Traitement d'une phobie de la chute chez une personne âgée

Even if cognitive-behavioral therapies have proven their efficiency and are the preferred treatment for phobias, they are little used with elderly patients. Few controlled tests on the treatment of fear of falling phobia in the elderly have been carried out. The rare published cases describe treatment based on exposure or cognitive restructuring (Tison, 2000) but do not mention the use of third wave CBT techniques. It seems interesting to present therapeutic work based on acceptance and commitment therapy (ACT) techniques (Hayes, 1999), used with a patient suffering from fear of falling. Our aim is to contribute towards the development of treatment adapted to elderly patients and to suggest new therapeutic methods to psychologists who are treating more and more elderly people due to the aging of the population. This article presents the clinical case of a fear of falling phobia observed in an 86-year-old woman. Mrs. Z. feared she would fall if she walked, or if situations involving walking were anticipated. When she was exposed to phobic situations she became anxious and felt physical symptoms: rapid heartbeat, tremors, oppression and muscular tension. Reeducation was very difficult and sometimes impossible because she avoided situations linked to walking. She could not, therefore, become autonomous enough to return home. The program consisted of fourteen therapy sessions spread over six months. ACT methods were used in order to improve psychological flexibility and commitment to therapy, and to facilitate exposure. ACT methods consisted in highlighting the patient's values and helping her to act in favor of those values (which was not the case with avoidance) even if it created discomfort with physical symptoms linked to anxiety. Mrs. Z. learned Jacobson relaxation in order to reduce physical manifestations of anxiety and to prepare exposure. Firstly, graduated imaginal exposure was used in order to increase familiarity with phobic situations. Then, in vivo exposure was used to desensitize her to real phobic situations. Collaboration with physiotherapists enabled them to adapt the sessions in accordance with work carried out during the exposure session. Evaluations were carried out in order to measure the effects of this program: the degree of anxiety (Beck et al., 1988; Bouvard and Cottraux, 2005) and depression (Delay and al., 1963; Collet and Cottraux, 1986), independence (De Lepelaire et al., 2004), and anxiety degree towards hierarchical subjective assessment for phobic situations. These evaluations were carried out before and after therapy. The anxiety score, which was 21 pre-therapy, fell to 5 post-theory (an improvement of 75%), bringing it in line with the general elderly population (M = 6.5; SD = 7.2) (Morin et al., 1999). The depression score of 4 in pre-therapy fell to 2 by the end of therapy (an improvement of 50%). The average score obtained on this scale by non-depressive elderly people 2.92 (SD = 3.44) (Scogin et al., 1988). A decrease in the level of anxiety was noted for different phobogenic situations, which were graded by the patient. Prior to therapy, she was dependent on caregivers for hygiene care, dressing, toilets and transfers. Following therapy, she was completely autonomous (an improvement of about 66%) and was able to return home. ACT methods are believed to have promoted therapeutic alliance, commitment to therapy and acceptance of exposure. Thanks to exposure she improved self-confidence, decreased her anxiety level, and became less dependent. Collaboration with physiotherapists was also very important. Elderly people need to receive appropriate care in order to avoid potentially tragic physical and/or psychological complications. Cognitive-behavioral therapies present many possibilities for this population and should be developed.