Fear of Falling in Older Adults Living in a Community-Dwelling Facility: Prevalence and Its Impact on Activity Behavior and Physical Function

Application of study findings

• Fear of falling should be given as much attention as falls, and not only as its “side-effect”. Thus, our results help inform strategies and interventions that should be, in parts, different from those developed specifically to target falls.

Introduction

Falls are highly prevalent among older adults, representing a significant public health concern due to their health-related consequences and economic burden (Florence et al., 2018; James et al., 2019; Leilei et al., 2019). This is manifested through substantial medical expenditures required to treat fall-related injuries. Recent data from the United States indicate that 27.5% of individuals aged 65 years and older reported at least one fall in the previous year and approximately 10% reported a fall-related injury (Moreland & Ramakrishna Kakara, 2020). Another significant consequence of falls is the development of fear of falling (FOF). FOF is characterized by a persistent concern about falling and affects a significant portion of the older adult population, particularly those who have previously experienced a fall in the past. Previous studies indicate that FOF is reported by 20–60% of older adults living in the community (Martínez-Arnau et al., 2021; Su et al., 2021; Van Haastregt et al., 2007).

FOF has been identified as an independent risk factor associated with reduced quality of life (Schoene et al., 2019), reduced participation in daily activities (i.e., activity curtailment) (Liu et al., 2021), and an increased risk of falls (Martínez-Arnau et al., 2021). Additional evidence suggests that older adults living in rural areas who report FOF demonstrate lower scores in functional tests compared to their counterparts without FOF (Su et al., 2021). As previously described, FOF is associated with reduced daily activities, potentially leading to a further decline in physical activity participation, an increase sedentary behavior, and an overall reduction in physical function capacity.

Most studies addressing FOF have primarily focused on older adults in the general population, and not much is known about factors associated with FOF in older adults living in community-dwelling facilities such as Continuing Care Retirement Communities (CCRCs). This is important because there is evidence suggesting that older adults living in these facilities may experience a higher prevalence of falls and FOF compared to their counterparts in the general population (Okoye et al., 2021). Both falls and FOF in these settings are believed to be influenced by cultural, environmental, and facility-related factors (e.g., age-related changes in physical capacity, reduced physical activity participation, poor ambulatory surfaces, and unfavorable attitudes towards walking aids) as well as intrinsic factors (e.g., psychological factors, concentration/attention, socio-demographic factors, and morbidity-related factors) (Okoye et al., 2021).

Continuing Care Retirement Communities, a type of facility-based long-term care service, provide different levels of care, including independent housing (houses or apartments), assisted living, and skilled nursing care, all in one location (Krout et al., 2002). Despite falling under the same umbrella category of community-dwelling facility, CCRCs differ from senior housing in the level of care and services offered. CCRCs provide a more comprehensive continuum of care, allowing residents to age in place. On the other hand, senior housing, despite offering several housing levels, generally provides a specific level of care (Carroll & Qualls, 2014).

Building upon previous studies that explored FOF in older adults from the general population and the limited scientific literature on those living in community-dwelling facilities such as CCRCs, this study examined the impact of FOF on physical activity, sedentary time, and physical function in older adults living in a CCRC. We hypothesized that older adults reporting FOF would report lower levels of physical activity, spent more time in sedentary behavior, and demonstrate worse physical function compared to their counterparts without FOF.

Methods

Results

Participant Characteristics

Table 1 provides a detailed overview of the sample characteristics. Briefly, the average age of the participants was 84.7 years with approximately 69% of the sample being female. Overall, participants were classified as overweight, reported an average daily intake of over six different medications, and a median of three diagnosed chronic diseases. Notably, a significant amount of the participants perceived their health as excellent/very good or good.

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Table 1.

General Demographic and Health Characteristics of the Sample Overall and Separated by Fear of Falling Status.

	Overall (n = 93)	Fear of falling		p
		No (n = 49)	Yes (n = 44)
Age, years	84.7 (6.2)	83.9 (6.5)	85.6 (5.8)	.201
Sex, n (%)				.747*
Female	64 (68.8)	33 (67.3)	31 (70.5)
Male	29 (31.2)	16 (32.7)	13 (29.5)
Race, n (%)
White	93 (100)	49 (100)	44 (100)
BMI, kg/m2	28.1 (6.0)	28.2 (5.8)	27.7 (6.2)	.669
Perceived health, n (%)				.421*
Excellent/Very good	38 (40.4)	23 (46.9)	15 (34.1)
Good	41 (43.6)	20 (40.8)	21 (47.7)
Fair/Poor	14 (16.0)	6 (12.2)	8 (18.2)
Medication, number	6.7 (4.6)	6.6 (4.9)	7.0 (4.3)	.670
Chronic diseases, mdn (IQR)	3.0 (3.0)	3.0 (2.0)	3.5 (3.0)	.477
Nr. of falls, min-max (IQR)	0.0 – 8.0 (1.0)	0.0 – 4.0 (1.0)	0.0 – 8.0 (1.0)	.266
Assistive device				.007*
Yes	24 (25.8)	7 (14.3)	17 (38.6)
No	69 (74.2)	42 (85.7)	27 (61.4)

Note. ^* p-value for Pearson Chi-Square test; Medication = prescribed plus over the counter.

Physical Activity, Sedentary Behavior, and Physical Function

Table 2 displays mean and standard deviation, and between-group (no FOF vs. yes FOF) comparisons for PA, SB, and physical function tests. Briefly, the group reporting FOF presented with significant lower physical function scores compared to those without FOF (p < .05). However, there were no significant differences in PA and SB between groups (p > .05).

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Table 2.

Mean and Standard Deviation Values of Physical Activity, Sedentary Behavior, and Physical Function Overall and Separated by Fear of Falling Groups.

	Overall (n = 93)	Fear of falling		d	p
		No (n = 49)	Yes (n = 44)
Physical Activity
PASE, score	57.3 (43.5)	62.7 (44.9)	51.4 (41.6)	.26	.210
Sedentary Behavior
ST weekday, min/day	599.7 (197.9)	575.1 (204.3)	625.9 (191.5)	.25	.219
Physical Function
TUG, s	11.1 (6.9)	9.4 (3.9)	13.2 (8.8)	.56	.010
T25FW, s	7.3 (2.7)	6.7 (2.0)	7.9 (3.3)	.44	.029
SPPB, score
Balance	3.1 (1.0)	3.4 (0.8)	2.8 (1.2)	.58	.003
Gait	3.0 (1.0)	3.2 (0.9)	2.7 (1.4)	.42	.008
Lower-extremity strength	2.2 (1.5)	2.7 (1.7)	1.6 (1.6)	.66	.001
SPPB Total/summary	8.3 (2.9)	9.3 (2.6)	7.1 (3.0)	.78	<.001
30CST, repetitions	9.2 (6.4)	11.2 (5.6)	7.0 (6.6)	.68	.001

Note. PASE: Physical Activity Scale for the Elderly; ST: Sedentary Time; TUG: Timed Up and Go; T25FW: Timed 25-foot Walk; SPPB: Short Physical Performance Battery; 30CST: 30-s Chair Stand Test; s: seconds; min/day: minutes per day.

Discussion

The present study investigated differences in activity behavior (i.e., PA and sedentary time) and physical function among older adults living in a CCRC facility in the Midwest region of the United States, based on the presence of FOF. Our main findings include: (1) a relatively high prevalence of FOF independent of sex or fall history, (2) no significant difference in PA or SB between FOF groups, and (3) reduced physical function among older adults reporting FOF, even after controlling for assistive device use. Our findings partially support our hypothesis that FOF would be associated with low levels of PA, high amounts of sedentary time, and reduced physical function among older adults living in a CCRC.

The prevalence of FOF in older adults of the general population has varied considerably (20%–60%) (Dhar et al., 2022; Martínez-Arnau et al., 2021; Su et al., 2021; Van Haastregt et al., 2007). This variation is also notable in older adults with history of severe fall-related injuries, ranging from 21% to 95% (Jørstad et al., 2005; Scheffer et al., 2008). A study focusing on individuals aged 60 years and older, attending an outpatient hospital department, reported a prevalence of FOF at 42% (Dhar et al., 2022). Another study involving older Canadians residing in public housing in Ontario observed a prevalence of 39% among residents. The authors further demonstrated that males had a significantly lower odds of experiencing FOF compared to females, while alcohol consumption was associated with increased odds of FOF (Pirrie et al., 2020). In a recent large-scale study utilizing the National Health and Aging Trend Study, which the evaluation methods were the same as our study, researchers observed a prevalence of 48.8% for FOF in older adults who experienced a fall in the previous year, and 46.8% in those who experienced a fall in the previous month (Chen et al., 2021). Our results corroborate somehow with those observed in older adults from the general population. Despite not observing a significant different FOF prevalence based on fall history (presence x absence), we observed higher absolute values in those reporting previous falls compared to the National Health and Aging Trend Study. Moreover, our finding on FOF prevalence was higher compared to those observed in the Canadian study. However, unlike the Canadian study, we did not observe a significant difference in FOF prevalence based on sex. Variations in FOF prevalence across studies may be partly attributed to differences in assessment methods and the characteristics of the population under investigation.

Our findings demonstrated differences in the subcomponents of the SPPB, namely, balance, lower-extremity strength, and the overall summary/total score, as well as in the 30 Second Chair Stand Test between groups experiencing FOF and those not reporting FOF. Importantly, the differences remained significant even after accounting for the use of assistive device to walk, with the group reporting no FOF presenting with better performance in the physical function tests compared to their counterparts with FOF. Our findings corroborate results from previous studies on FOF and physical function in older adults from the general population (Huang et al., 2022; Su et al., 2021). For example, Huang et al. conducted a study involving 105 older adults, investigating the association between FOF and seven common physical function measures. Their results, after controlling for age, suggested that participants reporting FOF performed significantly worse in physical performance tests assessing balance (i.e., Berg Balance Scale), lower-extremity function (i.e., SPPB), walking speed, function mobility (i.e., TUG), and lower-extremity strength (i.e., Five Times Sit to Stand Test) (Huang et al., 2022). Similarly, Su et al. investigated the prevalence of FOF and its association with physical function and fall history among older adults (≥75 years old) living in rural areas of China (Su et al., 2021). The findings demonstrated that FOF was independently associated with functional mobility (i.e., TUG), balance (i.e., 4-Stage Balance Test), and fall history in the participants. In addition, previous studies have suggested a direct effect of FOF on physical function performance in older adults (Lee & MoonKi Choi, 2017; Park et al., 2014), including associations with leg muscle strength (Deshpande et al., 2008). Collectively, our findings coupled with results from previous work and suggest a potential association between FOF and reduced physical function in older adults, both in the general population and those living in CCRC. This is a concern because researchers suggest that older adults may limit their daily activities due to FOF (da Costa et al., 2012). Such activity curtailment may contribute to a subsequent decline in muscular strength, creating a detrimental cycle and ultimately affecting their ability and confidence to perform activities of daily living without falling (Liu et al., 2021).

Despite the low level of PA and high amount of sedentary time observed in the participants of our study, we did not observe a significant difference in any of these behaviors between groups of FOF (no FOF vs. yes FOF). This unexpected finding contrasts with previous research suggesting an association between FOF and activity restrictions in older adults (da Costa et al., 2012), which technically result in reduced PA and increased sedentary time. A recent systematic review, exploring the association between objectively measured PA and SB with falls, FOF, and fractures, reported that FOF is associated with lower engagement in PA and increased sedentary time (Ramsey et al., 2022). The inconsistency between our study and the available scientific literature may, in part, be attributed to our chosen method for assessing these behaviors. In our study, both PA and sedentary time were assessed using self-report questionnaires. While these questionnaires have been validated for use among older adults, it is important to acknowledge the challenges associated with self-report assessment of PA and SB, particularly in the older adult population (Ogonowska-Slodownik et al., 2022).

This study comes with limitations. First, the cross-sectional study design employed greatly limits our ability to establish-and-effect, which should be explored by longitudinal studies. Second, the use of a single question to assess FOF, while demonstrating a good level of agreement with established measures such as FES-I, prevents us to identify potential levels of FOF (e.g., moderate and high). This is important because certain outcomes may be influenced by the severity/level of FOF. Additionally, previous research suggests differences in FOF as a function falls (presence or absence) and FOF that may or may not alter activity (e.g., activity restrictions/curtailment). Although we were able to address FOF in the context of the presence or absence of falls in our sample, data on potential activity restriction/curtailment associated with FOF were not collected in the original study. Third, PA and sedentary time were assessed using self-report measures, and self-report assessment of both PA and SB can be challenging among older adults. Future studies should attempt to replicate the present findings but adopting an objective measure of PA and SB such as accelerometer. Lastly, data were collected in a convenience sample of older adults living in a wealthy CCRC located in the Midwest region of the United States, with 100% the participants self-reported as White and nearly 70% were female. Consequently, the generalizability of our findings is limited to this demographic; therefore, caution is need in extrapolating the results to a more diverse population.

Despite the limitations, this study adds to the scarce literature on FOF in older adults living community dwelling facilities such as CCRC and provides valuable information regarding the association between FOF and physical function in this population. Given that FOF is associated with nearly three-fold increase in the risk of falls among older adults (Deandrea et al., 2010), even after adjusting for factors such as age and chronic disease (Chen et al., 2021), it warrants special attention. In addition, FOF appears to be independently associated with the occurrence of falls. For example, an old individual may be afraid of falling, without necessarily having previously fallen in the last year, yet this fear increases the likelihood of falls, particularly for older women (Lavedán et al., 2018; Schoene et al., 2019). Thus, our findings underscore the need for targeted interventions aimed at mitigating risk factors associated with falls, specifically focusing on addressing FOF within CCRC populations.

Our findings suggested similar levels of self-reported PA and sedentary time between groups categorized by FOF (no FOF vs. yes FOF). However, the group reporting FOF presented with significant worse physical function, as demonstrated by the lower scores in the SPPB and its subcomponents (except gait, and 30CST), compared to their counterparts reporting on FOF. Considering the wide range of negative health implications, including physical functional decline, it is important that FOF be given as much attention as falls, rather than addressing as its “side-effect.” Thus, it is important to develop strategies and interventions that should be, in parts, different from those developed specific to target falls. This is because studies need to demonstrate that reducing FOF will lead to increased participation in PA, decreased sedentary time and improved physical function in this population. To this end, the implementation of targeted FOF prevention programs is key to improving health behaviors and physical function of older adults living in CCRC and older adults in the general population, considering the high prevalence of FOF in both groups. In doing so, strategies and interventions of this nature have the ultimate potential to lead to fall prevention, improved overall health, and consequently improved quality of life among this population.