Exposure-Based Treatment for Fear of Falling: Pacing the Plan
Mr. K is a 72-year-old man 5 months after a hip fracture and surgical repair. He completed physical therapy but now refuses to walk without a rollator and a spotter, and has stopped leaving his apartment. He reports intrusive images of falling and has not fallen since surgery. He scores 14/21 on a fear-of-falling measure (high). He has hypertension and takes a beta-blocker. He is motivated but says 'if I fall again I'll end up in a nursing home.' His daughter calls daily to check on him and has started doing his shopping. You plan a graded exposure program coordinated with PT.
1. How do you design the exposure hierarchy and pace it?
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Build a collaborative hierarchy from least to most feared, anchored in real activities: standing at the counter unsupported, walking to the mailbox with the rollator, walking to the mailbox without the spotter, crossing the lobby, going to the store. Rate each 0–100 for fear and for likelihood of falling, and note the catastrophic belief ('nursing home').
Pace by predicted fear and actual capability, not by the calendar. Start where he can succeed with moderate anxiety (not zero), and stay in each step until fear drops meaningfully before advancing. Coordinate with PT so the physical demands are safe and the exposure is not undermined by a therapist who 'rescues' him.
Key design points: (1) exposure must be repeated and in vivo, not just discussed; (2) do not use the spotter as a safety behavior once he can tolerate its removal, or the fear will not extinguish; (3) plan for setbacks - a near-miss should be processed, not treated as failure; (4) build in generalization to the community, since avoidance is the target.
2. He takes a beta-blocker. How does this affect your use of exposure and any physiological monitoring?
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A beta-blocker blunts heart rate and other sympathetic responses, so heart rate is an unreliable index of his fear level. Do not titrate exposure to HR or use HR as the primary outcome; rely on self-reported fear (SUDs), behavioral indicators, and his catastrophic cognitions.
It also means he may not get the full interoceptive 'signal' that exposure normally provides, so emphasize cognitive and behavioral markers. Do not stop or adjust his medication - that is the prescriber's decision - but note it in the formulation and coordinate with his physician if there is any question about the regimen.
Document that physiological monitoring was limited by medication so the record is clear about why you used subjective and behavioral anchors.
3. His daughter does his shopping and calls daily. How do you address this?
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The daughter's behavior is well-intentioned accommodation that maintains avoidance. Address it directly but without blaming her: explain the exposure rationale and invite her into the plan as a supporter, not a rescuer.
Negotiate a graded reduction in instrumental help: first she shops with him, then he shops with her nearby, then he shops alone with a phone check-in. Reduce the daily calls to a scheduled check-in, with a clear plan for what to do if he has a fall (call, don't panic).
Assess her own anxiety - her behavior may be driven by her fear, and she may need her own support. If she cannot reduce accommodation, that is a treatment barrier to name explicitly and work on, not to route around. Document the family agreement and revisit it at each session.