Fall Worry Restricts Social Engagement in Older Adults

Abstract

Objective: To examine cross-sectional and longitudinal associations between (a) activity-limiting fall worry (ALW) and (b) self-reported health-related restrictions and social engagement among older adults. Method: The National Health and Aging Trends Study Waves 5 (T1) and 6 (T2) provided data (n = 6,279). Binary and multinomial logistic regression models were used to examine association of T2 social engagement restrictions with T2 fall worry and association of T1–T2 changes in social engagement restrictions with T1–T2 changes in fall worry. Results: ALW was significantly associated with both informal and formal social engagement restriction at T2. Onset of ALW and continued ALW between T1 and T2 were also significantly associated with newly reported restrictions in both informal and formal social engagement at T2 even controlling for falls incidents and changes in health status and other covariates. Discussion: The findings underscore the importance of reducing fall worry and preventing social disengagement in late life.

Keywords

fall worry fear of falls falls social engagement activity participation

Introduction

Given age-related increases in fall risks including chronic medical conditions, sensory and cognitive impairments, gait deficits, and polypharmacy (Reuben et al., 2017), many older adults worry about falling (often referred to as fear of falling), whether or not they have fallen in the past (Austin, Devine, Dick, Prince, & Bruce, 2007; Kumar, Carpenter, Morris, Iliffe, & Kendrick, 2014; Patil, Uusi-Rasi, Kannus, Karinkanta, & Sievänen, 2014; Trombetti et al., 2016). A bit of worry may lead to helpful caution (Lee, Mackenzie, & James, 2008) that protects against falling. However, a subset of older adults unnecessarily restricts physical activities due to excessive fear of falling (Hughes, Kneebone, Jones, & Brady, 2015). For them, this physical activity restriction tends to increase concomitantly with fear of falling (Sawa et al., 2018).

Studies show that older adults who restrict their activities due to fear of falling are more physically frail and are more likely to have a history of an injurious fall, a greater burden of chronic conditions, pain, and depressive symptoms than those with fear of falling who did not restrict their activities (Denkinger, Lukas, Nikolaus, & Hauer, 2015; Murphy, Williams, & Gill, 2002; Stubbs, West, Patchay, & Schofield, 2014). In addition, fear of falling and subsequent fear-induced activity restriction/avoidance in daily life contribute to a more sedentary lifestyle, decreased confidence of balance, actual balance, incident mobility impairment, and disability in instrumental activities of daily living and other physical functioning, which all further increase risks and incidents of falls (Allison, Painter, Emory, Whitehurst, & Raby, 2013; Auais et al., 2018; Delbaere, Crombez, Vanderstraeten, Willems, & Cambier, 2004; Deshpande, Metter, Lauretani, et al., 2008; Donoghue, Cronin, Savva, O’Regan, & Kenny, 2013; Hadjistavropoulos, Delbaere, & Fitzgerald, 2011; Hadjistavropoulos et al., 2007; Kader, Iwarsson, Odin, & Nilsson, 2016 Landers, Oscar, Sasaoka, & Vaughn, 2016; Makino et al., 2018; Stubbs, Patchay, Soundy, & Schofield, 2014; Yardley & Smith, 2002). Allison et al. (2013) found that participation restriction, not fear of falling per se, predicts actual balance and mobility abilities in rural community-dwelling older adults, suggesting the significant impact of activity restriction on functioning.

Despite the large body of research on the relationship between fall worry and activity avoidance, most studies have focused on physical and instrumental daily living activities. Little research has been done on the association between fall worry and social activity participation (social engagement hereafter). Studies (Allison et al., 2013; Kader et al., 2016; Yardley & Smith, 2002) based on the Survey of Activities and Fear of Falling in the Elderly (SAFE/mSAFFE; Lachman et al., 1998) often do not separate social engagement (e.g., visiting a friend or relative, going out in crowds) from physical and instrumental activity (e.g., getting out of bed, preparing meals, reaching overhead, walking outside). Along with physical and instrumental daily living activities, social engagement is an important aspect of late-life functioning and quality of life. Lack of social engagement, including gathering with friends and relatives for social support and recreational purposes and engaging in more formal/organized activities, can lead to social isolation, which in turn can decrease older adults’ self-reported health and health-related quality of life and increase morbidity and all-cause and disease-specific mortality (Cacioppo, Hawkley, Norman, & Berntson, 2011; Cornwell & Waite, 2009; Coyle & Dugan, 2012; Hawton et al., 2011; Heffner, Waring, Roberts, Eaton, & Gramling, 2011; Steptoe, Shankar, Demakakos, & Wardle, 2013). A recent study also found that socially isolated older adults are less likely than nonisolated older adults to consistently engage in healthy behaviors (weekly moderate-to-vigorous physical activity or consuming five fruit and vegetable servings daily; Kobayashi & Steptoe, 2018). In addition, a prospective cohort study in Japan found that the number of organizations (e.g., local community, hobby, and sports) in which older adults participated was inversely associated with incident functional disability (i.e., certification of the need for long-term care; Kanamori et al., 2014).

Using data from two waves (Time 1 [T1] and Time 2 [T2], 12 months apart) of interviews with a nationally representative sample of older adults, we examined cross-sectional and longitudinal associations between fall worry and self-reported health-related restrictions in informal and formal social engagement, controlling for the incidence of falls, chronic illnesses, functional impairment, pain, depressive symptoms, social engagement in the previous interview, and demographic factors. Previous studies have found associations between depression and both fear of falling and fear-induced activity avoidance (Deshpande, Metter, Bandinelli, et al., 2008b; van Haastregt, Zijlstra, van Rossum, van Eijk, & Kempen, 2008). Studies have also shown that older women are more likely than men to report fear of falling and have subsequent falls (Auais et al., 2018; Delbaere et al., 2004; LeBouthillier, Thibodeau, & Asmundson, 2013).

We focused on self-reported health-related restrictions in social engagement (as restrictions may be due to reasons other than health such as lack of transportation or interest) by comparing older adults with activity-limiting fall worry to those with no fall worry or nonactivity-limiting fall worry (given concerns about activity-limiting fall worry). Our preparatory analysis confirmed (a) no significant associations between any type of fall worry and nonhealth-related restrictions in social engagement, and (b) no significant difference between no fall worry and nonactivity-limiting fall worry in their associations with social engagement restrictions. By examining relationships between activity-limiting fall worry and social engagement, this study expands knowledge about fall worry and activity restriction. Based on previous research on fall worry and physical activity restriction, the study hypotheses were as follows:

Hypothesis 1 (H1; T2 cross-sectional): Compared to older adults without fall worry, those with past-month activity-limiting fall worry will be more likely to report health-related restrictions in (a) informal and (b) formal social engagement.

Hypothesis 2 (H2; T1-T2 longitudinal): Compared to older adults with no fall worry or nonactivity-limiting fall worry at both T1 and T2, those who developed/continued activity-limiting fall worry between T1 and T2 will be more likely to develop or continue health-related restrictions in (a) informal and (b) formal social engagement between T1 and T2.

Method

Data and Sample

Data came from Waves 5 and 6 of the National Health and Aging Trends Study (NHATS) conducted in 2015 and 2016, respectively. NHATS Wave 1 was conducted in 2011 with a representative sample of U.S. Medicare beneficiaries 65 years or older as of September 30, 2010, who resided in the community in their own or another’s home or in a residential care (but not a nursing home) setting (Montaquila, Freedman, Edwards, & Kasper, 2012). The Wave 1 cohort was interviewed annually. Replenishment occurred in Wave 5 with a sample drawn from the Medicare enrollment database serving as the sampling frame as of September 30, 2014, and using the same stratified three-stage sample design as in Wave 1 (DeMatteis, Freedman, & Kasper, 2016). At Wave 5, of the total sample size of 8,334 persons, 7,070 who resided in the community and 429 who resided in residential care facilities were interviewed (n = 442 via proxy). At Wave 6, 364 of these sample persons were deceased, 95 had moved to a nursing home, and 741 were not interviewed for other reasons (refusal, unavailability, inability to locate, illness, etc.). Of the remaining 6,299 sample persons (representing 39 million older Medicare beneficiaries) residing in the community or a residential care facility who were interviewed at both Waves 5 and 6 (5,944 self and 355 proxy interviews), we included the 6,279 sample persons who provided data on whether their health limited their informal and formal social engagement. Hereafter, we refer to Waves 5 and 6 as T1 and T2, respectively.

Measures

Fall worry and changes between T1 and T2

Fall worry was measured with two questions: “In the last month, did you (or sample person, in the case of proxy interview) worry about falling down?” and “In the last month, did this worry ever limit your (or sample person’s) activities?” (types of “activities” were not specified). Responses were categorized as no worry (NW), nonactivity-limiting worry (NALW), and activity-limiting worry (ALW). Changes (or lack thereof) in fall worry between T1 and T2 were (a) no worry or nonactivity-limiting worry at both T1 and T2 (i.e., T1 and T2 NW or NALW or fluctuations between NW and NALW), (b) increased worry (i.e., T1 NW or NALW to T2 ALW), (c) continued worry (i.e., T1 & T2 ALW), and (d) decreased worry (i.e., T1 ALW to T2 NW or NALW).

Informal and formal social engagement at T1 and T2

Each sample person or proxy was also asked about specific activities in which the sample person “ever” participated in the last month. In this study, we included the following informal social engagement: (a) visiting with friends or family with whom they did not reside and (b) going out for enjoyment (e.g., to dinner, a movie, gamble, hear music, see a play) and the following formal social engagement: (a) attending religious services, (b) participating in clubs, classes, or other organized activities, and (c) doing volunteer work. Engagement referred to participation in any of the two types of informal activity and any of the three types of formal activity (yes = 1, no = 0). T1 and T2 past-month exercise activity (walking for exercise and vigorous activities that increased heart rate and made breathing harder such as working out, swimming, running, biking, or playing a sport) were examined for descriptive purposes only.

Health-related restriction in social engagement and changes between T1 and T2

Each sample person (or proxy) was asked about restrictions in each specified activity due to health or functioning problems (“In the last months, did your [or sample person’s] health or functioning ever keep you [her/him] from doing this activity?”). (Hereafter, “restriction” refers to health-related restriction.) Affirmative responses regarding restricting both types of informal social engagement were coded as informal social engagement restriction. Affirmative responses regarding restricting all three types of formal social engagement were coded as formal social engagement restriction. Changes (or lack thereof) in social engagement restriction between T1 and T2 were (a) no restriction at both T1 and T2 or T1 restriction but T2 no restriction, (b) T2 new restriction (i.e., T1 no restriction but T2 restriction), and (c) T1-T2 continued restriction (i.e., restriction at both T1 and T2).

Past-year fall status at T1 and T2

These were measured with the question, “In the past 12 months, have you (or has the sample person) fallen down?” (yes or no). If needed, the following was provided: “By falling down, we mean any fall, slip, or trip in which you lose your balance and land on the floor or ground or at a lower level.” Those who answered yes were asked, “In the last 12 months, have you/has the sample person fallen down more than one time?” Based on responses to these two questions, fall status was coded as no fall, one fall, and 2+ (multiple) falls. T1 fall status was examined for descriptive purposes only.

Health status at T1 and T2

These included (a) the number of chronic illnesses diagnosed by a physician, ranging from 0 to 9 (high blood pressure, heart attack/heart disease, arthritis, osteoporosis, diabetes, lung disease, stroke, cancer, and dementia); (b) the number of activities and instrumental activities of daily living (ADLs/IADLs), ranging from 0 to 11 (feeding, bathing, toileting, dressing, bed transfer, moving inside the house, doing laundry, shopping, preparing meals, taking medication, and managing money), in which the sample person had any difficulty (i.e., a little, some, or a lot) in the past month; (c) whether the person was bothered by body pain in the past month (yes or no); and (d) depressive symptoms, measured with the two-item Patient Health Questionnaire-2 (PHQ-2; Kroenke, Spitzer, & Williams, 2003), which captures cognitive/affective symptoms of anhedonia and depressed mood by asking “Over the last month, how often have you/has the sample person (a) had little interest or pleasure in doing things; and (b) felt down, depressed, or hopeless?” Responses were based on a 4-point scale (0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day). The combined PHQ-2 score was used as an overall symptom severity score, and scores > 3 were used to indicate probable major depression (Kroenke et al., 2003). Use of mobility assistive devices at T2 was examined for descriptive purposes only.

Demographic variables

Demographic variables were age (65-69, 70-74, 75-79, 80-84, 85-89, 90+), gender (female vs. male), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, all other), marital status (married/partnered, divorced/separated, widowed, never-married), residence (in a residential care facility vs. community), and household income (% of national median income in 2015 [US$56,516]: <50%, 50%-99%, 100%-199%, 200+%), and living arrangement (alone vs. not alone, for descriptive purposes only).

Analysis

All analyses were conducted with Stata/MP 15’s (Statacorp LLC, College Station, TX) svy function to account for NHATS’ stratified, multistage sampling design. We used χ² and t tests to compare study variables between those who reported any informal or formal social engagement restriction and those who did not. To test H1 (association of T2 social engagement restrictions with T2 fall worry), we used two logistic regression models, with informal social engagement restriction as the dependent variable in the first model and formal social engagement restriction in the second model. Covariates for both models were T2 health status, T1 social engagement, and demographic variables. To test H2 (association of T1-T2 changes [or lack thereof] in social engagement restrictions with T1-T2 changes (or lack thereof) in fall worry), we used two multinomial logistic regression models, with changes (or lack thereof) in informal and formal social engagement restrictions as the dependent variables. Covariates for both models were T1-T2 changes (or lack thereof) in number of chronic illnesses and ADL/IADL impairments, T2 bothersome pain and T2 depressive symptom scores (rather than change because overall change in these variables from T1 to T2 was not significant), T1 social engagement, and demographic variables. Variance inflation factor diagnostics, using a cut-off of 2.50 (Allison, 2015), showed that multicollinearity among the covariates was not a concern. Logistic regression results are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI), and multinomial logistic regression results as relative risk ratios (RRR) with 95% CI. Statistical significance was set at p < .05.

Results

Sample Characteristics

Table 1 shows that at T2, 23.5% of the sample reported health-related restriction in either informal or formal social engagement in the past month. Compared to 76.5% of the sample without restriction, those with restriction included higher proportions of older, female, racial/ethnic minority, and nonmarried individuals, those who lived alone and had lower incomes, and residential care facility residents. Those with restriction also had more chronic illnesses and ADL/IADL impairments, higher proportions of people with bothersome pain, higher depressive symptom scores and probable major depression, and mobility assistive device users.

Table 1.

Sample Demographic and Health Status Characteristics at T2 by Health-Related Social Engagement Restriction Status.

	All (n = 6,279; 100%)	Those without restriction^a (n = 4,573; 76.51%)	Those with restriction^a (n = 1,706; 23.49%)	p
Age (yearrs, %)				<.001
65-69	25.62	26.77	21.88
70-74	27.36	29.29	21.05
75-79	20.42	21.11	18.18
80-84	13.04	12.40	15.11
85-89	8.66	6.95	14.23
90+	4.90	3.48	9.55
Gender (%)				<.001
Female	55.36	51.78	67.03
Male	44.64	48.22	32.97
Race/ethnicity (%)				.063
Non-Hispanic White	78.03	78.92	75.13
Non-Hispanic Black	8.09	7.53	9.89
Hispanic	7.19	7.05	7.64
All other	6.70	6.50	7.35
Marital status (%)				<.001
Married/partnered	55.89	59.09	54.48
Divorced/separated	14.29	13.49	16.90
Widowed	26.22	24.04	33.32
Never married	3.60	339	4.30
Residence (%)				<.001
In the community	95.20	96.40	91.30
In residential care facility	4.80	3.60	8.70
Living alone (%)	29.80	27.63	36.88	<.001
Income (% of national median income in 2015)
<50%	37.23	33.15	50.52
50-99%	27.92	48.49	26.06
100-199%	23.14	24.92	17.34
200+%	11.71	13.44	6.08
Health status
Number of chronic illnesses (M, SE)	2.33 (0.02)	2.11 (0.03)	3.06 (0.04)	<.001
Number of ADL/IADL impairments (M, SE)	1.52 (0.04)	0.80 (0.03)	3.87 (0.08)	<.001
Bothersome pain in last month (%)	55.16	48.51	76.83	<.001
Depression (n = 6,235)
Symptom severity score (M, SE)	0.90 (0.02)	0.66 (0.02)	1.67 (0.05)	<.001
Probable major depression (PHQ-2 > 3; %)	12.03	7.73	26.12	<.001
Cane, walker, or wheelchair use (%)	25.71	16.45	55.88	<.001

Note: Probability values, calculated using Pearson χ² tests for categorical variables and t tests for continuous variables, denote differences between those without any health-related restriction and those with health-related restriction. ADL = activities of daily living; IADL = instrumental activities of daily living; PHQ = Patient Health Questionnaire-2.

Refers to health-related restrictions in both types of informal social activity (visiting with friends/family and going out for enjoyment) and/or three types of formal social activity (attending religious services, attending meetings, and volunteering).

Fall Worry, Fall Incidents, Social Engagement, and Changes in Fall Worry and Social Engagement

Table 2 shows that at T2, 9.7% of the study sample had ALW. However, the rate was 25.9% among those with social engagement restriction compared with 4.7% among those without. About 32% of the study sample reported one or more falls in the year preceding the T2 interview. Fall incidents/frequency was significantly higher among those with social engagement restriction (20.2% had one fall and 30.2% had two or more falls) compared with those without restriction (17.3% and 8.8%, respectively).

Table 2.

Fall Worry, Fall Incidents, and Social Engagement at T1 and T2 and T1-T2 Changes in Fall Worry and Social Engagement.

	All (n = 6,279; 100%)	Those without restriction^a (n = 4,573; 76.51%)	Those with restriction^a (n = 1,706; 23.49%)	p
T1 fall worry (%)				<.001
NW	73.65	80.08	52.70
NALW	17.53	15.07	25.52
ALW	8.82	4.84	21.77	<.001
T2 fall worry (%)
NW	70.51	77.02	49.32
NALW	19.80	18.27	24.75
ALW	9.69	4.71	25.93
T1-T2 changes in fall worry				<.001
T1 and T2 NW	37.98	69.23	37.98
T1 and T2 NALW or fluctuations between NW and NALW	26.97	22.84	26.97
T1 NW/NALW to T2 ALW (increased worry)	13.28	3.08	13.38
T1 and T2 ALW (continued worry)	12.65	1.63	12.65
T1 ALW to T2 NW/NALW (decreased worry)	9.13	3.22	9.13
T1 fall status (%)				<.001
None	69.23	74.24	52.90
One fall	17.49	16.44	20.93
2+ falls	13.28	9.32	26.18
T2 fall status (%)				<.001
None	68.22	73.91	49.69
One fall	17.98	17.31	20.15
2+ falls	13.80	8.78	30.16
T1 any informal social engagement (yes; %)	94.63	95.81	90.81	<.001
T2 any informal social engagement (yes; %)	93.71	95.21	88.81	<.001
Visits with friends/family	87.19	88.84	81.79	<.001
Going out to enjoy	80.32	84.45	66.88	<.001
T1 any formal social engagement (yes; %)	71.25	71.25	69.57	.147
T2 any formal social engagement (yes; %)	71.37	73.21	63.72	<.001
Religious service attendance	56.13	57.65	51.16	<.001
Clubs/classes/other organized activities	39.68	42.57	30.25	<.001
Volunteering	26.89	30.28	15.86	<.001
T2 health-related restriction in (%)
Visits with friends/family	8.44	0	35.95
Going out to enjoy	9.38	0	40.04
Religious service attendance	12.23	0	52.29
Clubs/classes/other organized activities	10.36	0	44.19
Volunteering	9.79	0	41.70
T1-T2 changes in informal engagement restriction				<.001
T1 and/or T2 no restriction	68.74	100	43.15
T2 new restriction	8.21	0	33.80
T1-T2 continued restriction	23.05	0	23.05
T1-T2 changes in formal engagement restriction				<.001
T1 and/or T2 no restriction	80.03	100	14.85
T2 new restriction	9.99	0	42.61
T1-T2 continued restriction	9.98	0	43.54
T1 exercise activity^b (%)	72.02	76.41	57.71	<.001
T2 exercise activity^b (%)	71.91	77.28	54.43	<.001

Note. Probability values, calculated using Pearson χ² tests, denote differences between those without any health-related restriction and those with health-related restriction. NW = no fall worry; NALW = nonactivity-limiting worry; ALW = activity-limiting worry.

Refers to health-related restrictions in both types of informal social engagement (visiting with friends/family and going out for enjoyment) and/or three types of formal social engagement (attending religious services, attending meetings, and volunteering).

Walking for exercise and/or vigorous physical activity.

Table 2 also shows that 13.4% of those with social engagement restriction at T2 compared with 3.1% of those without had increased fall worry between T1 and T2 (i.e., change from T1 NW/NALW to T2 ALW); 12.7% of those with restriction compared with 1.6% of those without had continued fall worry (i.e., ALW at both T1 and T2); and 9.1% of those with restriction compared with 3.2% of those without had decreased fall worry (i.e., T1 ALW to T2 NW/NALW). Additional analyses also showed that rates of multiple falls increased significantly between T1 and T2 among those with restriction but not among those without.

Those with social engagement restriction at T2 also had a lower rate of informal social engagement at T1 than those without restriction at T2; however, the two groups did not differ on T1 formal social engagement. Exercise activities declined between T1 and T2 among those with social engagement restriction at T2 but not among those without. Of those with restriction at T2, 33.8% and 42.6% developed such restriction in informal and formal social engagement, respectively, between T1 and T2, and 23.1% and 43.5% had continued restriction in informal and formal social engagement, respectively, between T1 and T2.

Cross-Sectional Association of Social Engagement Restriction With Fall Worry at T2

Table 3 shows that compared to NW, ALW was significantly associated with higher odds of reporting restriction in both informal (AOR = 1.74, 95% CI = [1.22, 2.48]) and formal (AOR = 1.49, 95% CI = [1.07, 2.06]) social engagement at T2, controlling for fall incidents in the preceding 12 months, T2 health status, T1 social engagement, and demographics. NALW did not differ significantly from NW.

Table 3.

Association of T2 Health-Related Social Engagement Restriction With T2 Fall Worry: Logistic Regression Results.

	No restriction vs. restriction of
	Informal socialengagement AOR (95% CI)	Formal social engagement AOR (95% CI)
T2 fall worry: NW vs.
NALW	0.95 [0.75, 1.20]	0.95 [0.74, 1.21]
ALW	1.74 [1.22, 2.48]**	1.49 [1.07, 2.06]*
T2 fall status: No fall vs.
One fall	1.15 [0.80, 1.66]	1.14 [0.87, 1.48]
2+ falls	1.49 [1.15, 1.93]**	1.53 [1.20, 1.94]**
T2 number of chronic illnesses	1.08 [0.99, 1.18]	1.14 [1.06, 1.21]***
T2 ADL/IADL impairments	1.46 [1.40, 1.52]***	1.45 [1.39, 1.51]***
T2 bothersome pain	1.88 [1.50, 2.37]***	1.95 [1.64, 2.32]***
T2 depressive symptom score	1.22 [1.12, 1.32]***	1.14 [1.06, 1.22]**
T1 informal social engagement	0.90 [0.61, 1.34]
T1 formal social engagement		1.84 [1.47, 2.31]***
Age group: 65-69 years vs.
70-74	0.72 [0.50, 1.04]	0.91 [0.68, 1.21]
75-79	0.68 [0.49, 0.95]*	1.07 [0.80, 1.42]
80-84	0.90 [0.64, 1.28]	1.28 [0.93, 1.76]
85-89	1.07 [0.75, 1.54]	1.92 [1.34, 2.75]**
90+	0.93 [0.61, 1.43]	1.82 [1.16, 2.87]*
Female (vs. male)	1.37 [1.07, 1.75]*	1.61 [1.32, 1.96]***
Race/ethnicity: Non-Hispanic White vs.
Non-Hispanic Black	0.92 [0.70, 1.22]	1.02 [0.80, 1.28]
Hispanic	0.44 [0.29, 0.66]***	0.73 [0.51, 1.06]
Other	1.06 [0.72, 1.57]	0.86 [0.54, 1.38]
Marital status: Married/partnered vs.
Divorced/separated	1.25 [0.85, 1.84]	1.20 [0.88, 1.64]
Widowed	0.94 [0.74, 1.19]	0.93 [0.71, 1.21]
Never married	1.08 [0.52, 2.26]	1.40 [0.81, 2.42]
Lived in a residential care facility (vs. community)	1.28 [0.85, 1.94]	1.08 [0.76, 1.53]
Income level: 200+% of national median income vs.
<50%	1.54 [0.92, 2.58]	1.13 [0.74, 1.74]
50%-99%	1.69 [1.04, 2.74]*	1.27 [0.87, 1.86]
100%-199%	1.92 [1.21, 3.03]**	1.08 [0.72, 1.62]
	n = 6,216; F(25, 32) = 23.31; p < .001	n = 6,211; F(25, 32) = 30.52; p < .001

Note. AOR = adjusted odds ratio; NW = no fall worry; NALW = nonactivity-limiting worry; ALW = activity-limiting worry; ADL = activities of daily living; IADL = instrumental activities of daily living.

p < .05. **p < .01. ***p < .001.

Of the covariates, multiple falls, more ADL/IADL impairments, bothersome pain, higher depressive symptom severity scores, and female gender were associated with higher odds of both informal and formal social engagement restriction. More chronic illnesses, any T1 formal social engagement, and being aged 85+ years were associated with higher odds of formal social engagement restriction only. Any T1 informal social engagement, being aged 75 years to 79 years, and being Hispanic were associated with lower odds of informal social engagement restriction only, while income 50% to 199% of the national median (as opposed to 200+%) was associated with higher odds of informal social engagement restriction only.

Association of T1-T2 Changes in Social Engagement Restriction With T1-T2 Changes in Fall Worry

Table 4 shows that compared to NW/NLAW at both T1 and T2, increased fall worry (change from T1 NW/NALW to T2 ALW) was associated with higher risk of T2 new restriction of informal (RRR = 1.96, 95% CI = [1.31, 2.94]) and formal (RRR = 2.09, 95% CI = [1.45, 3.01]) social engagement and T1-T2 continued restriction of informal (RRR = 2.26, 95% CI = [1.26, 4.03]) and formal (RRR = 2.45, 95% CI = [1.66, 3.61]) social engagement. Continued fall worry (ALW at both T1 and T2) was also associated with higher risk of new or continued restriction in informal social engagement and continued (but not new) restriction in formal social engagement. Compared to NW/NLAW at both T1 and T2, decreased fall worry (T1 ALW to T2 NW/NLAW) was also associated with higher risk of continued restriction of informal and formal social engagement.

Table 4.

Association of T1-T2 Changes in Health-Related Social Engagement Restriction With Changes in Fall Worry: Multinomial Logistic Regression Results.

	T1 and/or T2 no restriction of informal social engagement vs.		T1 and/or T2 no restriction of formal social engagement vs.
	T2 new restriction RRR (95% CI)	T1-T2 continued restriction RRR (95% CI)	T2 new restriction RRR (95% CI)	T1-T2 continued restriction RRR (95% CI)
T1-T2 changes in fall worry: T1 and T2 NW/NALW vs.
T1 NW/NALW to T2 ALW (increased worry)	1.96 [1.31, 2.94]**	2.26 [1.26, 4.03]**	2.09 [1.45, 3.01]***	2.45 [1.66, 3.61]***
T1 and T2 ALW (continued worry)	2.24 [1.43, 3.49]**	5.05 [2.97, 8.59]***	1.07 [0.68, 1.69]	3.18 [2.06, 4.88]***
T1 ALW to T2 NW/NALW (decreased worry)	1.17 [0.69, 1.97]	3.67 [2.33, 5.77]***	1.08 [0.70, 1.68]	3.15 [2.10, 4.71]***
T2 fall status: No fall vs.
One fall	1.16 [0.80, 1.69]	1.00 [0.66, 1.51]	1.18 [0.88, 1.60]	1.05 [0.76, 1.45]
2+ falls	1.46 [1.09, 1.96]*	2.48 [1.73, 3.53]***	1.80 [1.33, 2.45]***	1.97 [1.51, 2.57]***
T1-T2 change in number of chronic illnesses	0.94 [0.78, 1.15]	1.00 [0.81, 1.22]	0.99 [0.86, 1.13]	0.87 [0.72, 1.04]
T1-T2 change in ADL/IADL impairments	1.37 [1.30, 1.44]***	1.19 [1.11, 1.28]***	1.33 [1.26, 1.40]***	1.25 [1.19, 1.32]***
T2 bothersome pain	2.01 [1.52, 2.65]***	2.43 [1.70, 3.48]***	1.75 [1.42, 2.17]***	3.00 [2.22, 4.06]***
T2 depressive symptom score	1.23 [1.11, 1.36]***	1.51 [1.38, 1.65]***	1.15 [1.06, 1.24]**	1.39 [1.28, 1.50]***
T1 informal social engagement	0.94 [0.56, 1.59]	0.52 [0.33, 0.85]**
T1 formal social engagement			1.88 [1.39, 2.54]***	1.12 [0.87, 1.45]
Age group: 65-69 years vs.
70-74	0.90 [0.60, 1.36]	0.58 [0.34, 0.97]*	1.04 [0.75, 1.45]	0.89 [0.63, 1.26]
75-79	0.91 [0.67, 1.25]	0.57 [0.31, 0.92]*	1.04 [0.74, 1.48]	1.30 [0.92, 1.83]
80-84	1.40 [0.96, 2.05]	0.76 [0.45, 1.28]	1.55 [1.08, 2.23]*	1.52 [1.01, 2.31]*
85-89	1.59 [1.01, 2.49]*	1.21 [0.74, 2.00]	2.47 [1.64, 3.72]***	2.60 [1.70, 3.96]***
90+	1.41 [0.89, 2.23]	1.89 [1.14, 3.27]*	2.78 [1.79, 4.31]***	3.44 [2.08, 5.67]***
Female (vs. male)	1.28 [1.03, 1.60]*	1.65 [1.13, 2.42]*	1.25 [1.01, 1.56]*	2.38 [1.84, 3.09]***
Race/ethnicity: Non-Hispanic White vs.
Non-Hispanic Black	1.08 [0.79, 1.48]	1.31 [0.92, 1.87]	1.29 [1.02, 1.65]*	1.21 [0.93, 1.58]
Hispanic	0.54 [0.33, 0.89]*	0.65 [0.39, 1.10]	1.05 [0.69, 1.62]	0.82 [0.52, 1.31]
Other	1.13 [0.69, 1.85]	1.18 [0.64, 2.18]	0.78 [0.41, 1.51]	1.13 [0.67, 1.93]
Marital status: Married/partnered vs.
Divorced/separated	1.44 [0.96, 2.17]	0.59 [0.36, 0.96]*	1.11 [0.82, 1.50]	0.92 [0.62, 1.35]
Widowed	0.91 [0.70, 1.17]	0.68 [0.48, 0.97]*	0.83 [0.61, 1.13]	0.84 [0.59, 1.19]
Never married	1.20 [0.55, 2.62]	0.60 [0.24, 1.51]	1.36 [0.67, 2.76]	1.17 [0.67, 2.02]
Lived in a residential care facility (vs. community)	1.72 [1.05, 2.83]*	1.32 [0.81, 2.15]	1.53 [0.97, 2.45]	1.30 [0.95, 1.80]
Income level: 200+% of national median income vs.
<50%	2.53 [1.36, 4.71]**	1.59 [0.75, 3.36]	1.25 [0.77, 2.02]	1.94 [1.07, 3.50]*
50%-99%	2.68 [1.51, 4.73]**	1.24 [0.63, 2.46]	1.15 [0.74, 1.76]	1.948 [1.08, 3.47]*
100%-199%	3.28 [1.90, 5.67]***	0.82 [0.34, 1.983]	1.18 [0.76, 1.83]	1.07 [0.59, 1.93]
	n = 6,204; F(52, 5) = 31.05; p < .001		n = 6,198; F(52, 5) = 29.10; p < .001

Note. RRR = relative risk ratios; NW = no fall worry; NALW = nonactivity-limiting worry; ALW = activity-limiting worry; ADL = activities of daily living; IADL = instrumental activities of daily living.

p < .05. **p < .01. ***p < .001.

Of the covariates, T1-T2 increase in ADL/IADL impairments, T2 multiple falls, bothersome pain, higher depressive symptom scores, and female gender were associated with higher risk of new or continued restriction of both informal and formal social engagement. Older age groups (80+ years) also had higher risk of new or continued restriction in formal social engagement.

Discussion

The impact of fall worry on physical activity restriction/avoidance in late life has been well-researched. This study on the association between fall worry and social engagement restriction adds a new dimension to this knowledge. The findings show that of older Medicare beneficiaries who lived in the community and residential care facilities (not nursing homes), nearly a quarter (9.2 million people) reported that they restricted either informal or formal social engagement due to their health and functioning problems. Although about 70% of older adults reported no fall worry and one fifth reported NLAW, one in 10 reported ALW. Of those who reported health-related informal or formal social engagement restriction, more than one quarter had ALW.

A majority (82%) of those who reported health-related restriction in social engagement still visited with family/friends (perhaps because family/friends visited in the older adult’s home). However, they apparently curtailed engagement that required going outside/traveling (to enjoy, attend religious services, participate in other organized activities, and volunteer). Given that more than half of those with social engagement restriction used mobility assistive devices, balance and mobility difficulties and associated fall worry could have led to the restriction. Balance and mobility difficulties undoubtedly stem from chronic illnesses, functional impairments, and bodily pain, and these difficulties could have been a factor in fall incidents as more than half of those who reported health-related social engagement restriction had at least one fall and 60% of fallers had multiple falls. Fall-related injuries could also have contributed to mobility difficulties that impeded social engagement.

The key study findings are as follows: (a) T2 ALW was significantly correlated with higher odds of both informal and formal social engagement restriction at T2 even controlling for falls incidents, health conditions, depressive symptoms, previous social engagement, and demographics. (b) Increased fall worry (change from T1 NW/NALW to T2 ALW) between T1 and T2 was significantly associated with higher riskof newly reported restrictions in both informal and formal social engagement between T1 and T2 even controlling for falls incidents and changes in health status and other covariates. (c) Continued fall worry (ALW at both T1 and T2) was significantly associated with higher risk of new or continued restrictions in informal social engagement and continued restrictions in formal social engagement. ALW’s lack of association with newly reported health-related restrictions in formal social engagement is likely because formal social engagement had already been reduced at T1 due to fall worry. (d) Even with decreased fall worry between T1 and T2, informal and formal social engagement restriction continued at T2, suggesting that older adults need help with restoring or increasing social engagement once they disengage.

The significant cross-sectional and longitudinal associations between activity-limiting fall worry and social engagement restriction shown in this study suggest fall worry’s potential effect on curtailment of social engagement. Additional research could help further clarify whether fall worry has direct independent effects on social engagement curtailment or if it affects curtailment through mediating variables (e.g., balance, gait, other mobility difficulties, and depression). As previous studies show, fall worry may lead to sedentary behaviors, which can further increase disability and depression (Auais et al., 2018; Stubbs, Patchay, Soundy, & Schofield, 2014), and activity restriction, not fear of falls per se, has been found to predict balance and mobility difficulties (Allison et al., 2013). In the present study, a substantial number (one quarter) of those who reported health-related social engagement restriction had probable major depression. Disengagement from healthy behaviors resulting in fewer rewards, less positive reinforcement, and social isolation contributes to and reinforces depressive mood (Carvalo & Hopko, 2011). Worsening health problems, increasing disability, increasing fall worry, and lack of participation in meaningful social activities are likely to exacerbate depression, and vice versa, among these older adults.

The study has limitations related to NHATS study design and measures. First, although two waves of data were used, only associations, not causal inferences, can be made as survey methodology was used to collect data. Second, fall worry and associated activity limitation were measured with two questions rather than a validated multiitem scale (e.g., mSAFFE) and may not represent the full spectrum of fear of falls. Falls were categorized only as once and more than once instead of the specific number of falls. Lack of data on frequency of fall worry and activity limitation was also a barrier to more in-depth data analysis. Finally, though we included chronic illnesses and ADL/IADL impairments to reflect all-cause disability, future research should examine the potentially additive effects of sensory and cognitive impairments on fall worry and social engagement.

Despite these limitations, the findings underscore the importance of reducing fall worry and preventing social disengagement in late life. Evidence-based interventions for achieving these goals are, however, limited. A meta-analysis found that exercise interventions to reduce fear of falls in community-dwelling older people immediately following the intervention had limited effectiveness, and whether they subsequently reduce fear of falls or increase physical activity is not known (Kendrick et al., 2014). One randomized clinical trial demonstrated that cognitive–behavioral therapy-based interventions to reduce fear of falls in older adults did reduce fear of falls, but it had no effect on falls, injuries, social engagement, loneliness, physical function, anxiety/depression, or quality of life (Parry et al., 2016). Given the significant role of activity in enhancing older adults’ physical and mental health and quality of life, more research on innovative interventions to help reduce fall worry and increase physical activity and social engagement is needed. Our findings suggest that interventions with the dual aims of reducing fall worry and increasing or restoring activity participation are needed. Greater investment in existing resources may also decrease fall worry and increase activity participation. For example, neighborhood senior centers are important venues for enhancing older adults’ mental and physical health by increasing their physical and social activity participation and teaching fall prevention skills and reducing fall worry (Li & Harmer, 2014). Interventions to reduce fall worry can also be incorporated into other community-based programs (e.g., senior centers without walls Newall & Menec, 2015) that are aimed at increasing social engagement among older adults who are disabled, frail, and homebound.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Namkee G. Choi

References

Allison

L. K.

Painter

J. A.

Emory

Whitehurst

Raby

(2013). Participation restriction, not fear of falling, predicts actual balance and mobility abilities in rural community-dwelling older adults. Journal of Geriatric Physical Therapy, 36, 13-23. doi:10.1519/JPT.0b013e3182493d20

Allison

(2015). When can you safely ignore multicollinearity? Retrieved from https://statisticalhorizons.com/multicollinearity

Auais

French

Alvarado

Pirkle

Belanger

Guralnik

(2018). Fear of falling predicts incidence of functional disability 2 years later: A perspective from an international cohort study. The Journal of Gerontology: Biological and Medical Sciences, 73, 1212-1215. doi:10.1093/gerona/glx237

Austin

Devine

Dick

Prince

Bruce

(2007). Fear of falling in older women: A longitudinal study of incidence, persistence, and predictors. Journal of the American Geriatrics Society, 55, 1598-1603. doi:10.1111/j.1532-5415.2007.01317.x

Cacioppo

J. T.

Hawkley

L. C.

Norman

G. J.

Berntson

G. G.

(2011). Social isolation. Annals of the New York Academy of Sciences, 1231, 17-22. doi:10.1111/j.1749-6632.2011.06028.x

Carvalo

J. P.

Hopko

D. R.

(2011). Behavioral theory of depression. Journal of Behavior Therapy & Experimental Psychiatry, 42, 154-162.

Cornwell

E. Y.

Waite

L. J.

(2009). Social disconnectedness, perceived isolation, and health among older adults. Journal of Health and Social Behavior, 50, 31-48.

Coyle

C. E.

Dugan

(2012). Social isolation, loneliness and health among older adults. Journal of Aging and Health, 24, 1346-1363. doi:10.1177/0898264312460275

Delbaere

Crombez

Vanderstraeten

Willems

Cambier

(2004). Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age and Ageing, 33, 368-373.

10.

DeMatteis

Freedman

V. A.

Kasper

J. D.

(2016). National Health and Aging Trends Study Round 5 sample design and selection (NHATS Technical Paper #16). Baltimore, MD: Johns Hopkins University School of Public Health. Available from www.NHATS.org

11.

Denkinger

M. D.

Lukas

Nikolaus

Hauer

(2015). Factors associated with fear of falling and associated activity restriction in community-dwelling older adults: A systematic review. American Journal of Geriatric Psychiatry, 23, 72-86. doi:10.1016/j.jagp.2014.03.002

12.

Deshpande

Metter

E. J.

Bandinelli

Lauretani

Windham

B. G.

Ferrucci

(2008). Psychological, physical, and sensory correlates of fear of falling and consequent activity restriction in the elderly: The InCHIANTI study. American Journal of Physical Medicine & Rehabilitation, 87, 354-362. doi:10.1097/PHM.0b013e31815e6e9b

13.

Deshpande

Metter

E. J.

Lauretani

Bandinelli

Guralnik

Ferrucci

(2008). Activity restriction induced by fear of falling and objective and subjective measures of physical function: A prospective cohort study. Journal of the American Geriatrics Society, 56, 615-620. doi:10.1111/j.1532-5415.2007.01639.x

14.

Donoghue

O. A.

Cronin

Savva

G. M.

O’Regan

Kenny

R. A.

(2013). Effects of fear of falling and activity restriction on normal and dual task walking in community dwelling older adults. Gait & Posture, 38, 120-124. doi:10.1016/j.gaitpost.2012.10.023

15.

Hadjistavropoulos

Delbaere

Fitzgerald

T. D.

(2011). Reconceptualizing the role of fear of falling and balance confidence in fall risk. Journal of Aging & Health, 23, 3-23. doi:10.1177/0898264310378039

16.

Hadjistavropoulos

Martin

R. R.

Sharpe

Lints

A. C.

McCreary

D. R.

Asmundson

G. J.

(2007). A longitudinal investigation of fear of falling, fear of pain, and activity avoidance in community-dwelling older adults. Journal of Aging & Health, 19, 965-984. doi:10.1177/0898264307308611

17.

Hawton

Green

Dickens

A. P.

Richards

S. H.

Taylor

R. S.

Edwards

. . . Campbell

J. L.

(2011). The impact of social isolation on the health status and health-related quality of life of older people. Quality of Life Research, 20, 57-67. doi:10.1007/s11136-010-9717-2

18.

Heffner

K. L.

Waring

M. E.

Roberts

M. B.

Eaton

C. B.

Gramling

(2011). Social isolation, C-reactive protein, and coronary heart disease mortality among community-dwelling adults. Social Science & Medicine, 72, 1482-1488. doi:10.1016/j.socscimed.2011.03.016

19.

Hughes

C. C.

Kneebone

I. I.

Jones

Brady

B. A.

(2015). A theoretical and empirical review of psychological factors associated with falls-related psychological concerns in community-dwelling older people. International Psychogeriatrics, 27, 1071-1087. doi:10.1017/S1041610214002701

20.

Kader

Iwarsson

Odin

Nilsson

M. H.

(2016). Fall-related activity avoidance in relation to a history of falls or near falls, fear of falling and disease severity in people with Parkinson’s disease. BMC Neurology, 16, Article 84. doi:10.1186/s12883-016-0612-5

21.

Kanamori

Kai

Aida

Kondo

Kawachi

Hirai

, . . . JAGES Group. (2014). Social participation and the prevention of functional disability in older Japanese: The JAGES cohort study. PLoS ONE, 9, e99638. doi:10.1371/journal.pone.0099638

22.

Kendrick

Kumar

Carpenter

Zijlstra

G. A.

Skelton

D. A.

Cook

J. R.

. . . Delbaere

(2014). Exercise for reducing fear of falling in older people living in the community. Cochrane Database of Systematic Reviews, 28(11), CD009848. doi:10.1002/14651858.CD009848.pub2

23.

Kobayashi

L. C.

Steptoe

(2018). Social isolation, loneliness, and health behaviors at older ages: Longitudinal cohort study. Annals of Behavioral Medicine, 52, 582-593. doi:10.1093/abm/kax033

24.

Kroenke

Spitzer

R. L.

Williams

J. B.

(2003). The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41, 1284-1292.

25.

Kumar

Carpenter

Morris

Iliffe

Kendrick

(2014). Which factors are associated with fear of falling in community-dwelling older people? Age and Ageing, 43, 76-84. doi:10.1093/ageing/aft154

26.

Lachman

M. E.

Howland

Tennstedt

Jette

Assmann

Peterson

E. W.

(1998). Fear of falling and activity restriction: The survey of activities and fear of falling in the elderly (SAFE). Journal of Gerontology: Psychological and Social Sciences, 53, P43-P50.

27.

Landers

M. R.

Oscar

Sasaoka

Vaughn

(2016). Balance confidence and fear of falling avoidance behavior are most predictive of falling in older adults: Prospective analysis. Physical Therapy, 96, 433-442. doi:10.2522/ptj.20150184

28.

LeBouthillier

D. M.

Thibodeau

M. A.

Asmundson

G. J.

(2013). Severity of fall-based injuries, fear of falling, and activity restriction: Sex differences in a population-based sample of older Canadian adults. Journal of Aging and Health, 25, 1378-1387. doi:10.1177/0898264313507317

29.

Lee

Mackenzie

James

(2008). Perceptions of older people living in the community about their fear of falling. Disability and Rehabilitation, 30, 1803-1811. doi:10.1080/09638280701669508

30.

Harmer

(2014). Protocol for disseminating an evidence-based fall prevention program in community senior centers: Evaluation of translatability and public health impact via a single group pre-post study. Implementation Science, 9, Article 63. doi:10.1186/1748-5908-9-63

31.

Makino

Makizako

Doi

Tsutsumimoto

Hotta

Nakakubo

. . . Shimada

(2018). Impact of fear of falling and fall history on disability incidence among older adults: Prospective cohort study. International Journal of Geriatric Psychiatry, 33, 658-662. doi:10.1002/gps.4837

32.

Montaquila

Freedman

V. A.

Edwards

Kasper

J. D.

(2012). National Health and Aging Trends Study Round 1 sample design and selection (NHATS Technical Paper #1). Baltimore, MD: Johns Hopkins University School of Public Health. Available from www.NHATS.org

33.

Murphy

S. L.

Williams

C. S.

Gill

T. M.

(2002). Characteristics associated with fear of falling and activity restriction in community-living older persons. Journal of the American Geriatrics Society, 50, 516-520.

34.

Newall

N. E.

Menec

V. H.

(2015). Targeting socially isolated older adults: A process evaluation of the senior centre without walls social and educational program. Journal of Applied Gerontology, 34, 958-976. doi:10.1177/0733464813510063

35.

Parry

S. W.

Bamford

Deary

Finch

T. L.

Gray

MacDonald

. . . McColl

E. M.

(2016). Cognitive-behavioural therapy-based intervention to reduce fear of falling in older people: Therapy development and randomised controlled trial—The strategies for increasing independence, confidence and energy (STRIDE) study. Health Technology Assessment, 20(56), 1-206. doi:10.3310/hta20560

36.

Patil

Uusi-Rasi

Kannus

Karinkanta

Sievänen

(2014). Concern about falling in older women with a history of falls: Associations with health, functional ability, physical activity and quality of life. Gerontology, 60, 22-30. doi:10.1159/000354335

37.

Reuben

D. B.

Herr

K. A.

Pacala

J. T.

Pollock

B. G.

Potter

J. F.

Semla

T. P.

(2017). Geriatrics at your fingertips (19th ed.). New York, NY: American Geriatrics Society.

38.

Sawa

Asai

Doi

Misu

Murata

Ono

(2018). The associations between physical activity, including physical activity intensity, and fear of falling differs by fear severity in older adults living in the community. Journal of Gerontology: Psychological and Social Sciences, 14. Epub ahead of print as of Januray 2019. doi:10.1093/geronb/gby103

39.

Steptoe

Shankar

Demakakos

Wardle

(2013). Social isolation, loneliness, and all-cause mortality in older men and women. Proceedings of the National Academy of Sciences United States of America, 110, 5797-5801. doi:10.1073/pnas.1219686110

40.

Stubbs

Patchay

Soundy

Schofield

(2014). The avoidance of activities due to fear of falling contributes to sedentary behavior among community-dwelling older adults with chronic musculoskeletal pain: A multisite observational study. Pain Medicine, 15, 1861-1871. doi:10.1111/pme.12570

41.

Stubbs

West

Patchay

Schofield

(2014). Is there a relationship between pain and psychological concerns related to falling in community dwelling older adults? A systematic review. Disability and Rehabilitation, 36, 1931-1942. doi:10.3109/09638288.2014.882419

42.

Trombetti

Reid

K. F.

Hars

Herrmann

F. R.

Pasha

Phillips

E. M.

Fielding

R. A.

(2016). Age-associated declines in muscle mass, strength, power, and physical performance: Impact on fear of falling and quality of life. Osteoporosis International, 27, 463-471. doi:10.1007/s00198-015-3236-5

43.

van Haastregt

J. C.

Zijlstra

G. A.

van Rossum

van Eijk

J. T.

Kempen

G. I

. (2008). Feelings of anxiety and symptoms of depression in community-living older persons who avoid activity for fear of falling. American Journal of Geriatric Psychiatry, 16, 186-193. doi:10.1097/JGP.0b013e3181591c1e

44.

Yardley

Smith

(2002). A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. The Gerontologist, 42, 17-23.