To the Editor—In countries with long life expectancies, geriatric fractures due to falls, particularly hip fractures, are an increasing health concern associated with high morbidity and mortality.1 The overall 1-year mortality rate of elderly patients with hip fracture has been estimated as 17%.2 3 Orthopaedic reparative surgeries in elderly patients are intricate, and most patients need to be hospitalised for a long period of time with restricted mobility. Activity restriction or immobility for elderly patients is a degenerative process that contributes to several complications, such as ulceration, infection, decreased cardiovascular function, deep vein thrombosis, and psychophysiological dysfunction such as delirium.4 These complications can increase the length of hospital stay and the cost of care; therefore, efforts must be made to prevent these complications by early mobilisation of these elderly patients.

Several barriers to mobilising elderly patients have been identified, including pathophysiological and psychological factors.5 6 Previous studies have shown that history of falls and self-perceived mobility problems are among the independent predictors for recurrent falls.5 Fear of falling, typically due to the lack of self-confidence in sustaining stability during walking, is a major psychological impediment to mobilising a patient with a previous fall.7 More than 55% of patients with previous fall experience are frightened of falling again; thus, they prefer to stay immobile.8 From the patient’s perspective, immobility may be considered as a psychological response to previous falls or a self-protective behaviour to prevent a next possible fall.9 However, from the medical perspective, fear of falling is a vicious cycle that can physically and psychologically restrict patient activity and mobility, owing to the physical imbalance, lack of self-confidence, low self-efficacy, and low self-reliance.7 8 Whatever the cause, this type of fear can lead the patient to experience ‘self-imposed immobility’, an immature concept that I use to express the consequence of fear of falling.

Many health care providers around the world have experienced patients with self-imposed immobility, either in hospitals or in other settings such as nursing homes.9 A key responsibility of the health care team is helping and empowering such elderly patients to overcome their fear.10 In recent years, several physical interventions have been implemented, by either nurses or other members of the health care team, to strengthen and empower the elderly to overcome the fear of falling.9 11 However, evidence suggests that these interventions only reduce the fear of falling to a limited extent and for a short time. In addition, there is a lack of practical interventions that are suitable for helping elderly patients to overcome the fear of falling.6 11 Consequently, fear of falling remains a major obstacle to patient mobility. One of the possible reasons for the failure of physical interventions is that these interventions cannot affect and change the cognitive and psychological state of the patient. Thus, it seems that interdisciplinary teamwork is needed, to provide both physical and psychological interventions. Accordingly, further well-designed trials are required to evaluate the optimal physical interventions to overcome this fear, and psychological interventions, such as cognitive emotional behavioural therapy, must be evaluated and integrated into physical rehabilitation therapies. Future research should focus on the possible psychological interventions that can be combined with physical interventions in order to overcome the self-imposed immobility of elderly patients with previous fall experience.

The author has disclosed no conflicts of interest. The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

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