J. Whitney et al.
Age and Ageing 2013; 42: 754–758
doi: 10.1093/ageing/aft130
© The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Development and validation of a fall-related
impulsive behaviour scale for residential care
JULIE WHITNEY1, STEPHEN H. D. JACKSON1, JACQUELINE C. T. CLOSE2, STEPHEN R. LORD3
1
Clinical Age Research Unit, Clinical Gerontology, Kings College Hospital NHS Foundation Trust, London, UK
Department of Geriatric Medicine, Prince of Wales Clinical School, Sydney, New South Wales, Australia
3
Neuroscience Research Australia, Falls and Balance Research Group, Randwick, New South Wales, Australia
2
Address correspondence to: J. Whitney. Tel: 020 3299 3420; Fax: 020 3299 3441. Email: [email protected]
Abstract
Introduction: impulsivity in older people with cognitive impairment has yet to be examined rigorously as a risk factor for
falls. The objective of this study was to evaluate the psychometric properties of a new fall-related impulsive behaviour scale
(FIBS) for a cognitively impaired population living in residential care.
Methods: one hundred and nine care home residents (84.5 ± 8.3 years) were assessed on the FIBS and a range of behavioural,
physical and neuropsychological measures. Participants were then prospectively followed up for falls for 6 months.
Results: the internal reliability (Cronbach’s α = 0.77) and test–retest reliability (intra-class correlation coefficient = 0.93) of the
FIBS were both good. Construct validity was supported by significant correlations between the FIBS and the neuropsychiatric
inventory (r = 0.43, P < 0.001), wandering (r = 0.33, P = 0.001) and global cognition (r = −0.2, P = 0.04). Compared with residents with FIBS scores <1, those with FIBS scores of ≥1 were nearly three times more likely to fall in the following 6 months,
AOR = 2.92 (95% CI: 1.03–8.29).
Conclusion: the FIBS is a simple, valid and reliable scale for assessing fall-related impulsivity in care home residents and can
be recommended for use in this group for both research and clinical purposes.
Keywords: impulsivity, aged, accidental falls, cognitive impairment, residential care, older people
Background
Falls are a serious problem, particularly for older people with
cognitive impairment. The reasons for falls in this group are
multi-factorial and include an increased prevalence of risk
factors present in the general population of older people such
as gait and balance impairments as well as specific cognitive
deficits and behavioural and psychological symptoms associated with dementia [1]. Impulsivity has been postulated to be
risk factor for falls [2], but this behavioural factor in the context
of falls risk has not been adequately described or defined.
Within psychiatry literature, impulsivity is a term used to
describe a variety of personality types and behaviours[3].
Moeller et al. [4] defined impulsivity as ‘behaviour without adequate thought including elements such as acting on the spur
of the moment, inattention to the task and lack of planning’
but many other definitions of impulsivity also exist.
Impulsiveness can occur along a spectrum ranging from mild
impulsive personality traits to psychopathology. Impulsivity
constructs fall into three major categories; (i) difficulty with
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sustained attention, poor concentration and lack of forward
planning described as ‘acting without thinking’ [5], (ii) risk
taking or conscious sensation seeking described as ‘seeking
new and exciting experiences’ [6] and (iii) inability to control
impulses or lack of self-control described as ‘trouble controlling impulses or difficulty waiting’ [7]. Impulsivity has also
been classified as either venturesome where a conscious decision has been made to take a high-risk option or unconscious,
where an action is taken without a consideration of the risk [8].
Impulsivity in people with dementia has been found to
reflect lack of forward planning and sustained attention
rather than risk or sensation seeking [9] and impulsive and
unsafe behaviours have been found to be one of the most
common disruptive behaviours in residential care settings
[10]. Two studies have identified impulsivity as contributing
to around one-third of falls in hospital inpatients [11, 12].
However, as impulsivity in this context has not been clearly
defined or operationalised; a simple, valid and reliable impulsive behaviour scale could assist in the care and management
of older people with cognitive impairment living in
Development and validation of a fall-related impulsive behaviour scale
residential care. The aim of this study was to develop and
evaluate the validity and reliability of a new fall-related impulsive behaviour scale (FIBS) for use in this setting.
Methods
Participants
This study was undertaken as part of a larger study examining
fall risk factors in older people with cognitive impairment
living in care homes [1]. To be included in the study, participants had to be: aged >60 years, be stable in the facility for at
least 6 weeks following any recent hospital admission, not be
bedbound or have an illness with a prognosis indicating likely
mortality within six months. Participants also had to have evidence of cognitive impairment [Addenbrooke’s Cognitive
Examination (ACE-R) <82]. The South London and
Maudsley and Institute of Psychiatry joint ethics committee
approved the study and informed consent for participation in
the study was obtained from the participants or legal carers.
the neuropsychiatric inventory (NPI) [14], anxiety using the
Goldberg Anxiety Scale (GAS) [15], depression using the
Geriatric Depression Scale (GDS) [16] and wandering
using the wandering scale from the minimum data set [17].
The physical activity and mobility in residential care
scale (PAM-RC) was used to measure physical activity [18]
and balance was assessed using a simple graded standing
balance test [19]. It was noted whether each participant had
urinary incontinence as this could influence frequency and
urgency with which a person tries to get up. Each participant
was followed up prospectively for 6 months and falls
recorded. Participants with <4 months follow-up (unless
they had fallen prior to loss of follow-up) were excluded
from the analysis. A fall was defined as ‘an unexpected event
in which the participant came to rest on the ground, floor or
lower level’ [20]. Residents were classified as non-fallers if
they suffered no falls and fallers if they suffered one or more
falls in the 6 month follow-up period.
Statistical analysis
The FIBS
The initial questionnaire drafted by the authors was
designed to assess impulsive behaviour over the previous
week and be answered by a carer who knew the resident. It
was subsequently reviewed by five carers for comments,
revised and then piloted in 10 residents. Following further
redrafting, the final scale comprising four questions was
produced.
The first FIBS question was ‘Is resident n impulsive?’
where impulsivity was operationalised as ‘rushing to carry
out an activity without thinking about it first’. One point was
given if the answer was yes and none if the answer was no.
To identify impulsive actions during mobility tasks three
further questions were asked:
How often does the resident do the following?
(1) Try to sit down before getting right up to the chair/
toilet/bed?
(2) Attempt to stand before wheelchair brakes have been
applied/footplates moved or walking frame placed in
front of them?
(3) Try to walk without help when asked not to?
The answers to these questions were graded as: never/NA
(=0), occasionally (=1), often (=2), frequently (=3) or very
frequently (=4). The FIBS score was calculated by summing
the scores for the four questions. Carers were asked all four
questions regardless of the answer to question 1.
The FIBS was repeated after 1 week in a random selection
of 30 residents (28% of the full sample) to determine test–
retest reliability.
Cognitive, behavioural, affect and mobility measures
Global cognition was assessed using the Addenbrooke’s cognitive examination-Revised (ACE-R) [13], behaviour using
The components of the FIBS were analysed for consistency
using Cronbach’s alpha. Principal component analysis with
varimax rotation was then conducted to identify distinct
factors of the FIBS based on eigenvalues of >1. Test–retest
reliability of the total FIBS score was analysed using an intraclass correlation coefficient.
Continuously scaled data were analysed for positive
skewness and log transformed if necessary to permit parametric analysis. Pearson’s correlation coefficients were used
to measure convergent validity between FIBS scores and
NPI total and subcomponents, the wandering score and
ACE-R scores and subcomponent scores. Pearson’s correlations were also used to check for divergent validity between
FIBS scores and measures of anxiety, depression, physical
activity and balance. This was to determine whether other
variables possibly linked with impulsivity could be responsible for fall risk such as a high impulsivity score reflecting
higher levels of physical activity thereby increasing exposure
to falls.
To determine validity to predict falls, differences in FIBS
scores between fallers and non-fallers were calculated using
group t-tests. Pearson’s correlation was used to determine
the association between FIBS and number of falls. The FIBS
measure was also dichotomised using the Youden index [21]
and the odds of impulsivity increasing the risk of falls was
calculated using logistic regression analysis while adjusting
for potential confounders. All data analyses were conducted
using SPSS version 19.
Results
One hundred and nine residents from seven residential care
homes, with a mean age of 84.5 (±8.32), completed falls
follow-up for this study. Completed FIBS were collected for
all participants. Further data are presented in Table 1. Frame
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J. Whitney et al.
users and those taking antidepressants, particularly selective
serotonin reuptake inhibitors (SSRIs), had higher FIBS
scores but no differences were found in the other measures
as presented in Table 1.
Internal structure and test–retest reliability
The Cronbach’s alpha for the FIBS was 0.77 and all four
questions were significantly correlated with each other, the
mean inter item correlation being r = 0.48 (ranging 0.36–
0.79). Factor analysis revealed only one factor with all four
questions loading highly (question 1 = 0.68, 2 = 0.70,
3 = 0.86 and 4 = 0.89). Sixty two percent of the variance in
the questionnaire was explained by these questions. The scale
had good test–retest reliability—ICC2,1 = 0.93 (95% CI:
0.85–0.97).
Convergent validity
The mean total FIBS score was 1.39 (±2.72) with scores
ranging from zero to the maximum possible score of 13
(skewness = 2.69), with 40% of participants exhibiting signs
of impulsivity. Impulsivity (log) scores were strongly correlated
with wandering scores and total NPI and ACE-R scores
(Table 2). The individual domains of the NPI that were most
strongly related to impulsivity were anxiety, disinhibition, irritability, motor disturbance and disturbed night time behaviour.
Attention and concentration and fluency were the domains of
the ACE-R most strongly related to impulsivity.
There were no significant associations between impulsivity
and physical activity, depression or standing balance
(Table 2).
Table 1. Differences in impulsivity scores between residents
with or without potential risk factors (characteristics
dichotomised as present or absent)
Proportion of the
sample %
Impulsivity score mean
(SD)
P-value
No
Yes
63
82
36
43
0.82 (1.86)
1.10 (2.05)
0.96 (2.14)
1.06 (1.87)
1.71 (3.06)
1.46 (2.85)
2.18 (3.42)
1.83 (3.52)
0.06
0.64
0.04
0.77
26
1.10 (2.14)
2.25 (3.86)
0.04
4
16
6
7
16
25
1.22 (2.42)
1.44 (2.76)
1.27 (2.52)
1.40 (2.79)
1.37 (2.84)
1.20 (2.28)
2.35 (3.94)
0.25 (0.50)
3.14 (4.70)
1.38 (1.60)
1.53 (2.03)
2.00 (3.73)
0.04
0.30
0.18
0.15
0.33
0.44
64
0.82 (1.86)
1.71 (3.06)
0.06
........................................
Sex = female
Fall in last year
Frame user
Urinary
incontinence
Any antidepressant
use
SSRI
Tricyclic
Other
Anxiolytic/hypnotic
Antipsychotic
Two plus medical
conditions
>5 medications
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Fifty three participants (49%) fell one or more times during
the 6-month follow-up period. Fallers had significantly
higher FIBS scores than non-fallers: 1.83 (±3.08) and 0.96
(±2.28), respectively, t107 = 2.93, P = 0.004 and there was a
significant correlation between falls and FIBS scores
r = 0.36; P < 0.001. Residents with FIBS scores ≥1 had a
2.92 increased odds of falling (95% CI: 1.03–8.29) after adjustment for ACE-R, NPI and wandering.
Discussion
The study findings provide evidence to support the FIBS as
a simple, valid and reliable scale for assessing fall-related impulsivity in residential care dwellers. The FIBS’s predictive
validity was established through its ability to discriminate
between fallers and non-fallers assessed during a 6-month
follow-up period and the scale had good internal consistency
and test–retest reliability.
The FIBS was significantly related to similar dementiarelated behaviours (wandering frequency and NPI total and
subcomponent scores) indicating good convergent validity
and the insignificant associations between FIBS scores and
measures of depression, balance and physical activity levels is
indicative of good divergent validity, suggesting high FIBS
scores are not merely reflections of these different constructs.
Table 2. Correlations between impulsivity scores and other
potential risk factors
Divergent validity
Variable
Predictive validity
Relationship to impulsivity
score
r
P-value
−0.20
−0.22
−0.16
−0.22
−0.13
−0.14
0.43
0.00
−0.03
0.01
0.13
0.45
0.12
0.24
0.33
0.36
0.25
0.42
−0.07
−0.16
0.19
0.05
0.33
−0.09
0.09
0.04
0.02
0.09
0.02
0.19
0.16
<0.001
0.99
0.80
0.89
0.18
<0.001
0.22
0.01
0.001
<0.001
0.008
<0.001
0.46
0.09
0.05
0.62
0.001
0.35
0.38
........................................
ACE-R
Attention and concentration
Memory
Fluency
Language
Visuopatial
NPI
Delusions
Hallucinations
Agitation
Depression
Anxiety
Elation
Apathy
Disinhibition
Irritability
Motor disturbance
Night time behaviour
Appetite
Standing balance
Goldberg Anxiety Scale
Geriatric Depression Scale
Wandering
Physical activity (PAM-RC)
Age
Development and validation of a fall-related impulsive behaviour scale
The FIBS was a feasible test completed by carers for all participants, without requiring participants’ active involvement.
The cut point that best identified the difference between
fallers and non-fallers was a score of ≥1. This indicates that
any impulsive behaviour increases fall risk. On this basis, it
would be reasonable to suggest that a positive response to
any one of the questions, without the need for grading the intensity of the behaviour would be sufficient to use in a fall
risk assessment.
The pattern of associations between FIBS scores and
other measures provides some insight into the mechanisms
by which impulsivity may lead to falls in older people with
cognitive impairment. Impulsivity was not related to physical
activity which suggests that impulsive behaviour does not
contribute to falls risk simply by increasing time spent
walking thereby exposure to falls. Instead it appears impulsivity, as measured by the FIBS, reflects poor concentration and
lack of forward planning. This is in line with previous study
findings [11, 12] and supported by the significant associations
we found between FIBS scores and the attention and concentration section of the ACE-R. It is also interesting to note that
those taking SSRI antidepressants were more likely to be impulsive and there is some evidence to suggest that impulsive
behaviours are modulated through serotonergic systems [3].
There was no significant relationship between depression
(GDS) and FIBS and since in a similar study, use of antidepressants and impulsivity were both significant and independent predictors of falls [22], it is unlikely that the impulsive
behaviour resulted from or caused antidepressant prescription.
The correlations between FIBS and the NPI scores of
disinhibition, irritability, motor behaviour and night time disturbance were not unexpected as such behaviours are closely
associated with those described in the FIBS. However, the relationship with anxiety was more surprising. The wording of
this question included ‘unable to relax’ and ‘feeling excessively tense’ which could have been interpreted by care staff to
mean impulsive mobility behaviour. On the other hand, an
individual who is physiologically on ‘high alert’ and more
likely to respond in a ‘flight or fight’ manner without thinking
about an action first, could be more likely to act on impulse.
The fact that there was a trend towards higher GAS scores,
completed by participants rather than carers, also being associated with higher FIBS scores suggests this relationship was
not purely due to poor interpretation. The positive correlation between impulsivity and apathy was also unexpected. If
the apathy question reflected general activity levels, it would
be reasonable to expect those with lower levels of apathy to
be more impulsive. However, apathy was not related to physical activity or depression. Again, it may be due to interpretation of the question ‘do they seem less interested in their
usual activities’. Our anecdotal experience is that carers interpret the term ‘activity’ to mean activities organised by the
home and those with difficult to manage behaviours such as
impulsivity, may be less likely to participate in organised
activities.
There are several limitations to this study. First, we found
frame users were more likely to be considered impulsive.
However, they had more opportunity to be classified as impulsive due to the nature of the questions (i.e. waiting for the
frame to be placed in front). Secondly, the sample was relatively small and although the study was conducted in seven
care homes, our findings require external validation. In addition, the sample consisted of cognitively impaired participants therefore results may not be applicable to a cognitively
intact population. Thirdly, we did not collect data on sensitivity to change over time which would be of relevance when
considering interventions to modify behaviour. Finally, since
FIBS asks carers about behaviours, it is not possible to definitively diagnose residents as impulsive as these questions
do not measure personality traits but behaviours for which
there are several possible causes. However, in a population
with high levels of cognitive impairment, administration of
questionnaires or other tests to determine personality may
not be feasible and since the behavioural manifestations are
probably what lead to falls, these aspects of impulsivity are
important to measure. Nevertheless, it is possible that certain
personality traits are preserved as cognition and judgement
declines; resulting in more impulsive behaviours in those
who are driven to remain active.
In conclusion, the FIBS is a simple, valid and reliable
scale for assessing and operationalising fall-related impulsivity in care home residents with cognitive impairment.
Key points
• Impulsivity has been described as a cause of falls but not
defined or operationalised.
• The falls-related impulsive behaviours scale had good psychometric properties and discriminated between fallers and
non-fallers.
• Impulsivity in cognitive impairment appears to be related
to poor attention and concentration.
Conflicts of interest
None declared.
Funding
This work was supported by a British Geriatrics Society/
Dunhill Medical Trust research fellowship. The funders had
no role in the design, execution, analysis and interpretation
of data, or writing of the study.
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Received 26 November 2012; accepted in revised form
11 April 2013
© The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Location tracking: views from the older
adult population
LISA THOMAS1, LINDA LITTLE1, PAM BRIGGS1, LYNN MCINNES1, EMMA JONES2, JAMES NICHOLSON1
1
Department of Psychology, Northumbria University, Newcastle upon Tyne, UK
Emergency Response Department, Health Protection Agency, Salisbury, UK
2
Address correspondence to: L. Thomas. Tel: 0191 227 3716. Email: [email protected]
Abstract
Background: there has been a rise in the use of social media applications that allow people to see where friends, family and
nearby services are located. Yet while uptake has been high for younger people, adoption by older adults is relatively slow,
despite the potential health and social benefits. In this paper, we explore the barriers to acceptance of location-based services
(LBS) in a community of older adults.
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