“Being careful”: How much caution is enough? The relational context of fear of older adult falling in older adult-family caregiver dyads

Approximately 30% of community-dwelling older adults fall each year.1 Family caregivers play an important role in managing and preventing older adult falls.2,3 Fear of older adult falling is a core concept in the study of falls, including older adults’ own fear of falling (FOF), and family caregivers’ fear of the older adult falling (FOAF). The former has been a primary focus of falls research, whereas the latter is a new concept, and little research has been done on this topic. FOF has been operationalized as both a consequence of having fallen4,5 and a predictor of future falls and injury.6,7 The premise is that FOF results in a downward spiral in which fallers limit their physical activities and consequently aggravate deconditioning and weakness, which in turn increases the risk of future falls.

In psychological research, fear is an affective construct that implies a generalized defensive response to threats and stimuli8 and a generalized manifestation of anxiety and worry.9 Research on depression and anxiety in older adults indicates that future-oriented thoughts about anticipated events that fixate on the threat or negative impact are associated with excessive rumination, and thus are associated with anxiety and depression.10 Fear is often linked to either defensive avoidance behaviors or proactive coping behaviors depending on the levels of fear.11 In fall research, FOF has been defined as a lasting concern about falling or balance1,12 that is linked to avoidance of behaviors such as physical activity, which presumably serve as a risk factor for deconditioning and future falls.13 However, some studies found that FOF was not necessarily a risk factor for falling but could serve as a protective factor.11,14,15 FOF could lead to stabilizing adaptive behaviors,14 such as reduced gait and ambulating speed, or even as a motivator for people to exercise.16,17 These findings raise an important question about what FOF truly means to older adults.

Dyadic studies on fear of older adult that include both older adults and their family caregivers are limited. Recently, a few researchers began to acknowledge that fear of older adult falling might not only affect older adults, but also their family caregivers due to older adults’ significant care needs after falls.18,19 There is a nascent view of developing fear of older adult falling as a relational condition that impacts both older adults and family caregivers because of the interdependence of older adults and their family caregivers.2 A recent guideline emphasizes the importance of including the lived experiences (e.g., fear of falling) of family caregivers in managing and preventing falls.3 Nevertheless, our knowledge about what fear of older adult falling means to individual dyadic members and the degree to which each dyadic member's fear affects the other member is scarce.

To address this gap, the aims of this mixed-method study were to 1) gain an understanding of the meaning of fear of older adult falling from a linguistic perspective (Aim 1), and 2) understand dyadic coping strategies used to deal with fear of older adult falling and whether strategies are similar or different for older adults and caregivers (Aim 2). Linguistic analysis is not new and has been widely used to measure and detect people's internal thoughts with the assumption that people's inner thoughts, psychological states, and social concerns or bias can be captured by their linguistic features. At its core, we assumed that the meaning of fear of older adult falling is reflected in participant dyads’ verbal accounts of their experiences and that empirical features of these accounts, such as pronoun use and choice of terms used to indicate subjective experiences, are linguistic markers of the hidden meaning within dyad perceptions of fear of older adult falling.

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