Differences in fear of falling and fall risk indicators among white and black older adults: a cross sectional study

Background Falling among older adults is common and can cause chronic health complications. This study investigated differences between White and Black community-dwelling older adults in fall history, fear of falling, and indicators of fall risk. Methods All assessments and analyses were conducted in a clinical laboratory at Emory University in the Department of General Medicine and Geriatrics on 84 diverse community-dwelling older adults (White, n=37; Black, n=47). Statistical analyses included one-way ANOVA for continuous variables, the Fisher exact test for categorical variables, the Mann-Whitney-Wilcoxon test for ordinal variables, and an ordinal logistic regression model to examine which factors predicted fear of falling. Measures included fall history, fear of falling, and fall risk indicators. The Montreal Cognitive Assessment, Activities-Specific Balance Confidence Score, Gait Speed, Short Form 12 Physical Component Score and Mental Component Score, fear of falling and quality of life rating scales and demographics questionnaires were administered.


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Background Every year, up to 30 percent of adults aged 65 and older fall, which can lead to chronic complications and a decreased quality of life (1). Approximately 2.8 million older adults are admitted annually to an emergency room due to fall-related injuries (2). Research from the Centers for Disease Control and Prevention indicates that after just one fall, older adults develop a fear of falling and perceive a higher risk of falling, which increases risk of falling (2). The National Council on Aging found that older people have increased mortality risk from falls and fall-related injuries (3). In 2016, one in four deaths among people aged 65 or older were from a fall-related injury (3). Death rates from falls and fallrelated injuries were higher for those aged 85 and older. As the percentage of American people over the age of 65 increases, fall incidence and healthcare costs will increase (4).
Several factors are associated with fall risk among older adults. General health appears to be an important factor for both fall risk indicators and fear of falling (5). Older adults who use an assistive device to walk and those with more chronic diseases are at an increased risk for falling (6). Additionally, polypharmacy, the use of multiple prescription medications by a single person to treat one or more conditions, is associated with greater fall risk among older adults (7). Some medications have side effects that increase fall risk.
For example, older adults take more anti-depressants than any other age group, and taking anti-depressant medication is associated with falls. (8,9) Additional factors associated with fall risk include cognitive function, a history of falling. Individuals with cognitive impairments are at an increased risk for falling, (10) and individuals who have fallen in the past are more likely to fall in the future (11).
Socio-demographic factors, including education level, physical activity level, and living alone are also associated with fall risk. Research suggests that increased fall risk is associated with lower education levels, because increased education leads to improved thinking and decision-making about health behaviors (12). Conversely, individuals with lower education levels may not have the opportunity to develop the same skills and behaviors, which could increase risk of falling (12). Evidence also suggests that Caucasian/white groups generally fall more than African American/black groups, (13) despite having on average fewer chronic diseases, (14) higher incomes, and higher educational levels (15). The decreased risk of falling among black populations has been hypothesized to be related to the fact that black older adults are less likely to live alone and that higher rates of motor disabilities combined with lower rates of physical activity among black populations might be protective against falls, as individuals who are less physically active might be less likely to participate in activities where they might fall (13).
In fact, a large nationally representative longitudinal survey of 7,609 community-dwelling participants in the National Health and Aging Trends Study reported blacks had a 30-40% decreased fall risk as compared to whites. However, this phenomenon was not explained by differences in motor disability, physical activity, or living alone (13). Current understanding of differences in socio-demographic factors is insufficient to explain differences in fall risk, particularly in relationship to race.
Despite the morbidity and mortality risks associated with falls among older adults, no research currently exists that examines differences in fall risk indicators and fear of falling between white and black groups.Furthermore, black and minority older adults are historically underrepresented in scientific research; however, including them in research is crucial to a holistic understanding of falling among older adults. If factors that protect older black populations from falling can be better understood, interventions can be created to help decrease fall risk among all older adults. Given that fear of falling is a subjective measure that is associated with several factors that increase actual risk of falling, we were interested in exploring differences in fear of falling by race. Concurrent with previous research, we hypothesized that white older would fall more often than black older adults. Furthermore, we are interested in seeing if fall risk indicators such as an increased use of assistive device, number of prescriptions and comorbidities, number of falls experienced in the past year, and decreased education level would lead to a greater fear of falling. Therefore, due to literature suggesting that black older adults tend to have an increased number of chronic diseases and fall risk indicators, we hypothesized that black older adults would have a greater fear of falling.
The aim of this paper was to add to the current literature, which mostly examines factors associated with fall risk separately between races, by exploring fall risk factors and perceptions among races. A difference in fall rate among races is well-documented, but the reasons for these varying fall rates have yet to yield significant findings. The findings of this study may help elucidate reasons for the well-documented yet little understood differences in fall prevalence among white and black populations.

Methods
Ethics: The Institutional Review Board at Emory University School of Medicine and the Research and Development Committee of the Atlanta VA approved this work under IRB # IRB00060613 and IRB00080676. Participants provided written informed consent before participating. This study includes veteran and non-veteran participants. Veterans were recruited through the VA Informatics and Computing Infrastructure database. Recruitment for non-veteran participants included educational meetings, newsletters and foundation events, physician referrals, word of mouth, and outreach events. Interested individuals provided contact information to make an initial assessment appointment. All paper and electronic data files were coded and de-identified to maintain participant confidentiality.
Design: This cross-sectional study used retrospective secondary data analysis on data collected from participants who participated in two studies conducted between 2013 and Participants: Inclusion criteria for participants (n = 84; 64 women) was age older than 55 years, at least 12 years of education and a MoCA score>16. White participants (n = 37) averaged 69.13 years old (SD = 6.17), while black participants (n = 47) averaged 66.9 years old (SD = 6.17). On average, participants had 15 years of education, three comorbidities, and took three prescription medications. Participants represented diverse socio-economic and educational sectors of the population in metro Atlanta, GA (Table 1). The Activities-Specific Balance Scale (ABC) is a 16-item self-reported measure where participants rate their confidence to maintain their balance during common activities.
In general, how would you rate the quality of your life? (7-point Likert scale ranging from 1 = "very low" to 7 = "very high") (22).

Data Analysis
Data were analyzed for normality. Descriptive analyses were performed on all characteristics and outcome variables to obtain item means and standard deviations. One- Results Table 1 describes sample characteristics. All participants had at least a high school education, but black participants had on average, 2.5 years less than white participants.
Given that years of education were significantly different between groups, education was controlled for in the logistic model ( Table 3). The black and white groups were not significantly different in any other measured socio-demographic category.
Fast gait speed and MoCA were significantly different between black and white participant groups, with black participants having slower fast gait speeds and lower average MoCA scores ( Table 2). No other fall risk indicators were different between groups. White participants reported being more afraid of falling than black participants (p = 0.043).
There were no significant differences between groups in quality of life or balance confidence ( Table 2). The ordinal logistic regression model with dependent variable, fear of falling, and backward selection method examined different factors which might explain the significant difference in fear of falling by racial group (Table 3). Variables that remained significant in the final model included race (Figure 1), sex (Figure 1), gait speed (Figure 2), and use of an assistive device for walking (Table 3).  In contrast to the single item assessing fear of falling, black and white participants did not differ significantly on average ABC score. The ABC measures both vestibular and nonvestibular balance, as well as functional mobility (23). Although decreased functional mobility and impaired balance increases risk of falling, there is a subtle difference in asking people how confident they are that they can keep their balance under various circumstances compared to asking people "How worried are you about falling?" Perhaps the participants do not engage in the scenarios covered by the ABC scale such as walking on an icy sidewalk, or perhaps confounding factors such as use of an assistive device for walking, impede the ability of the ABC to predict how worried someone will be about falling. The ABC is not designed to measure fear of falling but functional dis/ability, whereas the single-item "fall worry" rating scale question has this explicit purpose.
Despite the differences in risk factors and fear of falling, black and white participants did not differ significantly in number of falls in the past 12 months. While literature suggests that white older adults tend to fall more often than black older adults, (14) this difference was not observed in our sample.
Race, sex, gait speed, and use of an assistive device were predictive of fear of falling in the regression model, suggesting that the contributions of these combined factors may interact to partially explain fear of falling. The suggestion that multiple factors contribute to fear of falling may help explain why it has been difficult to elucidate race-based differences in being worried about falling in studies that sought to isolate fall risk factors.
Sex: Although not examined in this sample, sex differences in falling and in fear of falling have been documented in other studies, suggesting that there are differences in where people fall (indoor vs. outdoor) between men and women, and that women are nearly twice as likely as men to be injured when they fall indoors (24). Additionally, women are more likely to be worried about falling (25). The results of our regression analysis are consistent with this literature in that sex is an important factor for predicting fear of falling.
Race: Racial differences in health have been well documented, with significant health disparities among black populations observed for all-cause mortality, heart disease mortality, cancer mortality, female breast cancer mortality, diabetes mellitus mortality, motor vehicle crash mortality, tuberculosis case rate, and syphilis case rate (26). It remains unclear why white populations fall more frequently than black populations, given the many differences observed in black populations where blacks have poorer health outcomes than white counterparts. Our study suggests that white participants may also have greater fear of falling than black participants, but our data are insufficient to explain this observed difference.
Gait Speed: Gait speed is associated with fear of falling in older adult populations (27).
People who are at risk of falling tend to have slower gait speeds; however, by walking more slowly, fall risk is mitigated (28). One study examining the relationship between sex and gait speed in older adults found that differences in gait speed and sex are not significant when adjusted for the height of the participant (5). Our study did not measure participant height, and therefore the association between gait speed and fear of falling may be confounded by participant height and other physical characteristics that were not examined. More focused research is needed to understand the interaction between sex and gait speed in the production of fear of falling. However, since fall risk is associated with slower gait speed, (28) it would stand to reason that people who are more afraid of falling walk more slowly to compensate for greater fear of falling.
Use of Assistive Device: Literature suggests that black older adults are more likely to use an assistive device than white older adults (29). People who have a fear of falling have been shown to compensate for this fear by using an assistive device, often a cane (11). In a large nationally-representative study, use of an assistive device for walking was not found to be associated with greater incidence of falls (11). Studies also suggest that people who use an assistive device for walking are more likely to be injured when they fall (30). A study examining fear of falling among blacks versus whites who all use assistive devices is needed to determine the nature of the relationship between race, fear of falling, and use of an assistive device. However, it is likely that the findings in our study are consistent with other studies showing that using an assistive device is indicative of greater fear of falling, regardless of race or ethnicity.

Limitations:
The greatest limitation to our study is that we did not have qualitative information exploring individual factors that influenced fear of falling. This information would have allowed for more nuanced exploration of socio-cultural factors that cause white participants to be more afraid of falling than black participants. Indeed, given that the higher fall rate among white older adults has been well document and researched extensively but remains unexplained, asking participants to describe their fear of falling may provide the "missing link" needed to identify important variables influencing both fear of falling and fall risk differences between races. Additionally, larger samples are needed to confirm the findings of this study. Analyzing differences in fear of falling by sex, education level, physical function and cognitive function would be helpful for determining to what extent factors other than race influence fear of falling.

Conclusion
While differences in race, sex, gait speed, and use of an assistive device for walking may contribute to the understanding why some older adults are more afraid of falling than others, this study highlights the need to explore the root causes of fear of falling between racially different populations. Moving forward, additional qualitative questions including "What are your concerns about falling?" and "What do you think would happen if you experienced a fall?" would help clarify the nuances of being worried about falling so that differences in fear of falling between racial groups might be more easily understood.

Abbreviations
The provided contact information to make an initial assessment appointment. All paper and electronic data files were coded and de-identified to maintain participant confidentiality.

Consent for Publication: Not Applicable
Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available due to the fact that the study is ongoing but are available from the corresponding author on reasonable request.
Competing Interests: The authors declare they have no competing interests. The funding agencies played no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.