Carers’ concern for older people falling at home: an integrative review

Search strategy

A systematic search was conducted in CINAHL, Embase, MEDLINE, PsycINFO, Scopus and Web of Science. Additional records were identified by hand searching reference lists of the selected studies. Search terms included: ‘caregiver’, OR ‘carer’, OR ‘support person’, AND ‘fall efficacy’, OR ‘fear of falling’, OR ‘worry of falling’, OR ‘concern of falling’. Search strategies were modified according to individual databases. Proximity searches and truncation to identify terms in their adjectival form were used. The full search strategy for all databases is presented in the supplementary table (Appendix, Supplementary Table I).

Inclusion criteria for the review were empirical studies published in English between January 1993 and September 2018 exploring carers’ concern for older people falling at home, with a focus on the general older population or those with age-related chronic illnesses. In this review, a ‘carer’ is defined as an individual providing informal ambulation support and activities of daily living assistance to an older person living at home. Studies that focused on professional carers, falls that occurred in the hospitals or nursing homes, or falls related to paediatric population were excluded from the literature search.

Search outcomes

The initial search yielded a total of 359 studies. After the removal of 220 duplicates, 143 studies, including four additional studies identified from the reference lists of the remaining studies, were reviewed using their title and abstract. Based on the inclusion criteria, 25 studies were selected for full-text review. Ten studies were excluded due to insufficient detail on carers’ concern about their care recipients falling, such as evaluation of this concern, its causative factors, and its impact on the carers and older person. Finally, 15 studies were used for this integrative review. The search strategy and procedures were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses framework (Fig. 1).

Fig. 1

Chart shows the search strategy and procedures used to identify the studies.

Quality appraisal

The systematic search resulted in 15 studies: five quantitative, eight qualitative and two mixed-method studies relating to carers’ concern for falls in older persons. Methodological quality of the included studies was assessed using the 17-criteria Mixed Methods Appraisal Tool (Table I).(21) All 15 studies fulfilled the screening criteria by having research methodologies that were congruent to the study aims.

Table I

Methodological quality of included studies.

Among the eight qualitative studies, four applied grounded theory,(12,13,22,23) three were descriptive designs(24-26) and one used focus groups.(27) All studies had relevant qualitative data sources and analyses, and appropriately addressed the study findings to the context. Only two studies appropriately considered potential researcher bias.(23,24)

Of the five quantitative studies, one was a randomised controlled trial,(28) two were cohort studies,(29,30) and the rest used a cross-sectional design.(14,31) Methodological quality of the randomised controlled trial was robust, fulfilling all the criteria related to randomisation description, blinding, completed outcome data > 80% and low dropout rate.(28) The other four quantitative studies also achieved minimisation of selection bias, applied appropriate measurements and recruited comparable participants. One study did not obtain an acceptable response rate of more than 60%(31) as required by the Mixed Methods Appraisal Tool. However, for the purpose of identifying additional factors related to carers’ concern, that study was included, as it explored the relationship between care recipients’ fall risk and caring burden.

Both the mixed-method studies used a prospective longitudinal design for the quantitative component. For the qualitative component, one study applied a focus group,(32) while the other study used face-to-face interviews.(18) Methodological quality for individual quantitative and qualitative components was robust, with both studies fulfilling most of the quality criteria. However, only one study demonstrated appropriate integration of qualitative and quantitative data.(18)

Data extraction

A narrative analysis was used to review evidence related to the phenomenon of carers’ fall concern. Data was extracted using a data reduction method to facilitate systematic comparison of primary studies and understanding of the relationship between each theme and the phenomenon of concern.(20) Seven studies were used to describe the causes for carers’ concern about older people falling. Findings were extracted and grouped into two themes: prevalence and measurement of fall concern; and carers’ fall concerns. 13 studies provided findings on the impact of fall concern. These findings were pooled and categorised into four themes: impact on physical and psychological health; lifestyle changes; increased caregiving burden; and impact on fall prevention strategies used. A summary of these studies is provided in Table II.

Table II

Summary of review of selected literature to carers’ fall concern.

Prevalence and measurement of fall concern

Three quantitative studies explored the prevalence of carers’ concern about the older persons falling.(28-30) Among older people with a history of falls in the community, between 58% and 91% of their carers reported being fearful that their care recipients would fall again.(28,30) In a quantitative study of older people with stroke who were discharged from hospital, many carers were concerned about their care recipients falling regardless of whether they had fallen previously, and 57% (42/74) and 45% (33/74) of these carers continued to experience fall concern at the eight-week and six-month follow-up, respectively.(29) To measure carers’ concern for their care recipients falling, two studies used a single-item question with ‘yes’ or ‘no’ response,(28,29) and one study used a three-point scale of ‘no fear’, ‘some fear’ and ‘great fear’.(30) No aspects of validity and reliability were tested for any single-item measures.

Carers’ fall concerns

Two studies reported carers’ concerns about the outcomes of falls in care recipients.(12,13) While the possibility of older people falling was the main concern of carers, there is evidence suggesting that carers are equally distressed over other consequences of a fall. A qualitative study on carers whose spouses with Parkinson’s disease experienced recurrent falls found that their concerns exceeded the immediate consequences of the fall, to the possible impact on the older person’s quality of life and survival.(13) Carers of frail older people also described fear about the unknown consequences of a fall, such as fractures or hospitalisation, regardless of the frequency of previous falls.(12)

Four studies discussed carers’ concern about the older person’s lack of awareness of their fall risk and their continued engagement in high-risk activities, exposing them to the potential of falling.(12,13,24,32) A focus group of carers from the general elderly population found that care recipients forgetting their mobility aids or refusing to use them were common causes of concern among carers.(32) A similar concern was highlighted by the spouses of stroke survivors when the older persons chose to walk without their prescribed walking aids.(24)

Furthermore, Faes et al reported that carers of older people with cognitive impairment experienced emotional distress when their care recipients refused to adhere to their fall prevention advice.(12) As a result, carers often felt that the falls were beyond their control and could not be prevented. Carers of older people with Parkinson’s disease also attributed the causes of falls and their concern to the care recipients’ risk-taking behaviour, which was complicated by the older persons’ desire for independence.(13)

Impact on physical and psychological health

Only one study reported on carers who injured themselves while trying to stop their spouses from falling, or when helping them up from a fall.(13) Due to the common occurrence of falls, some carers were reluctant to seek help despite lacking the physical strength to lift their spouse up from a fall, which put the carers at further risk of personal injury.(13)

The psychological impact of an older person’s fall was explored in four studies.(13,29,31,32) Forster and Young found that carers of older people with stroke were significantly more stressed if their care recipients had fallen six months after hospital discharge.(29) Among the general elderly population, carers of care recipients with a high fall risk expectation experienced higher levels of depression.(31) Another study revealed from qualitative interviews that carers experienced mixed feelings of emotional and psychological consequences such as anxiety, worry, fear, shock, anger and frustration due to their care recipients falling.(13) Dow et al concluded that some carers blamed themselves for not monitoring their care recipients closely enough.(32)

Lifestyle changes

Seven studies discussed carers’ social restrictions related to the older person falling at home.(12,13,18,25,26,29,32) Fear of older people falling meant carers had to be constantly vigilant and avoid leaving the care recipient alone.(12,13,32) One study reported that carers would only leave their spouses for brief periods, or when someone else was available to supervise their spouses in their absence.(26) The reluctance to leave the older persons alone limited the carers’ opportunity to participate in individual or social activities, leading to social withdrawal.(12,13,18,29) Carers also reported changing their daily routines, such as work arrangements and social engagements, to facilitate greater supervision of the older person after a fall.(25,32)

Increased caregiving burden

The literature search identified seven studies that discussed the carers’ experience of increased burden related to caring for older people at risk of falling.(12,14,22,24,26,31,32) Besides having to ensure their care recipients’ safety, some carers also experienced a change in the level of care; this could be due to the older persons requiring more help in mobility or daily activities, or the carers having to attend to their care recipients’ injuries after a fall.(32) As a result, more time was needed to assist the older person, and carers were often unable to complete their chores or get enough rest. This lack of time and energy was also explored in a qualitative study among spouses of stroke survivors.(24) The theme ‘time is constantly on my mind’ emerged from the interviews as carers described difficulty fulfilling work and home responsibilities while looking after their spouses. According to Faes et al, carers of frail older people experienced increasing burden as they became more aware of their care recipients’ dependence, and many carers also felt fatigue and overwhelmed by the changes in caring roles and duties.(12)

The relationship between falls and caregiving burden was examined in two Australian quantitative studies, which found a significant increase in general caregiving burden for carers looking after older people with a higher fall risk(31) and those who had fallen once in 12 months.(32) A Japanese study using a large cross-sectional sample of 1,478 carers also found that carers of older people who had fallen in the past six months had a significantly higher caregiving burden than those caring for non-fallers.(14)

When carers’ burden of care exceeds their ability to provide adequate care, the care recipients who had experienced a fall often end up being placed in institutional care.(22) Carers identified falls with severe injury as one of the main reasons for sending their family members with Parkinson’s disease to long-term care. Yet, falls are an accepted part of Parkinson’s disease progression, and carers are not always able to minimise the risk of their care recipients falling. To mitigate this burden, some carers turned to respite care for support. However, in the studies reviewed, respite care was sometimes met with reservations due to either the carers’ previous bad experience or the care recipients’ refusal to accept care.(26,32)

Impact on fall prevention strategies used

Caregivers’ fall concern has an influence on the strategies used for fall prevention at home, and this was discussed in seven studies.(12,13,18,23,25,27,32) Six of these studies described carers who stayed vigilant in order to prevent older people from falling.(12,13,23,25,27,32) Some strategies included frequent telephone calls or visitations, close monitoring of care recipients’ activities, constant reminders and awareness of their individual fall risk. Other carers used strategies such as giving advice on posture and walking, promoting physical activity or attendance at rehabilitation clinics, encouraging the use of walking aids, and making changes to the home environment.(12,13,27,32) Besides preventing possible falls, carers also resorted to modifications of the home environment, such as installation of grab rails/sensor lights and removal of mats, to minimise the potential impact of a fall occurring.(13)

Due to concerns about older people’s risk of falling, some carers chose to accompany their care recipients to social activities or assist them in their chores.(12) However, one study found that carers of older people with dementia do not always want to undermine their care recipients’ independence with over-support.(25) Stevenson and Taylor stated that carers generally do not wish to restrict their care recipients from participating in their daily activities, despite the risks involved.(27) They further suggested that the risk would be worth it if their older care recipient could get out of the house, be mentally stimulated or experience some enjoyment from being cared for in a flexible environment. Some carers, however, tried to intervene by taking over or by restricting activities that are perceived to be risky.(27) Buri and Dawson reported that, to reduce the likelihood of a fall occurring, some carers even attempted to control their care recipients with dementia by physically confining them to a controlled space or restricting their freedom to move around.(23) While these preventive strategies appeared to reduce the risk of occurrence of falls and increase the carers’ feeling of control, they can potentially contribute to greater dependence among older people.(18)

Implications to practice

Recognising carers’ concern can be incorporated into caregiver training, rehabilitation and fall prevention programmes to assist healthcare professionals to identify carers who might have difficulty in managing falls at home. Interventions could then be tailored to the individual carer and the older person. For instance, a distressed carer may be referred to a medical social worker or psychologist for counselling to ameliorate excessive concern. Information on access to resources and community services, such as home care assistance, respite care, counselling support and financial aids, could also be provided.

It is also important for healthcare professionals to identify carers’ concern during discharge planning and to provide targeted discharge advice for older people admitted for recurrent falls. In countries with inadequate community services (i.e. nurses) to assist home carers in supporting the older person at risk of falling, it would be prudent to review the involvement of community nursing and care coordinators in the support of carers living at home with the older person at risk of falling.

Recommendations for future research

Many studies have focused on older people with specific medical conditions. Future studies are needed to further examine carers’ concern for the general population of elderly people experiencing functional decline due to ageing, which puts them at risk of falling. A multi-item measure could be developed to effectively capture a comprehensive picture of the impact of an older person’s fall on the carers, and this can be used as an alternative outcome measure for fall prevention programmes.(42)

Many carers experience lifestyle changes during the care of older people, which can aggravate physical and emotional burden. More research into how families can be better supported, especially in countries where families are considered the main support structure for older people, would be beneficial.(43) For example, in some parts of the world, the family’s children juggle with full-time jobs in addition to the care of their parents or other older family member. This situation often means that paid carers such as foreign domestic workers (FDWs) are engaged to help them.(43) These FDWs are often lowly educated and poorly paid, regulated by only a work permit system binding them to an individual employer from one household.(43) In this context, unlike a spouse or a relative, the FDWs have a paid duty to provide care for the older person living at home. Further research about paid carers’ fall concern and support, and how family carers can be equipped to support and complement the roles of FDWs is crucial in the continuing care of the older person.

The majority of studies regarding falls and fall concern have been conducted in Western developed countries. Future research conducted in Asian cultures is recommended to allow for a detailed analysis of potential cultural influences on carers’ fall concern.(36) Such research could clarify and identify alternative approaches to the cultural care of older people at risk of falling who live at home. Fall concern research in Asian cultures could involve understanding filial responsibility and its profound influence on carers’ fall concern and fall prevention strategies. Studies that include socioeconomic and environmental considerations related to fall prevention could also be worthy of deeper investigation.