Assessment of Fear of Falling in Older Adults: The Falls Efficacy Scale-International (FES-I)

By: Sherry A. Greenberg, PhD, RN, GNP-BC, Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing

WHY: Any older adult who falls, with or without sustained injury, may develop a fear of falling. This may cause curtailment of  activities, leading to reduced mobility and physical fitness, and increasing risk of falling and injury (CDC, 2016; Vellas et al., 1997).  Assessment of fear of falling, followed by appropriate interventions, is crucial to promote independence, function, wellness, and safety of older adults.

BEST TOOL: The Falls Efficacy Scale-International (FES-I) is a short, easy to administer tool that measures the level of concern about falling during 16 social and physical activities inside and outside the home whether or not the person actually does the  

activity.  The level of concern is measured on a four point Likert scale (1=not at all concerned to 4=very concerned) (Yardley et al., 2005).  The FES-I was developed in a collaborative effort with members of the Prevention of Falls Network Europe (ProFaNE), European Committee focused on fall prevention and the psychology of falling. The group tested the FES-I using different samples in different countries and translated the tool into several languages.
TARGET POPULATION: Older adults with or without a history of fear of falling.
VALIDITY AND RELIABILITY: Upon initial development and validation, the FES-I had excellent internal validity (Cronbach’s  alpha=0.96) as well as test-retest reliability (ICC=0.96) (Yardley, Beyer et al., 2005). This tool was developed to expand on the initial Falls Efficacy Scale (FES) (Tinetti et al., 1990) to include social activities that may be considered more challenging by more active people, thereby potentially causing more concerns about falling than the basic activities presented in the initial FES. These additional activities correspond to items 11-16 on the FES-I.  The FES-I was developed with factor analysis and demonstrates excellent  psychometric properties in comparison to the FES. Research demonstrated validity and reliability with both cognitively intact and cognitively-impaired older adults (Hauer et al., 2010).
STRENGTHS AND LIMITATIONS:  The wording of the items on the FES-I accounts for cross-cultural differences (Yardley et al., 2005) and has been translated into many languages. The FES-I provides more detail regarding concerns about falling in relation to conducting various activities compared to a single item rating measure (Greenberg et al., 2016).
FOLLOW UP: As needed or on a yearly basis to assess for fear of falling.
Best practice information on care of older adults:
Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). (2016). Older adult falls. Retrieved June 21, 2018 from
Greenberg, S. A. (2012). Analysis of measurement tools of fear of falling among high-risk, community-dwelling older adults. Clinical Nursing Research, 21(1), 113-130. doi:  10.1177/1054773811433824 
Greenberg, S. A., Sullivan-Marx, E., Sommers, M. S., Chittams, J., & Cacchione, P. Z. (2016). Measuring fear of falling among high-risk, urban, community-dwelling older adults. Geriatric Nursing, 37(6), 489-495. doi: 10.1016/j.gerinurse.2016.08.018 
Hauer, K.A., Kempen, G.I., Schwenk, M., Yardley, L., Beyer, N., Todd, C., Oster, P., & Zijlstra, G.A.  (Online Oct 22, 2010). 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, 56(2), 290-199. doi: 10.1159/000320054.
Kempen, G.I., Todd, C.J., Van Haastregt, J.C., Zijlstra, G.A., Beyer, N., Freiberger, E., Hauer, K.A., Piot-Ziegler, C., & Yardley, L. (2007). Cross-cultural validation of the Falls Efficacy Scale International (FES-I) in older people: Results from Germany, the Netherlands and the UK were satisfactory. Disability and Rehabilitation, 29(2), 155-162.
Tinetti, M.E., Mendes de Leon, C.F., Doucette, J.T., & Baker, D.I.  (1994). Fear of falling and fall-related efficacy in relationship to functioning among community-living elders.  Journal of Gerontology: Medical Sciences, 49(3), M140-M147.
Tinetti, M.E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling.  Journal of Gerontology, 45(6), P239-P243. doi:10.1093/geronj/45.6.P239. 
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 and Ageing, 34(6), 614-619. doi:10.1093/ageing/afi196.