CHAPTER 21: TINETTI FALLS EFFICACY SCALE (FES)
Description
The Falls Efficacy Scale (FES) by Tinetti, Richman, and Powell (1990) is a standardized questionnaire designed to quantify a person’s fear of falling. Operationalized by two related but separate constructs, falls self-efficacy and balance confidence, the assessment is loosely based on Bandura’s Self-Efficacy theory, which proposes that an individual’s perceived ability has an effect on functional performance regardless of actual ability. Also, several investigators have argued that fear of falling may be more extensive of a problem in the elderly than actual falling; thus, the ability to quantify that fear is important for occupational therapy practitioners (McAuley, Mihalko, and Rosengren, 1997; Schepens, Sen, Painter, & Murphy, 2012). Through analysis, the FES examines the person’s degree of confidence at avoiding a fall during 10 relatively non-hazardous activities of daily living (ADLs), such as cleaning the house, taking a bath or shower, or reaching into cabinets or closets (Tinetti et al., 1990). The assessment can be completed as an interview or as a self-report measure where each item is rated from 1, very confident to 10, not confident at all. FES scores range from 0 to 100, with higher scores suggestive of a greater fear of falling. A modified international version (FES-I) of the measure also exists that has an expanded 16 items scored along a 4-point scale from 1, not at all concerned to 4, very concerned. The FES-I is designed to include more demanding and challenging activities, which may be of interest for higher functioning individuals, such as walking on a slippery surface, walking in a place with crowds, going out to a social event (i.e., family gathering or club meeting), walking up or down a slope, reaching for something above your head or on the ground, and visiting a friend or relative (Delbaere et al., 2010). Both the FES and FES-I can be completed in less than 10 minutes.
TABLE 21-1
EXAMPLE ITEMS OF THE FALLS EFFICACY SCALE
• Cleaning the house |
• Getting dressed and undressed |
• Preparing a simple meal |
• Taking a bath or shower |
• Simple shopping |
• Getting in and out of a chair |
• Going up and down stairs |
• Walking around the neighborhood |
• Reaching into cabinets or closets |
• Answering the door or phone |
Adapted from Tinetti, M., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45(6), P241.
Psychometrics
Hauer et al. (2010) found test-retest reliability to be good with a range of r = 0.81 to 0.88, whereas internal reliability was 0.89 to 0.92. They also found that scores differed between administration methods in cognitively impaired individuals (i.e., self-report or interview) but not in the cognitively intact group, indicating that impaired persons may express less concern about falling in self-reports. Original research in 2 samples of community-living elderly persons showed good test-retest reliability at r = 0.71, and that subjects who reported avoiding activities because of fear of falling had higher FES scores, representing lower self-efficacy or confidence than subjects not reporting fear of falling (Tinetti et al., 1990). A later study, also by its creators, found that the FES was able to stratify scores among a group cohort where 57% denied a fear of falling, 24% acknowledged fear but denied effect on activity, and 19% acknowledged avoiding activities because of a fear of falling. Furthermore, 24% of recent fallers vs 15% of non-fallers acknowledged activity restriction due to fear of falling (Tinetti, Mendes de Leon, Doucette, & Baker, 1994).
Advantages
The FES is a relatively quick and simple questionnaire that can be used across a number of patient populations as a self-report or interview-based measure. There is a considerable amount of research in support of its use in clinical practice and no special training is required. There are several modified versions available and the more complex 16-item (FES-I) international version has been well validated. The FES-I maintains a website devoted to the measure where translations and research information can be found.
Disadvantages
The FES scale has been critiqued for its poor discriminant validity and some argue that it may be difficult for respondents to distinguish between their self-confidence in performing a task and their actual ability to perform the task (Edwards & Lockett, 2008). The scale has also yielded results that may be erroneous for subjects with good mobility where data from a sample of 1103 subjects ≥ 72 years old, who were ambulatory within the household, showed that 39% had scores with highest perceived efficacy, 38% moderate, and only 23% low self-efficacy (Edwards & Lockett, 2008).
Administration
Assessment requires the individual to rate his or her perceived fear of falling while performing various ADLs along a numerical rating scale from 1 (very confident) to 10 (not confident at all). The FES has maximum score of 100 points where a score greater than 70 indicates that the person has a fear of falling.
Permissions
The FES and FES-I are free to use in clinical practice. Use of either, in research or publication, can be obtained by contacting their creators at the information following or contacting the publisher that contain the assessments. More information can be found in the following journal articles:
Tinetti, M., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45(6), P239-P243
Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd C. (2005). Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing, 34(6), 614-619.
Summary
| POPULATION | General |
| TYPE OF MEASURE | Self-report or interview questionnaire |
| WHAT IT ASSESSES | Fall risk, balance, self-efficacy |
| TIME | < 10 minutes |
| COST | Free |
Contact
Mary Elizabeth Tinetti, MD
Yale University School of Public Health
New Haven, Connecticut
Web: http://publichealth.yale.edu/people/mary_tinetti.profile
Chris Todd, PhD
The University of Manchester, United Kingdom
The School of Nursing, Midwifery and Social Work
Web: www.nursing.manchester.ac.uk/staff/ChrisTodd/
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