Fragility, fear of falling, physical activity and falls among older persons: Some theoretical considerations to interpret mediation

doi:10.1016/j.ypmed.2008.01.016

Preventive Medicine

Volume 46, Issue 6, June 2008, Pages 612-614

https://doi.org/10.1016/j.ypmed.2008.01.016 Get rights and content

Abstract

Background

In their letters to the editor, Lacherez et al. [Lacherez, P.F., Wood, J.M., Kerr, G.K., 2007. Does activity level mediate or suppress the association between fear of falling and falls? Prev. Med. 31; (Electronic publication ahead of print)] and Hafeman and Schwartz [Hafeman, D., Schwartz, S., 2007. Assessing mediation: The necessity of theoretical considerations. Prev. Med. 26; (Electronic publication ahead of print)] questioned the correctness of using the term ‘mediation’ in our paper [Wijlhuizen, G.J., Jong, R. de, Hopman-Rock, M., 2007. Older persons afraid of falling reduce physical activity to prevent outdoor falls. Prev. Med. 44, 260–264.]. In this paper, we concluded that (outdoor) Physical activity mediates the relationship between Fear of falling and outdoor Falls. We investigated whether the term ‘inconsistent mediation’ might be a more appropriate term to use in this context.

Methods

Based on literature, we describe the relationship between fear of falling, physical activity, and falls within a causal model.

Results

Two causal pathways between Fear and Falls exist, with the causal pathway going from Fear of falling via Physical activity to Falls counteracting (is inconsistent with) the causal pathway going from Fear of falling via Hesitancy to Falls.

Conclusion

The term ‘inconsistent mediation’ might be more appropriate to describe the causal relationships between Fear of falling, Falls, and Physical activity.

Introduction

In their letters to the editor, Lacherez et al. (2008) and Hafeman and Schwartz (2008) questioned the correctness of using the term ‘mediation’ in our paper (Wijlhuizen et al., 2007). In this paper, we concluded that (outdoor) physical activity mediates the relationship between fear of falling and outdoor falls. Both letters suggested that it would be more appropriate to use the term ‘suppression’, and expressed the need for a theoretical basis for the terminology used to describe this relationship. Lacherez et al. (2008) specifically mentioned the lack of evidence for assuming a causal relationship between fear of falling and falls.

The purpose of this letter is to describe the relationship between fear of falling, physical activity, and falls within a causal model, and investigate whether the term ‘inconsistent mediation’ might be a more appropriate term to use in this context.

Section snippets

Theoretical considerations: a hypothesized causal model of falls

People fall when it becomes too difficult for them to control their balance, that is, when the demands on balance control (e.g., exposure to indoor and outdoor environmental influences) at a certain point in time become greater than their capabilities (body function) to control balance (Wijlhuizen et al., 2007). For the current purpose only the following three factors which theoretically independently increase the risk of falling (Fig. 1) are included in the causal model. Other factors related

Conclusion

In this model (Fig. 2), the reduction in physical activity (the indirect pathway) due to fear suppresses the counteracting effect of a combination of ‘Fragility’ and ‘Hesitancy’. Two causal pathways between fear and falls are assumed, with the causal pathway going from Fear of falling via Physical activity to Falls counteracting (is inconsistent with) the causal pathway going from Fear of falling via Hesitancy to Falls. These causal paths operate within a relative small time frame, because in

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Older adults who are afraid or worried about falling have limitations in ADL and IADL and take more time to execute the tasks, showing a more careful pattern of movement (Lavedán et al., 2018). Wijlhuizen et al. (2008) described this event as a “slow mode of balance control” where the individual enters a state of hesitation during the task execution, which frequently determines the movement speed and quality. The FSST could not discriminate between non-frail and pre-frail older adults while adjusting for age.
To identify the usefulness of Four Square Step Test (FSST) in discriminating balance control in non-frail, pre-frail, and frail community-dwelling older adults.
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Cross- sectional study conducted in specialized outpatient geriatric care settings. One hundred and fifty-six consecutive patients without severe cognitive impairment and who could walk were included. We classified participants as non-frail, pre-frail, and frail using the Fried frailty phenotype. FSST was assessed by measuring the time (seconds) participants took to step into each of the four quadrants formed by four sticks arranged on the floor (clockwise and counterclockwise as quickly as possible) without knocking the sticks.
Of all participants, 36% were non-frail, 37% pre-frail, and 27% frail. Frail and pre-frail older adults took significantly more time to execute the FSST (23.1, 95% CI 18.8–27.4; p < 0.001 and 17.9; 95% CI 14.3–21.5; p = 0.003, respectively) compared to with non-frail (11.6, 95% CI 11.0–12.3). Frail and pre-frail older adults were not significantly different (p = 0.058). Most participants who failed to perform the test were frail (n = 15; 36%), followed by pre-frail (n = 7; 12%) and non-frail (n = 2; 3.5%).
Our results showed that pre-frail and frail older adults had poorer performance in FSST when compared to non-frail older adults. It is important to use instruments that allow early identification, especially of pre-frail older adults, as they are still at the beginning of the frailty process when the control and reversal of adverse outcomes are promising. Failing the test could be a sign of mobility loss, particularly due to balance and cognitive problems. Clinical practitioners could use the test to compare individual's performance attending rehabilitation programs over different periods of time.
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It was an unexpected finding that PA and SB were associated with fear of falling but not falls or fractures because we hypothesized that these outcomes would be similarly associated. However, this finding underscores the importance of understanding engagement in PA (or lack thereof) and SB as health behaviours to which fear of falling poses a psychological barrier [72,73]. Fear of falling is a common psychological symptom and can be the consequence of a fall and associated with poor quality of life independent of the actual number of falls [74].
Higher physical activity (PA) and lower sedentary behaviour (SB) are associated with better muscle strength, balance, and functional ability, which are imperative for avoiding falls. This systematic review aimed to describe the association between objectively measured PA and SB with falls, fear of falling, and fractures.
Six databases were searched from inception to July 21, 2020 for articles reporting the association of objectively measured PA/SB with falls, fear of falling, and/or fractures in community-dwelling older adults ≥60 years old. Results were synthesized in effect-direction heat maps and albatross plots expressed as Pearson's correlation coefficients (R).
A total of 43 articles were included, representing 27,629 (range 26–5545) community-dwelling older adults (mean [SD] age 76.6 [8.4] years, 47% female). Longitudinal associations were reported in 13 articles and cross-sectional associations in 30. Falls were reported in 11 articles, fear of falling in 18 and fractures in 2. Higher PA and lower SB were associated with less fear of falling (median [interquartile range] Rs = steps: -0.214 [0.249; -0.148], total PA: -0.240 [0.267; -0.144], and moderate-to-vigorous PA: -0.180 [0.382; -0.121]), but these associations did not extend to falls or fractures, which showed inconsistent effect directions.
Fear of falling is associated with less engagement in PA and more SB, thus indicating that it is a psychological barrier to an active lifestyle. Varying effect directions for associations between PA and SB with falls and fractures may provide evidence for non-linear associations and require further research considering details of the fall or fracture incident.
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2016, Cities
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Fear of injury due to falling off lowered the physical activity level of youngsters and elders (Bruce, Devine, & Prince, 2002; Mowat, Wang, Pickett, & Brison, 1998; Wijlhuizen, de Jong, & Hopman-Rock, 2007). For example, Wijlhuizen, Chorus, and Hopman-Rock (2008) stated that elders would withdraw from situations such as climbing stairs or walking on uneven pavements due to the difficulty in controlling balance and fear of falling. Lack of high quality natural and built environment may induce a feeling of discomfort or unpleasantness and eventually become barriers for individuals.
The growing worldwide awareness of the significant impacts of physical activities on physical and physiological health has aroused great interest in the role of the physical built environment plays in walking and cycling activities. This comprehensive review shows how specific details of the built environment enhance people's walking and cycling. This was accomplished through identifying the barriers to walking and cycling activities as well as the general and specific characteristics of the major physical built environment attributes within a residential neighborhood that can help overcome these barriers and enhance the walking and cycling activity levels. Also the effectiveness of some individual attributes was also compared. Of particular value of this study is that its structure and level of details of information laid out in this review can facilitate building designers and neighborhood planners in creating a supportive environment within residential neighborhoods.
Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis
2013, Archives of Gerontology and Geriatrics
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History of falls and use of walking aids, were associated with an approximately two-threefold risk of falling. From a conceptual point of view (Wijlhuizen, Chorus, & Hopman-Rock, 2008) history of falls may mask the influence of factors causing these earlier falls. History of falling, thus, is not a causal factor, but merely an indicator of an underlying problem, e.g. impaired balance, which is the real causal agent.
This is a systematic review and meta-analysis aimed at providing a comprehensive and quantitative review of risk factors for falls in older people in nursing homes and hospitals. Using MEDLINE, we searched for prospective studies investigating risk factors for falls in nursing home residents (NHR) and older hospital inpatients (HI). When there were at least 3 studies investigating a factor in a comparable way in a specific setting, we computed the pooled odds ratio (OR) using random effect models. Twenty-four studies met the inclusion criteria. Eighteen risk factors for NHR and six for HI were considered, including socio-demographic, mobility, sensory, medical factors, and medication use. For NHR, the strongest associations were with history of falls (OR = 3.06), walking aid use (OR = 2.08) and moderate disability (OR = 2.08). For HI, the strongest association was found for history of falls (OR = 2.85). No association emerged with age in NHR (OR = 1.00), while the OR for a 5 years increase in age of HI was 1.04. Female sex was, if anything, associated with a decreased risk. A few other medical conditions and medications were also associated with a moderately increased risk. For some important factors (e.g. balance and muscle weakness), a summary estimate was not computed because the measures used in various studies were not comparable. Falls in older people in nursing homes and hospitals have multifactorial etiology. History of falls, use of walking aids and disability are strong predictors of future falls.
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2010, Preventive Medicine
Citation Excerpt :
According to Skelton (2001) and Jørstad-Stein et al. (2005), while exercise has a beneficial effect on a person's balance, it can also be considered a general measure of that person's exposure to hazardous situations that put demands on that person's ability to control balance. In this respect, Wijlhuizen et al. (2007) found that outdoor falls occurred more often among persons who walked and bicycled more frequently, and that falls at home occurred most frequently at those times of the day that persons are most physically active (Wijlhuizen et al., 2008a,b). In addition, Lawton et al. (2009) found more falls and injuries among an intervention group which was encouraged to become more physically active, and Ebrahim et al. (1997) reported that brisk walking may increase the risk of falls.
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The fear of falling reported by participants reinforces the view that a fall involving traumatic injury can be a physically and emotionally debilitating experience. Older adults who perceive at risk of falling outside the home adjust their behavior to reduce their exposure to activities that may lead to further falls30 and negatively decrease their level of physical activity.31 This restriction can lead to in-home confinement,32 increased dependency and increased risk of future falls.33
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CommentaryFragility, fear of falling, physical activity and falls among older persons: Some theoretical considerations to interpret mediation

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Theoretical considerations: a hypothesized causal model of falls

Conclusion

Prev. Med.

Prev. Med.

Gait Posture

Hum. Mov. Sci.

Prev. Med.

The Physical Performance Test as a predictor of frequent fallers: a prospective community-based cohort study

Clin. Rehabil.

Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention

J. Am. Geriatr. Soc.

Commentary
Fragility, fear of falling, physical activity and falls among older persons: Some theoretical considerations to interpret mediation