Fractures & falling

Falls: fear of falling  (FES: Falls Efficacy Scale)


Contact: Natasja van Schoor

About 30% of community-dwelling persons over the age of 65 fall at least once each year and about 15% fall two or more times a year (Tinetti, Speechly & Ginter, 1988; Tromp et al., 1998). The consequences of falls could be serious, for example a fall could result in a hip fracture (1%), other fractures (3%), or a head trauma (3%). Up to 50% of the community-dwelling older persons report fear of falling (Zijlstra et al, 2007). Older persons with fear of falling have an increased risk of falling (again) (e.g. Pluijm et al. 2006)

Development and validation
The Falls Efficacy Scale (FES) was developed as an instrument to measure fear of falling, based on the operational definition of this fear as "low perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living" (Tinetti et al, 1990). The original FES consists of 10 items with a 10-point scale ranging from extreme confidence to no confidence at all. The items in the original FES included cleaning the house, getting dressed/undressed, preparing simple meals, taking a bath or shower, going to the shop, getting in or out of a chair, going up or down stairs, walking around outside, reaching up or bending down, and answering the telephone (Yardley et al., 2005). The FES showed good test-retest reliability (Pearson’s correlation=0.71) and adequate construct validity (associations with avoiding activities, walking pace, anxiety and depression). In the literature, many modified versions and translations of the FES can be found (Jorstad et al, 2005). Note that the psychometric characteristics differ across these versions.

The FES was developed from a US perspective and focussed mainly on low functioning in older persons. Therefore, an international version of the FES was developed, the FES-I. This version consisted of 16 items, has been translated in Dutch and validated in a sample of 213 Dutch persons of 70 years and older. The FES-I was one-dimensional and internally consistent (Cronbach alpha=0.96), with good test-retest reliability (intra-class correlation=0.82) and acceptable construct validity (associations with age, gender, fall history and overall fear of falling) (Kempen et al, 2007).

Measurement of FES in LASA
A modified version of the FES (not the FES-I, because this version was developed in a later stage) was assessed in the medical interviews of LASA-C (lasac183) and LASA-D (lasad183). In LASA, the participant was asked to score how concerned he/she felt to fall during 10 activities of daily living. The 10 activities included cleaning the house, (un)dressing, preparing simple meals, bathing/showering, shopping, getting in/out of a chair, going up/down stairs, walking in the neighbourhood, reaching in a deep/low cupboard, and answering the phone. Instead of the original 10-point rating scale, the score ranged from 0, not concerned, to 3, very concerned (see example below).

Example 1.
How concerned are you that you may fall when:

I4 cleaning the house (such as sweeping and dusting)?


  • not concerned


  • a little concerned


  • fairly concerned


  • very concerned


  • does not or cannot


In LASA-C, if the respondent said that he/she did not do or could not do an activity, then the question was repeated and the respondent was asked to pretend that he/she did do the activity and report how concerned he/she would be if he/she would perform the activity. These items were denoted as the subjective interpretation of the FES. In LASA-D, the subjective interpretation was not asked.

Previous use of the FES in LASA
In previous LASA papers, per activity points were assigned: 0 points if not concerned, and 1 to 3 points if a little, fairly or very concerned, respectively (Example 1). If the participant did not do or was unable to do the activity, 0 points were assigned. Then, the points were summed (range 0-30). In LASA-C, the sum scores can be computed using the original items (cmvar301-cmvar310) or additionally using the subjective items (cmvr301-cmvr310). The Figures below show the distributions of the sum scores in LASA-C (both the original FES and subjective FES scores) and in LASA-D. figures
The sum scores are highly skewed with over 50% of the participants scoring 0 or 1 points. Fear of falling has been used both continuous (e.g. Stel et al, 2004) and dichotomous (e.g. ≥ 1 points, Pluijm et al, 2006; ≥ 3 points, Tromp et al, 1998). There are no standardized cut-off values in the literature and (even within LASA) different cut-off values have been used to dichotomize fear of falling. Saskia Pluijm used both the original sum scores and subjective sum scores for the development of the fall risk profile. Results were similar and she decided to include only the results of the original sum scores in the paper. The subjective scores have not been used in the any of the LASA-publications yet.

In LASA, the FES has been used as a potential predictor for fall risk (Tromp et al, 1998; Pluijm et al, 2006) and risk of decline in functional status, social activities and physical activities as a consequence of falling (Stel et al, 2004). The FES has not been used yet as an outcome measure or central determinant in LASA.


  1. Jorstad EC, Hauer K, Becker C, Lamb SE. (2005) Measuring the psychological outcomes of falling: a systematic review. J Am Geriatr Soc. 53: 501-510.
  2. Kempen GI, Zijlstra GA, van Haastregt JC. Het meten van angst om te vallen met de Falls Efficacy Scale-International (FES-I). (2007) Achtergrond en psychometrische kenmerken. Tijdschr Gerontol Geriatr. 38: 204-212.
  3. Pluijm SM, Smit JH, Tromp EA, Stel VS, Deeg DJ, Bouter LM, Lips P. (2006) A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int, 17: 417-425.
  4. Stel VS, Pluijm SM, Deeg DJ, Smit JH, Bouter LM, Lips P. (2003) A classification tree for predicting recurrent falling in community-dwelling older persons. J Am Geriatr Soc. 51: 1356-1364.
  5. Stel VS, Smit JH, Pluijm SM, Lips P. (2004) Consequences of falling in older men and women and risk factors for health service use and functional decline. Age Ageing. 33: 58-65.
  6. Tinetti, M. E., Speechly, M., & Ginter, S. F. (1988). Risk factors for falls among elderly persons living in the community. New Engl J of Med. 319: 1701-1707.
  7. Tinetti ME, Richman D, Powell L. (1990) Falls efficacy as a measure of fear of falling. J Gerontol. 45: 239-243.
  8. Tromp, A. M., Smit, J. H., Deeg, D. J. H., Bouter, L. M., Lips, P. (1998). Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J Bone Min Res. 13: 1932-1939.
  9. 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: 614-619.
  10. Zijlstra GA, van Haastregt JC, van Eijk JT, van Rossum E, Stalenhoef PA, Kempen GI. (2007) Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age Ageing. 36: 304-309.

Syntax FES