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1 Journals of Gerontology: MEDICAL SCIENCES The Author Published by Oxford University Press on behalf of The Gerontological Society of America. Cite journal as: J Gerontol A Biol Sci Med Sci September;68(9): All rights reserved. For permissions, please journals.permissions@oup.com. doi: /gerona/glt007 Advance Access publication May 16, 2013 Brief Report Validation of the Iconographical Falls Efficacy Scale in Cognitively Impaired Older People Kim Delbaere, 1 Jacqueline C. T. Close, 1,2 Morag Taylor, 1,2 Jacqueline Wesson, 3 and Stephen R. Lord 1 1 Falls and Balance Research Group, Neuroscience Research Australia and 2 Prince of Wales Clinical School, University of New South Wales, Randwick, Sydney, Australia. 3 Ageing, Work and Health Research Unit, Faculty of Health Sciences, University of Sydney, Cumberland Campus, Lidcombe, Sydney, Australia. Address correspondence to Kim Delbaere, PhD, Falls and Balance Research Group, Neuroscience Research Australia, University of New South Wales, Barker Street, Randwick, NSW 2031, Australia. k.delbaere@neura.edu.au Background. This study evaluated psychometric properties of the Iconographical Falls Efficacy Scale () to measure fear of falling in cognitively impaired older people. uses pictures as visual cues to prompt responses. Methods. A total of 50 community-dwelling older people with moderate cognitive impairment were assessed on Icon- FES, Falls Efficacy Scale-International, and various physical and cognitive measures. Results. Overall structure and measurement properties of, as evaluated with item response theory, were good. Internal consistency was high (Cronbach s alpha = 0.97). Distribution was near normal, indicating absence of floor and ceiling effects. construct validity was supported by its relation with Falls Efficacy Scale-International (r =.68, p <.001) and its ability to discriminate between groups relating to fall risk factors (gender, balance, falls). Scores were not affected by different levels of cognitive functioning, as assessed with the Mini-Mental State Examination and Trail Making Test. Conclusions. is the first measure of fear of falling that compensates for reduced abstract abilities by using pictures to match the verbal descriptions. This study supports its feasibility, reliability, and validity to assess fear of falling in people with moderate cognitive impairment or dementia living in the community. Compared with Falls Efficacy Scale-International, was better at identifying participants with higher fall risk and did not show a floor effect likely due to a greater range of physically challenging activities. Key Words: Falls Geriatric assessment Alzheimer s disease Fear of falling Dementia. Received September 19, 2012; Accepted January 8, 2013 Decision Editor: Stephen Kritchevsky, PhD Fear of falling is common in community-dwelling older adults, with higher prevalence in people who are frail and in those who have a history of falling (1 3). The few studies that have investigated fear of falling in older people with cognitive impairment have reported inconsistent findings. Two studies have found that older people with cognitive impairment report high levels of fear of falling and that this is related to concomitant physical impairments and frailty (4,5). In contrast, it has been suggested that people with Alzheimer s disease report lower levels of fear of falling (6), that they are less likely to restrict activities as a result of falling (7), and that their fear of falling may be unrelated to fall frequency in this group (4). It is possible that a lack of awareness of risk of falls might result in an inappropriately low level of fear relative to physical ability. Accuracy of the reported level of fear of falling in people with cognitive impairment may be strongly influenced by difficulty in comprehending questions or reporting on subjective states. The Iconographical Falls Efficacy Scale () is a fear of falling questionnaire using pictures as visual cues to provide more complete environmental contexts (1). Both full (30-item) and shortened (10-item) versions of the previously demonstrated strong psychometric properties in cognitively intact older people, including its normal distribution and its ability to assess fear of falling in high functioning older people (1). This study evaluated the in people with cognitive impairment. The use of pictures might compensate for reduced abstract abilities in people with cognitive impairment and therefore be a more feasible assessment in this population. 1098

2 ICONOGRAPHICAL FALLS EFFICACY SCALE 1099 Methods A total of 50 participants were randomly recruited from a cohort of 177 community-dwelling people aged 65 years or older and participating in a study on understanding fall risk factors in cognitively impaired older adults (8). The main inclusion criterion for cognitive impairment was defined as an Addenbrooke s Cognitive Examination-Revised score of 82 or lower (9), or a Mini-Mental State Examination score of 23 or lower (10), or where a specialist clinician had made a diagnosis of cognitive impairment or dementia. Exclusion criteria were presence of Parkinson s disease, recent stroke (within 18 months), other neurodegenerative disorders, known as end-stage illness, or insufficient knowledge of the English language to complete the tasks. All participants had an identified and willing person responsible with at least 3.5 hours of weekly face-to-face contact. All participants and their person responsible consented to participate in the study prior to interview. Study approval was obtained from the University of New South Wales Human Studies Ethics Committee. is an interview-based questionnaire using a combination of pictures and matching short phrases. Icon- FES provides information on level of concern about falls for a range of activities of daily living (Figure 1). The long version contains 30 items scored on a 4-point scale (1 = not at all concerned to 4 = very concerned); the shortened version contains 10 items (1). Concern about falling during seven activities of daily living was also assessed by interview using the shortened Falls Efficacy Scale-International (FES-I; total score range = 7 28 [11]). Postural sway was assessed by recording body displacements at waist level (mm) while standing on a foam mat with eyes open and feet hip width apart (12). The Physiological Profile Assessment was used to gain an estimate of physiological fall risk (12). Trail Making Test (Trails A) was performed as a measure of visual search and processing speed. Participants were asked to connect consecutively numbered circles as fast as possible (13). Information pertaining to falls in the previous year and during a 12-month follow-up period using falls diaries was also obtained from participants or carers (8). Questionnaire structure was evaluated by using item response theory, that is, Rasch modelling (Winsteps, JM Linacre). Further reliability analyses were performed using SPSS for Windows (Version 20, SPSS, Inc., Chicago, IL). Construct and discriminant validity of was assessed by using independent t tests to examine betweengroup differences in total scores according to age, gender, various fall risk factors, and cognitive performance (cutoff: median). Effect sizes for group differences of and FES-I scores were calculated (1). Results Mean age of participants was 82.1 years (SD = 5.9) and 26 (52%) were women. Seventy-two percent (n = 36) of participants reported one or more falls in the previous year, of which half (n = 18) fell twice or more. Mean Physiological Profile Assessment fall risk score was 2.2 (SD = 1.8), mean Mini-Mental State Examination score was 22.4 (SD = 4.4), and on average, participants took seconds (SD = 85.8) to complete Trails A. Rasch analyses indicated that most items fitted well within the unidimensional fear of falling scale, suggesting 1. Cleaning the house 2. Getting dressed or undressed* 3. Preparing simple meals 4. Taking a bath* 5. Taking a shower* 6. Going to the shop* 7. Getting in or out of a chair 8. Going up stairs 9. Going down stairs* 10. Walking around in the neighborhood* 11. Walking in the neighborhood in rainy weather 12. Walking in the neighborhood in windy weather 13. Walking in the neighborhood in the dark 14. Reaching for something above your head (ground) 15. Reaching for something above your head (safe step)* 16. Reaching for something above your head (chair)* 17. Reaching for something on the ground 18. Going to answer telephone before it stops ringing 19. Walking on a slippery surface 20. Visiting a friend or relative 21. Walking in a place with crowds 22. Walking on an uneven surface 23. Walking down a slope 24. Going out to a social event* 25. Cleaning the gutter* 26. Taking the escalator 27. Running to catch the bus 28. Crossing the street 29. Crossing a busy street 30. Crossing the street against the lights Figure 1. Bubble chart for Iconographical Falls Efficacy Scale () as a graphical representation of measures and fit values. Bubbles are named after the item was presented on the right and sized by their standard errors. Items assessing high levels of concern are at the top of the fear of falling continuum (positive logits) and items assessing lower levels of concern are at the bottom (negative logits). Bolded circles and items with * are included in the shortened.

3 1100 DELBAERE ET AL. a good overall structure (Figure 1). Location of items along the x-axis (weighted t statistic) of the bubble chart ranged between 2.00 and 2.00, except for taking a shower (t Outfit Zstd = 2.3). Location of items along the y-axis (average measure, expressed in logits), with values between 2.75 and logits, indicated a good diversity of scale items. The person separation index was 4.2 for 30-item, which indicates that the scale can differentiate people with and without concern about falling on four levels. The person separation index for 10-item was 2.6. Table 1 summarizes scoring and reliability estimates of and FES-I scales. Full range of responses (ie, 1 through 4) was used for nearly every item of the, except for being very concerned while preparing simple meals. Minimum score was given by four people (8%) for 30-item and eight people (16.0%) for 10-item, compared with 20 people (40.0%) for FES-I, indicating a reduction in floor effect for scales. Distributions of scales were near normal, and distribution of FES-I was mildly skewed to the left. Overall, internal consistency was high for all scales. Inter-item correlations were lower for scales compared with FES-I. Items asking about concern for falling while preparing simple meals, getting in or out of a chair, and cleaning the gutter correlated poorly with other items. The range of inter-item correlations for all other items was between 0.30 and 0.70, which is within the optimal range for good internal consistency. Good construct validity was confirmed by the moderate correlation between total scores of and FES-I (Spearman s rho = 0.68, p <.001). Good discriminant validity was confirmed by significantly higher scores in women, participants with increased physiological fall risk and poor balance, and participants who suffered two or more falls in the past year and during 12-month follow-up (Table 2). Effect sizes for between-group differences were better for score compared with FES-I (Table 2). Scores were not affected by different levels of cognitive functioning (assessed with Mini-Mental State Examination and Trails A). Table 1. Scoring and Reliability Estimates of Iconographical Falls Efficacy Scale (; range = ), 10-Item (range = 10-40), and Shortened Falls Efficacy Scale-International (FES-I; range = 4-28) for 50 Cognitively Impaired Older Adults Living in the Community 10-Item FES-I Mean score (SD) 55.3 (21.8) 18.9 (7.4) 11.1 (5.4) Median (range) 52 (30 117) 17 (10 39) 9 (7 26) Minimum score (floor effect), n (%) 4 (8.0) 8 (16.0) 20 (40.0) Maximum score (ceiling effect), n (%) 0 (0.0) 0 (0.0) 0 (0.0) Cronbach s alpha Mean (minimum-maximum) inter-item correlations 0.53 ( ) 0.50 ( ) 0.65 ( ) Skewness (SEM) 0.87 (0.34) 0.66 (0.34) 1.32 (0.34) Kurtosis (SEM) 0.21 (0.66) 0.23 (0.66) 0.50 (0.66) Notes: SD = standard deviation; SEM = standard error of the mean. Table 2. Mean and Standard Deviation (SD) of Iconographical Falls Efficacy Scale (; range = ), 10-Item Icon- FES (range = 10-40), and Shortened Falls Efficacy Scale-International (FES-I; range = 4-28) Scores for Subgroups Based on Demographic Characteristics, Fall Risk Factors, and Cognitive Performance N Group 1 Group 2 Effect Size* 10-Item FES-I N 10-Item FES-I 10-Item FES-I Age (y) ± ± ± 5.2 > ± ± ± Gender Male ± ± ± 4.5 Female ± ± ± Previous falls ± ± ± 5.0 > ± ± ± Future falls ± ± ± 4.1 > ± ± ± PPA score ± ± ± 5.5 > ± ± ± Postural sway (mm 2 ) ± ± ± 4.8 > ± ± ± Trails A ± ± ± 5.5 > ± ± ± MMSE score > ± ± ± ± ± ± Notes: MMSE = Mini-Mental State Examination; PPA = Physiological Profile Assessment. *Effect sizes for group differences on FES-I, 30-item, and 10-item. Median of total sample. p.050. p.001.

4 ICONOGRAPHICAL FALLS EFFICACY SCALE 1101 Discussion is the first fear of falling scale to combine words with pictures and also includes a greater range of physically challenging activities. This study supports feasibility, reliability, and validity of to assess fear of falling in people with moderate cognitive impairment or dementia living in the community. Compared with FES-I, scales were better at identifying participants with higher fall risk and its data distributions were near normal. The poor fit of the item asking about concern when taking a shower according to Rasch analyses could be due to our relatively small sample size. Overall, has excellent psychometric properties and can be used to assess fear of falling in people with moderate cognitive impairment. This was further confirmed by similar scores obtained in people with different levels of cognitive functioning. One of the challenges of assessing an abstract concept as fear of falling in older people with cognitive impairment is to establish with the person that the topic being considered is their fear of falling. The use of interviewbased questionnaires has therefore been recommended (4). Impaired recognition memory, especially for recent events, also makes it difficult to assess people with cognitive impairment using self-assessment methods. The main advantage of over more traditional fear of falling scales is its use of pictures providing clear, unambiguous contexts. Previous research has suggested that pictures allow patients with cognitive impairment to better recognize and identify a situation compared with using just words, by enhancing familiarity (14,15). Therefore, using pictures in combination with words is likely to assist with correct interpretation of the contextual meaning. Furthermore, expressive and receptive disorders of language are common in cognitive impairment and can limit full participation in discussions about fear of falling. Use of facial expressions as line drawings, such as those used in response categories, can facilitate completion of the scale and has been used successfully in people with dementia to assess mood (16). To get a complete picture of fear of falling in people with cognitive impairment, inclusion of at least one high risk activity is crucial. This helps determine whether low levels of fear are due to poor insight or are a true reflection of a low fall risk. Older people with poor insight as a consequence of conditions such as Alzheimer s disease might take undue risks relative to their physical ability., both long and shortened version, is the only fear of falling scale that includes high-risk activities such as climbing on chairs or ladders to reach high places. Therefore, may also have potential to identify risk-taking behaviors that might result in increased fall risk through exposure to dangerous situations. Discussions around modifying such risk behaviors could have significant positive outcomes for this population. We acknowledge that this study has certain limitations. First, the sample size is relatively small. Second, was assessed in community-dwelling older adults with moderate cognitive impairment. Future research should confirm feasibility and psychometric properties of Icon- FES in alternate settings and older people with severe cognitive impairment. In addition, future research should explore appropriateness of the chosen cartoons across cultures and environmental circumstances. In conclusion, both long and shortened are reliable and valid measures of concern about falling in community-dwelling older adults with cognitive impairment. The is the first measure of fear of falling that compensates for reduced abstract abilities by using pictures to match the verbal descriptions. Future studies should use larger samples and explore the s test retest reliability and sensitivity to change following interventions. Acknowledgments Dr. Delbaere is a National Health and Medical Research Council (NHMRC) Career Development Fellow and Prof. Lord is a NHMRC Senior Principal Research Fellow. The Iconographical Falls Efficacy Scale (iconfes) is now available as a not-for-profit ipad application through Neuroscience Research Australia (NeuRA). References 1. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66: Helbostad JL, Taraldsen K, Granbo R, Yardley L, Todd CJ, Sletvold O. Validation of the Falls Efficacy Scale-International in fall-prone older persons. Age Ageing. 2010;39: Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale- International (FES-I). Age Ageing. 2005;34: Hauer K, Yardley L, Beyer N, et al. Validation of the Falls Efficacy Scale and Falls Efficacy Scale International in geriatric patients with and without cognitive impairment: results of self-report and interviewbased questionnaires. Gerontology. 2010;56: Hauer KA, Kempen GI, Schwenk M, et al. Validity and sensitivity to change of the falls efficacy scales international to assess fear of falling in older adults with and without cognitive impairment. Gerontology. 2011;57: Uemura K, Shimada H, Makizako H, et al. A lower prevalence of self-reported fear of falling is associated with memory decline among older adults. Gerontology. 2012;58: Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing. 2004;33: Taylor ME, Lord SR, Delbaere K, Mikolaizak AS, Close JCT. Physiological Fall Risk Factors in Cognitively Impaired Older People: a One Year Prospective Study. Dement Geriatr Cogn. 2012;34: doi: / Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Addenbrooke s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry. 2006;21: Folstein MF, Robins LN, Helzer JE. The Mini-Mental State Examination. Arch Gen Psychiatry. 1983;40: Kempen GI, Yardley L, van Haastregt JC, et al. The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age Ageing. 2008;37:45 50.

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