Geriatric Nursing 42 (2021) 1035 1041

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Factors associated with fear of falling among frail older adults

Francisco M. Martínez-Arnau, PT, PhDa,b, Lucía Prieto-Contreras, RN, PhDc,

rez-Ros, RN, PhDb,d,*
Pilar Pe
a
Department of Physiotherapy, University of Valencia, Gasco
Oliag 5, 46010, Valencia, Spain
b
Frailty and cognitive impairment organized group (FROG), University of Valencia, Valencia, Spain
c
Department of Nursing, Universidad Cato
lica de Valencia San Vicente Ma
rtir, Espartero 7, 46007, Valencia, Spain
d
Department of Nursing, Faculty of Nursing and Podiatry, University of Valencia, Mel
endez y Pelayo s/n, 46010 Valencia, Spain

A R T I C L E I N F O A B S T R A C T

Article history: Some factors increase the fear of falling in frail older adults. Our aim is to quantify the influence of these fac-
Received 4 May 2021 tors. This cross-sectional study involved 229 community-dwelling prefrail and frail older adults aged 70 years
Received in revised form 4 June 2021 and older. Fear of falling was moderate in 38.9% of our sample and high in 12.2%. Higher values were
Accepted 8 June 2021
observed in women, those living alone, and those meeting criteria for slowness and feelings of exhaustion. A
Available online 10 July 2021
linear regression showed that being a woman, a history of falls, and depressive symptoms were related to
higher fear of falling, while high levels of independence in basic and instrumental activities of daily living,
Keywords: along with good gait and balance, were associated with lower fear of falling. Screening for depressive symp-
Frail elderly toms and fear of falling in the comprehensive geriatric assessment of frail community-dwelling older adults
Depression could help to support preventive strategies.
Falls © 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
Community
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Functional status

Introduction
The last decade has seen a boom in research in frail older adults.1 A
better understanding of frailty can favor its prevention, as this syndrome
is an emerging global health challenge both in clinical practice and in
the public health arena. Frailty is characterized by a decline in the func-
tionality of multiple physiological systems, accompanied by increased
vulnerability to stressors. Its development in older people increases the
risk of loss of function, dependency and other geriatric syndromes, and
it is associated with increased costs and health care use.2
Gait and balance disorders, along with falls, are the geriatric syn-
dromes most closely related to frailty. From a holistic point of view,
these syndromes have consequences that involve all spheres of the
older person’s life and health. Medical consequences comprise frac-
tures and contusions; functional consequences, increased dependence
in basic activities of daily living (ADL) and instrumental activities of
Abbreviations: abc, activities-specific balance confidence scale; Adl, basic activities
of daily living; Bmi, body mass index; Eq-5d index, euroqol 5 dimensions-3 levels
index; Eq-5d vas, euroqol 5 dimensions-3 levels visual analogic scale; Fes, falls efficacy
scale; Fes-i, falls efficacy scale international; FoF, Fear of falling; GDS, Short Form Geri-
atric Depression Sale; IADL, Instrumental activities of daily living; mFES, Modified Falls
Efficacy Scale; MMSE, Mini-Mental State Examination; ProFaNE, Prevention of Falls
Network Europe; SPPB, Short Physcal Performance Battery

rez-Ros, Melendez Pelayo 19, 46010, Valencia
*Corresponding author: Pilar Pe
(Spain).
E-mail address: maria.p.perez-ros@uv.es (P. Pe
rez-Ros).
daily living (IADL); and social consequences, the tendency to isolate
and decrease the level of activity.3 Moreover, psychological conse-
quences include a fear of falling (FoF), defined as low perceived self-
efficacy or confidence in avoiding falls during essential, nonhazardous
activities of daily living.4 Anywhere between 20% and 85% of older
community-dwelling people are afraid of falling; this fear occurs in
those who have previously fallen but also in 33% to 46% of those who
have not.5 Evidence shows that this fear is not unfounded, constituting
a predictor for future falls.6
FoF increases in the frail population, while the risk of sarcopenia
rises in older people with a history of falls. This association is more
pronounced in those with recurrent falls; previous fractures related
to falls; high comorbidity and polypharmacy; vision and hearing loss;
and impaired ADLs, IADLs and gait and balance. FoF is also related to
the emotional sphere, with an increased risk in older people with
depression.7
FoF can be assessed by means of different instruments, including
single-item questions (e.g. Are you afraid of falling?) and scales mea-
suring various aspects of this fear, such as different versions of the
Falls Efficacy Scale (FES) (modified: mFES; international: FES-I, and
short FES-I), the Activities-specific Balance Confidence scale (ABC),
the Mobility Efficacy Scale, and the Survey of Activities and Fear of
Falling in the Elderly scale.8
Comprehensive geriatric assessments should systematically eval-
uate FoF in both older fallers and non-fallers because of the high asso-
ciation between fear and activity restriction, and in turn the

https://doi.org/10.1016/j.gerinurse.2021.06.007
0197-4572/$ see front matter © 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
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1036 F.M. Martínez-Arnau et al. / Geriatric Nursing 42 (2021) 1035 1041
subsequent complications related to immobility, loss of function,
impaired gait and balance, sarcopenia and falls.9 Mobility restriction
and poor physical performance also affect the emotional sphere, gen-
erating increased anxiety and depression,10 12 as well as the social
sphere, contributing to a decrease in social contacts.13,14 Several
authors have analyzed the relationship that FoF has with anxiety and
depression,15 17 with some studies identifying FoF as a risk factor for
depression,10 others emphasizing depression and its consequent
restriction of activity as favoring FoF,11,12,18,19 and still others failing
to observe a definitive link.20
Most previous research has analyzed the increased risk of
FoF,6,7,9,21 23 but only Scarlett quantified the implication of different
factors in FoF in a sample of older adults.12 There is thus a need to
complement this evidence with further studies identifying the factors
most related to FoF. This knowledge can favor necessary measures to
prevent it and its consequences, including the transition to end-stage
disability.13,14,17 This situation occurs in the frail older community
population, who carry an important risk of loss of activity and func-
tion. Therefore, this study aims to quantify FoF in the prefrail and frail
community older population and identify both protective and risk
factors associated with it.
Materials and methods
Study design and participants
This cross-sectional study was carried out in primary care centers
and social centers for older adults in La Ribera, Valencia, Spain.
Recruitment and assessment covered the period from August 2016 to
December 2016.
The 2016 census data estimates that this region has a population
of about 220,676 inhabitants, of which around 15% are at least
70 years old. We randomly selected five of the region’s municipalities
where the population has an above-average proportion of individuals
over 70 years of age: Algemesí, Albalat de la Ribera, Alzira, Carcaixent
and Sollana. Inclusion criteria were participants aged 70 years or
older meeting at least one frailty criterion and capable of walking
independently (with the possibility of ambulatory assistive devices
but excluding the help of another person), and routinely seen in pri-
mary care centers in La Ribera. Exclusion criteria were patients with
disease processes indicating a life expectancy of under 6 months;
people with total hearing or vision loss; participants with serious
psychiatric disorders or moderate to severe cognitive impairment;
and patients rejecting participation or failing to sign informed con-
sent. Participants were recruited with the aid of posters and leaflets
in primary care centers, civic centers and associations of retired peo-
ple and pensioners.
Sample size description
The sample was calculated using XLstats software, based on the

rez-Ros et al.,24 where the frail and pre-frail older popula-
study by Pe
tion had a mean FES-I of 20.27 (standard deviation [SD] 17.07).
Assuming a sampling error of § 3%, a=5 and an expected attrition
rate of 10%, the minimum sample required for this study was 142
older adults.
A total of 432 elderly community members were recruited, but
115 did not meet any frailty criterion, 56 refused to participate, and
32 did not sign the informed consent form. Thus, the final sample
included 229 participants.
Ethics
The study was approved by the Research Ethics Committee of La
Ribera University Hospital. The data obtained were processed in
compliance with Spanish Personal Data Protection Law (LOPD) 15/
1999, of 13 December, and Law 14/2002, of 14 November, regulating
patient autonomy, rights and obligations with regard to clinical infor-
mation and documentation. The study likewise complied with the
ethical principles guiding research, as specified in the Declaration of
Helsinki. All participants signed informed consent before inclusion in
the study and statistical processing of the data.
Data collection
Comprehensive geriatric assessments were performed in primary
care centers by four nurses with at least six years’ experience in two
physical activity-related fall prevention programs.
Age, gender, number of daily drugs, and comorbidities were col-
lected from electronic medical records. Participants orally reported
the number of falls they had suffered in the 12 previous months, and
health professionals extracted any other available data recorded
from visits to the emergency department after a fall. A fall was
defined as an event which results in a person coming to rest inadver-
tently on the ground, floor, or other lower level.
Geriatric assessment
Fried frailty phenotype
Primary care nurses performed a comprehensive geriatric assess-
ment to categorize patients according to the Fried frailty pheno-
types25 ( 3/5 characteristics = frail; 1 2 characteristics = prefrail).
Weakness was assessed following standardized procedures, using a
100 kg dynamometer (Smedley S, TTM, Tokyo, Japan). Grip strength
cutoffs in the lowest 20%, denoting weakness, were stratified for gen-
der and body mass index (BMI). Slowness was dichotomized based
on the time taken to walk 4.5 m, with a cutoff value of < 0.8 m/s.
Unintentional weight loss was defined as a loss of 4.5 kg or 5% of
body weight in the last year (determined by direct measurement of
weight). Participants were considered to have low physical activity
according to the weighted score of kilocalories expended per week
(men, 383 kcal/week and women, 270 kcal/week). Lastly, poor endur-
ance and energy were defined by self-reported exhaustion: (a) “I felt
that everything I did was an effort”; (b) “I could not get going.”
Fear of falling
Following selection of participants based on the frailty assess-
ment, we collected data on FoF (FES-I, a=0.96 and ICC=0.96).26 This
instrument measures “fear of falling” or, more properly, “concerns
about falling”, which are suitable for use in research and clinical prac-
tice. The FES-I was developed as part of the Prevention of Falls Net-
work Europe (ProFaNE), following an intensive review of FoF, self-
efficacy and balance confidence questionnaires. The FES-I scale
ranges from a minimum score of 16 (no concern about falling) to a
maximum score of 64 (severe concern about falling). Participants
were classified as having low (16 19 points), moderate (20 27
points), and high (28 64 points) concern about falling.
Functional dimension
Variables considered FoF risk factors were collected,27 along with
functional and psychosocial variables. Functional parameters were
assessed based on the Barthel index (a=0.70 and ICC=0.76), which
consists of 10 items that measure daily functioning, particularly
activities of daily living (ADL). The items include feeding, transfers
(from bed to chair and back, and to and from the toilet), grooming
and toileting, walking on a level surface, going up and down the
stairs, dressing, and bowel and bladder continence. The total score
ranges from 0 (dependent) to 100 (independent).28,29
The Lawton IADL scale (a=0.94 and ICC=0.99), was used to assess
people’s ability to perform eight activities (using the telephone,
 F.M. Martínez-Arnau et al. / Geriatric Nursing 42 (2021) 1035 1041
shopping for groceries, food preparation, housekeeping, laundering,
self-medicating, transportation, and managing finances). The total
score ranges from 0 (totally dependent) to 8 (totally independent).30
Gait and balance were assessed using the Tinetti index (Cron-
bach's alpha 0.95).31 The index has 17 items totaling up to 28 points.
A score of less than 19 points indicates a five-fold increase in the risk
of falls, so the lower the total score, the higher the risk of falls.
In addition, the Short Physical Performance Battery (SPPB,
Kappa=0.38 0.95 and ICC= 0.88 0.92)32 was used to assess the phys-
ical performance of the lower extremities. To do this, the battery adds
up the results of the Balance Test, the Walking Test, and the Repeated
Chair Stand Test. The score for each of the three tests ranges from 0
to 4, where 0 is the worst result and 4 the best. Thus, the SPPB score
ranges from 0 to 12.33 The cutoff point of  8 was considered indica-
tive of frailty and sarcopenia.34
Cognitive dimension
Cognitive assessment was undertaken using the Mini-Mental
State Examination35 (MMSE, a=0.9036 and reliability 0.80 0.9537).
The items are grouped into five sections that assess orientation, fixa-
tion of knowledge in memory, concentration and calculation,
deferred memory, and language and construction. The cut-off point
for dementia is usually set at under 24 points.
Emotional dimension
Emotional assessment was performed using Yesavage et al.’s38
Short Form Geriatric Depression Sale (GDS a=0.94 and reliability
0.89 0.96) ,39 comprising 15 questions. A score of 0 4 points is con-
sidered normal, depending on age, education and complaints; a score
of 5 8 indicates mild depression; 9 11, moderate depression; and
12 15, severe depression. The Cronbach’s alpha is 0.94.
Quality of life
Health-related quality of life was measured using the EQ-5D
(EuroQol 5 Dimensions-3 levels, R = 0.45 0.8140) index and the EQ-
5D visual analog scale (VAS), according to the parameters of the
Spanish population. The EQ-5D Index score ranges from less than 0
to 1, (where 0 is a health state equivalent to death and negative val-
ues are worse than death), and 1 is the most positive score (the maxi-
mum level of perceived QoL according to the five dimensions
included on the scale). The EQ VAS score is obtained by asking the
patients to rate their health on a 20-cm vertical scale. The scale
ranges from 0 to 100, where 0 is the ‘worst imaginable health’ and
100 is the ‘best imaginable health’.41
Physical activity
The level of physical activity was assessed with the Baecke Index
(reliability 0.88 0.81 and 0.74 for each dimension),42 a questionnaire
for evaluating a person's physical activity and separating it into three
distinct dimensions: (1) work activity, (2) sports activity, and (3) lei-
sure activity. A score of less than 9 indicates sedentarism; 9 to 16,
moderate sedentarism; and more than 16, an active lifestyle.43
Statistical analysis
Variables were reported as proportions and/or the mean and SD.
Parametric tests (student’s t-test) were used to compare continuous
variables, while nonparametric tests (chi-squared test and linear
trend test) were used to compare categorical variables.
The Pearson correlation coefficient was performed to correlate FES-
I and quantitative variables, and a linear regression model was con-
structed to assess the importance of the risk factors related to FoF.
We first considered the complete model with all the variables that
yielded significant associations with the FES-I during the bivariable
analysis, using backwards elimination to remove the variables failing
1037
to produce an important change (defined as the absence of an
adjusted effect of > 10%) or which did not result in an improved stan-
dard error of the estimate on adjusting the model without such varia-
bles. Consensus was sought among the investigators in cases where
two or more subsets of variables with the same degree of fit were
obtained.
Based on these criteria, the variables included in the model were:
age; gender; number of frailty criteria; living arrangements (alone ver-
sus with someone); dichotomous frailty criteria (slowness, weakness,
low physical activity, self-reported exhaustion and unintentional
weight loss); and continuous variables including dynamometer mea-
sure, MMSE score, GDS score, Barthel score, Lawton score, EQ-5D Index
score, and SPPB score.
The study data were entered in MS Excel spreadsheets, and statis-
tical analysis was performed with SPSS software (IBM Corp. Released
2010. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY:
IBM Corp).
Results
We recruited a sample of 229 older people, dominated by women
(70.3%) and with a mean age of 77.8 (SD 4.9) years. There was a
higher percentage of frail (59%) compared to prefrail (41%) people,
with the most prevalent criterion being loss of strength, as assessed
by dynamometer in the dominant hand (84.7%). In the clinical assess-
ment, the prevalence of arterial hypertension and the prescription of
more than five drugs per day stand out. At the functional level, inde-
pendence was observed in the performance of basic and instrumental
ADLs, as assessed by Barthel index and Lawton index, respectively
(Table 1). Scores on the Tinetti index showed some evidence of
impaired balance and gait, while the mean score on the SPPB
approached the cutoff for sarcopenia and frailty in the lower extremi-
ties. The mean score of the cognitive assessment was over 24, the cut-
off point below which cognitive impairment is defined, and low
scores were obtained on the GDS, showing an absence of depressive
symptoms. Perceived quality of life was quite high, both according to
the EQ-5D index and the VAS, with mean scores of over 70%. Finally,
exercise performance was low, with a mean score of less than 7 on
the Baecke scale.
The mean score for FoF on the FES-I (Falls Efficacy Scale) was
21.59 (SD 8.73); 48.9% (n = 112) had low concern about falling
(16 19 points); 38.9% (n = 89), moderate concern (20 27); and
12.2% (n = 28), high concern (28 64 points). The prevalence of self-
reported falls was 54.9% (n = 121), while 38.8% (n = 89) had at least
one fall recorded in their medical history.
There were differences in the FES-I according to gender, cohabita-
tion status, and frailty (Fig. 1), with higher scores in women versus
men (22.66 vs 19.04, mean difference [MD] 3.61; 95% confidence
interval [CI] 1.17, 6.05; p = 0.004), people living alone versus living
with relatives (23.11 vs 20.89 points, MD 2.23, 95% CI 0.07, 4.52;
p = 0.049), and those who were frail versus prefrail (23.08 vs 19.44
points, MD 3.65; 95% CI 1.69, 5.06; p<0.001).
In addition, older people meeting criteria for slowness (22.83 vs
19.89 points; MD 2.95, 95% CI 0.90, 4.99; p = 0.005) and self-reported
exhaustion (23.05 vs 20.05 points, MD 2.99, 95% CI 0.77, 5.22;
p = 0.008) also had a significantly higher FoF than their counterparts
without these characteristics (Fig. 2). Other frailty criteria did not
yield significant differences.
Finally, FES-I scores were analyzed according to comorbidity and
history of falls. Older people with a history of falls showed higher
FES-I scores than those without (23.16 vs 20.59 points; MD 2.57, 95%
CI 0.26, 34.89; p = 0.029). Conversely, people with no history of frac-
ture showed more FoF than those who had (20.06 vs 21.83, MD 1.77,
95% CI 0.002, 3.54; p = 0.049; Fig. 3).
1038 F.M. Martínez-Arnau et al. / Geriatric Nursing 42 (2021) 1035 1041

Table 1 A linear regression was fitted to quantify the impact of the previ-
Characteristics of the sample. ously analyzed variables on FoF. The model yielded statistically sig-
n Mean (SD)/% nificant results (R = 0.59, R2=0.35; F = 19.715, p = 0.001). FoF
increased in women (2.14 points) and with each previous fall (+1.11
Age 229 77.75 (4.86)
points) and point obtained on the depression scale (+0.81 points). All
Gender
Men 68 29.7% dimensions of functionality, both in basic and instrumental ADLs
Women 161 70.3% along with gait as assessed by the SPPB, played an important protec-
Living arrangements tive role. Each point on the Lawton scale decreased FoF by 0.62
Alone 75 32.8%
points, on the Barthel index by 0.21 points, and on the SPPB by 0.3
With relatives 154 67.3%
Frail phenotype
points (Table 3).
Prefrail 94 41%
Frail 135 59% Discussion
Frailty criteria
Slowness 132 57.6%
Weakness 194 84.7% Older people have a high prevalence of frailty, and among this
Low physical activity 168 73.4% group, FoF is present in fallers and non-fallers alike. Both factors are
Self-reported exhaustion 117 51.1% associated with immobility, loss of function, impairment of gait and
Unintentional weight loss 33 14.4% balance, sarcopenia and falls.9 This study quantified FoF in the prefrail
Clinical
Arterial hypertension 161 70.3%
and frail community-dwelling older population and identified both
Hyperlipidemia 97 42.9% protective and risk factors. Overall, 38.9% of our sample showed mod-
Diabetes mellitus 65 28.8% erate FoF, and 12.2% high FoF. Scores on the FES-I increased in women,
Osteoporosis 66 29.2% and with each previous fall and each point obtained on the GDS
Previous fractures 32 14.0%
depression scale. On the other hand, the greater the independence on
Orthostatic hypotension 29 12.7%
Depressive syndrome 99 43.6% the ADL, IADL and gait and balance scales, the lower the FoF.
Daily drugs, number 229 5.05 (3.3) Our sample is similar to those described in other community-
BMI, kg/m2 229 29.99 (4.55) based studies worldwide7,9,21,22,44 46 in terms of gender, age, comor-
Functional bidities and functionality. The prevalence of FoF in older adults
Barthel Index, score 0 100 229 92.31 (12.12)
Lawton Index, score 0 8 229 7 (1.67)
ranges from 30.7% to 42.9%.6,21 23,46 48 In prefrail and frail older peo-
Tinetti Index, score 0 28 228 22.16 (5.05) ple, reported ranges are higher, from 44.8% to 94.1;%7,9,46,48 this wide
SPPB, score 0 12 201 8.73 (3.04) range encompasses the higher level of fear in frail compared to pref-
Baecke Index, score 0 20 194 6.35 (3.72) rail older people,9 along with varying levels of comorbidity and func-
Dynamometer, kg 229 17.75 (6.99)
tionality in the samples.48
Cognitive and emotional
MMSE, score 0 24 229 24.9 (4.36) The factors associated with increased risk of FoF in our analysis
GDS, score 0 15 229 2.83 (2.93) are female sex, previous falls, and depressive symptoms. Women
Quality of life have more FoF, with several studies showing a two to threefold dif-
EQ-5D Index, score 0 1 229 0.72 (0.25) ference compared to men.9,22 Similarly, our results show that female
EQ-ED VAS, score 0 100 228 71.9 (22.8)
sex increases FoF by 2.14 points on the FES-I scale. Another predictor
EQ-5D: EuroQoL 5 dimensions; GDS: Geriatric Depression Scale; MMSE: Mini Mental of FoF is having suffered a previous fall, and this fear increases with
State Examination; SD: standard deviation; SPPB: Short Physucal Performance Battery;
more falls.7,9,11,22 This same pattern is observed in the sample ana-
VAS: visual analog scale.
lyzed, with one point more for each previous fall suffered.
Several authors have also pointed to a diagnosis of depression as a
The correlation between FoF and other quantitative variables was risk factor for FoF.7,9,11 17,20,49 51 In our sample, each point on the
analyzed. The strongest correlations (r > 0.4) were the Barthel and Yesavage GDS increased FoF by 0.8 points; with a maximum GDS
GDS scales, with a positive correlation between FoF and depression score of 15 points, FoF would increase up to 12 more points. Indeed,
and a negative correlation between FoF and functional independence. of all the continuous variables tested, those showing the strongest
Negative correlations of r > 0.3 were observed for balance and walk- correlation with FoF were GDS score and the Barthel index. Although
ing independence and quality of life, with slightly lower negative cor- depression is an important public health problem in older adults, it is
relations with independence in IADLs (Table 2). Thus, FoF is under-identified and underreported by both healthcare professionals
correlated with age, number of frailty criteria, dependence in ADLs, and older adults. Some studies have found a prevalence of depressive
balance and gait impairment, low activity, cognitive impairment, symptomatology ranging from 10% to 40% in older community-
depressive symptoms, and lower quality of life. dwelling adults.52,53 The relationship between anxiety and

Fig. 1. FES-I scores by gender, cohabitation, and frailty status. * significant at p<0.05; ** significant at p<0.001.
 F.M. Martínez-Arnau et al. / Geriatric Nursing 42 (2021) 1035 1041 1039

Fig. 2. FES-I scores in people fulfilling versus not fulfilling each criterion for the frailty phenotype* significant at p<0.05; ** significant at p<0.001.

depression and FoF is not clear, but the bidirectional connection the-
ory seems promising.54,55 Indeed, FoF may decrease activity and con-
sequently increase the risk of depression,10 but other authors have
proposed the opposite causal direction,18,19 studying depression as a
predictor of falls and fear of falling in three contexts. Firstly, the neu-
rophysiological sequelae caused by depression affect attention and
concentration. Secondly, pharmacological treatments for depression
can lead to sleep problems, altered states of consciousness, loss of
strength, vision, and attention. Thirdly, depression can modify gait,
increasing its variability.54,56 Finally, some studies conclude that even
stating that one will act on depression can held decrease FoF.12,45
Screening for depression can help in preventing severe disability and
other complications; the most widely used scale worldwide for the
rapid screening of depression among older adults is the GDS,57,58 and
specifically the GDS-15, with a pooled sensitivity of 86%, specificity of
79%, and high diagnostic accuracy (AUC = 0.90).57 Depression is
related to an increased risk of physical problems; decreased physical,
social, and cognitive functions; and poor quality of life. Moreira also
observed a relationship between depressive symptoms, gait and bal-
ance disorders, and FoF in a sample of older community women with
type 2 diabetes mellitus, raising the need to further explore these
results and to implement screening for depression and FoF in com-
munity health care.59
Older people who lived alone also had a higher FoF than those liv-
ing with relatives or caregivers. Loneliness increases the risk of FoF,7
with implications for short-, medium- and long-term health out-
comes. Older people are afraid of not being able to get up after a fall
and by the potential need for immediate help. Similarly, the fear of a
possible fracture and/or the need for help from third parties in the
performance of ADLs is also a concern for older people.60 Higher FoF
levels are also observed in people who are most frail, with several
studies describing the relationship between frailty, FoF and falls.9,61
Both frailty and FoF can lead to activity restriction, which increases
the risk of falls and vice versa. The frailty criteria that most increased
FoF scores in our sample are slowness and feelings of exhaustion, an
association also observed by Blain et al.62 These findings should also
be further investigated, because if not all frailty criteria have the
same impact on FoF or other outcomes, this may suggest the need for
refining criteria for the detection and prevention of frailty.
On the other hand, functionality has also been shown to be
inversely related to FoF, that is, the higher the independence in ADLs
and IADLs, the lower the FoF.7,9,22,49,63,64 Malini7 observed this

Fig. 3. FES-I scores in presence or absence of comorbidity. * significant at p<0.05, **significant at p<0.001.
1040 F.M. Martínez-Arnau et al. / Geriatric Nursing 42 (2021) 1035 1041

Table 2 warranted in the community-dwelling frail population. This, along

Correlation between Falls Efficacy Scale International and continuous variables. with preventive interventions for depressive symptoms and mainte-
r p value nance and/or improving functionality, gait and balance, could pre-
vent FoF in frail community-dwelling older adults.
Age, years 0.138* 0.037
Previous falls, number 0.602 0.37
Frailty criteria, number 0.238** <0.001 Funding
Fractures, number 0.034 0.96
Daily drugs, number 0.009 0.89
BMI, score 0.083 0.21 No funding was received for this study. The Government authori-
Dynamometer, kg 0.218* 0.001 ties and the Catholic University of Valencia, University of Valencia
Barthel score (0 100) 0.453** <0.001 and Hospital Universitario de la Ribera played no role in the perfor-
Lawton score (0 8) 0.284** <0.001
mance of this study. None of the authors received financial support
Tinetti, score (0 28) 0.356** <0.001
SPPB, score (0 12) 0.281** <0.001 for this study.
Baecke, score (0 20) 0.155* 0.031
EQ-5D Index, score (0 1) 0.386** <0.001
EQ-5D VAS, score (0 100) 0.356** <0.001 Conflicts of interest
MMSE, score (0 24) 0.195 0.003
GDS, score (0 15) 0.434** <0.001 The authors declare that they have no conflicts of interest in rela-
BMI: Body Mass Index; EQ-5D: EuroQoL 5 dimensions; GDS: Geriatric Depression tion to the present study.
Scale; MMSE: Mini Mental State Examination; r: correlation; SPPB: Short Physical Per-
formance Battery; VAS: visual analog scale. * significant at p<0.05, **significant at
p<0.001. Acknowledgments

relationship most strongly in ADLs. We observed a strong correlation We would like to thank all the participants of the PRECARI-II project.
between ADLs and FoF, but in the regression IADLs had a greater
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