The Impact of Misaligned Perceived and Objective Fall Risk in Cognitively Impaired Older People

Abstract

Background:

Cognitive impairment (CI) may impair the ability to accurately perceive physical capacity and fall risk.

Objective:

We investigated perceived (measured as concern about falls) and physiological fall risk in community-dwelling older people with CI, the characteristics of the aligned and misaligned groups and the impact of misaligned perceptions on falls.

Methods:

Participants (n= 293) with mild-moderate CI were classified into four groups based on validated physiological and perceived fall risk assessments: 1) vigorous: low perceived and physiological fall risk; 2) anxious: high perceived and low physiological fall risk; 3) unaware: low perceived and high physiological fall risk; and 4) aware: high perceived and physiological fall risk. Groups were compared with respect to neuropsychological and physical function, activity and quality of life measures, and prospective falls (12-months).

Results:

The anxious (IRR = 1.70, 95% CI = 1.02–2.84), unaware (IRR = 2.00, 95% CI = 1.22–3.26), and aware (IRR = 2.53, 95% CI = 1.67–3.84) groups had significantly higher fall rates than the vigorous group but fall rates did not significantly differ among these groups. Compared with the vigorous group: the anxious group had higher depression scores and reduced mobility and quality of life; the unaware group had poorer global cognition, executive function and mobility and lower physical activity levels; and the aware group had an increased prevalence of multiple physical and cognitive fall risk factors.

Conclusions:

Fall rates were increased in participants who had increased perceived and/or physiological fall risk. Contrasting fall risk patterns were evident in those who under- and over-estimated their fall risk. Understanding these characteristics will help guide fall risk assessment and prevention strategies in community-dwelling older people with CI.

Keywords

Accidental falls aged Alzheimer’s disease cognitive dysfunction dementia fear of falling perception risk factors

INTRODUCTION

Nearly two thirds of older people with cognitive impairment (CI) fall annually, a rate twice that of cognitively intact older people.1,2, 1,2 Falls in people with CI result in fractures, traumatic brain injuries, disability, fear of falling, reduced quality of life, social isolation, institutionalization, and death. 3 With population aging, the issue of falls in people with CI will increase rapidly. Estimates suggest that by 2050 there will be approximately 140 million people with dementia worldwide. 4

Several risk factors for falls in older people with CI have been identified. These include physical factors such as poorer balance, slower walking speed, shorter stride length, and cognitive risk factors such as deficits in specific cognitive domains including visuospatial function, psychomotor speed, executive function, and attention.5,6,7 , 5,6,7 In addition, there is evidence that poor judgement of physical capacity may predispose older people with CI to falls. For example, in a study involving a reaching task, those with the largest mismatch between perceived and actual maximal reach had poorer executive function, slower reaction time, poorer balance, and experienced more falls over a prospective 12-month period. 8

Poor judgement of physical capacity has also been examined by contrasting performances in physical tests (as measures of physiological or objective fall risk) with self-report ratings of falls efficacy or concern about falls (as measures of perceived fall risk) in healthy older people, people with multiple sclerosis and older people with CI undergoing rehabilitation.9,10,11 , 9,10,11 These studies have found that while perceived and physiological fall risk both contribute to falls, many people misjudge their perceived and/or physiological risk.9,10,11 , 9,10,11 For example, in the study involving older people with CI hospitalized for rehabilitation, Hauer et al. used the short Falls Efficacy Scale-International and Performance Oriented Mobility Assessment to document perceived and objective fall risk, respectively. 10 They found two thirds of their sample misjudged their fall risk, with 38% underestimating and 29% overestimating. 10

While the above studies have drawn attention to misalignments between perceived and physiological fall risk, they have been conducted in healthy older people, people with multiple sclerosis or used past falls in people with CI hospitalized for rehabilitation.9,10,11 , 9,10,11 Group differences compared low and high perceived fall risk groups within high and low objective/physiological fall risk groups, so for example, the low perceived fall risk/high objective fall risk group was compared to the high perceived/objective fall risk group. This means the mismatch groups have not been contrasted with each other and that the groups’ characteristics have not been fully corroborated. Understanding the characteristics of those who align and misalign their fall risk may be particularly important in older people with CI who have an increased prevalence of concomitant fall risk factors including impaired executive functioning, anxiety, depression and reduced physical activity levels.2,5,6,12,13 , 2,5,6,12,13

The aim of this study was to investigate the alignment of perceived (measured as concern about falls) and physiological fall risk in relation to falls in a large sample of community dwelling older people with CI, and to elucidate the effect of misalignment on fall risk factors and fall incidence rates. We hypothesized: 1) many participants would not appropriately align their perceived and physiological fall risk, 2) participants with either a high physiological or perceived fall risk would have an increased rate of falls and that these risks would be additive, 3) those with an excessive concern about falling would have high anxiety levels, low physical activity levels, and reduced quality of life, 4) those with an inadequate concern about falling would have impaired executive function, and 5) those with both high physiological and perceived fall risk would have multiple physical and cognitive risk factors for falls. Addressing these aims may improve our understanding of fall risk and guide fall prevention strategies in older people with CI.

METHODS

Participants

Participants were drawn from 309 community-living older people with CI from the i-FOCIS randomized controlled trial (RCT). 14 The i-FOCIS RCT evaluated the efficacy of a fall prevention intervention (home-based exercise and home hazard reduction). Inclusion criteria were: aged 65 years or older, community-dwelling and a diagnosis of CI/dementia or cognitively impaired based on validated screening tools, i.e., Addenbrooke’s Cognitive Examination-III (ACE-III) score below 83, Mini-Addenbrooke’s Cognitive Examination (m-ACE) or Mini-Mental State Examination (MMSE) score below 24 or a diagnosis by a specialist clinician.15,16,17 , 15,16,17 The ACE-III, m-ACE, and MMSE have high sensitivity and specificity for dementia (ACE-III: sensitivity 93%, specificity 100%; m-ACE: sensitivity 79%, specificity 91%; MMSE: sensitivity 89%, specificity 89%).15,16,18 , 15,16,18 Participants were required to have a person responsible or caregiver with whom they had at least 3.5 h of face-to-face contact during the week to support their participation in the study. Exclusion criteria comprised: residence in an aged care facility, severe CI (MMSE or m-ACE score below 12), unable to communicate in English, unable to walk more than one meter despite assistance (walking aid and/or another person), progressive neurological disease other than dementia, or a medical condition precluding exercise. For this study, participants needed to have at least 8 months follow-up (n = 293) to classify them as non-multiple fallers (0– 1 falls)/multiple fallers (2 or more falls).

Assessments

Physiological fall risk

Sensorimotor function was assessed using the Physiological Profile Assessment (PPA). 19 The PPA tests five sensorimotor domains: visual contrast sensitivity, lower limb proprioception, knee extension strength, simple hand reaction time, and postural sway on foam. 19 Using an algorithm, 19 the scores of the five tests are used to calculate an overall risk score (developed in cognitively healthy older people), varying from a mild physiological fall risk at scores of 0 to 1, to a very high physiological fall risk with scores of 3 to 4 + . The PPA has been validated for use in people with dementia 20 and has previously been used to determine fall risk in cognitively impaired older people. 21

Perceived fall risk (measured as concern about falls)

Perceived fall risk was assessed using the 10-item Iconographical Falls Efficacy Scale (Icon-FES).22,23, 22,23 The Icon-FES measures concern about falling during a variety of activities of daily living including getting dressed or undressed, taking a bath or shower, going to a shop or a social event, cleaning the gutter, and walking around in the neighborhood. Each of the 10 items is scored from 1 (not concerned) to 4 (very concerned), with the total score ranging from 10 (low) to 40 (high). We chose the Icon-FES as our measure of concern about falling as it compensates for reduced abstract abilities by using pictures to match the verbal descriptions, and because it has been shown to be feasible, reliable, and valid for assessing concern about falling in people with mild to moderate CI or dementia living in the community. 22

Demographic characteristics, medical history, neuropsychological and physical function and activity levels

Demographics and medical history were collected through participant and caregiver interview at baseline. The ACE-III 16 was used to assess cognitive function. The ACE-III tests 5 cognitive domains (attention, memory, fluency, language, and visuospatial skills) and is scored out of 100 with higher scores indicating better performance. Executive function was assessed using the Frontal Assessment Battery (FAB; score 0– 18, higher scores indicate better performance). 24 The Goldberg Anxiety Scale was used to assess symptoms of anxiety (score 0– 9; higher scores indicate greater symptomatology). 25 The 15-item Geriatric Depression Scale was used to assess depressive symptoms, with higher scores indicating more depressive symptoms. 26 The EQ-5D-5L was scored using the UK crosswalk weights and assessed quality of life (higher scores indicating better quality of life). 27 The Short Physical Performance Battery (SPPB) assessed mobility and balance. 28 The SPPB tests gait speed, sit-to-stand ability and standing balance, which are each scored from 0 (worst) to 4 (best). The total SPPB score ranges from 0 to 12, with higher scores indicating better mobility/physical function. Physical activity levels were assessed using the Incidental and Planned Activity Questionnaire (IPEQ), which measures hours of incidental and planned activity per week. 29

Falls

Falls were recorded using monthly calendars with reply paid envelopes for the 12-month follow-up period. If participants/caregivers failed to return their calendar, they were telephoned to obtain information about falls. A fall was defined as “an unexpected event in which the participant comes to rest on the ground, floor, or lower level”. 30 Participants with at least 8-months follow-up were classified as either multiple fallers or non-multiple fallers.

Statistical analyses

Data were analyzed using IBM SPSS 26. Categorical data are presented as frequency (%) and continuous data are reported as mean±standard deviation (SD) or median (interquartile range, IQR). Physiological fall risk outliers (n = 2) were capped at 3SD above the mean. The Youden index and receiver operating curves were used to derive sample-specific cut-points for perceived (Icon-FES) and physiological (PPA) fall risk with multiple falls (during follow-up) as the dependent variable. Participants were classified into four “perceived vs. objective” fall risk groups (vigorous, anxious, unaware, and aware) using the derived cut-points (Fig. 1). Differences in group characteristics were analyzed using pairwise comparisons from generalized linear models with robust estimates. Adjustments for age and sex were made for all variables except age, sex, education, and follow-up days. Between group comparisons for ACE-III and FAB scores were additionally adjusted for education. Unadjusted fall rates per 365-days were calculated for each group. Negative binomial regression (with follow-up days as the offset variable) was used to compare fall rates among the four groups while adjusting for group allocation, age, and sex. Falls were capped at 12 (n = 4) to prevent very frequent fallers from unduly influencing our findings. p-values <0.05 were considered statisticallysignificant.

Fig. 1

Classification tree based on cut-points derived from ROC curves and Youden index for perceived and physiological fall risk with multiple prospective falls as the dependent variable.

RESULTS

Baseline characteristics

Participant baseline characteristics are reported for the whole sample in Table 1. The mean age of the participants was 82 (SD 6) years and 138 (47%) were female. Most participants (n = 212, 73%) reported a formal diagnosis of dementia.

Table 1

Participant characteristics at baseline (n = 293)

Characteristic, n (%), mean±SD
Age, y	82.2±6.0
Female	138 (47)
Education, y	12.0±3.7
Lives alone	54 (18)
Fall in the past year	151 (52)
Indoor walking aid use	66 (23)
Self-reported comorbidities, n^a	3.5±1.7
Medication use, n	5.7±2.9
Iconographical falls efficacy scale (Icon-FES)	18.4±1.8
Physiological profile assessment (PPA)	2.9±1.8

Higher scores indicate poorer performance for Icon-FES (score range 10 to 40) and PPA. ^aComorbidities = stroke, transient ischemic attack, heart disease, hypertension, diabetes, arthritis, osteoporosis, lung disease, thyroid disease, cancer, dementia, sleep apnea, depression.

Alignment of perceived and physiological fall risk

When participants were classified into four groups using the Youden index cut-points for the PPA (2.26) and Icon-FES (16.5) assessments (Fig. 1), most (n = 192, 66%) aligned their perceived risk with their physiological fall risk; with 71 (24%) classified as ‘vigorous’ (lower perceived and low physiological fall risk) and 121 (41%) classified as ‘aware’ (higher perceived and high physiological fall risk). Forty-six participants (16%) considered their fall risk to be high, whereas their PPA sores indicated a low fall risk; these participants were classified as ‘anxious’. Finally, 55 participants (19%) considered their fall risk to be low, whereas their PPA sores indicated a high fall risk; these participants were classified as ‘unaware’.

Characteristics of the vigorous, anxious, unaware, and aware groups

Table 2 shows the baseline characteristics for the vigorous, anxious, unaware and aware groups. Compared to the vigorous group; the anxious group had more depressive symptoms, reduced mobility and poorer quality of life; the unaware group had poorer cognitive performance (global cognition [ACE-III] and executive function [FAB]), reduced mobility and lower physical activity levels; and the aware group had more symptoms of anxiety and depression, poorer cognitive performance (global cognition [ACE-III] and executive function [FAB]), reduced mobility, lower activity levels and lower quality of life.

Table 2

Baseline characteristics of 293 cognitively impaired older people divided into four groups (vigorous, anxious, unaware, aware) based on physiological fall risk (PPA score) and perceived fall risk (Icon-FES score)

Baseline characteristics,	Low physiological fall risk		High physiological fall risk
n (%) or mean±SD	(PPA < 2.26; n = 117)		(PPA≥2.26; n = 176)
	Vigorous (a)	Anxious (b)	Unaware (c)	Aware (d)
	(n = 71)	(n = 46)	(n = 55)	(n = 121)
	(Low perceived risk:	(High perceived risk:	(Low perceived risk:	(High perceived risk:
	Icon-FES <16.5)	Icon-FES≥16.5)	Icon-FES <16.5)	Icon-FES≥16.5)
Physiological fall risk
Physiological profile assessment score	1.2±0.7^cd	1.3±0.6^cd	3.7±1.3^ab	4.0±1.5^ab
Perceived fall risk
Iconographical falls efficacy scale	13.2±2.1^bd	20.4±3.9^acd	13.4±2.0^bd	22.9±5.1^abc
Demographics
Age, y	79.7±5.8^cd	80.6±5.9^cd	83.2±5.5^ab	83.9±5.7^ab
Female	24 (34)^d	23 (50)	21 (38)^d	70 (58)^ac
Education, y	13±3^d	12±3^d	12±4	11±4^ab
Indoor walking aid use	2 (3)^d	5 (11)^d	9 (16)^d	50 (41)^abc
Fall in the past year (≥1)	23 (32)^bd	26 (57)^a	23 (42)^d	79 (65)^ac
Multiple falls in the past year (≥2)	11 (15)^d	13 (28)	38 (31)	48 (40)^a
Self-reported comorbidities	2.9±1.6^bd	3.8±1.6^ac	3.2±1.4^bd	3.9±1.8^ac
Quality of life, EQ-5D-5L	0.87±0. 12^bd	0.80±0.16^ad	0.84±0.16^d	0.70±0.20^abc
Cognitive performance
Addenbrooke’s cognitive examination-III	71±13^cd	71±15^cd	58±20^ab	58±19^ab
Frontal assessment battery	13.5±3.5^cd	12.8±3.5^cd	11.0±5.1^ab	10.1±4.4^ab
Psychological performance
Goldberg anxiety scale > 0	29 (41)^d	27 (59)^c	18 (33)^bd	66 (55)^ac
Geriatric depression scale (15-item)	2.3±2.4^bd	3.3±2.9^ac	2.3±1.9^bd	3.4±3.0^ac
Short physical performance battery	9.9±1.8^bcd	8.9±2.3^acd	7.5±2.7^abd	5.5±2.6^abc
Incidental and planned exercise questionnaire,	22.6±14.0^cd	21.5±14.2^d	15.5±12.8^a	14.6±12.9^ab
h/week

Lower scores indicate poorer status or performance for EQ-5D-5L, Addenbrooke’s Cognitive Examination III (/100), Frontal Assessment Battery (/18), Short Physical Performance Battery (/12) and Incidental and Planned Exercise Questionnaire. Higher scores indicate poorer performance for the Physiological Profile Assessment (PPA), Iconographical Falls Efficacy scale (Icon-FES; score range 10 to 40), Goldberg Anxiety Scale and 15-item Geriatric Depression Scale. Self-reported comorbidities = stroke, transient ischemic attack, heart disease, hypertension, diabetes, arthritis, osteoporosis, lung disease, thyroid disease, cancer, dementia, sleep apnea, and depression. Between-group contrasts were made using Generalized Linear Models with robust estimates, cognitive measures were adjusted for age, sex and education, all other variables (except for age, sex, and education) were adjusted for age and sex: ^aSignificantly (p < 0.05) different from the vigorous group, (a) also shown in column header to identify this group. ^bSignificantly different from the anxious group, (b) also shown in column header to identify this group. ^cSignificantly different from the unaware group, (c) also shown in column header to identify this group. ^dSignificantly different from the aware group, (d) also shown in column header to identify this group.

Fall rate by group classification

The median follow-up days for the four groups was 365 days (IQR 365-365) and there were no between-group differences in follow-up days (p = 0.900 overall, p = 0.494–0.923 for pairwise comparisons). Thirty-six (51%) in the vigorous, 25 (54%) in the anxious, 36 (66%) in the unaware and 83 (69%) in the aware group reported one or more falls during follow-up. The proportion of participants experiencing multiple falls during follow-up is presented by group in Fig. 1. Unadjusted fall rates per 365 person-days are presented in Table 3. While adjusting for intervention/control group allocation, age and sex, the anxious, unaware and aware groups all had significantly higher fall rates than the vigorous group (Table 3). The 12-month adjusted fall rates among the anxious, unaware and aware groups did not differ significantly.

Table 3

Fall rate per 365-days and incidence rate ratio of falls by group (vigorous, anxious, unaware, aware)

	Low physiological fall risk		High physiological fall risk
	(PPA < 2.26; n = 117)		(PPA≥2.26; n = 176)
	Vigorous	Anxious	Unaware	Aware
	(n = 71)	(n = 46)	(n = 55)	(n = 121)
	(Low perceived risk:	(High perceived risk:	(Low perceived risk:	(High perceived risk:
	Icon-FES <16.5)	Icon-FES≥16.5)	Icon-FES <16.5)	Icon-FES≥16.5)
Unadjusted fall rate per 365-days (95% CI)	0.96 (0.76, 1.22)	1.69 (1.35, 2.12)	1.94 (1.60, 2.35)	2.40 (2.14, 2.69)
Incidence rate ratio (95% CI) ^ab	ref	1.70 (1.02, 2.84)	2.00 (1.22, 3.26)	2.53 (1.67, 3.84)

^aAdjusted for group allocation, age and sex. ^bOffset = follow-up days.

DISCUSSION

Our findings show that almost a third of community-dwelling cognitively impaired older people either underestimated (unaware group) or overestimated (anxious group) their fall risk. Our findings further revealed contrasting fall rates and risk factor profiles among the four “perceived vs. objective” fall risk groups. We found the anxious, unaware, and aware groups all had significantly higher fall rates than the vigorous group. Compared with the vigorous group: the anxious group had higher depression scores, reduced mobility and poorer quality of life; the unaware group had impaired global cognition and executive function, reduced mobility and lower physical activity levels; and the aware group had an increased prevalence of multiple physical and cognitive risk factors for falls: more depressive symptoms, greater anxiety, poorer cognitive performance, reduced mobility, lower activity levels and lower quality of life. Our five specific hypotheses relating to the contrasting characteristics of the four “perceived vs. objective” fall risk groups are discussed below.

Our first hypothesis was that many participants would not appropriately align their perceived and physiological fall risk. We found that over one third of participants misaligned their perceived and physiological fall risk; this proportion was similar to a previous study of cognitively healthy older people and US public health care beneficiaries who had fallen in the past year,11,31, 11,31 and notably lower than a study in community-dwelling older Thai people, people with multiple sclerosis and studies in hospitalized older people including one sample with CI.9,10,32,33 , 9,10,32,33 A few differences may explain the variance in misalignment rates and the findings of the current study. It is possible that by providing visual images of fall risk scenarios, the Icon-FES (as used in this study) better enabled our participants, particularly when compared to the Hauer et al. study involving hospitalized people with CI, to appropriately rate their perceived fall risk than the FESI that provides short written descriptors.9,10,32,33 , 9,10,32,33 It is also possible that participants in the previous studies had elevated perceived fall risk due to their recent falls (e.g. in Hauer et al. 59% with≥1 injurious fall or≥2 falls in the past year; Gunn et al. 64% in the past year) and reduced mobility associated with their need for hospital/rehabilitation care.9,10,32 , 9,10,32

Our second hypothesis was that participants with either a high physiological or perceived fall risk would have an increased rate of falls and that these risks would be additive was partially supported. We found that when adjusting for confounders, the anxious, unaware and aware groups all had significantly higher fall rates than the vigorous group, but that the adjusted fall rates among the anxious, unaware and aware groups did not differ significantly. This indicates that both high physiological and perceived fall risk are sufficient to increase the incidence of falls. Similar patterns, although with varying incidence rates, were also seen using retrospective falls in a Thai population, in people with MS, in people with CI receiving rehabilitation care and US public health care beneficiaries who had fallen in past year.9,10,31,33 , 9,10,31,33 In contrast, in community-dwelling older people without CI, the pattern of falls differed in that 20% of the vigorous group were classified as fallers, 39% of the anxious group, 34% of the stoic/unaware/fearless group and 41% of the aware/realistic group. However, similar conclusions can be drawn, regarding both perceived and physiological fall risk increasing falls when contrasted with the vigorousgroup.

Our finding that compared to the vigorous group, the anxious group had more depressive symptoms, reduced mobility and poorer quality of life is in line with our third hypothesis and similar to the findings in cognitively healthy people. 11 While it is not possible to tease out causal pathways due to the cross-sectional nature of the baseline data, these findings suggest that an elevated perceived risk of falls or excessive fear form part of a vicious cycle that involves depression, anxiety and mobility impairment that leads to not only falls but also to poor quality of life.34,35, 34,35 This is further supported by the differences identified between the aware and unaware groups, where the aware group had more symptoms of anxiety and depression and poorer quality of life than the unaware group. These differences in quality of life scores are important because low quality of life has been associated with higher mortality and other negative health outcomes.36,37, 36,37

In line with our fourth hypothesis, those with an inadequate concern about falling (the unaware group) had impaired executive function. In addition, this group also had poorer global cognition, fewer symptoms of anxiety and depression, reduced mobility and lower physical activity levels. We anticipated, based on previous research demonstrating that executive function is associated with greater reach judgement errors and falls in people with CI, that participants who are unaware of their fall risk may take unnecessary risks and/or have poor judgement in carrying out activities of daily living that would increase their propensity to fall.6,8, 6,8 However, the unaware group’s fall rate, although higher than the anxious group and lower than the aware group, was only significantly higher than the vigorous group, indicating that in these groups stratified by objective and perceived fall risk, poorer executive function is not further impacting fall risk. In previous research involving people with dementia, reaction time and postural sway, both components of the PPA (our objective fall risk measure), mediated the relationship between executive function and falls. 6 This perhaps explains why executive function is less impactful in our unaware group. Of note and perhaps a manifestation of the group’s lack of insight into their risk of falling, indoor walking aid use was significantly lower in the unaware group compared with the aware group. Alternatively, the lower use of walking aids in the unaware group may indicate better mobility compared with their aware counterparts, as is reflected by their SPPB scores.

Our final hypothesis was that those with both high physiological and perceived fall risk would have multiple physical and cognitive risk factors for falls. We found that our aware group had more depressive symptoms and greater anxiety when compared to the vigorous and unaware groups, poorer cognitive performance (global cognition and executive function) and lower activity levels when compared to the vigorous and anxious groups and reduced mobility and lower quality of life when compared to the vigorous, anxious and unaware groups. Some of these characteristics are consistent with previous research, e.g., more depressive symptoms,10,11,31 , 10,11,31 lower quality of life, 29 reduced mobility, 10 and lower activity levels, 11 with many of these characteristics evaluated by a limited number of studies.

Clinical implications

Our findings provide insight into why older people with CI fall and assist in tailoring fall prevention for this group. They highlight the importance of considering both physiological and perceived fall risk when evaluating fall risk in people with CI, as both were associated with elevated fall risk when compared to the vigorous group. Interventions should focus on implementing strategies to alleviate physical impairments and manage psychological symptoms (concern about falls, anxiety, and depression), tailored to the individual’s needs. Increasing physical activity in the groups with high physiological fall risk should be undertaken cautiously, and interventions to address their identified physical impairments should be undertaken as a priority. Concerningly, in the aware group, who make up 41% of the cohort, 69% experienced falls and nearly half experienced multiple falls during follow-up. In the unaware group, this was only marginally better with 66% experiencing falls during follow-up. More research is needed to understand the best way to prevent falls in these high-risk groups that made up 60% of the cohort, as evidence so far tends to indicate that falls can be prevented in community-dwelling people with dementia and better physical function.14,38, 14,38

Strengths and limitations

Strengths of this study include the inclusion of a broad range of physical, psychological, and neuropsychological measures, the assistance provided by caregivers in providing the assessment and falls information, and the relatively large sample. We acknowledge our findings should be interpreted while considering some limitations. First, we used the icon-FES as our measure of perceived fall risk. This scale measures concerns about falling (i.e., not only a person’s perception of their risk of falling but also their feared consequences of a fall). It is possible that a measure of balance confidence/falls efficacy (i.e., the Activities-specific and Balance Confidence scale [ABC] or Falls Efficacy Scale etc.39,40, 39,40) that measures how confident a person is in performing activities without losing their balance or falling would have provided a purer measure of perception of participants’ fall risk, and therefore further insight into perceived and actual fall risk disparities. However, any changes in our findings may be marginal as ABC and icon-FES scores have been reported to correlate highly (i.e., –0.80 to –0.89).41,42, 41,42 Second, while the study used validated assessment tools to assess physiological and perceived fall risk, they do not account for all cognitive, physical and affective fall risk factors and do not assess all aspects of risk-taking behavior. To some extent, this is demonstrated by SPPB performance, whereby the anxious group had significantly poorer performance (lower scores) than the vigorous group and the unaware group had significantly better performance than the aware group. Future research should also validate the PPA and Icon-FES cut points derived in the current sample with CI in external samples.

Conclusions

Fall rates were increased in participants who had elevated perceived and/or physiological fall risk and contrasting fall risk profiles were evident in those who under- and over-estimated their fall risk. Documenting these characteristics may improve our understanding of fall risk and guide fall prevention strategies in older people with CI.

AUTHOR CONTRIBUTIONS

Morag E. Taylor (Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing; Student supervision); Luuk Kerckhaert (Conceptualization; Data curation; Formal analysis; Investigation; Writing – original draft; Writing – review & editing); Jacqueline C.T. Close (Conceptualization; Funding acquisition; Investigation; Project administration; Supervision; Writing – review & editing); Kimberley S. van Schooten (Conceptualization; Formal analysis; Investigation; Writing – original draft; Writing – review & editing; Student supervision); Stephen R. Lord (Conceptualization; Funding acquisition; Investigation; Supervision; Writing – original draft; Writing – review & editing).

Footnotes

ACKNOWLEDGMENTS

We would like to thank the participants and their families for the contribution to this research. We would like to thank Dr Roel Weijer for making the introductions for this project.

FUNDING

The iFOCIS trial was supported by the Australian National Health and Medical Research Council (NHMRC) reference number 1060191. SRL holds a NHMRC Investigator Grant Fellowship. KSvS holds a Human Frontier Science Program Fellowship (LT001080/2017). MET’s salary is partially funded by the Centre for Research Excellence in the Prevention of Fall-related Injuries (NHMRC). The funders did not have a role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

CONFLICT OF INTEREST

The Physiological Profile Assessment (FallScreen) is commercially available through Neuroscience Research Australia. Morag Taylor is an Associate Editor of this journal but was not involved in the peer-review process of this article nor had access to any information regarding its peer-review.

DATA AVAILABILITY

Ethical approval would be needed to share data as permission was not sought at the time of consent. (m.taylor@neura.edu.au).

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