Association between Fear of Falling (FOF) and all-cause mortality

doi:10.1016/j.archger.2020.104017

Archives of Gerontology and Geriatrics

Volume 88, May–June 2020, 104017

https://doi.org/10.1016/j.archger.2020.104017 Get rights and content

Highlights

•
This study showed a significant relationship between fear of falling and mortality (HR = 1.861, p < 0.001).
•
For males, the association between fear of falling and mortality was statistically significant (HR = 1.943, p < 0.001).
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For females, the association between fear of falling and mortality was statistically significant (HR = 1.796, p < 0.001).

Abstract

Objective

To longitudinally investigate the effect of fear of falling on all-cause mortality.

Methods

Data from the KLoSA from 2006 to 2016 was used and 10,219 middle aged and older adults were included for analysis. The association between fear of falling and all-cause mortality was analyzed by Cox proportional hazard model with controlling for demographic characteristics, number of chronic conditions, depressive symptoms and fall experience.

Results

Of the 10,219 individuals at baseline 2006, those with fall experience for 2 years were 411 participants (4.2 %) and about 18.5 % of these participants (n: 76) died. In terms of FOF, 14.83 % of participants (1,515/10,219) reported serious fear for falling. Adjusted hazard ratio (HR) of all-cause mortality shows those who are very afraid of falling had a significantly increased risk of mortality compared with those without a FOF (HR 1.861, 95 % CI 1.589–2.179, P-value:.0001).

Conclusion

This study shows a statistically significant association between fear of falling and all-cause mortality in a Korean middle aged and aged population.

Introduction

Fear of falling (FOF) is a well-known condition in older adults, and in previous studies, the prevalence ranged from as low as 20 % to as high as 85 %, depending on study methods, for those residing in community settings (Hausdorff, Rios, & Edelberg, 2001; Mane, Sanjana, Patil, & Sriniwas, 2014; van Hout et al., 2004; Zijlstra et al., 2007). Furthermore, about 20%–30% of older adults with FOF will experience moderate to severe injuries, require hospitalization and increased risk of mortality (Alexander, Rivara, & Wolf, 1992).

Originally, FOF was considered as a psychological condition named ptophobia, which was also referred to as ‘post-fall syndrome’, resulting from a trauma of falling (Bhala, O’Donnell, & Thoppil, 1982). In the 1980’s, Murphy and Isaacs noticed that various health outcomes occurred after a fall, and since then, FOF has started to be considered as a major health problem for older adults (Legters, 2002). More importantly, subsequent studies found that FOF did not necessarily follow an experience of falling (Friedman, Munoz, West, Rubin, & Fried, 2002; Jorstad, Hauer, Becker, Lamb, & ProFa, 2005; Tinetti, Speechley, & Ginter, 1988), but the data supporting this direction of association were mixed.

Gait changes, activity restriction, and deconditioning are some of the known potential mediators of FOF, and this was shown in previous studies. For instance, Maki et al. (Maki, 1997) showed an association between FOF and gait changes. In terms of gait changes, decreased stride length, speed, clinical gait scores, and increased double stance time, as well as stride width were shown to be important. Activity restriction was also indicated as an important factor, secondary to FOF (Howland et al., 1998; Nevitt, Cummings, Kidd, & Black, 1989), that could lead to functional declines, deconditioning, social isolation, falls, and institutionalization (Lachman et al., 1998).

Even though, FOF is widely experienced among older adults, the mechanisms linking it to injury has not been clearly investigated (Naraynsingh, Sammy, Paul, & Nunes, 2015; Yeung et al., 2008). Previous studies have focused on the actual falling experience, but le so on FOF (Sampalis et al., 2009; Sterling, O’Connor, & Bonadies, 2001). In previous studies, commonly evaluated factors in association with FOF were age, gender (Friedman et al., 2002; Zijlstra et al., 2007), history of previous falls (Mane et al., 2014; Zijlstra et al., 2007), depression (Mane et al., 2014), and poor subjective health(Zijlstra et al., 2007). Additionally, adverse outcomes such as development of deconditioning (Zijlstra et al., 2007), reduced social interactions, (Scheffer, Schuurmans, van Dijk, van der Hooft, & de Rooij, 2008) subsequent falls (Friedman et al., 2002) and a poor quality of life (Scheffer et al., 2008), were related to FOF. Despite previous findings, most studies were cross-sectional in nature, and follow-up studies investigating the FOF in regards to activities and functional abilities were scarce, warranting the necessity for additional studies in the field.

Up to now, the evidence was not sufficient to declare a long-term mortality outcome of older adults with FOF. Considering the aging societies around the world, it could be assumed that the prevalence of falls will increase. The aim of this study was to investigate the relationship between FOF and all-cause mortality among adults aged 45 years and older living in the community using longitudinal data and hypothesized that fear of falling is a significant risk factor of all-cause mortality.

Section snippets

Data source

The data used for the following analyses were derived from the Korean Longitudinal Study of Aging (KLoSA) in 2006, 2008, 2010, 2012, 2014 and 2016, containing data for community-dwelling Koreans 45 years of age and older, and followed up to 2016. Participants were selected randomly using a multistage, stratified probability sampling design to create a nationally representative sample. As per the KLoSA study protocol, trained surveyors collected informed consents from participants and conducted

Fear of falling (FOF) and fall experience for the last 2 years (Chang, Chen, & Chou, 2017)

FOF referred to self-reported data responding to the question “Do you worry too much that you will fall on your own?” Responses were assigned 1 of 3 subcategories: Not at all, a little or very worried.

All-cause mortality

All-cause mortality during the time interval from year 2006 to the end of follow-up was the main outcome of the study. Anonymous ID were assigned and then linked to death certificates data over a maximum follow-up period of 10 years.

Control variable

In terms of factors that associated with all-cause mortality in middle-aged and aged people, age (45–54, 55–64, 65–74, ≥75), education level (≤ Elementary school, Middle school, high school, ≥ College), gender (male or female), residential region (urban or rural), marital status (married or single), labor (yes or no), national health insurance (health insurance or medical aid), smoking status (never, former smoker or smoker), alcohol use (never, former drinker or drinker), number of chronic

Statistical analysis

In this study, using 2006 as the baseline year and considering the follow-up period until 2016 we employed chi-square test and cox proportional hazards model. To examine the impact of fear of falling on all-cause mortality adjusted hazard ratio (HR) and stratification analysis by sex, cox proportional hazard model was calculated. SAS statistical software package, version 9.4 (SAS Institute, Inc., Cary, NC, USA) was used in all analyses. All statistical tests were two-tailed, with the null

Sample characteristics

Table 1 shows the baseline characteristics of participants. As shown in Table 1, of the 10,219 individuals at baseline 2006, those with fall experience for 2 years were 411 participants (4.2 %) and about 18.5 % of these participants (n: 76) died during the follow-up period. In terms of FOF, 14.83 % of participants (1,515/10,219) reported serious fear for falling and about 29.8 % of these participants (n: 451) died during the follow-up period. Those with a little fear for falling composed 30.57

Discussion

In this population-based follow-up study of 10,219 middle aged and older adults at baseline, our primary purpose was to investigate whether fear of falling was responsible for all-cause mortality rate after adjusting for fall experience for the last 2 years as well as covariates including socioeconomic status, health risk and behavior factors using nationally representative database in South Korea. In this study, there were 4 major findings. First, the overall prevalence of FOF in this study

Conclusion

In conclusion, our findings in the present study suggest that FOF is a significant risk for all-cause mortality, the predictors of developing FOF may have more-obvious implications for primary prevention strategies, efforts to reduce further fall risk (Lord, Ward, Williams, & Strudwick, 1995) may in turn reduce the risk of developing FOF. Further research is needed to identify factors related to FOF and should be carried out to clarify the mechanisms between FOF and mortality.

Authors’ contributions

Kim JH designed the study, researched data, performed statistical analyses and wrote the manuscript. Kim JH contributed to the discussion and reviewed and edited the manuscript. Kim JH is the guarantor of this work and as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Declaration of Competing Interest

No author has any financial or other conflict of interest to declare.

Acknowledgements

None.

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This study aims to examine the bidirectional association between fear of falling (FOF) and frailty among community-dwelling older adults. Longitudinal analyses were conducted over a representative sample of 5,829 community-dwelling individuals ≥65 years from the National Health and Aging Trends Study. FOF was ascertained by asking participants whether they worried about falling and if this worry ever limited their activities. Frailty status was assessed based on frailty phenotype. At baseline, 71.4% of participants reported no FOF, 16.7% reported FOF without fear-related activity restriction (FAR), and 11.9% reported FOF with FAR. The proportion of robust, pre-frail and frail respondents at baseline was 36.1%, 48.7% and 15.2%, respectively. Multinomial logistic regression models indicated FOF with and without FAR predicted pre-frailty and frailty. Pre-frailty predicted FOF with and without FAR, while frailty only predicted FOF with FAR. Tailored intervention strategies are needed for preventing adverse outcomes of FOF and frailty among the older population.
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As a potential consequence of falls, FOF is used as a general term for fall-related psychological concerns such as specific fall-related fear, fall-related self-efficacy, and balance confidence, all of which are highly related.2 FOF is associated with many adverse outcomes, such as decreased physical function, more frequent falls, more severe frailty, and rising mortality rates.3–6 In recent years, FOF has become among the most important and potentially modifiable threats to autonomy in older adults.7
This cross-sectional study aimed to examine the associations of objectively-measured physical activity (PA) and sedentary behavior (SB) patterns with fear of falling (FOF) in Chinese community-dwelling older women. Data from Physical Activity and Health in Older Women Study were analyzed for 1101 older women aged 60 to 70. Variables were demographics, objectively-measured PA, SB and FOF. Logistic regressions were conducted. All SB variables, light-intensity PA variable and bouted moderate-to-vigorous intensity PA (MVPA) were not associated with FOF. Total MVPA, sporadic MVPA and steps were independently associated with FOF. Multivariable-adjusted ORs in fully-adjusted models were 0.61, 0.59; 0.73, 0.62; 0.72, 0.59 for increasing tertiles of total MVPA time, sporadic MVPA time, and steps per day, respectively. The current finding which enables encourages PA in older women group could be complemented to maximize the overall level of potential public healthcare gains especially in community dwelling older population.
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In addition, FOF is more than just a by-product of falls. FOF can happen in persons without a falls history and causes poor physical performance, mobility deficits, and increased mortality [5–7]. Although the importance of addressing FOF is recognized in the research literature, assessments of FOF are remarkably limited due to the lack of comparability among various measurements.
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(1) Are 360º roller coaster videos effective to induce FOF? And (2) Which COP parameter(s) is/are feasible to quantify FOF?
Nineteen young, healthy adults (24 ± 2.47 years) were recruited in the present study. Subjects were required to watch three 360º videos: one control video and two roller coaster videos, through virtual reality goggles during standing and sitting. Six trials (3 during standing and 3 during sitting) with video were performed. Subjects were required to rate their FOF on a visual analogue scale after watching each video. COP mean power frequency, COP root mean square, and COP range were measured. The Friedman test was used to assess differences in COP parameters under different video conditions, and Spearman’s correlation analysis was used to assess the relationship between FOF and COP parameters.
Similar COP changes were observed in sitting and standing conditions. With increased FOF, participants demonstrated decreased COP mean power frequency and increased COP root mean square in the medial-lateral direction during both sitting and standing.
Our study provided evidence that 360º roller coaster videos are effective tools to induce FOF and change in COP parameters. The relationship between FOF and COP parameters suggests that the measurement of body sway may be an objective way to quantify FOF. More research are needed to solidify the evidence.
Experiences of falling and depression: Results from the Korean Longitudinal Study of Ageing
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Older adults are more vulnerable to falls, as most of the physical and psychological impairments are due to the inevitable aging process (Verma et al., 2016; Yoon et al., 2016). A possible mechanism is that falls could have psychological consequences (e.g., depression, increased fear that result in increased later death(Kim and Bae, 2020), and poor life satisfaction (Arfken et al., 1994). In addition, depression has been reported to precede falls (Kallin et al., 2002).
This study estimates the association between fall experiences during the last two years and risk of depression.
Data from 9,355 subjects of the Korean Longitudinal Study of Ageing from 2006 to 2016 were included with baseline at 2006. To analyze the association between fall experiences during the last two years and depression, a generalized estimating equation (GEE) model and chi-square tests were used.
At baseline 2006, the odds ratio (OR) of depressive symptoms in those with fall experiences was 1.36 times higher (p < .0001) than those with non-fall experience. In those 64 years or younger and 65 years or older, the OR of depressive symptoms in fall experience was 1.45 times higher (p =0.003) and 1.34 times higher (p =0.000) than those with non-fall experience, respectively. In males and females, the OR of depressive symptoms in those with fall experience was 1.47 times higher (p 0.008) and 1.34 times higher (p =0.000) than those with non-fall experience, respectively.
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El objetivo general del estudio es conocer la prevalencia de la preocupación a caer en personas mayores, independientes para la deambulación, que viven en la comunidad, según la versión reducida del FES-I y los factores asociados que influyen en esta preocupación.
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Centro de Salud El Greco (Getafe), Gerencia Asistencial de Atención Primaria de Madrid.
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La prevalencia del MC fue del 42,9% (IC 95%: 35,5-50,2). Los factores asociados al MC en el análisis multivariante final fueron: sexo femenino, vivir solo, alto riesgo de caídas, presencia de fragilidad, uso de hipotensores y lesiones asociadas a caídas previas.
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189 patients ≥ 70 years with a Barthel ≥ 60, independent for walking (walk 45 minutes without help or with a cane). The study was offered to a total of 328 people, of these accepted 217 and rejected 111.
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The prevalence of FOF in older people is high. Primary Care professionals should systematize the screening of this health problem, prioritizing especially in people who present the following risk factors: being a woman, living alone, having a low score on the SPPB (as an indicator of frailty) or presenting a high risk of falls.
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View all citing articles on Scopus

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Association between Fear of Falling (FOF) and all-cause mortality

Highlights

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Data source

Fear of falling (FOF) and fall experience for the last 2 years (Chang, Chen, & Chou, 2017)

All-cause mortality

Control variable

Statistical analysis

Sample characteristics

Discussion

Conclusion

Authors’ contributions

Declaration of Competing Interest

Acknowledgements

Maturitas

Archives of Physical Medicine and Rehabilitation

Experimental Gerontology

Clinics in Geriatric Medicine

Injury

Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women

Circulation

The cost and frequency of hospitalization for fall-related injuries in older adults

American Journal of Public Health

Ptophobia. Phobic fear of falling and its clinical management

Physical Therapy

Falls and fear of falling: Burden, beliefs and behaviours

Age and Ageing

Fear of falling and mortality among community-dwelling older adults in the Shih-Pai study in Taiwan: A longitudinal follow-up study

Geriatrics & Gerontology International

Characteristics associated with fear of falling and activity restriction in south Korean older adults

Journal of Aging and Health

Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study

Age and Ageing

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

Journal of the American Geriatrics Society

Association between anxiety and factors of coagulation and fibrinolysis

Psychotherapy and Psychosomatics

Heart rate variability in depressive and anxiety disorders

American Heart Journal

Phobic anxiety and ischaemic heart disease

British Medical Journal

Covariates of fear of falling and associated activity curtailment

The Gerontologist

Fear of falling among the community-dwelling elderly

Journal of Aging and Health