Prevalence of falls and fear of falling in older adults: a multidimensional analysis based on comprehensive geriatric assessment

Abstract

Objectives  To assess the prevalence of falls and fear of falling in community-dwelling older adults and identify associated factors.

Methods  A cross-sectional study was conducted of 400 older adult users of a primary healthcare unit in São Paulo, Brazil. Sociodemographic, clinical, cognitive, and function data were collected. Falls were evaluated through self-report, and fear of falling was measured using the Falls Efficacy Scale-International (FES-I). Hierarchical regression was used to analyze associations.

Results  The sample had a mean age of 75.23 (SD: 8.53) years, and a predominance of females (63.2%). The prevalence of falls was 62.7%, with 20.3% reporting falls in the past 12 months. Fear of falling was reported by 90.5%. Younger age was associated with a lower risk of falls (OR=0.93; p=0.003). Female sex (OR=3.78; p<0.001), poor self-rated health (OR=9.62; p=0.001), previous hospitalizations (OR=3.13; p<0.001), and worse cognitive function (OR=1.14; p=0.012) were associated with an increased risk of falls. Factors associated with fear of falling included older age (β=0.288; p<0.001), female sex (β=-12.265; p<0.001), history of falls (β=7.448; p=0.001), and dependence for instrumental activities (β=2.532; p=0.027).

Conclusion  Multidimensional interventions in primary care are essential to prevent falls and mitigate fear of falling, promoting quality of life in the Brazilian older population.

Keywords
Accidental Falls; Aging; Geriatric Assessment.

Resumo

Objetivos  Avaliar a prevalência de quedas e medo de cair em pessoas idosas residentes em domicílio e identificar os fatores associados.

Métodos  Estudo transversal com 400 pessoas idosas usuárias de uma Unidade Básica de Saúde em São Paulo, Brasil. Dados sociodemográficos, clínicos, cognitivos e funcionais foram coletados. Quedas foram avaliadas por autorrelato e medo de cair pela escala Falls Efficacy Scale-International (FES-I). Regressão hierárquica foi utilizada para análise de associações.

Resultados  A média de idade foi 75,23 anos (dp: 8,53), com predominância feminina (63,2%). A prevalência de quedas foi de 62,7%, com 20,3% nos últimos 12 meses. O medo de cair foi relatado por 90,5%. Menor idade foi associada a menor risco de quedas (OR=0,93; p=0,003). Sexo feminino (OR= 3,78; p<0,001), autoavaliação de saúde ruim (OR=9,62; p=0,001), internação prévia (OR=3,13; p<0,001) e pior função cognitiva (OR=1,14; p=0,012) aumentaram o risco. Fatores associados ao medo de cair incluíram maior idade (β=0,288; p<0,001), sexo feminino (β=-12,265; p<0,001), histórico de quedas (β=7,448; p=0,001) e dependência para atividades instrumentais (β=2,532; p=0,027).

Conclusão  Intervenções multidimensionais na atenção primária são essenciais para prevenir quedas e mitigar o medo de cair, promovendo qualidade de vida na população idosa brasileira.

Palavras-chave
Acidentes por Quedas; Envelhecimento; Avaliação Geriátrica.

INTRODUCTION

The Brazilian population is experiencing the trend of aging seen across developing countries, a process accompanied by an increase in adverse health events and greater demand for geriatric care¹. Falls are critical events, representing one of the leading causes of morbidity and mortality in older adults, having a major impact on their health, autonomy and quality of life. Globally, an estimated 684,000 people die from falls annually, with most cases occurring in low-to-middle income countries, such as Brazil².

The prevalence and consequence of falls warrant special attention. In Brazil, between 2000 and 2020, the Brazilian National Health System (SUS) Hospital Information System registered 1,746,097 hospital admissions of older adults due to falls, translating to costs of approximately R$ 2.3 billion.³ Besides actual physical falls, fear of falling is a common psychological phenomenon which significantly affects the mobility and quality of life of older adults, leading to reduced physical activity and to social isolation⁴,⁵.

​There is a body of evidence in the national and international literature on risk factors associated with falls and fear of falling. Meta-analyses show that recurrent falls in older individuals result from multiple factors, including daily use of medications, sensory and neuromuscular deficits, as well as chronic conditions⁶,⁷. In Brazil, studies report a significant prevalence of falls and their impacts on the functioning and quality of life of the older population⁸,⁹. However, despite the robustness of these findings, most studies focus on single factors and fail to address the multidimensional complexity of falls and fear of falling.

The present study bridges this gap by incorporating a multi-dimensional approach based on Comprehensive Geriatric Assessment (CGA) which encompasses sociodemographic factors, and both physical and mental health factors, cognitive function, depressive symptoms and functional capacity¹⁰. This approach allows interactions between modifiable and non-modifiable variables to be identified, helping to inform the development of more effective preventive strategies. Moreover, because the sample is representative of primary health, the findings have practical application in the formulation of public policies and interventions to reduce falls and fear of falling in the older population. Therefore, the aim of the present study was to bridge these gaps by assessing the prevalence of falls and fear of falling among community-dwelling older adults in Brazil and to identify the factors associated with these events.

METHODS

A cross-sectional study involving a simple randomized sample of individuals aged ≥60 years, users of Basic Health Unit (UBS) in the eastern region of São Paulo city (São Paulo state), Brazil, was conducted. The study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool¹¹. The study was approved by the Research Ethics Committee of the Municipal Health Secretariat for São Paulo (permit no. 2.468.315, of 17 ^th January, 2018; CAAE 79340017.2.0000.0086). The investigation was performed in accordance with the ethical and legal precepts set forth in Resolution no. 466/2012, governing investigations involving humans, and in Resolution no. 510/2016, which regulates the standards applicable to studies in Human and Social Sciences.

The study involved older adult users of the Belenzinho Basic Health Unit (UBS), situated in the eastern region of São Paulo city (São Paulo state). In 2018, the UBS had approximately 40,000 registered users, of which 12.5% (n=5,000) comprised the older population (age ≥60 years). For calculating the sample size, a total of 400 participants was estimated. The primary objective was to explore, using Hierarchical Logistic Regression analysis, the prevalence of falls in the past 12 months (27.6%) and fear of falling (41.5%) as dependent variables, together with 17 independent variables. The calculation was based on the dependent variable with lowest prevalence (history of falls), adopting a significance level of 5% (α=0.05) and two-tailed test. The analysis showed a statistical power of 99.00%.

The study participants were older adults aged ≥60 years and registered users of the Belenzinho UBS. Individuals with severe physical limitation or undergoing treatment for dementia, such as Alzheimer disease, were excluded. Data collection was carried out between February and August 2018 by a health professional experienced in primary care and in conducting studies on aging. This professional was previously trained to perform standard application of the scale used in the study. Participant selection was done by simple random sampling using the UBS patient medical records. Interviews were conducted individually during nursing consultations and had a mean duration of 40 mins.

To probe the occurrence of falls, participants answered the question: “Have you fallen or had a fall in the past 12 months?” (yes or no).

Fear of falling was assessed using the Falls Efficacy Scale-International (FES-I) developed by Yardley in 2005, and validated for Brazilian Portuguese in 2010 (Cronbach´s alpha =0.96)¹². Each activity is scored on a Likert-type scale from 1 (not at all concerned) to 4 (very concerned). Example questions include: "How concerned are you that you might fall if you clean the house (e.g., sweeping, vacuuming, or dusting)?”; and “How concerned are you that you might fall if you go up or down stairs?”. Total scores range from 16 (not concerned at all) to 64 (very concerned), with cut-offs defined as 16-22 for low level of concern and 23-64 for high level of concern¹². In the present study, Cronbach´s alpha was 0.89, indicating high reliability of the scale.

Patient characteristics collected included age (60-69; 70-79; ≥80 years; sex (male or female); marital status (with or without partner); can read/write (yes or no); formal education (yes or no); and living alone (yes or no).

Cognitive function was assessed using the Mini-Mental State Exam (MMSE) devised by Folstein in 1976 and transculturally adapted for Brazilian Portuguese in 1994 ¹³. The MMSE is used as a screening test for possible cognitive impairment in older adults, but not recommended for establishing clinical diagnoses. Score ranges from 0 to 30 points, with higher scores indicating better cognitive performance. Example questions include: “What is the date today (day, month, year)?” and “Repeat the following numbers in the same order: 8-3-2 ¹³.

Depressive symptoms were assessed using the 15-item Geriatric Depression Scale (GDS-15) developed by Yesavage in 1983 and validated for Brazilian Portuguese in 2005. The GDS-15 tool is easy to understand and apply and can be self-administered. The scale has 15 items with dichotomous responses (yes/no) and a score of 0-15. Individuals scoring <5 are classified as having no depressive symptoms, where scores ≥ 6 indicate the presence of depressive symptoms. Example questions include: “Do you feel that your life is empty?” and “Do you feel dispirited most of the time?”. The GDS-15 has sensitivity of 86% and specificity of 79% for diagnosing depression¹⁴.

The prevalence of hospital admission was probed by the question: “Have you been hospitalized for more than 24 hours in the past 12 months?” (yes or no). Also, quality of life and health status variables were analyzed, such as satisfaction with life (“Are you satisfied with your life?” - yes/no), satisfaction with health (“How is your health?” – poor, fair, good, excellent), presence of chronic diseases (yes/no), daily use of medications (yes/no), polypharmacy (daily use ≥5 medications), and tobacco use (yes/no).

Basic activities of daily living (BADL) were assessed by the Katz Index, developed in 1976 and validated for Portuguese in 2008 ¹⁵,¹⁶. This tool measures level of independence for six basic functions: bathing, dressing, toileting, transferring, continence and feeding. Scores range from 0 to 6, where a score of 0 indicates total independence, and scores ≥1 indicate dependence¹⁶. Example questions include: “Are you able to bathe by yourself, without help from others?” and “Can you get dressed without help?”¹⁶.

Instrumental activities of daily living (IADL) were assessed using the Lawton Scale, devised by Lawton & Brody in 1969 and validated for Portuguese in 2008 ¹⁷. The scale measures 7 instrumental activities: telephoning, transportation, shopping, preparing food, housekeeping, managing medications and handling finances. Total score ranges from 0 to 21, classifying participants as dependent (score≤20) or independent (score=21)¹⁸. Example questions include: “Are you able to do the shopping independently?”; and “Are you able to prepare your meals independently?”.

On the descriptive analysis, categorical variables were expressed as absolute and relative values. Multiple Logistic Regression with hierarchical models was used for the dependent variable “fall in past 12 months” (1=yes; 0=no). Three models were developed: Model 1 incorporated sociodemographic variables (age, gender, marital status, education and retirement status); Model 2 also included health variables (perception of life, perceived health, presence of chronic diseases, daily use of medications, tobacco use, hospitalization in past 12 months, musculoskeletal disease, stroke and cardiovascular disease); and Model 3 also included cognitive function (MMSE) and depressive symptoms (GDS-15).

For factors associated with fear of falling (numeric variable - FES-I), Multiple Linear Regression was applied for 5 hierarchical models. Model 1 incorporated sociodemographic variables (age, sex, education, marital status and retirement); Model 2 included health status (perception of life, perceived health, presence of chronic disease, daily use of medications, tobacco use and hospitalizations in past 12 months); Model 3 also incorporated cognitive function (MMSE) and depressive symptoms (GDS-15); Model 4 included history of falls (falls in past 12 months and history of falls); and Model 5 also included functional capacity (BADL - Katz and IADL - Lawton). The level of significance adopted was 5% (p<0,05), with a 95%¨confidence interval.

DATA AVAILABILITY

The full dataset underpinning the study results are available upon request from the corresponding author Luciano Magalhães Vitorino.

RESULTS

Of the 488 older adults invited to take part in the study, 400 (83.33%) agreed to answer the questionnaires in full. The participant characteristics are presented in Table 1. The sample had a mean age of 75.23 (SD: 8.53) years and contained a predominance of females and individuals without partner. In addition, most participants could read and write, and a third of the respondents lived alone.

Table 1
Characteristics of study participants (n=400). São Paulo city, São Paulo state, Brazil, 2018.

Variables	n (%)	95% CI
Age (years)
60-69	104 (26.00)	21.87 - 30.31
70-79	159 (39.70)	35.05 – 45.04
≥80	137 (34.30)	29.51 – 39.37
Sex
Male	147 (36.80)	32.08 – 41.53
Female	253 (63.20)	58.54 – 68.04
Marital status
With partner	132 (33.00)	28.28 – 37.82
Without partner	262 (67.00)	62.31 – 71.87
Can read/write
Yes	242 (60.50)	56.89 – 64.90
No	158 (39.50)	35.18 – 44.71
Formal education
Yes	158 (39.50)	35.08 – 44.77
No	242 (60.50)	54.22 – 65.35
Living alone
Yes	126 (31.50)	26.10 – 36.01
No	274 (68.50)	64.48 – 72.56
Satisfaction with life
Yes	183 (45.80)	41.88 – 49.85
No	217 (54.20)	50.79 – 60.42
Self-rated health
Poor/Fair	250 (62.60)	59.65 – 64.23
Good/Excellent	150 (37.40)	35.82 – 42.45
Chronic disease
Yes	369 (92.30)	89.5 – 94.8
No	31 (7.70)	5.3 – 10.5
Using Medications*
Yes	363 (90.70)	87.84 – 93.57
No	37 (9.30)	6.51 – 12.50
Polypharmacy**
Yes	148 (37.00)	32.34 – 41.88
No	252 (63.00)	58.31 – 67.85
History of Falls***
Yes	251 (62.70)	58.54 – 66.31
No	149 (37.30)	33.99 – 42.13
Last fall (<12 months)
Yes	51 (20.30)	17.21 – 23.87
No	200 (79.70)	75.84 – 83.79
Fear of falling – FES-I****
Yes	362 (90.50)	87.56 – 93.48
No	38 (9.50)	6.91 – 11.04

• *Daily use of medications; ** Daily use of 5 medications; ***in past 12 months; ****Cut-offs on FES-I scale <23 - Low concern, ≥ 23 - High concern. CI: Confidence Interval.

Regarding satisfaction with life, most participants reported being dissatisfied, and the majority also self-rated their health as poor or fair. Almost all participants had a chronic disease and took medications on a daily basis. With regard to falls, most participants reported having had at least one fall, while fewer than half reported falls within the last 12 months. Moreover, almost all participants reported fear of falling, scoring ≥23 on the FES-I, indicating a high level of concern.

The frequency of main chronic non-communicable diseases among participants is presented in Table 2.

Table 2
Prevalence of non-communicable diseases among participants (n=400). São Paulo city, São Paulo state, Brazil, 2018.

Comorbidities*	n (%)	95% CI
Cardiovascular
Yes	295 (73.70)	70.03 – 76.88
No	105 (26.30)	24.40 – 29.84
Neoplasia
Yes	19 (4.70)	2.87 – 7.01
No	381 (95.30)	93.12 – 99.35
Pulmonary
Yes	26 (6.50)	3.17 – 9.79
No	374 (93.50)	89.97 – 97.53
Musculoskeletal
Yes	118 (29.50)	27.09 – 33.85
No	282 (70.50)	67.44 – 73.98
Neurological
Yes	199 (49.80)	47.89 – 52.33
No	201 (50.20)	47.27 – 53.63
Cardiometabolic
Yes	206 (51.50)	48.65 – 54.07
No	194 (48.50)	45.83 – 51.73

• *Chronic diseases were categorized according to Prince et al.¹⁹. CI: Confidence Interval.

Results of the 3 hierarchical logistic regression models, for the dependent variable 'fall' (1=yes; 0=no), and the variables sociodemographics, health, cognitive function and depressive symptoms, are presented in Table 3.

Table 3
Hierarchical logistic regression among independent variables and prevalence of falls among participants (n=400). São Paulo city, São Paulo state, Brazil, 2018.

Models	Falls*	p-value
Models	Adjusted OR (95%CI)
Model 1**
Age (mean)	0.89 (0.86 – 0.93)	<0.001
Sex (Female)	3.28 (2.01 – 5.33)	<0.001
Marital status (without partner)	1.52 (0.92 – 2.51)	0.100
Formal education (yes)	1.51 (0.89 – 2.56)	0.123
Retired (yes)	1.08 (0.57 – 2.04)	0.800
Model 2***
Perception of life (dissatisfied)	1.49 (0.73 – 3.04)	0.266
Your health is (good)	4.21 (1.72 – 10.12)	0.001
Your health is (fair)	5.39 (1.81 – 16.03)	0.002
Your health is (poor)	10.17 (2.83 – 36.51)	<0.001
Any health problems (yes)	2.27 (0.43 – 12.04)	0.333
Medications use (yes)	0.93 (0.19 – 4.41)	0.932
Tobacco use (yes)	0.72 (0.38 – 1.32)	0.288
Hospitalizations in past 12 months (yes)	3.21 (1.74 – 5.89)	<0.001
Musculoskeletal (yes)	1.02 (0.58 – 1.79)	0.939
Stroke (yes)	4.06 (0.90 – 18.13)	0.066
Cardiovascular (yes)	1.25 (0.69 – 2.23)	0.451
Model 3****
Age (mean)	0.93 (0.88 – 0.97)	0.003
Sex (Female)	3.78 ( 2.13 – 6.69)	<0.001
Marital status (without partner)	1.20 (0.68 – 2.12)	0.520
Formal education (yes)	0.96 (0.50 – 1.85)	0.923
Retired (yes)	1.17 (0.58 – 2.36)	0.648
Perception of life (dissatisfied)	1.52 (0.73 – 3.16)	0.260
Your health is (good)	3.97 (1.63 – 9.65)	0.002
Your health is (fair)	4.63 (1.51 – 14.17)	0.007
Your health is (poor)	9.62 (2.63 – 35.20)	0.001
Any health problems (yes)	1.82 (0.34 – 9.78)	0.481
Medications use (yes)	1.08 (0.22 – 5.16)	0.918
Tobacco use (yes)	0.76 (0.40 – 1.42)	0.392
Hospitalization in past 12 months (yes)	3.13 (1.68 – 5.81)	<0.001
Musculoskeletal (yes)	0.95 (0.53 – 1.70)	0.886
Stroke (yes)	4.67 (1.01 – 21.56)	0.048
Cardiovascular (yes)	1.36 (0.75 – 2.47)	0.301
MMSE (mean)	1.14 (1.03 – 1.27)	0.012
Depressive symptoms (yes)	0.91 (0.82 – 1.01)	0.090

• MMSE: Mini-Mental State Exam; *Falls in past 12 months (0=yes; 1=no). **sociodemographics; ***sociodemographics + health status; ****sociodemographics + health status + mental health.

Model 1, which incorporated sociodemographic variables only, showed that younger participants had a lower propensity for falls, whereas female gender was associated with higher risks of falls. On Model 2, after inclusion of health-related variables, younger age continued to be associated with lower risk of falls. Moreover, the factors female gender, self-rated health of good, fair or poor, and hospital admission in the past 12 months, were associated with greater propensity for falls.

Model 3, which included cognitive function and depressive symptoms, younger age continued to be associated with lower risk for falls. However, a greater propensity for falls was identified among participants that were female, had self-rated health of good, fair or poor, had been hospitalized in the past 12 months, and had poorer cognitive function.

The results for 5 multiple linear regression models, exploring the association between the dependent variable “fear of falling” (FES-I) and variables sociodemographics, physical health, cognitive function, falls, depressive symptoms and functional capacity, are presented in Table 4.

Table 4
Hierarchical linear regression between independent variables and fear of falling* in participants (n=400). São Paulo city, São Paulo state, Brazil, 2018.

Models	B (SE)	Beta	p	Adjusted R2
Model 1**
Age (mean)	0.555 (0.070)	0.365	<0.001
Sex (Female)	-14.272 (0.988)	-0.530	<0.001
Formal education (yes)	-0.006 (1.040)	0.000	0.996	0.516
Marital status (without partner)	-2.297 (1.026)	-0.083	0.026
Retired (yes)	0.849 (1.284)	0.028	0.509
Model 2***
Perception of life (dissatisfied)	-0.035 (1.203)	-0.001	0.977
Your health is (excellent)	-1.479 (0.705)	-0.100	0.037
Health problems (yes)	-2.379 (3.202)	-0.049	0.458	0.535
Medications use (yes)	0.767 (2.910)	0.017	0.792
Tobacco use (yes)	1.663 (1.159)	0.057	0.152
Hospitalization in past 12 months (yes)	-1.853 (1.024)	-0.069	0.071
Model 3****
MMSE (mean)	-0.319 (0.185)	-0.070	0.085
Depression – GDS-15 (mean)	0.414 (0.166)	0.092	0.013	0.545
Model 4*****
Last fall <12 months (yes)	1.502 (1.251)	0.107	0.231
History of falls (yes)	9.021 (2.583)	0.335	<0.001	0.583
Model 5******
Age	0.288 (0.077)	0.190	<0.001
Sex (Female)	12.265 (1.006)	0.455	0.001
Formal education (yes)	1.330 (1.071)	0.050	0.215
Marital status (without partner)	-1.186 (0.999)	-0.043	0.236
Retired (yes)	0.081 (1.214)	0.029	0.469
Perception of life (dissatisfied)	-0.396 (1.155)	-0.015	0.732
Your health is (excellent)	-0.340 (0.681)	-0.023	0.618
Health problems (yes)	-0.408 (3.028)	-0.008	0.893
Medications use (yes)	-0.262 (2.757)	-0.006	0.924
Tobacco use (yes)	1.380 (1.095)	0.048	0.206
Hospitalizations in past 12 months (yes)	0.120 (1.015)	0.004	0.906	0.621
MMSE (mean)	-0.055 (0.181)	-0.012	0.760
Depression – GDS-15 (mean)	0.276 (0.159)	0.061	0.083
Last fall <12 months (yes)	1.024 (1246)	0.073	0.412
History of Falls (Yes)	7.448 (2.593)	0.277	0.001
Katz Total (dependent)	2.394 (1.305)	-0.082	0.067
Lawton Total (dependent)	2.532 (1.137)	0.095	0.027

• MMSE: Mini-Mental State Exam; KATZ: Basic Activities of Daily Living; LAWTON: Instrumental Activities of Daily Living; *FES I – Falls Efficacy Scale-International; **sociodemographics; ***sociodemographics + health status; ****sociodemographics + health status + mental health; *****sociodemographics + health status + mental health + falls: ******sociodemographics + health status + mental health + falls + functional capacity.

In Model 1, higher age, female gender and not having a partner were associated with greater fear of falling. On Models 2 and 3, which included the variables sociodemographics, and mental and physical health, the new variables exhibited no statistically significant associations. On Model 4, the inclusion of variables related to falls history revealed that participants with a history of falls had greater fear of falling.

On model 5, higher age, female gender, falls history and dependence for IADLs were identified as factors associated with greater fear of falling.

DISCUSSION

The present study assessed two important health issues affecting older adults, with results showing a high prevalence of both falls and fear of falling among the study participants. With respect to falls, younger age was associated with lower propensity for falls, whereas factors such as female gender, poor self-rated health, hospitalizations within the past 12 months, and low cognitive performance were associated with greater risk of falls. These findings corroborate the literature which recognizes falls as the leading cause of morbimortality due to injury in older adults, with adverse repercussions for quality of life, functional independence and mental health¹⁹,²⁰.

With regard to fear of falling among the study participants, significant associations were found with more advanced age, female gender, previous history of falls and dependence for IADLs. These factors underscore the multifactorial interdependent nature of fear of falling, which manifests as a direct consequence, but also as a mediator of the risk of future falls. Thus, the results contribute to understanding on the combined influence of both modifiable variables (such as cognitive function and independence) and non-modifiable variables (such as age and sex).

The prevalence of falls found in the present study exceeded global and national averages, which range from 25% to 27% in community-dwelling older adults¹¹,²¹. This result might be explained by the sample profile, comprising mostly women and individuals with negative self-rated health, factors recognized as independent predictors of falls²¹,²². The literature reports that female gender is associated with greater musculoskeletal frailty and functional risk, whereas negative perception of health reflects a greater burden of comorbidities and functional limitation. Taken together, these elements contribute to elevating the risk of falls and its clinical repercussions²¹,²².

Associated factors, such as female gender, advanced age, previous hospital admissions and polypharmacy, have been extensively documented in the literature. Evidence shows that the use of ≥7 medications is significantly associated with increased risk of falls, especially when involving psychotropic and cardiovascular drugs¹¹. Hence, specific interventions are recommended, including systematic review of medication prescribing and the adoption of functional rehabilitation programs. Exercises for building muscle strength and balance training have been shown to reduce the incidence of falls by up to 15%, as reported in recent meta-analyses²¹. Such strategies should be integrated into primary health routines.

Fear of falling, detected in 90.5% of participants, was significantly higher than the global average of 49,⁶%²³. This finding is consistent with evidence identifying fear as one of the main emotional consequences of falls, directly impacting independence and functioning of older individuals. By comparison, studies involving Brazilian and Portuguese older adults have reported lower prevalences, such as the 45.9% rate seen in multi-center analyses²⁰, suggesting variability related to contextual factors. These results emphasize the importance of understanding the cultural, social and psychological dimensions that modulate perceived risk and coping with fear of falling, particularly in community settings.

The current findings corroborate previous evidence identifying advanced age, female gender, history of falls and functional dependence as key determinants of fear of falling. A cross-sectional study in Brazil showed that older women with a history of falls and poor self-rated health had significantly higher rates of fear of falling²⁴. These factors reflect both physical and emotional vulnerabilities which, when concomitant, perpetuate the cycle of functional insecurity, social withdrawal and greater risk of further falls. Furthermore, a recent qualitative review revealed that fear of falling is influenced by emotional and psychosocial dimensions, such as perceived unmet needs and ineffective self-management strategies²³, deepening understanding of the complexity of this phenomenon. In addition, individuals aged ≥80 years require special attention because they have a significantly higher risk of falls. Recent studies stress that preventive interventions should be adapted to this age group, given their greater physical, functional and cognitive vulnerability²⁵.

A previous study found a relationship between fear of falling and functional instability, identifying greater variability in gait among older adults with this condition²⁵.These findings point to the need for specific interventions which address both physical strengthening and psychosocial support. Moreover, longitudinal studies highlight the persistence of fear of falling, especially in older individuals that have multiple comorbidities or a history of recurrent falls²².

In this context, the results of the present study support the relevance of multidimensional approaches in primary care, with an emphasis on identifying risk factors such as polypharmacy, depressive symptoms and functional instability²¹,²⁴. Although Comprehensive Geriatric Assessment (CGA) was not used to its full extent, the components employed showed clinical utility and can inform protocols adapted to the reality of primary care.

Interventions based on physical exercises are essential, both for reducing falls and boosting functional confidence²¹. Creating accessible environments, such as improved lighting and adapted public transport, is also an essential strategy for mitigating fear of falling and promoting independence of older individuals¹¹. Population-based studies, such as EpiFloripa Idoso, also illustrate the role of sensory factors, such as auditory perception, in the occurrence of falls in community-dwelling older adults²⁶. Additionally, public policies should focus on educational programs for these individuals and their caregivers, addressing both falls prevention and emotional management. These actions can help reduce hospital admissions, surgical procedures for fractures, and costs associated with these complications²⁰,²⁷.

Despite the importance of the findings, the study has some limitations. The cross-sectional design prevents drawing of causal inferences, while the use of self-reports may have introduced memory bias. The predominantly female sample also limits generalization of the results. Nevertheless, the study has several strengths. The use of validated scales confers greater reliability for the data and the application of robust statistical models allowed a detailed analysis of associated factors. Also, the focus on primary care reflects a realistic relevant setting, allowing practical application of findings.

CONCLUSION

The present study revealed a high prevalence of falls and fear of falling among the study participants, highlighting the complex interaction between modifiable and non-modifiable factors. Integrated preventive strategies, including functional assessment, physical rehabilitation, and psychosocial management are essential for mitigating these issues. Public policies to create accessible environments, and boosting of community support, are fundamental for promoting healthy aging and reducing the impacts of falls and fear of falling.

• DATA AVAILABILITY
  The full dataset underpinning the study results are available upon request from the corresponding author Luciano Magalhães Vitorino.
• Funding
  There was no funding for the execution of this work.

References

• ¹ Kirby T. Brazil facing ageing population challenges. Lancet. 18 nov 2023;402(10415):1821. https://doi.org/10.1016/s0140-6736(23)02561-8
• ² Salari N, Darvishi N, Ahmadipanah M, Shohaimi S, Mohammadi M. Global prevalence of falls in the older adults: a comprehensive systematic review and meta-analysis. Journal of orthopaedic surgery and research. 2022;17(1):334. https://doi.org/10.1186/s13018-022-03222-1
• ³ Lima JDS, Quadros DV, Silva S, Tavares JP, Pai DD. Costs of hospital admission authorizations due to falls among older people in the Brazilian National Health System, Brazil, 2000-2020: a descriptive study. Epidemiol Serv Saude. 2022;31(1):e2021603. https://doi.org/10.1590/S1679-49742022000100012
• ⁴ Birhanie G, Melese H, Solomon G, Fissha B, Teferi M. Fear of falling and associated factors among older people living in Bahir Dar City, Amhara, Ethiopia- a cross-sectional study. BMC Geriatr. 21 out 2021;21(1):586. https://doi.org/10.1186/s12877-021-02534-x
• ⁵ dos Santos Silva LM, Berto CM, da Silva FAA, Bezerra KMG, de Oliveira Marques AP. FATORES ASSOCIADOS AO RISCO DE QUEDA EM IDOSOS: UMA REVISÃO INTEGRATIVA. Revista Brasileira de Ciências do Envelhecimento Humano. 2020;17(2). https://doi.org/10.5335/rbceh.v17i2.11988
• ⁶ Sotoudeh GR, Mohammadi R, Mosallanezhad Z, Viitasara E, Soares JJ. A population study on factors associated with unintentional falls among Iranian older adults. BMC geriatrics. 2023;23(1):860. https://doi.org/10.1186/s12877-023-04571-0
• ⁷ Elias Filho J, Borel WP, Diz JBM, Barbosa AWC, Britto RR, Felício DC. Prevalência de quedas e fatores associados em uma amostra comunitária de idosos brasileiros: uma revisão sistemática e meta-análise. Cadernos de Saúde Pública. 2019;35:e00115718. https://doi.org/10.1590/0102-311X00115718
• ⁸ Ulian V. Acidentes por quedas em idosos: fatores demográficos, socioeconômicos, processo saúde-doença e características dos acidentes. 2021.
• ⁹ Li Y, Hou L, Zhao H, Xie R, Yi Y, Ding X. Risk factors for falls among community-dwelling older adults: A systematic review and meta-analysis. Frontiers in medicine. 2023;9:1019094. https://doi.org/10.3389/fmed.2022.1019094
• ¹⁰ Orcel V, Banh L, Bastuji-Garin S, et al. Effectiveness of comprehensive geriatric assessment adapted to primary care when provided by a nurse or a general practitioner: the CEpiA cluster-randomised trial. BMC Medicine. 2024/09/27 2024;22(1):414. https://doi.org/10.1186/s12916-024-03613-7
• ¹¹ Xiong W, Wang D, Ren W, Liu X, Wen R, Luo Y. The global prevalence of and risk factors for fear of falling among older adults: a systematic review and meta-analysis. BMC Geriatr. 5 abr 2024;24(1):321. https://doi.org/10.1186/s12877-024-04882-w
• ¹² Yardley L BN, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). 2005;34. https://doi.org/10.1093/ageing/afi196
  » https://doi.org/10.1093/ageing/afi196
• ¹³ Lourenço RA, Veras RP. Mini-Exame do Estado Mental: características psicométricas em idosos ambulatoriais. Revista de Saúde Pública. 2006;40:712-719. https://doi.org/10.1590/S0034-89102006000500023
• ¹⁴ Fontanela LC. A Escala de Depressão Geriátrica pode ser utilizada para rastrear quedas em idosos comunitários? 2021. https://doi.org/10.11606/issn.2317-0190.v28i1a185247
  » https://doi.org/10.11606/issn.2317-0190.v28i1a185247
• ¹⁵ Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv. 1976;6(3):493-508. https://doi.org/10.2190/uurl-2ryu-wryd-ey3k
• ¹⁶ Lino VTS, Pereira SRM, Camacho LAB, Ribeiro Filho ST, Buksman S. Adaptação transcultural da escala de independência em atividades da vida diária (Escala de Katz). Cadernos de saude publica. 2008;24:103-112. https://doi.org/10.1590/S0102-311X2008000100010
• ¹⁷ Holovatino LB. Dependência para a realização de atividades instrumentais de vida diária e sintomatologia depressiva em pessoas idosas residentes na comunidade. 2023. https://doi.org/10.11606/D.100.2023.tde-31052023-163530
  » https://doi.org/10.11606/D.100.2023.tde-31052023-163530
• ¹⁸ dos Santos RL, Júnior JSV. Confiabilidade da versão brasileira da escala de atividades instrumentais da vida diária. Revista Brasileira em Promoção da Saúde. 2008;21(4):290-296. https://doi.org/10.5020/575
• ¹⁹ Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimer's & dementia. 2013;9(1):63-75. e2. DOI: 10.1016/j.jalz.2012.11.007
• ²⁰ Vitorino LM, Marques-Vieira C, Low G, Sousa L, Cruz JP. Fear of falling among Brazilian and Portuguese older adults. Int J Older People Nurs. Jun 2019;14(2):e12230. https://doi.org/10.1111/opn.12230
• ²¹ Colón-Emeric CS, McDermott CL, Lee DS, Berry SD. Risk assessment and prevention of falls in older community-dwelling adults: a review. Jama. 2024;331(16):1397-1406. doi: 10.1001/jama.2024.1416.
• ²² Drummond FMM, Lourenco RA, Lopes CS. Incidence, persistence and risk factors of fear of falling in older adults: cohort study (2008-2013) in Rio de Janeiro, Brazil. Rev Saude Publica. 2020;54:56. https://doi.org/10.11606/S1518-8787.2020054001939
• ²³ Cui Q, Zhong Y, Gui Y, Ma S, Ge Y. Experiences and perceptions of fear of falling in older adults: A systematic review and meta-synthesis of qualitative studies. Geriatric Nursing. 2025;61:324-335. https://doi.org/10.1016/j.gerinurse.2024.11.003
• ²⁴ World Health Organization. World Health Statistics [Internet]. 2016.
• ²⁵ Guirguis-Blake JM, Perdue LA, Coppola EL, Bean SI. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. Jama. 2024;332(1):58-69. https://doi.org/10.1001/jama.2024.4166
• ²⁶ Barros VNd, Figueiró TH, Hillesheim D, d’Orsi E. A percepção da audição está relacionada à ocorrência de quedas entre idosos durante a pandemia de COVID-19? Uma análise longitudinal. Cadernos de Saúde Pública. 2024;40:e00022824. https://doi.org/10.1590/0102-311XPT022824
• ²⁷ Gambaro E, Gramaglia C, Azzolina D, Campani D, Molin AD, Zeppegno P. The complex associations between late life depression, fear of falling and risk of falls. A systematic review and meta-analysis. Ageing Res Rev. Jan 2022;73:101532. doi: 10.1016/j.arr.2021.101532.
  » https://doi.org/ 10.1016/j.arr.2021.101532

Edited by

• Edited by
  Camila Alves dos Santos

Data availability

The full dataset underpinning the study results are available upon request from the corresponding author Luciano Magalhães Vitorino.

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  2025

History

• Received
  21 Jan 2025
• Accepted
  16 May 2025