Gender perspective on fear of falling using the classification of functioning as the model

Figures & data

Table 1. Description of the variables included in the statistical analyses.

ICF	Variable	Standardized assessment or question and further information
Personal factors	Age	Self-reported, confirmed by national register, 75–93 years
	Educational level	Three levels: 1 = ≤6 years, 2 = 7–9 years, 3 = ≥10 years
	Experienced falls	Self-reported fall events in the past year: 0 = no falls, 1 = 1 fall, 2 = ≥2 falls
	Experienced fractures	Self-reported fractures in the past 5 years: 0 = no fractures, 1 = 1 fracture, 2 = ≥2 fractures
	Perceived confidence of one’s balance	Activities-specific Balance Confidence (ABC) scale [37]: 0–100 %: higher score indicates more self-reported balance confidence in 16 daily activities of greater or lesser challenge during position changes or walking
	Eating habits	Mini Nutritional Assessment [60]: 0–30 points: higher score indicates better self-reported nutritional status
	Emotional distress/ depressive symptoms	Geriatric Depression Scale 15 items [61]: (0–15 points): scores ≥5 points indicate depression might be present
	Other health conditions/comorbidities	Twenty self-reported comorbidities that might cause fall events: arthritis, stroke, Parkinson’s disease, diabetes mellitus, lung diseases, heart diseases, cancer, hypertension, inflammatory bowel syndromes, thyroid disease, anaemia, B-vitamin deficiency, kidney diseases, epilepsy, depression, eye diseases, osteoarthritis in knees or feet, normal pressure hydrocephalus, polyneuropathy, leg ulcers
Environmental factors	Residence	Self-reported: 1 = cottage/bungalow, 2 = apartment, 3 = senior living/sheltered housing
	Living circumstances	Self-reported: 0 = living with another person(s), 1 = living alone
	Walking device	Self-reported: 0 = no device, 1 = use device indoors or outdoors
	Medication	Prescription drugs considered to be fall risk factors (calcium preparations, potassium sparing diuretics, oxicams, anilides, anxiolytics and hypnotics [benzodiazepine derivatives], and thiazides): 0 = no drugs, 1 = one risk drug, 2 = ≥2 risk drugs
	Clothing	Foot wear at home: 0 = shoes, 1 = slippers, 2 = bare feet or socks
	Attitude of others	Response to question: “Do you think somebody else is afraid that you might fall?”: 0 = no, 1 = I don’t know, 2 = yes
Body function and structure	Bone mineral density	Dual-energy X-ray absorptiometry at hip and spine [36]: 0 = normal bone density, 1 = osteopenia, 2 = osteoporosis
	Dual-task cost in step width, counting backwards	A change in step width of 3.6 mm or more while counting backwards predicts falls [35]: 0 = ≤3.6 mm, 1 = >3.6 mm
	Dual-task cost in step width, carrying an object	A change in step width of 3.7 mm or less while carrying an object predicts falls [35]: 0 = ≥3.7 mm, 1 = <3.7 mm
	Trail Making Test B	Interval scale (time in seconds): higher score indicates slower performance [62]
	Attentional functions	Response to questions: “Do you need to think about being careful when walking:… indoors?… outdoors in the summer when on even ground?… on uneven ground?… during the winter on snowy ground?”: 0 = never/rarely, 1 = sometimes, 2 = often/always
	Cognitive state	Mini Mental State Examination [63], 0–30 points, higher score indicates better cognitive function
	Dizziness	For any reason: 0 = yes, 1 = no
	Sensation of falling	Response to questions “Do you feel unsteady when walking indoors?” and “… outdoors?”: 0 = never/rarely, 1 = sometimes, 2 = often/always
	Sensory functions: Visual acuity [64]	1 = excellent, 2 = good, 3 = fair, 4 = poor
	Visual contrast [64]	1 = excellent, 2 = good, 3 = fair, 4 = poor
	Hearing, subjective	Self-reported: 0 = normal, 1 = impaired
	Hearing, objective	As perceived by trained assessor using normal speaking tone: 0 = normal, 1 = impaired
	Touch	Monofilament 5.07 on sole of feet and lateral malleolus: 0 = normal, 1 = impaired
	Proprioception	Protractor placed between lower limbs, impaired if degrees differed between the positions of left and right big toes with eyes closed and feet up, mean of 5 trials: 1 = good, <2 degrees, 2 = between 2–4 degrees, 3 = impaired, >4 degrees
	Vibration	128 Hz tuning fork at lateral malleolus and tibial tuberosity: 0 = normal, 1 = impaired
Activity and Participation	Activities of Daily Living	Barthel Index [65], ordinal scale (0–20 points), higher score indicates higher level of independence
	Basic mobility	Timed Up and Go [66], interval scale (time in seconds): higher score indicates slower performance in standing up, walking 3 m, walking back and sitting down
	Activity avoidance	Survey of Activities and Fear of Falling in the Older [38], ordinal scale (17–51 points): higher score indicates greater avoidant behaviour
	Maintaining upright position	Standing balance [67], ordinal scale (0–4 points): 0 = standing < 10 s with feet together, 1 = standing ≥10 s with feet together, 2 = standing in semi-tandem-position ≥10 s, 3 = standing in tandem-position 3–9.99 s, 4 = standing in tandem-position ≥10 s
	Changing position	5 x Sit-to-Stand [68], interval scale (time in seconds): higher score equals a slower performance in standing up and sitting down
	Walking	Gait speed over 2.4 m [67], normal speed, interval scale (time in seconds): higher score indicates slower performance in walking straight forward
	Physical activity level (habitual)	Self-reported [69], ordinal scale: 1 = hardly any activity, 2 = sitting down most of the time, 3 = light physical activity, 4 = strenuous physical activity approximately 1–2 h every week, 5 = strenuous physical activity at least 3 h every week
Non-definable	Self-rated health	Response to the question: “In general, would you say your health is excellent, very good, good, fair or poor?”, ordinal scale: 1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor

Figure 1. All fall risk factors organized in the model of International Classification of Functioning, Disability and Health (n = 44).

Table 2. Baseline demographic and performance-based tests.

	Women (n = 166)	Men (n = 64)	p Value
Indicators of personal factors
Age (years), mean (SD)	79.6 (3.6)	79.3 (4.0)	0.559
Education ≤6 years, n (%)	55 (33)	19 (30)	0.647
History of falls past year, n (%)	87 (52)	39 (61)	0.244
History of fracture past five years, n (%)	85 (51)	10 (16)	<0.001
Activities-specific Balance Confidence scale 0–100%, mean (SD)	73 (1.9)	82 (1.8)	<0.001
Mini Nutritional Assessment, mean (SD)	26 (2.4)	27 (2.1)	0.005
Geriatric Depression Scale 15 items, 0–15 points, mean (SD)	2 (2.1)	1 (1.5)	0.061
Number of health complaints, mean (SD)	2 (1.3)	2 (1.2)	0.079
Indicators of environmental factors
Living in a house, n (%)	46 (28)	41 (64)	<0.001
Living alone, n (%)	110 (66)	13 (20)	<0.001
Uses walking device, n (%)	67 (40)	14 (21.9)	0.009
Uses ≥1 prescription drug^a, n (%)	86 (52)	19 (30)	0.003
Barefoot or socks indoors, n (%)	21 (13)	19 (30)	0.002
Others express concern about fall risk, n (%)	100 (60)	41 (64)	0.432
Indicators of body function & body structure
Osteoporosis or osteopenia, n (%)	126 (82)	38 (61)	0.001
Dual-task cost step width while counting backwards ≥3.6 mm, n (%)	109 (80)	40 (71)	0.188
Dual-task cost step width while carrying an object ≤3.7 mm, n (%)	35 (21)	11 (17)	0.508
Trail Making Test B (seconds), mean (SD)	161 (55.4)	161 (52.4)	0.979
Impaired visual acuity, n (%)	14 (9)	4 (6)	0.565
Impaired visual contrast, n (%)	45 (29)	14 (23)	0.276
Impaired hearing, in own opinion, n (%)	11 (8)	7 (13)	0.340
Impaired hearing, in observers opinion, n (%)	161 (98)	61 (95)	0.372
Impaired touch on soles of feet, n (%)	42 (25)	13 (20)	0.427
Impaired proprioception, n (%)	58 (35)	20 (31)	0.596
Impaired vibration malleolus, n (%)	87 (55)	44 (71)	0.027
Mini Mental State Examination, 0–30 points, mean (SD)	28 (1.9)	28 (1.7)	0.637
Chronic dizziness, n (%)	30 (18)	8 (13)	0.308
Often/always thinks about fall risk when… – walking indoors, n (%)	55 (33)	19 (30)	0.615
– walking outdoors on even ground, n (%)	48 (29)	8 (13)	0.009
– walking outdoors on uneven ground, n (%)	131 (79)	39 (61)	0.005
– walking outdoors on icy ground, n (%)	158 (95)	48 (75)	<0.001
Often/always have a sensation of instability when… – walking indoors, n (%)	62 (37)	21 (33)	0.521
– walking outdoors, n (%)	80 (48)	26 (41)	0.302
Indicators of activity and participation
Activity of Daily Living, Barthel Index 0–20 points, mean (SD)	20 (1)	20 (0)	0.029
Timed Up-and-Go (seconds), mean (SD)	10.5 (2.9)	10.1 (2.4)	0.354
Survey of Activities and Fear of Falling in the Elderly, 17–51 points, mean (SD)	23 (4.9)	21 (4.3)	0.003
Impaired standing balance (<10 s feet together), n (%)	1 (1)	1 (2)	0.482
5 × Sit-to-Stand (seconds), mean (SD)	11.9 (4.0)	11.1 (2.8)	0.190
Gait speed over 2.4 m (seconds), mean (SD)	3.6 (1.0)	3.7 (1.0)	0.113
Activity level summer, 0–5 points, mean (SD)	3.8 (0.7)	3.9 (0.9)	0.354
Activity level winter, 0–5 points, mean (SD)	3.6 (0.7)	3.7 (0.9)	0.185
Latent Factor: Global self-rated health^b 1–5 points, mean (SD)	3.0 (0.8)	2.6 (0.7)	0.004

^aCalcium preparations, potassium sparing diuretics, oxicams, anilides, anxiolytics and hypnotics (benzodiazepine derivatives), thiazides.

^b1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good. Observed variables (indicators) are classified according to the International Classification of Functioning and Disability.

Table 3. Distribution of the responses to the question “Are you afraid of falling?”.

Responses	Women n = 166	Men n = 64
No/Yes	74/92	50/14
Rarely/Never	74 (45)	50 (78)
Sometimes	54 (32)	7 (11)
Often/Always	38 (23)	7 (11)

Presented as numbers and proportions, n (%). “No” corresponded to Rarely/Never, and “Yes” corresponded to Sometimes and Often/Always.

Figure 2. Structural equation model exploring the paths of the ICF model to Fear of Falling. The latent variables (factors) are represented by the circles. Values adjacent to arrows are regression weights, labelled as b. M = men, W = women. Solid paths are statistically significant (p < 0.001). These results provide support for the role of the ICF components Personal factors and Activity and Participation in relation to the Fear of Falling. No interrelationships between factors were tested.

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