Using a nationally representative sample of community-dwelling older adults, this study examined the independent effects of fear of falling on development of activity limitations adjusting for covariates and previous falls, and vice versa. The prevalence rates of previous falls and fear of falling in Round 1 of this study were 18% and 9%, respectively. These rates were lower than those of previous studies in which fall rates ranged from 29–45% and fear of falling rates ranged from 20–60% [23–28]. This is expected as we excluded participants with limited activities in Round 1 for the study purpose.
As we hypothesized, fear of falling may have a greater impact on daily activity limitations than previous falls. This hypothesis was confirmed by results from the adjusted GEE models. Delbaere et al. showed that previous falls do not directly lead to changes in daily behaviors, but effective-cognitive variables associated with falls, such as a concern about falling during activity, can mediate this process . Further their modelling supported that catastrophic fear of falling, such as fear of hip fracture or institutionalization, can lead to activity and mobility restriction without having had a fall. Thus, fear of falling as an affective-cognitive variable, whether a worry about falls or a fear of falling, is an important influencing factor leading to changes in daily activities. Another study has shown that even without previous falls, there was still a strong relationship between fear of falling and limited daily activities . Excessive fear of falling can have a major impact on physical performance and lead to poor balance [30, 31]. In some older adults with impaired mobility, fear of falling may result in ADLs impairments, depression, and disability [14, 15, 32, 33]. On this basis, our research adds to previous research findings, recognizing that fear of falling may be more important than previous falls in limiting the daily activities of older adults. Studies have shown that fear of falling can be alleviated by improving cognitive behavior and daily activities in older adults [34, 35]. For older adults who have fear of falling, lifestyle changes are recommended to achieve effective intervention and reduce the incidence of falls .
Our results showed that fear of falling had a significant impact on limited self-care activities, but previous falls did not. Self-care activities include eating, bathing, toileting, and dressing, which are considered to be ADLs . Hoang al. pointed out that there is a strong negative correlation between the score of ADLs and fear of falling . The lower the ability to perform daily activities, the less secure people felt about their physical abilities, and the more likely to experience fear of falling. Similarly, our study shows that fear of falling has a greater impact on self-care activities in older adults. One explanation is that fear of falling can lead to activity limitations for older people, which in turn leads to a decline in activity capacity, and eventually have the consequences of being afraid to go out. Staying at home for a long time in older adults can lead to a significant decrease in their daily activities, which leads to a decrease in physical ability and confidence in self-care activities . The association between fear of falling and self-care activities may contribute to the development of prevention strategies to reduce the daily activity limitations of older adults, and improving their confidence in daily activities.
One strength of this study is that we used a nationally representative longitudinal dataset that allows us to examine the temporal effects of previous falls and fear of falling on the development of activity limitations. A comprehensive list of covariates were assessed and adjusted for in this study and this allows to provide relatively robust findings. However, there are also some limitations to this study. First, fear of falling was measured by a single item asking if they were worried about falling for which the reliability and validity are still unknown. However, this measure has been widely used in cohort studies and showed consistent findings on health outcomes. Second, recall bias might occur when asking participants about fall experience. We used previous falls as a binary variable instead of a continuous variable, which may lessen the threat to the robustness of our findings. Third, our sample is relatively small after excluding those who missed for follow-ups and had activity limitations in Round 1, therefore, our study results mainly apply to predominantly healthy and physically active older adults. Yet, fear of falling could have a less relevant influence on daily activities in subjects presenting with a higher number and severity of comorbidities, which may have a greater impact than fear of falling on individuals' autonomy.