22. [DOI:10.5152/tftrd.2015.77861]
[13] Morrison S, Colberg SR, Mariano M, Parson HK, Vinik AI. Balance training reduces falls risk in older individuals with type 2 diabetes. Diabetes Care. 2010;33(4):748-50. [DOI:10.2337/dc09-1699]
[14] Hewston P, Deshpande N. Fear of Falling and Balance Confidence in Older Adults with Type 2 Diabetes Mellitus: A Scoping Review. Can J Diabetes. 2018;42(6):664-70. [DOI:10.1016/j.jcjd.2018.02.009]
[15] Maurer MS, Burcham J, Cheng H. Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. J Gerontol A Biol Sci Med Sci. 2005;60(9):1157-62. [DOI:10.1093/gerona/60.9.1157]
[16] Cameron NE, Eaton SE, Cotter MA, Tesfaye S. Vascular factors and metabolic interactions in the pathogenesis of diabetic neuropathy. Diabetologia. 2001;44(11):1973-88. [DOI:10.1007/s001250100001]
[17] Davis TM, Yeap BB, Davis WA, Bruce DG. Lipid-lowering therapy and peripheral sensory neuropathy in type 2 diabetes: the Fremantle Diabetes Study. Diabetologia. 2008;51(4):562-6. [DOI:10.1007/s00125-007-0919-2]
[18] Moghtaderi A, Bakhshipour A, Rashidi H. Validation of Michigan neuropathy screening instrument for diabetic peripheral neuropathy. Clin Neurol Neurosurg. 2006;108(5):477-81. [DOI:10.1016/j.clineuro.2005.08.003]
[19] Arevalo-Rodriguez I, Smailagic N, I Figuls MR, Ciapponi A, Sanchez-Perez E, Giannakou A, et al. Mini-Mental State Examination (MMSE) for the detection of Alzheimer’s disease and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev. 2015;2015(3):CD010783. [DOI:10.1002/14651858.CD010783.pub2]
[20] Hadjistavropoulos T, Delbaere K, Fitzgerald TD. Reconceptualizing the role of fear of falling and balance confidence in fall risk. J Aging Health. 2011;23(1):3-23. [DOI:10.1177/0898264310378039]
[21] Baharlouei H, Salavati M, Akhbari B, Mosallanezhad Z, Mazaheri M, Negahban H. Cross-cultural validation of the Falls Efficacy Scale International (FES-I) using self-report and interview-based questionnaires among Persian-speaking elderly adults. Arch Gerontol Geriatr. 2013;57(3):339-44. [DOI:10.1016/j.archger.2013.06.005]
[22] Hassan H, Zarrinkoob H, Jafarzadeh S, Akbarzade Baghban A. Psychometric evaluation of Persian version of Activities-specific Balance Confidence scale for elderly Persians. Aud Vestib Res. 2015;24(2):54-63.
[23] Schepens S, Goldberg A, Wallace M. The short version of the Activities-specific Balance Confidence (ABC) scale: its validity, reliability, and relationship to balance impairment and falls in older adults. Arch Gerontol Geriatr. 2010;51(1):9-12. [DOI:10.1016/j.archger.2009.06.003]
[24] Azizi F, Zarrinkoob H. [A Review of the Role of the Shortened Activities-Specific Balance Confidence Questionnaire in Predicting the Risk of Falling in the Elderly]. Scientific Journal of Rehabilitation Medicine. 2017;6(1):279-88. Persian. [DOI:10.22037/JRM.2017.1100273]
[25] Hewston P, Deshpande N. The Short Version of the Activities-Specific Balance Confidence Scale for Older Adults with Diabetes-Convergent, Discriminant and Concurrent Validity: A Pilot Study. Can J Diabetes. 2017;41(3):266-72. [DOI:10.1016/j.jcjd.2016.10.007]
[26] Greene BR, O’Donovan A, Romero-Ortuno R, Cogan L, Scanaill, CN, Kenny RA. Quantitative falls risk assessment using the timed up and go test. IEEE Trans Biomed Eng. 2010;57(12):2918-26. [DOI:10.1109/TBME.2010.2083659]
[27] Khasnis A, Gokula RM. Romberg’s test. J Postgrad Med. 2003;49(2):169-72.
[28] Morgan MT, Friscia LA, Whitney SL, Furman JM, Sparto PJ. Reliability and validity of the Falls Efficacy Scale-International (FES-I) in individuals with dizziness and imbalance. Otol Neurotol. 2013;34(6):1104-8. [DOI:10.1097/MAO.0b013e318281df5d]
[29] Fuzhong L, McAuley E, Fisher KJ, Harmer P, Chaumeton N, Wilson NL. Self-efficacy as a mediator between fear of falling and functional ability in the elderly. J Aging Health. 2002;14(4):452-66. [DOI:10.1177/089826402237178]
[30] Schott N. Reliability and validity of the German short version of the Activities Specific Balance Confidence (ABC-D6) scale in older adults. Arch Gerontol Geriatr. 2014;59(2):272-9. [DOI:10.1016/j.archger.2014.05.003]
[31] Legters K. Fear of falling. Phys Ther. 2002;82(3):264-72. [DOI:10.1093/ptj/82.3.264]
[32] Mendes da Costa E, Pepersack T, Godin I, Bantuelle M, Petit B, Levêque A. Fear of falling and associated activity restriction in older people. results of a cross-sectional study conducted in a Belgian town. Arch Public Health. 2012;70(1):1. [DOI:10.1186/0778-7367-70-1]
[33] de Souza Moreira B, Sampaio RF, Diz JB, de Carvalho Bastone A, Ferriolli E, Neri AL, et al. Factors associated with fear of falling in community-dwelling older adults with and without diabetes mellitus: Findings from the Frailty in Brazilian Older People Study (FIBRA-BR). Exp Gerontol. 2017;89:103-11. [DOI:10.1016/j.exger.2017.01.004]
[34] Lajoie Y, Gallagher SP. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr. 2004;38(1):11-26. [DOI:10.1016/s0167-4943(03)00082-7]
[35] Curcio C-L, Gomez F, Reyes-Ortiz CA. Activity restriction related to fear of falling among older people in the Colombian Andes mountains: are functional or psychosocial risk factors more important? J Aging Health. 2009;21(3):460-79. [DOI:10.1177/0898264308329024]
[36] Donoghue OA, Cronin H, Savva GM, O’Regan C, Kenny RA. Effects of fear of falling and activity restriction on normal and dual task walking in community dwelling older adults. Gait Posture. 2013;38(1):120-4. [DOI:10.1016/j.gaitpost.2012.10.023]
[37] Allet L, Armand S, de Bie RA, Golay A, Pataky Z, Aminian K, et al. Clinical factors associated with gait alterations in diabetic patients. Diabet Med. 2009;26(10):1003-9. [DOI:10.1111/j.1464-5491.2009.02811.x]
[38] Allet L, Armand S, de Bie RA, Golay A, Monnin D, Aminian K, et al. The gait and balance of patients with diabetes can be improved: a randomised controlled trial. Diabetologia. 2010;53(3):458-66. [DOI:10.1007/s00125-009-1592-4]
[39] Kelly C, Fleischer A, Yalla S, Grewal GS, Albright R, Berns D, et al. Fear of falling is prevalent in older adults with diabetes mellitus but is unrelated to level of neuropathy. J Am Podiatr Med Assoc. 2013;103(6):480-8. [DOI:10.7547/1030480]
[40] Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Diabetes, vestibular dysfunction, and falls: analyses from the National Health and Nutrition Examination Survey. Otol Neurotol. 2010;31(9):1445-50. [DOI:10.1097/MAO.0b013e3181f2f035]
[41] Dixon CJ, Knight T, Binns E, Ihaka B, O’Brien D. Clinical measures of balance in people with type two diabetes: A systematic literature review. Gait Posture. 2017;58:325-32. [DOI:10.1016/j.gaitpost.2017.08.022]
[42] Canadian Diabetes Association Clinical Practice Guidelines Expert Committee; Imran SA, Rabasa-Lhoret R, Ross S. Targets for glycemic control. Can J Diabetes. 2013;37 Suppl 1:S31-4. [DOI:10.1016/j.jcjd.2013.01.016]
IssueVol 31 No 4 (2022) QRcode
SectionResearch Article(s)
Type 2 diabetes mellitus aging fear of falling balance confidence

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Aslibeigi F, Zarrinkoob H, Erfanifar A, Akbarzadeh Baghban A, Denak F. Fear of Falling and Balance Confidence in Older Adults with Type 2 Diabetes. Aud Vestib Res. 2022;31(4):319-326.