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