573519 research-article2015
JAHXXX10.1177/0898264315573519Journal of Aging and HealthChoi and Ko
Article
Characteristics Associated With Fear of Falling and Activity Restriction in South Korean Older Adults
Journal of Aging and Health 1–18 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264315573519 jah.sagepub.com
Kyungwon Choi, PhD, RN1 and Young Ko, PhD, RN2
Abstract Objectives: The purpose of this study was to identify the characteristics associated with fear-induced activity restriction and determine those that distinguish older adults with fear-induced activity restriction from those with fear of falling alone. Method: Data taken from the survey of the Korean Longitudinal Study of Aging in 2010 were analyzed. Multiple logistic regression analysis was used to assess factors associated with fear of falling and fear-induced activity restriction. Results: A total of 22.5% of the participants reported no fear of falling, 48.6% reported fear of falling alone, and 28.9% reported fear-induced activity restriction. Characteristics independently associated with fear-induced activity restriction were low socioeconomic status, cognitive impairment, difficulty with activities of daily living, and a history of injurious falls. Discussion: The differences between older adults with fear-induced activity restriction and those with fear of falling alone may guide refinement of intervention and preventive programs. Keywords fear of falling, fear-induced activity restriction, Korean, older adults 1Hyechon 2Gachon
University, Daejeon, South Korea University, Incheon, South Korea
Corresponding Author: Young Ko, Assistant Professor, College of Nursing, Gachon University, 191 Hambakmoeiro, Yeonsu-Gu, Incheon 406-799, South Korea. Email: [email protected]
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
2
Journal of Aging and Health
Introduction Fear of falling is a common and potentially serious problem in older people, and can be present even in older adults who never fall (Scheffer, Schuurmans, van Dijk, van der hooft, & de Rooij, 2008). This fear is thought to lead to reduced or restricted activities (Donoghue, Cronin, Savva, O’Regan, & Kenny, 2013; Mendes da Costa et al., 2012) and cause adverse outcomes such as falls (Friedman, Munoz, West, Rubin, & Fried, 2002), functional decline (Lach & Parsons, 2013), and depression (Dias et al., 2011). Fear-induced activity restriction, which is caused by fear of falling, may lead to loss of independence and reduce social interactions when excessive, which, in turn, lead to physical inactivity, subsequent decline in physical capabilities, poorer self-rated health, reduced quality of life, more falls, greater frailty, and increased mortality (Donoghue et al., 2013; Friedman et al., 2002; Lach & Parsons, 2013; Mendes da Costa et al., 2012). However, activity restriction may not always occur in the presence of fear of falling (Friedman et al., 2002). In reality, the consequences of fear of falling may range from increased caution while performing daily tasks to limitations in activities. Curtailing or avoiding activities can protect against falling to a certain degree (Friedman et al., 2002). Therefore, fear of falling may not be harmful unless it is accompanied by excess restricted activity, which is potentially dangerous for the physical and psychological well-being of older adults. This observation underscores the need for a comprehensive investigation to identify potentially modifiable factors that contribute to fear-induced activity restriction in addition to those associated with fear of falling to formulate preventive strategies. Previous studies have provided a remarkable body of evidence regarding the factors related to fear of falling (Austin, Devine, Dick, Prince, & Bruce, 2007; Friedman et al., 2002; Scheffer et al., 2008). For example, fear of falling has been associated with demographic factors such as age (Scheffer et al., 2008), gender (Mendes da Costa et al., 2012), education level (Martinez et al., 2010), and socioeconomic status (Scheffer et al., 2008), as well as health-related factors such as chronic disease (Dias et al., 2011), a history of falls (Mendes da Costa et al., 2012), activities of daily living (ADLs)/independent activities of daily living (IADLs; Dias et al., 2011), visual function (Donoghue et al., 2013; Friedman et al., 2002), and depression (Dias et al., 2011). However, the factors independently related to fear-induced activity restriction are relatively understudied (Curcio, Gomez, & Reyes-Ortiz, 2009). Moreover, little is known about South Korean older adults with fear-induced activity restriction, although some studies have been conducted in other regions (Curcio et al., 2009; Dias et al., 2011; Hadjistavropoulos et al., 2007;
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
Choi and Ko
3
Mendes da Costa et al., 2012; Murphy, Williams, & Gill, 2002; Wilson et al., 2005; Yardley, & Smith, 2002). Fear of falling may not only be attributed to an individual’s appraisal of his or her ability to maintain balance (Hadjistavropoulos et al., 2007) but may also be affected by psychosocial problems such as depression and participation in social activities (Austin et al., 2007; Dias et al., 2011), in combination with a history of falls. Fear of falling is a salient predictor of reduced activities in older adults (Deshpande et al., 2008). Furthermore, previous research has demonstrated that a history of injurious falls, depressive symptoms, burden from chronic conditions, IADLs, disabilities, and sensory dysfunction may increase the impact of fear of falling on fearinduced activity restriction (Deshpande et al., 2008; Dias et al., 2011). It is possible that some factors may not only aggravate fear of falling but also trigger fear-induced activity restriction (Figure 1). The purpose of this study was to investigate the prevalence and factors associated with fearinduced activity restriction in South Korean older adults and to compare the characteristics associated with fear of falling and fear-induced activity restriction in South Korean older adults living in communities. We hypothesized that there are differences in demographic, physical, functional, and psychosocial functions between participants with fear-induced activity restriction and those with fear of falling alone.
Method Participants This study used a sample of data from the Korean Longitudinal Study of Aging (KLoSA). The KLoSA is a national public database composed of information from middle-aged or older individuals that was established to devise and implement effective social and economic policies to address trends emerging due to population aging. The participants read and signed a consent form before participating in the KLoSA study and agreed to be available for further research. Households were selected by multistage stratified probability sampling (based on geographical area) to serve as national representative samples. The participants were assigned anonymized ID numbers, and a survey was performed every even-numbered year starting in 2006. Third-wave data from the KLoSA were used in this analysis, because they reflect the up-to-date status of older people in Korea. Interviews with participants were conducted by well-trained interviewers to reduce interviewer bias. The protocol for the secondary analysis using these data was approved by the ethics review board of the university to which the researcher was affiliated.
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
4
Journal of Aging and Health
Figure 1. Conceptual framework.
In total, 7,920 individuals (3,412 males and 4,508 females; age ≥ 55 year) were interviewed for the third KLoSA sample in 2010. We limited our population to individuals aged ≥65 years and analyzed the data from 4,247 older adults.
Measurements Fear of falling and Fear-induced activity restriction. Fear of falling was assessed by the question “Are you afraid of falling?” Possible answers to the question
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
Choi and Ko
5
were “not at all,” “a little,” and “very much.” Participants who were not fearful of falling were classified as “no”; participants who reported that their fear of falling was “slight” or “very high” were classified as “yes.” Fear of falling was used as a dichotomous variable (yes or no). Fear-induced activity restriction was assessed by the question “Have you reduced any activity because you fear of falling?” (yes or no). Based on these responses, participants who reported no fear of falling were included in the “no fear of falling” group. Those who reported fear of falling but no restricted activity were included in the “fear of falling alone” group. The final group consisted of participants who had both fear of falling and fear-induced activity restriction. Among those who said they did not have fear of falling, 18 reported a reduction in some of their activities due to fear of falling. These persons were excluded from analyses. Outcome measures. The variables were grouped into four categories: (a) demographic factors, (b) physical and functional factors, (c) psychosocial factors, and (d) a history of falling. Demographic factors included age, sex, education, living arrangement, and subjective economic status. Living arrangement was classified as living alone or living with another family member. The participant’s socioeconomic status was assessed with subjective economic status and education level. Individual perception of one’s socioeconomic standing is a robust predictor of physical health in many societies (Nobles, Weintraub, & Adler, 2013). In this study, it was measured with the following question: “what do you perceive as your household’s economic status?” Five response options were given and recoded into tertiles including “high” (high and upper middle), “middle” (middle), and “low” (lower middle and low). Physical and functional factors included cognitive function, visual and auditory impairment, ADLs, IADLs, and the number of chronic diseases. Cognitive status was measured using the Korean Mini-Mental State Examination (K-MMSE) developed by Cockrell and Folstein (1988) and modified and standardized by Kwon and Park (1989). Psychometric properties of the K-MMSE including scoring validity have been evaluated by Kang, Na, and Hahn (1997). Individuals who scored ≥25 points were classified as “normal,” those who scored 21 to 24 points were classified as having “possible dementia,” and participants with ≤20 points had “confirmed dementia.” Cronbach’s alpha in this study was .82. Sensory function was assessed using a single-item measure with a 5-point rating scale. To evaluate visual impairment, the participants were asked to rate their eyesight using the question “How is your eyesight when wearing your glasses or contact lenses?” Auditory impairment was assessed with the
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
6
Journal of Aging and Health
question “How is your hearing when wearing your hearing aids?” Responses were classified as “good” (very good or good), “fair” (fair), or “poor” (bad or very bad). Functional capacity was measured using the Korean versions of the ADLs and IADLs scales. Respondents were asked whether they needed assistance when performing 7 daily activities (dressing, washing face/shampooing/ teeth-brushing, bathing, eating meals, getting up and moving out of the room, using the toilet, and controlling urination and defecation) and 10 different instrumental activities (personal grooming, doing house chores, preparing meals, doing the laundry, going outside without using transportation, going outside using transportation, shopping, managing money, using the telephone, and taking medications; Won et al., 2002). If the participants needed someone’s help for one or more activities, they were categorized as having difficulty completing the task. These instruments have been validated with high internal consistency (Cronbach’s αs = .937 and .935, respectively) and are used widely (Won et al., 2002). The Cronbach’s alpha values in this study were .98 and .97, respectively The number of chronic diseases was measured by self-reported disease history. Participants reported one or more physician-diagnosed diseases including hypertension, diabetes, cancer, lung disease, hepatic disease, cardiac disorders, stroke, and arthritis. Psychosocial factors included participation in social activities and depressive symptoms. Engagement in various types of social activity was measured with the following question: “Do you participate in religious organizations, fraternal organizations, leisure, culture, or sports clubs, school or family reunions, voluntary or charity work, political organizations, or other types of groups?” The responses were recorded as “yes” or “no.” The respondents were also asked how often they participated in social activities and responded on a 10-point Likert-type scale (1 = none, 2 = rarely, 9 = 2-3 times a week, 10 = every day). The frequency of participating in social activities was categorized into three groups. If the participants responded “rarely during the year” or “none,” they were considered to have rarely participated in social activities. Respondents who indicated that they participated in social activities several times per year were considered as having frequent social activities often. If respondents responded “every 2 weeks,” “two or three times per week,” “once per week,” or “almost every day” to one of the items, they were considered to have frequent social activities. Depressive symptoms were evaluated using the short-form Center for Epidemiological Studies–Depression (CES-D10), which consists of 10 items and assesses this type of symptoms experienced during the most recent week (Irwin, Artin, & Oxman, 1999). Eight items were negatively stated, and two
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
Choi and Ko
7
items were positively stated. The scores for each item ranged from 0 (very rarely; less than 1 day during the past week) to 3 (almost always; 5-7 days per week). The summed scores of the 10 items, with scores reversed for the positively stated items, were calculated. We used the cutoff score of ≥10 for the CES-D to identify older adults with symptoms of clinical depression. This cutoff value is valid for screening Korean older adults with clinically relevant symptoms of depression (Lee, Lyu, Lee, & Burr, 2014). The Cronbach’s alpha for the depression scale was .87 in this study. A history of falling included previous experiences with falling and injurious falls. Participants were asked whether they had fallen during the past 2 years. In addition, the respondents were asked to report whether they had suffered an injury related to the fall that required medical treatment.
Statistical Analyses We calculated the frequencies and weighted proportions of all variables. The chi-square test was used to compare the distribution of these frequencies according to fear of falling and fear-induced activity restriction. Multiple logistic regression analysis was used to assess the relationships between the variables and fear of falling or fear-induced activity restriction, with each variable serving as a predictive factor. We evaluated possible multicollinearity between fear of falling/fear-induced activity restriction and covariates by correlation analysis and collinearity statistical tests (tolerance and variance inflation factor tests), as suggested for logistic regression (Allison, 2003). p < .05 was considered to indicate significance. The data analysis was conducted with the SPSS Version 19.0 software (SPSS Inc., Chicago, Illinois, the United States).
Results Table 1 shows the characteristics of the study participants according to fear of falling. About one quarter of the participants (22.5%) reported no fear of falling (n = 955), 48.6% reported fear of falling alone (n = 2,063), and 28.9% reported fear-induced activity restriction (n = 1,229). In addition, 37.3% of the participants who reported fear of falling also reported restricting their activities. Significant differences were observed among the three groups in terms of demographic, physical, functional, and psychosocial factors as well as history of falls (p < .001). The proportion of participants aged ≥85 year, female, living alone, and reporting low subjective economic status was the highest in those with fear-induced activity restriction, intermediate in those with fear of
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
8
Journal of Aging and Health
Table 1. Characteristics of Participants.
Characteristics
No fear of falling n (weighted %)
Fear of falling alone n (weighted %)
Demographic factors Age (year) 65-74 756 (79.2) 1,343 (65.1) 176 (18.4) 623 (30.2) 75-84 22 (2.3) 98 (4.7) 85 above M ± SD 70.57 ± 5.35 73.02 ±5.95 Gender Male 608 (63.7) 824 (39.9) 347 (36.3) 1,239 (60.1) Female Education Less than 6 451 (47.2) 1,367 (66.3) years 161 (16.9) 277 (13.4) Middle school High school 343 (35.9) 420 (20.3) above Total 954 (100.0) 2,064 (100.0) Demographic factors Living arrangement Living alone 91 (9.5) 344 (16.7) Living with 864 (90.5) 1,719 (83.3) others Subjective economic status High 42 (4.4) 71 (3.4) Middle 531 (55.7) 963 (46.7) Low 381 (39.9) 1,029 (49.9) Physical and functional factors Cognitive impairment Normal 627 (65.7) 1,010 (49.0) Possible 217 (22.7) 646 (31.3) Confirmed 111 (11.6) 407 (19.7) Total 954 (100.0) 2,064 (100.0) Physical and functional factors Sensory function (vision) Good 261 (27.4) 312 (15.1) Fair 554 (58.1) 1,132 (54.9) Bad 139 (14.6) 619 (30.0)
Fear-induced activity restriction n (weighted %) Trend pa
580 (47.2) 495 (40.3) 154 (12.5) 75.90 ± 7.22
JAHXXX10.1177/0898264315573519Journal of Aging and HealthChoi and Ko
Article
Characteristics Associated With Fear of Falling and Activity Restriction in South Korean Older Adults
Journal of Aging and Health 1–18 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264315573519 jah.sagepub.com
Kyungwon Choi, PhD, RN1 and Young Ko, PhD, RN2
Abstract Objectives: The purpose of this study was to identify the characteristics associated with fear-induced activity restriction and determine those that distinguish older adults with fear-induced activity restriction from those with fear of falling alone. Method: Data taken from the survey of the Korean Longitudinal Study of Aging in 2010 were analyzed. Multiple logistic regression analysis was used to assess factors associated with fear of falling and fear-induced activity restriction. Results: A total of 22.5% of the participants reported no fear of falling, 48.6% reported fear of falling alone, and 28.9% reported fear-induced activity restriction. Characteristics independently associated with fear-induced activity restriction were low socioeconomic status, cognitive impairment, difficulty with activities of daily living, and a history of injurious falls. Discussion: The differences between older adults with fear-induced activity restriction and those with fear of falling alone may guide refinement of intervention and preventive programs. Keywords fear of falling, fear-induced activity restriction, Korean, older adults 1Hyechon 2Gachon
University, Daejeon, South Korea University, Incheon, South Korea
Corresponding Author: Young Ko, Assistant Professor, College of Nursing, Gachon University, 191 Hambakmoeiro, Yeonsu-Gu, Incheon 406-799, South Korea. Email: [email protected]
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
2
Journal of Aging and Health
Introduction Fear of falling is a common and potentially serious problem in older people, and can be present even in older adults who never fall (Scheffer, Schuurmans, van Dijk, van der hooft, & de Rooij, 2008). This fear is thought to lead to reduced or restricted activities (Donoghue, Cronin, Savva, O’Regan, & Kenny, 2013; Mendes da Costa et al., 2012) and cause adverse outcomes such as falls (Friedman, Munoz, West, Rubin, & Fried, 2002), functional decline (Lach & Parsons, 2013), and depression (Dias et al., 2011). Fear-induced activity restriction, which is caused by fear of falling, may lead to loss of independence and reduce social interactions when excessive, which, in turn, lead to physical inactivity, subsequent decline in physical capabilities, poorer self-rated health, reduced quality of life, more falls, greater frailty, and increased mortality (Donoghue et al., 2013; Friedman et al., 2002; Lach & Parsons, 2013; Mendes da Costa et al., 2012). However, activity restriction may not always occur in the presence of fear of falling (Friedman et al., 2002). In reality, the consequences of fear of falling may range from increased caution while performing daily tasks to limitations in activities. Curtailing or avoiding activities can protect against falling to a certain degree (Friedman et al., 2002). Therefore, fear of falling may not be harmful unless it is accompanied by excess restricted activity, which is potentially dangerous for the physical and psychological well-being of older adults. This observation underscores the need for a comprehensive investigation to identify potentially modifiable factors that contribute to fear-induced activity restriction in addition to those associated with fear of falling to formulate preventive strategies. Previous studies have provided a remarkable body of evidence regarding the factors related to fear of falling (Austin, Devine, Dick, Prince, & Bruce, 2007; Friedman et al., 2002; Scheffer et al., 2008). For example, fear of falling has been associated with demographic factors such as age (Scheffer et al., 2008), gender (Mendes da Costa et al., 2012), education level (Martinez et al., 2010), and socioeconomic status (Scheffer et al., 2008), as well as health-related factors such as chronic disease (Dias et al., 2011), a history of falls (Mendes da Costa et al., 2012), activities of daily living (ADLs)/independent activities of daily living (IADLs; Dias et al., 2011), visual function (Donoghue et al., 2013; Friedman et al., 2002), and depression (Dias et al., 2011). However, the factors independently related to fear-induced activity restriction are relatively understudied (Curcio, Gomez, & Reyes-Ortiz, 2009). Moreover, little is known about South Korean older adults with fear-induced activity restriction, although some studies have been conducted in other regions (Curcio et al., 2009; Dias et al., 2011; Hadjistavropoulos et al., 2007;
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
Choi and Ko
3
Mendes da Costa et al., 2012; Murphy, Williams, & Gill, 2002; Wilson et al., 2005; Yardley, & Smith, 2002). Fear of falling may not only be attributed to an individual’s appraisal of his or her ability to maintain balance (Hadjistavropoulos et al., 2007) but may also be affected by psychosocial problems such as depression and participation in social activities (Austin et al., 2007; Dias et al., 2011), in combination with a history of falls. Fear of falling is a salient predictor of reduced activities in older adults (Deshpande et al., 2008). Furthermore, previous research has demonstrated that a history of injurious falls, depressive symptoms, burden from chronic conditions, IADLs, disabilities, and sensory dysfunction may increase the impact of fear of falling on fearinduced activity restriction (Deshpande et al., 2008; Dias et al., 2011). It is possible that some factors may not only aggravate fear of falling but also trigger fear-induced activity restriction (Figure 1). The purpose of this study was to investigate the prevalence and factors associated with fearinduced activity restriction in South Korean older adults and to compare the characteristics associated with fear of falling and fear-induced activity restriction in South Korean older adults living in communities. We hypothesized that there are differences in demographic, physical, functional, and psychosocial functions between participants with fear-induced activity restriction and those with fear of falling alone.
Method Participants This study used a sample of data from the Korean Longitudinal Study of Aging (KLoSA). The KLoSA is a national public database composed of information from middle-aged or older individuals that was established to devise and implement effective social and economic policies to address trends emerging due to population aging. The participants read and signed a consent form before participating in the KLoSA study and agreed to be available for further research. Households were selected by multistage stratified probability sampling (based on geographical area) to serve as national representative samples. The participants were assigned anonymized ID numbers, and a survey was performed every even-numbered year starting in 2006. Third-wave data from the KLoSA were used in this analysis, because they reflect the up-to-date status of older people in Korea. Interviews with participants were conducted by well-trained interviewers to reduce interviewer bias. The protocol for the secondary analysis using these data was approved by the ethics review board of the university to which the researcher was affiliated.
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
4
Journal of Aging and Health
Figure 1. Conceptual framework.
In total, 7,920 individuals (3,412 males and 4,508 females; age ≥ 55 year) were interviewed for the third KLoSA sample in 2010. We limited our population to individuals aged ≥65 years and analyzed the data from 4,247 older adults.
Measurements Fear of falling and Fear-induced activity restriction. Fear of falling was assessed by the question “Are you afraid of falling?” Possible answers to the question
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
Choi and Ko
5
were “not at all,” “a little,” and “very much.” Participants who were not fearful of falling were classified as “no”; participants who reported that their fear of falling was “slight” or “very high” were classified as “yes.” Fear of falling was used as a dichotomous variable (yes or no). Fear-induced activity restriction was assessed by the question “Have you reduced any activity because you fear of falling?” (yes or no). Based on these responses, participants who reported no fear of falling were included in the “no fear of falling” group. Those who reported fear of falling but no restricted activity were included in the “fear of falling alone” group. The final group consisted of participants who had both fear of falling and fear-induced activity restriction. Among those who said they did not have fear of falling, 18 reported a reduction in some of their activities due to fear of falling. These persons were excluded from analyses. Outcome measures. The variables were grouped into four categories: (a) demographic factors, (b) physical and functional factors, (c) psychosocial factors, and (d) a history of falling. Demographic factors included age, sex, education, living arrangement, and subjective economic status. Living arrangement was classified as living alone or living with another family member. The participant’s socioeconomic status was assessed with subjective economic status and education level. Individual perception of one’s socioeconomic standing is a robust predictor of physical health in many societies (Nobles, Weintraub, & Adler, 2013). In this study, it was measured with the following question: “what do you perceive as your household’s economic status?” Five response options were given and recoded into tertiles including “high” (high and upper middle), “middle” (middle), and “low” (lower middle and low). Physical and functional factors included cognitive function, visual and auditory impairment, ADLs, IADLs, and the number of chronic diseases. Cognitive status was measured using the Korean Mini-Mental State Examination (K-MMSE) developed by Cockrell and Folstein (1988) and modified and standardized by Kwon and Park (1989). Psychometric properties of the K-MMSE including scoring validity have been evaluated by Kang, Na, and Hahn (1997). Individuals who scored ≥25 points were classified as “normal,” those who scored 21 to 24 points were classified as having “possible dementia,” and participants with ≤20 points had “confirmed dementia.” Cronbach’s alpha in this study was .82. Sensory function was assessed using a single-item measure with a 5-point rating scale. To evaluate visual impairment, the participants were asked to rate their eyesight using the question “How is your eyesight when wearing your glasses or contact lenses?” Auditory impairment was assessed with the
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
6
Journal of Aging and Health
question “How is your hearing when wearing your hearing aids?” Responses were classified as “good” (very good or good), “fair” (fair), or “poor” (bad or very bad). Functional capacity was measured using the Korean versions of the ADLs and IADLs scales. Respondents were asked whether they needed assistance when performing 7 daily activities (dressing, washing face/shampooing/ teeth-brushing, bathing, eating meals, getting up and moving out of the room, using the toilet, and controlling urination and defecation) and 10 different instrumental activities (personal grooming, doing house chores, preparing meals, doing the laundry, going outside without using transportation, going outside using transportation, shopping, managing money, using the telephone, and taking medications; Won et al., 2002). If the participants needed someone’s help for one or more activities, they were categorized as having difficulty completing the task. These instruments have been validated with high internal consistency (Cronbach’s αs = .937 and .935, respectively) and are used widely (Won et al., 2002). The Cronbach’s alpha values in this study were .98 and .97, respectively The number of chronic diseases was measured by self-reported disease history. Participants reported one or more physician-diagnosed diseases including hypertension, diabetes, cancer, lung disease, hepatic disease, cardiac disorders, stroke, and arthritis. Psychosocial factors included participation in social activities and depressive symptoms. Engagement in various types of social activity was measured with the following question: “Do you participate in religious organizations, fraternal organizations, leisure, culture, or sports clubs, school or family reunions, voluntary or charity work, political organizations, or other types of groups?” The responses were recorded as “yes” or “no.” The respondents were also asked how often they participated in social activities and responded on a 10-point Likert-type scale (1 = none, 2 = rarely, 9 = 2-3 times a week, 10 = every day). The frequency of participating in social activities was categorized into three groups. If the participants responded “rarely during the year” or “none,” they were considered to have rarely participated in social activities. Respondents who indicated that they participated in social activities several times per year were considered as having frequent social activities often. If respondents responded “every 2 weeks,” “two or three times per week,” “once per week,” or “almost every day” to one of the items, they were considered to have frequent social activities. Depressive symptoms were evaluated using the short-form Center for Epidemiological Studies–Depression (CES-D10), which consists of 10 items and assesses this type of symptoms experienced during the most recent week (Irwin, Artin, & Oxman, 1999). Eight items were negatively stated, and two
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
Choi and Ko
7
items were positively stated. The scores for each item ranged from 0 (very rarely; less than 1 day during the past week) to 3 (almost always; 5-7 days per week). The summed scores of the 10 items, with scores reversed for the positively stated items, were calculated. We used the cutoff score of ≥10 for the CES-D to identify older adults with symptoms of clinical depression. This cutoff value is valid for screening Korean older adults with clinically relevant symptoms of depression (Lee, Lyu, Lee, & Burr, 2014). The Cronbach’s alpha for the depression scale was .87 in this study. A history of falling included previous experiences with falling and injurious falls. Participants were asked whether they had fallen during the past 2 years. In addition, the respondents were asked to report whether they had suffered an injury related to the fall that required medical treatment.
Statistical Analyses We calculated the frequencies and weighted proportions of all variables. The chi-square test was used to compare the distribution of these frequencies according to fear of falling and fear-induced activity restriction. Multiple logistic regression analysis was used to assess the relationships between the variables and fear of falling or fear-induced activity restriction, with each variable serving as a predictive factor. We evaluated possible multicollinearity between fear of falling/fear-induced activity restriction and covariates by correlation analysis and collinearity statistical tests (tolerance and variance inflation factor tests), as suggested for logistic regression (Allison, 2003). p < .05 was considered to indicate significance. The data analysis was conducted with the SPSS Version 19.0 software (SPSS Inc., Chicago, Illinois, the United States).
Results Table 1 shows the characteristics of the study participants according to fear of falling. About one quarter of the participants (22.5%) reported no fear of falling (n = 955), 48.6% reported fear of falling alone (n = 2,063), and 28.9% reported fear-induced activity restriction (n = 1,229). In addition, 37.3% of the participants who reported fear of falling also reported restricting their activities. Significant differences were observed among the three groups in terms of demographic, physical, functional, and psychosocial factors as well as history of falls (p < .001). The proportion of participants aged ≥85 year, female, living alone, and reporting low subjective economic status was the highest in those with fear-induced activity restriction, intermediate in those with fear of
Downloaded from jah.sagepub.com at Bobst Library, New York University on April 20, 2015
8
Journal of Aging and Health
Table 1. Characteristics of Participants.
Characteristics
No fear of falling n (weighted %)
Fear of falling alone n (weighted %)
Demographic factors Age (year) 65-74 756 (79.2) 1,343 (65.1) 176 (18.4) 623 (30.2) 75-84 22 (2.3) 98 (4.7) 85 above M ± SD 70.57 ± 5.35 73.02 ±5.95 Gender Male 608 (63.7) 824 (39.9) 347 (36.3) 1,239 (60.1) Female Education Less than 6 451 (47.2) 1,367 (66.3) years 161 (16.9) 277 (13.4) Middle school High school 343 (35.9) 420 (20.3) above Total 954 (100.0) 2,064 (100.0) Demographic factors Living arrangement Living alone 91 (9.5) 344 (16.7) Living with 864 (90.5) 1,719 (83.3) others Subjective economic status High 42 (4.4) 71 (3.4) Middle 531 (55.7) 963 (46.7) Low 381 (39.9) 1,029 (49.9) Physical and functional factors Cognitive impairment Normal 627 (65.7) 1,010 (49.0) Possible 217 (22.7) 646 (31.3) Confirmed 111 (11.6) 407 (19.7) Total 954 (100.0) 2,064 (100.0) Physical and functional factors Sensory function (vision) Good 261 (27.4) 312 (15.1) Fair 554 (58.1) 1,132 (54.9) Bad 139 (14.6) 619 (30.0)
Fear-induced activity restriction n (weighted %) Trend pa
580 (47.2) 495 (40.3) 154 (12.5) 75.90 ± 7.22
