| 43
Pensar Enfermagem / v.27 n.01 / july 2023
DOI:10.56732/pensarenf.v27i1.259
Review article
Como citar este artigo: Oliveira R, Ramos O, Capelo J, Chamusca D. Fear of falling in the elderly in a
hospital setting: scoping review protocol. Pensar Enf [Internet]. 2023 Jul; 27(1):43-49. Available from:
https://doi.org/10.56732/pensarenf.v27i1.259
Fear of falling in the elderly in a hospital setting:
scoping review protocol
Abstract
Introduction
The expected changes in an aging process contribute to the increased risk of falling and
influence the person's own assessment of their risk of falling. In addition to physical injuries,
falls can have psychological consequences, such as fear of falling. This concept was defined
as a continuous concern of an individual, when standing or walking, with the occurrence of
falls, compromising the performance of daily activities. In this sense, the fear of falling is a
sensitive human response to nursing care. As health professionals, nurses should consider
evaluating the fear of falling and understand how this phenomenon manifests itself in the
elderly.
Objective
Mapping the available scientific evidence related to the fear of falling in the elderly in a
hospital environment.
Inclusion criteria
Quantitative, qualitative, or mixed studies will be considered, as well as systematic reviews
and grey literature. The review will include studies on the fear of falling in elderly people
who are in hospitals.
Methods
Scoping review protocol according to the Joanna Briggs Institute method. Three-phase
research strategy that will aim to locate published and unpublished studies in Portuguese,
English and Spanish. Temporal, geographic, or cultural limits will not be considered in the
research. The search strategy will be adapted to each database/repository in order to identify
relevant studies. The selection of studies will begin by analysing the title and abstract. The
full text of the selected studies will be analysed by two independent reviewers who will
extract data using a specific instrument.
The protocol was registered on the Open Science Framework platform (DOI -
https://doi.org/10.17605/OSF.IO/B5V6K).
Keywords
Fear of Falling; Elderly; Hospital; Review.
Rita Oliveira1
orcid.org/0000-0003-3014-2598
Olga Ramos2
orcid.org/0000-0002-0039-2433
Joana Capelo3
orcid.org/0000-0001-9181-3960
Daniela Chamusca4
orcid.org/0000-0002-5390-2193
1 Master. Institute of Health Sciences - Universidade
Católica Portuguesa, Porto, Portugal. Unidade Local de
Saúde de Matosinhos - Hospital Pedro Hispano,
Matosinhos, Portugal.
2 Master. Institute of Health Sciences - Universidade
Católica Portuguesa, Porto, Portugal. Unidade Local de
Saúde de Matosinhos - Hospital Pedro Hispano,
Matosinhos, Portugal.
3 Master. Centro Hospitalar Universitário de São João,
Porto, Portugal.
4 Master. Centro Hospitalar Universitário de São João,
Porto, Portugal.
Corresponding author
Ana Rita Capela Oliveira
E-mail: ritaoliveira2323@gmail.com
Received: 13.02.2023
Accepted: 17.04.2023
44 | Oliveira, A.
Review article
Introduction
According to the World Health Organization 1, by 2030, it
is estimated that the number of people over 60 years of age
will increase by 34%, from 1 billion in 2019 to 1.4 billion.
By 2050, this population will have doubled to 2.1 billion
worldwide.
In Portugal, demographic aging continues to increase
significantly. According to the 2021 Census2, the population
aging index, an indicator that compares the population aged
65 or over with the population aged 0 to 14, is 182, which
means that there are 182 elderly people for every 100 young
people.
With advancing age, it is expected that there will be changes
typical of the aging process. At the biological level, a variety
of molecular and cellular damage occurs, leading to a gradual
loss in physiological reserves and a functional decline in the
person's intrinsic capacity.3 Muscle weakness, compromised
balance, difficulties in locomotion and worsening of
cognition are some of the changes that occur in aging, and
these contribute to the increased risk of falls in elderly
people.4, 5
A fall can be defined as an unintentional event that results
in the change of position of the individual to a lower
postural level in relation to his/her initial position.6 The
International Council of Nurses (ICN) 7 in addition to
considering that a fall is an “event or episode”, adds that
falling is “a descent from a body from a higher level to a
lower level due to imbalance, fainting or inability to support
weight and stay upright”.
In the elderly, falls are frequent events with possible serious
consequences for the individual and with a significant
economic impact on health institutions. Globally, the
prevalence of falls in elderly people is 26.5%8, with one third
of this population falling at least once a year6, which
contributes to falls being considered the second leading
cause of injuries in the elderly.9
There are several risk factors that contribute to the
occurrence of falls, *and it is consensual to use the
classification of intrinsic and extrinsic factors.
Intrinsic factors are conditions that are related to the client,
such as age, comorbidity, history of previous falls, gait,
visual and auditory impairment, musculoskeletal changes,
and cognitive impairment.10
The extrinsic factors are related to the environment where
the client is inserted. At the hospital level, we highlight acute
illness, delirium, postoperative period, medication, change
of environment, support equipment, bed rest and
immobility, use of inappropriate footwear, lighting of
spaces, lack of knowledge about fall prevention, failure to
communicate between the client and the health
professional.6, 10 In this way, it is noticeable that the hospital
environment is a context where elderly people can present
an extremely high risk of falling.
With regard to the consequences of falls, in addition to
physical injuries, such as fractures and traumatic brain
injuries, it is important to analyse the psychological
consequences, which are harmful for the elderly in the long
term and contribute to a decrease in quality of life. Loss of
confidence and fear of falling are two examples of
psychological consequences and can result in compromised
activity levels, leading to reduced physical function and
social interactions.11
The ICN 7 defines fear as a “negative emotion: feeling
threatened, endangered or upset due to known or unknown
causes, sometimes accompanied by a physiological response
of the fight-or-flight type”.
The fear of falling has been recognized by the scientific
community, since the 1980s, as a health problem in the
elderly. This concept was called ptophobia, in 1982, and is
understood as the phobic reaction to keep standing and
walking, even when there is no neurological or orthopaedic
alteration.12
Subsequently, the fear of falling was defined as a continuous
concern of an individual, when standing or walking, with the
occurrence of falls, compromising the performance of daily
activities.13
Currently, fear of falling can be considered a protective or
pathological condition. On the one hand, fear as a protective
factor will lead the elderly to avoid risky behaviour and seek
to promote safety, either through measures that prevent falls
or through gait adaptations that increase stability. On the
other hand, the pathological fear of falling can lead to a
decline in quality of life and increase the risk of falls by
reducing the activities necessary to maintain self-esteem,
confidence, strength, and balance.5, 14
The fear of falling can cause a loss of confidence in the
ability to perform everyday tasks, leading the elderly to
restrict their daily activities15, social isolation, decline in
physical capacity and loss of independence16, which can
result in changes in mental health, namely the emergence of
depressive and anxious states.17–19 Other psychological
aspects, such as self-efficacy related to falls and self-
perception of health status, are associated with fear of
falling.16
The fear of falling proves to be a risk factor for falls in
elderly people, whether or not they have a history of
previous falls.20 People who are afraid of falling tend not to
be confident in their ability to prevent or avoid falls, which
increases the risk of falling and requires psychotherapeutic
and physical rehabilitation intervention.21
The estimated prevalence of elderly people with fear of
falling is around 36%, which is more evident in people who
have fallen in the last three months.22 In a hospital
environment, the fear of falling in elderly people who are
hospitalized varies between 36 and 83% .17, 23
It is also known that in hospitalized elderly people, the fear
of falling may have a greater influence on functional
recovery than the presence of pain or emotional changes.
Fear of falling also reduces the participation of individuals
in exercises during the rehabilitation process, as they have
functional limitations and reluctance to move.17, 24
The International Classification of Nursing Diagnoses by
NANDA International, Inc. (NANDA-I) 25 presents the
diagnosis “Risk of falls in adults” which is defined as the
“adult susceptibility to experience an event that results in
inadvertent displacement to the ground, floor or other lower
level that may compromise health”.25(p468) Still in this
Pensar Enfermagem / v.27 n.01 / july 2023 | 45
DOI:10.56732/pensarenf.v27i1.259
Review article
diagnosis it is possible to verify that the fear of falling
appears in the risk factors, namely in the
“psychoneurological factors”.25
In this sense, it is noticeable that the fear of falling is a
sensitive human response to nursing care. As health
professionals, nurses should consider evaluating the fear of
falling and understand how this phenomenon manifests
itself in the elderly.
Considering this issue, a preliminary scoping review was
carried out in the following databases/sources: Open
Science Framework (OSF), Medical Literature Analysis and
Retrieval System Online (MEDLINE) (via PubMed) and
Cumulative Index to Nursing and Allied Health Literature
(CINAHL) (via EBSCO). A scoping review18 was found
that mapped the evidence about fear of falling in elderly
people living in the community. In addition, the review
concentrated on the results of articles published between
2015 and 2020 and the search was carried out only in a
database.
In this way, this review differs from the scoping review
mentioned above in that it intends to address the fear of
falling of elderly people who are hospitalized. Knowledge
on this topic lacks completeness and a scoping review will
facilitate the necessary mapping of this knowledge.
In addition to a scoping review allowing to map the available
evidence about a phenomenon, it also allows the
identification of the main characteristics or factors related
to a concept, including those that are related to
methodological research.26
The objective of this scoping review is to map the available
scientific evidence regarding the fear of falling in the elderly
in a hospital setting.
Review Question
Following the recommendations of the Joanna Briggs
Institute (JBI) 27 for the preparation of a scoping review, the
review question is designed using the PCC mnemonic for
scoping review, where P stands for “participants”, C for
“concept” and C for "context".
For this review, it was defined as Participants – people aged
65 or over, Concept – fear of falling and Context – hospital
environment, which leads us to the following review
question:
What is the published evidence on the fear of falling in the
elderly in a hospital environment?
From the defined review question, this scoping review may
also answer the following questions:
- What is the published evidence on the related/etiological
factors inherent to the fear of falling in the elderly?
- What is the published evidence on the clinical
indicators/defining characteristics of fear of falling in the
elderly?
- What are the instruments that assess the fear of falling in
the elderly in a hospital environment?
Inclusion Criteria
Based on the PCC mnemonic, we defined the inclusion
criteria regarding participants, concept, and context
Participants
Regarding Participants, the review will consider all studies
that include elderly people as participants. Gender, ethnicity,
or other personal characteristics will not be considered. An
elderly person is understood to be one who is 65 years of
age or older.28
Concept
As for the Concept, the review will consider studies that
explore the fear of falling. Fear of falling is understood as a
continuous concern of an individual, when standing or
walking, with the occurrence of falls, compromising the
performance of daily activities.13
Context
Regarding the Context, the review will consider all studies
carried out in a hospital context, regardless of the type of
establishment, whether public or private, general, or
specialized, urban, or rural, teaching or not, and certified or
not.
Types of sources
This scoping review will include studies with quantitative,
qualitative, or mixed methods designs.
Quantitative studies include any experimental study
(including randomized controlled trials, non-randomized
controlled trials, or other quasi-experimental studies,
including before and after studies) and observational studies
(descriptive studies, cohort studies, cross-sectional studies,
case studies, and follow-up studies, series of cases).
Qualitative studies include studies with qualitative data
analysis, but are not limited to phenomenological studies,
grounded theory, ethnography, qualitative description, and
action research.
Systematic reviews that meet the inclusion criteria will also
be considered, depending on the research question. Finally,
the grey literature, namely theses and dissertations, will also
be included in the research.
Methods
The scoping review will be conducted in accordance with
the methodology proposed by the JBI for scoping review.27
This scoping review protocol is registered on the OSF
platform (DOI -
https://doi.org/10.17605/OSF.IO/B5V6K).
Search strategy
The search strategy will aim to locate published and
unpublished studies in Portuguese, English and Spanish.
Temporal, geographic, or cultural limits will not be
considered in the research.
46 | Oliveira, A.
Review article
JBI 27, 29 recommends a three-phase research process that
should be used in developing a comprehensive research
strategy:
The first phase involved conducting a limited initial search
of the MEDLINE (via PubMed) and CINAHL (via
EBSCO) databases to find articles on the phenomenon of
interest, using the search terms: “fear of falling”; “aged”;
"hospital*". In relevant articles, the words contained in the
titles and abstracts were analysed, as well as the indexing
terms used to describe the articles, in order to develop a
complete search strategy for CINAHL complete (via
EBSCO), Web of Science Core Collection, MEDLINE (via
PubMed), Scopus.
Search strategies will be adapted and individualized for each
database of published studies, as each uses its own
controlled vocabulary. Chart 1 presents a research strategy
proposal in one of the databases.
Chart 1 – Search strategy used in the database - MEDLINE (via PubMed)
Research Strategy
Results
#1: "fear of falling"[All Fields]
#2: "aged"[MeSH Terms] OR "aged"[Title/Abstract]
#3: "elder*"[Title/Abstract]
#4: “older”[Title/Abstract]
#5: "senior*"[Title/Abstract]
#6: "older adult*"[Title/Abstract]
#7: "older people"[Title/Abstract]
#8: "geriatric*"[Title/Abstract]
#9: "older person*"[Title/Abstract]
#10: #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9
#11: "hospital setting"[Title/Abstract]
#12: "inpatient*"[MeSH Terms] OR "inpatient*"[Title/Abstract]
#13: “hospital*"[MeSH Terms] OR "hospital*"[Title/Abstract]
#14: "ward*"[Title/Abstract]
#15: #11 OR #12 OR #13 OR #14
#16: #1 AND #10 AND #15
#17: #16 AND (English[Filter] OR Portuguese[Filter] OR Spanish[Filter])
2,279
3,898,782
302,509
535,444
49,998
113,680
38,820
75,485
13,565
4,221,852
13,929
157,237
1,991,749
71,416
2,066,169
262
246
Sources of unpublished studies, namely grey literature,
include OpenGrey, RCAAP (Portuguese Open Access
Scientific Repository) and Coordination for the
Improvement of Higher Education Personnel Theses Bank
(CAPES) (Brazil). The search in this grey literature was
carried out with the term “fear of falling”.
The second phase involves performing database-specific
searches on each of the bibliographic databases and
information sources selected and reported in the protocol.
The third phase involves the inclusion of any relevant
additional studies in the reference lists of all studies selected
for the review.
Selection of studies
All identified bibliographic references will be grouped and
managed in the Rayyan Intelligent Systematic Review
software, (Cambridge/United States of America,
Doha/Qatar), and duplicates will be removed.
After the search, the selection of relevant results will begin
with the analysis of titles and abstracts by two independent
reviewers, based on the inclusion criteria for the review
previously described.
Subsequently, the full text of the selected studies will be
evaluated in detail based on the inclusion criteria by two
independent reviewers. After analysing the full text, studies
that do not meet the inclusion criteria will be excluded. The
reasons for excluding these studies will be described in one
of the appendices of the scoping review.
Any disagreements that arise between the reviewers will be
resolved through discussion and consensus or by resorting
to a third reviewer.
The evaluation of the methodological quality of the included
studies will not be carried out because it is a scoping
review.29
Pensar Enfermagem / v.27 n.01 / july 2023 | 47
DOI:10.56732/pensarenf.v27i1.259
Review article
The research process will be exposed in full in narrative
form and presented in schematic form through a flow
diagram known as Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA), using the extension
for scoping reviews called Preferred Reporting Items for
Systematic Reviews and Meta-Analyses extension for
Scoping Reviews (PRISMA-ScR).30 This diagram
demonstrates, in detail, how the search was carried out, the
selection of results used in accordance with the inclusion
criteria and the elimination of duplicates.27
Data extraction
Data extraction from the included articles will be carried out
by two independent reviewers, with the support of a third
reviewer to resolve any divergence.
An instrument will be used that considers specific details
about the population, concept, context, and research
methods relevant to the issue and stated objective of this
scoping review, as indicated by the methodology developed
by the JBI (Chart 2).
Chart 2 – Data extraction instrument
Scoping Review details
Review title:
Fear of falling in the elderly in a hospital setting: a scoping review
Purpose of the review:
Mapping the available scientific evidence related to the fear of falling in the elderly in
a hospital environment.
Review question:
What is the published evidence on the fear of falling in the elderly in a hospital
environment?
Inclusion criteria
Participants
Studies that include elderly people aged 65 or over as participants.
Concept
Studies that explore the fear of falling.
Context
Studies carried out in a hospital environment, specifically hospitals, regardless of the
type of establishment, whether public or private, general, or specialized, urban, or
rural, teaching or not, and certified or not.
Font types
Quantitative, qualitative, or mixed studies. Systematic reviews and grey literature.
Details and Characteristics of the Studies
Article title
Magazine (volume, edition, pages)
Publication year
Author(s)
Country
Context
Participants
Methodology used for data collection and analysis
Results found
Fear of falling in the elderly person in a hospital environment
Related/etiological factors inherent to the fear of falling in the
elderly
Clinical indicators/Defining characteristics of fear of falling in the
elderly
Instruments that assess the fear of falling in the elderly in a hospital
context
Research Recommendations/Suggestions
Relevant bibliographical references
In order for researchers to become familiar with the data
extraction instrument, a pilot test will be carried out with the
first five articles. If necessary, the data extraction instrument
may undergo relevant changes, according to the conclusions
of the pilot test and the emerging needs of the analysis of
eligible articles.
Data Analysis and Presentation
The organization and synthesis of the collected information
will be carried out using tables and charts that facilitate the
reader's interpretation. In this way, the collected data will be
presented in schematic form through a table and
accompanied by descriptive summary tables of the articles
included in the scoping review. The conclusions of the selected
studies will be described through a narrative summary.
48 | Oliveira, A.
Review article
Subsequently, the results found will be categorized
according to their similarity, in line with the objective and
review questions that were proposed in this protocol.
In short, the presentation of the data will allow identifying,
characterizing, and synthesizing the knowledge about the
fear of falling in the elderly in a hospital setting.
Authors’ contributions
RO: Study conception and design; Data collection; Data
analysis and interpretation; Manuscript writing.
OR: Analysis and interpretation of data; Drafting of the
manuscript.
JC: Critical revision of the manuscript.
DC: Critical revision of the manuscript.
Conflicts of interests
No conflict of interest declared by the authors.
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