Journal of Gerontology: MEDICAL SCIENCES
2005, Vol. 60A, No. 3, 355–360
Copyright 2005 by The Gerontological Society of America
Fear of Falling and Related Activity Restriction
Among Middle-Aged African Americans
Margaret-Mary G. Wilson,1 Douglas K. Miller,1,2,3 Elena M. Andresen,2 Theodore K. Malmstrom,1
J. Philip Miller,4 and Fredric D. Wolinsky5
Schools of 1Medicine and
Public Health, Saint Louis University, St. Louis, Missouri.
3
Geriatric Research, Education, and Clinical Center, St. Louis Veterans Affairs Medical Center, Missouri.
4
Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri.
5
College of Public Health, University of Iowa, Iowa City.
2
Background. The prevalence of fear of falling and related activity restriction, and their joint distribution with falls and
falls efficacy, have been inadequately addressed in population-based studies of middle-aged and African-American groups.
Methods. The African American Health project is a population-based panel study of 998 African Americans born in
1936–1950 from two areas of metropolitan St. Louis (an impoverished inner-city area and a suburban area). Fear of falling,
fear-related activity restriction, and 24 frailty-related covariates were assessed during in-home evaluations in 2000–2001.
Results. We found that 12.6% of participants reported having fear of falling without activity restriction, 13.2% had fear
of falling with activity restriction, and 74.2% had no fear of falling. Neither fear of falling nor fear-related activity
restriction varied significantly across three birth cohorts (1946–1950, 1941–1945, and 1936–1940). Lack of overlap of
these two phenomena with having a fall in the past 2 years and low falls efficacy was considerable. When examined across
three groups (no fear, fear without activity restriction, and fear with activity restriction), a consistent pattern of decreasing
health status and social, emotional, and physical functioning was demonstrated.
Conclusions. In this population-based sample of 49- to 65-year-old African Americans, fear of falling and fear-related
activity restriction were surprisingly common and not well explained by prior falls or low falls efficacy. These phenomena
were already evident by age 49–55. Further study is warranted, including detailed qualitative investigations examining the
timing, precursors, and consequences of fear of falling and fear-related activity restriction in minority and majority
populations.
W
ORRY that one might fall is a serious and common
concern among older adults (1,2) regardless of
whether it is measured as a general fear that one might
fall (denoted ‘‘fear of falling’’ in this article) or a lack of
confidence that one can perform activities without falling
(denoted ‘‘falls efficacy’’) (2–4). Reported prevalence in the
community of fear of falling or low falls efficacy ranges
from 12% to 65% in adults older than 60 years, and fear
of falling occurs frequently in the absence of a recent fall
(2,4–7). Worry regarding falling is associated with restriction of physical activity, de-conditioning, poorer healthrelated quality of life, more falls, greater frailty, and
increased mortality (5,8–11). Among older persons, there
appears to be a continuum of functional status from those
with no fear of falling (best), to those with fear of falling
without activity restriction (intermediate), to those with fearrelated activity restriction (worst) (12).
Although there is considerable evidence that fear of falling
is a multifactorial syndrome resulting from a complex and
dynamic interplay among physical, psychological, and social
factors in older adults (1,7,11,13), much remains unknown
about fear of falling and low falls efficacy. Although there
are some data about the prevalence of these phenomena at
the population level (6,7,14,15), more studies are needed
among minority populations—such as African Americans—
as available evidence highlights the existence of significant
differences, which may have important clinical and therapeutic implications. For example, one recent study (3) demonstrated that the expression of fear of falling and falls
efficacy and their relationships to other falls-related factors
differ between African-American and white women. Compared to age- and activity-matched white women, older
African-American women had higher self-efficacy and comparable balance performance but slower gait speeds. The
relationships among the three measures also varied between
the two racial groups. Such data underscore the need to
investigate these phenomena within different population
groups. To our knowledge, there is no published information
about the amount of overlap, or lack thereof, between fear of
falling and falls efficacy at the population level. The prevalence of fear of falling and low falls efficacy among
younger adults also deserves additional investigation. Available data are scanty and limited to selected cohorts with
disabling diseases such as rheumatoid arthritis or lower
extremity amputations (16,17).
The African American Health (AAH) project is a population-based panel study of community-dwelling middle-aged
African Americans living in the St. Louis metropolitan area.
In a previous article that focused on the correlates of fear of
falling, low falls efficacy, and falls in this cohort, we reported
the simple prevalences of these problems but did not examine the overlap among them, their variation by age, or their
355
356
WILSON ET AL.
relationships to activity restriction (18). In this report, we
examine the overlap among the four problems (including
fear-related activity restriction) in this group and attempt to
identify when these phenomena first become evident by
exploring their prevalences across the available age range.
We also inspect the functional status of participants with fear
of falling with activity restriction versus the statuses of those
with fear of falling alone and those without fear of falling.
METHODS
Participants
Participants were recruited in their own homes using a twostage random selection process. Recruitment was conducted
from two catchment areas selected to maximize socioeconomic differences: a poor inner city area of St. Louis,
Missouri, and higher socioeconomic status suburban communities just northwest of the city. The inner-city area
comprised predominantly African-American residents, but
the racial composition of the suburban area was quite
variable. Therefore, suburban blocks with a population of at
least 10% African Americans based on the 1990 Census were
selected. Sampling fractions were chosen to facilitate
recruitment of approximately equal numbers of participants
from both communities to maximize socioeconomic contrast.
Because the inner city area had fewer eligible participants
than the suburban area, it was oversampled relative to population size. This resulted in higher probabilities of selection in
the inner-city area. Thus, when the total sample was weighted
by the probability of selection, the inner-city area had a lesser
impact on results. Inclusion criteria included: not living in
an institution, having a birth date between 1936 and 1950
(inclusive), self-reporting black race or African-American
ethnicity, having a standardized Mini-Mental Status Examination score (SMMSE) 16 (19,20), and willing to provide
signed informed consent. In-home assessments were conducted on all recruited participants between September 2000
and July 2001. Recruitment rate was 76%.
Outcome Variables
To categorize participants into the three groups (no fear of
falling, fear of falling alone, and fear of falling with associated activity restriction), we first asked participants, ‘‘Are
you afraid of falling?’’ (2,5,12) Positive responders were
asked to grade the severity of that fear as ‘‘somewhat’’ or
‘‘very much.’’ Fear-related activity restriction was ascertained by asking positive responders, ‘‘Has fear of falling
made you avoid any activities?’’ Participants who reported
no fear of falling constitute the ‘‘no fear’’ group. Those
individuals who reported fear of falling but no activity
restriction are included in the ‘‘fear of falling alone’’ group.
The final group consists of participants who had both fear
of falling and fear-related activity restriction.
Covariates
For falls history, participants were asked whether they had
fallen in the past 2 years, and individuals who reported falling in the past 2 years were asked if they had fallen in the past
year. Participants were determined to have suffered an injurious fall in the past year if they had experienced any of the
following after one or more falls: need for medical attention,
inability to get up on their own without help from someone
else, bone fracture, or need to cut down on their usual
activities due to the fall. Falls efficacy was measured using
Tinetti’s 10-item Falls Efficacy Scale (FES), designed to
measure confidence in performing everyday activities without falling, with the response for each item ranging from
0 (no confidence) to 10 (complete confidence) (14). These
activities were cleaning house, dressing, preparing simple
meals, taking a bath or shower, light shopping, getting in and
out of a chair, going up and down stairs, walking around the
neighborhood, reaching into cabinets or closets, and rushing
to answer the telephone. The FES score ranged from 0 to 100
(mean 93.3, SD 15; Cronbach’s alpha coefficient ¼ 0.93).
The FES score distribution was highly skewed with a large
ceiling effect (59.3% of participants scored 100). We defined
those participants scoring in the lowest quartile (score 0–95)
to have low FES scores. This technique is consistent with
approaches used in previous studies that also identified
highly skewed FES data (10). Demographic variables
included sex, years of formal education, and whether the
participant lived alone. Participants’ self-reports of physicians’ diagnoses of each of nine chronic conditions (hypertension, diabetes mellitus, cancer other than a minor skin
cancer, chronic airway obstruction, coronary artery disease,
congestive heart failure, arthritis, stroke, and chronic kidney
disease) were obtained by interview, and the number of
reported conditions was summed. Fair or poor health was
measured using the SF-36’s self-rated health question (21).
Visual acuity was measured using a 3-item scale (3 ¼
excellent to 15 ¼ poor, alpha ¼ 0.74) from the 2000 Health
and Retirement Survey (HRS) (22) and included subjective
ratings for eyesight in general, for seeing things at a distance,
and for seeing things up close (with corrective lenses, if
applicable). Hearing was assessed using a single-item,
subjective rating of hearing (with use of a hearing aid, if
applicable) with a five-level response ranging from excellent
to poor (22). Interviewers also obtained the SMMSE (19),
a 5-item social support scale derived from the MOS instrument (alpha ¼ .85) (23), and depressive symptoms using the
11-item Center for Epidemiological Studies Depression
symptoms index (CES-D) (24) (alpha ¼ 0.83).
The basic activities of daily living (BADL; alpha ¼ 0.84)
scale was the simple count of items with reported difficulty
performing seven different activities (bathing, dressing, eating, getting in and out of bed or chair, walking across room,
getting outside, and using the toilet; range 0–7) using the
wording and method of the Second Longitudinal Study on
Aging (LSOA II) (25). The instrumental activities of daily
living (IADL; alpha ¼ 0.82) scale involved a simple count of
eight activities from the LSOA II and from Lawton and Brody
(26) (preparing meals, shopping for groceries, managing
money, making phone calls, performing light housework,
performing heavy housework, getting to places out of walking
distance, and managing medications; range 0–8) for which the
participant reported difficulty. Six items from the Nagi
physical performance scale (27) were used to construct a scale
tapping lower body limitations (0 ¼ no difficulties to 6 ¼
difficulties on all activities; alpha ¼ 0.87); these items
included difficulties in walking a quarter of a mile, walking
FEAR OF FALLING IN MIDDLE-AGED BLACKS
357
Table 1. Characteristics of Participants in the African American Health Project by Level of Fear of Falling and Activity Restriction
Level of Fear of Falling–Activity Restriction*
Variable
N
No Fear
(N ¼ 693)
Fear of Falling
Alone
(N ¼ 149)
Fear, Plus Activity
Restriction
(N ¼ 155)
p Valuey
997
997
995
995
56.74 (4.43)
54.4
12.75 (2.79)
21.0
56.53 (4.35)
69.7
11.92 (3.05)
27.2
57.28 (4.54)
68.3
11.54 (2.47)
32.6
¼.102
,.001
,.001
,.01
997
998
982
997
998
27.8
1.50 (1.20)
7.91 (2.41)
2.25 (1.02)
28.30 (2.18)
55.0
2.15 (1.50)
9.19 (2.59)
2.52 (1.07)
27.73 (2.35)
73.1
2.66 (1.45)
9.48 (2.88)
3.03 (1.05)
26.51 (3.33)
,.001
,.001
,.001
,.001
,.001
991
993
20.15 (4.60)
3.96 (4.06)
17.99 (4.20)
6.40 (4.47)
16.72 (4.78)
9.01 (5.73)
,.001
,.001
Demographics
Age
Female sex, %
Years of education
Living alone, %
Health status
Self-rated health (%, fair or poor)
No. of chronic conditions
Vision scale
Hearing scale
Mini-Mental State Examination
Social and emotional status
Social support scale (MOS)
Depressive symptoms (CES-D)
Reported physical function
Basic activities of daily living
Instrumental activities of daily living
Upper body limitations
Lower body limitations
991
994
997
993
0.33
0.39
0.24
1.08
(0.94)
(0.98)
(0.62)
(1.54)
0.97
1.22
0.70
2.24
(1.69)
(1.70)
(1.00)
(1.82)
1.94
2.44
1.18
3.30
(2.15)
(2.21)
(1.20)
(1.73)
,.001
,.001
,.001
,.001
908
745
792
792
485
36.25
11.41
20.53
14.39
0.82
(11.91)
(3.95)
(11.08)
(11.62)
(0.24)
30.40
13.14
18.21
12.99
0.72
(10.46)
(3.89)
(11.49)
(11.10)
(.25)
28.39
15.59
12.37
10.05
0.69
(11.37)
(6.61)
(12.02)
(10.48)
(0.21)
,.001
,.001
,.001
,.01
,.01
Measured physical function
Handgrip (kg)
Chair stands
One leg stand
Tandem stand, eyes closed
Gait speed (m/s)
Fall related
Noninjurious fall in past year (%)
Injurious fall in past year (%)
Falls Efficacy Scale 95 (%)
997
997
997
11.7
8.3
14.9
14.3
13.1
41.5
15.5
28.0
72.8
¼.204
,.001
,.001
Note: All data are weighted to represented population and represented as mean (SD), except where noted.
*Amount of missing data varied across variables.
y
Chi-Square for trend was computed for dichotomous variables and analysis of variance for linear trend computed for continuous variables.
MOS ¼ Medical Outcomes Study; CES-D ¼ Center for Epidemiological Studies–Depression scale.
up and down 10 steps without rest, standing for 2 hours,
stooping, lifting 10 pounds, and pushing large objects. Three
items from the Nagi scale tapped upper body limitations (0 ¼
no difficulties to 3¼difficulties on all activities; alpha¼0.57);
these items included difficulties reaching up over one’s head,
reaching out as if to shake hands, or reaching to grasp an
object. Handgrip strength was obtained with the Baseline
hand dynamometer (Smith & Nephew, Germantown, WI).
Timed performance measures included five chair stands (28),
usual walking speed of 3 or 4 meters (28), tandem stance with
eyes closed (29), and one-leg stand (30). Data were available
on almost all participants for the interview items, whereas
proportions of participants with missing data for measured
physical function varied by the function (Table 1).
Analyses
Unweighted data were used to report number of participants. Proportions, means, standard deviations, and statistical differences between groups were determined using data
weighted to the total population or the catchment area (as
required by the specific analysis) using the SPSS weight
cases function (SPSS, Chicago, IL). Falls history, fear of
falling, and fear-related activity restriction were evaluated
across three progressively older age groups separately for
men and women using chi-square for trend, and by sex and
catchment area using chi-square for independence. FES
scores across the age groups by sex were evaluated by
ANOVA for linear trend. Amount of overlap among those
persons who experienced one or more falls in the past 2 years,
those with an FES score 95, those with either moderate or
severe fear of falling, and those with fear-related activity
restriction was calculated using cross-tabulations. Information for falls and fear of falling was available for all participants, but one participant was missing an FES score. The
relationship between the covariates and the three levels of
fear of falling and activity restriction was examined using
analysis of variance for linear trend for continuous variables
and chi-square for trend for dichotomous measures (12).
RESULTS
Nine hundred ninety-eight participants participated in
the study; these comprised 627 (62.8% unweighted; 58.8%
WILSON ET AL.
358
Table 2. Fall in the Past 2 Years, Fall in Past Year, Harmful Fall in Past Year, Falls Efficacy Scale, Fear of Falling, and Activity Restriction Due to
Fear of Falling Among Participants in the African American Health Project by Sex, Date of Birth, and Catchment Area*
Birth Year
Sex
Variabley
1946–1950
1941–1945
1936–1940
1946–1950
Men
627
56.9 (4.5)
37.0
22.3
12.0
371
56.6 (4.4)
34.1
26.3
10.8
257
52.1 (1.5)
33.4
18.4
9.0
196
57.3 (1.4)
39.9
24.8
12.1
174
62.3 (1.6)
38.5
24.5
15.3
168
52.0 (1.6)
33.8
27.2
9.4
121
57.3 (1.6)
36.4
29.8
15.9
92.9 (15.2)
93.3 (15.3)
94.9 (15.0)
92.6 (15.2)
90.9 (15.4)§
94.2 (14.3)
No fear
Somewhat fearful
Very fearful
69.4
15.0
15.6
80.9{
12.1
7.0
72.9
12.3
14.8
66.1
15.6
18.3
68.4
17.6
14.0
Activity restriction due to
fear of fallingk
50.6
52.3
41.9
57.3
52.7
Unweighted n
Mean age (SD)
Fall in past 2 years
Fall in past year
Injurious fall in past year
Falls Efficacy Scale,
mean (SD)
Women
1941–1945
Women
1936–1940
Men
Catchment Area
Inner City
Suburbs
82
61.9 (1.5)
32.0
21.4
6.8
463
57.3 (4.8)
38.6
27.0
14.0
535
56.6 (4.3)z
35.0
23.2
10.8
93.1 (13.5)
92.4 (18.3)
91.1 (17.5)
93.6 (14.5)z
78.4
15.2
6.3
79.9
13.2
6.9
85.2
6.8
8.0
65.7
17.5
16.8
76.5{
12.8
10.7
58.6
40.2
59.0
52.7
50.6
Fear of falling
*
Notes: All data are weighted to the represented population, except as noted. Percentages are presented, unless otherwise noted.
Statistical contrasts are computed separately for each of four groups: 1) sex, 2) catchment area, 3) birth year for women only, and 4) birth year for men only. For
groups 1 and 2, chi-square for independence was computed for fall in past 2 years, fall in past year, harmful fall in past year, fear of falling, and activity restriction; and
t test was computed for age and Falls Efficacy Scale. For groups 3 and 4, chi-square for trend was computed for fall in past 2 years, fall in past year, harmful fall in
past year, fear of falling, and activity restriction; and analysis of variance for linear trend was computed for Falls Efficacy Scale.
z
p , .05 by t test.
§
p , .05 by analysis of variance for linear trend.
{
p , .001 by chi-square for independence.
k
Activity restriction is among those who reported moderate or severe fear of falling.
y
weighted) women and 371 (37.2% unweighted; 42.2%
weighted) men. Mean age was 56.8 (64.44 SD; range 49–
65 years), 23.7% lived alone, average educational attainment
was 12.4 years (range 0–25), and average number of chronic
conditions was 2.10. In the entire cohort, 35.8% of the
participants had a fall in the past 2 years, 24.0% had a fall in
the past year, 11.5% had an injurious fall in the past year,
74.2% had no fear of falling, 25.8% had some degree of fear
of falling (13.8% somewhat fearful and 12.0% very fearful),
and 51.2% of those with fear of falling had fear-related
activity restriction. The average FES score was 93.1, and
25.9% had a score of 95. The inner-city group was more
likely to have fear of falling (34.4%) than were the suburban
participants (23.5%). There were no significant differences
across the three age groups for either sex, except for a fourpoint drop in FES score for women (Table 2). Although the
differences were not significant, the oldest men (born in
1936–1940) demonstrated lower prevalence of falls and fear
of falling than did the younger men, whereas the FES scores
worsened modestly from youngest to oldest men.
The correlation between FES score and the three categories of fear of falling (none, somewhat, and very much)
was 0.47 by Spearman rank correlation coefficient. Of the
304 participants with fear of falling, 144 (47%) had no fall in
the past 2 years, and 53 (37%) of those had fear-related
activity restriction. Of the 304, 128 (42%) did not have low
FES scores, but 42 (33%) of them also had activity restriction. Of those with fear of falling, 76 (25%) had neither fallen
in the past 2 years nor had low FES scores, and 16 (21%) of
these had activity restriction.
All of the covariates showed worsening status across the
three fear-of-falling activity-restriction groups, except for
age and noninjurious falls. Controlling for age and sex (analysis of covariance for continuous variables, multinomial
logistic regression for categorical variables) did not materially change any of these associations (data not shown).
DISCUSSION
The results of this study have several themes worth
highlighting. To our knowledge, the AAH project is the first
population-based study of fear of falling in a large sample of
African Americans and exclusively in middle-aged individuals (18). Because fear of falling manifests itself differently
in African Americans than in whites (3), race-/ethnicityspecific studies such as this are essential. Previous studies
among older adults (2,4,5,7) report a prevalence of fear of
falling that ranged from 40% to 73% among fallers and from
20% to 46% among non-fallers). Additionally, Vellas and
colleagues (11) identified fear-of-falling–related activity restriction in 41% of fallers and 23% of non-fallers. Earlier
studies (11,14,15) show that adults with fear of falling are
significantly older than adults without this fear. However,
fear of falling and fear-related activity restriction were not
quite as prevalent in the total AAH project population as
was reported in previous population-based studies of older
persons. Nevertheless, both phenomena were surprisingly
high for this younger group, especially in the inner city,
where the fear of falling prevalence was one in three and was
similar to that reported for older persons (6,7,14,15). No
change in the prevalence of either fear of falling or fearrelated activity restriction was demonstrated across the available age range. Thus, we were unable to identify an age at
which these problems appear to become common in this
population, except to note that they were already evident in
FEAR OF FALLING IN MIDDLE-AGED BLACKS
the 49- to 55-year age group. In addition, the pattern of fear of
falling and numbers of falls across age among men is unusual
and deserves additional research with in-depth qualitative
and longitudinal studies to investigate whether this finding is
due either to denial in the older age group or to some other
factor. Our results confirm the findings of Murphy and
colleagues (12) that the functional status of persons with fear
of falling alone is intermediate between those with no fear
and those with fear and activity restriction in a younger and
different race than in their study.
There was considerable lack of overlap between the
measure of low falls efficacy and both fear of falling and
fear-related activity restriction. In addition, falls efficacy
increased significantly across the available age range in
women, whereas fear of falling did not. Thus, these variables
appear to measure different constructs. This finding is supported by other literature (2,11,31) and has several implications. Investigators should not treat falls efficacy and fear
of falling as synonymous; they should use both of them or
the one that best meets the needs of their study. In addition,
although fear of falling and related activity restriction appear
common, firm understanding of why people become fearful
or restrict their activities is lacking. Therefore, more detailed
qualitative and quantitative studies of the age of onset, precursors, clinical course, and consequences of fear of falling
and fear-related activity restrictions are warranted. In particular, additional longitudinal studies and detailed focus group
investigations fully exploring the origins and consequences
of these phenomena are essential, with the recognition that
the answers may vary by age, sex, race-ethnicity, and social
circumstances. For example, fear of falling was more frequent in the inner-city group, as expected, due to earlier
reports of an association between low socioeconomic status
and low self-efficacy (32–35). Although the exact reasons for
this finding require additional exploration, it is possible that
the increased risk of environmental hazards, inadequate
resources, and socioeconomic disadvantage in inner-city
neighborhoods increase the perception of fall risk among
resident elders.
This study has limitations as well as strengths. Its confinement to middle-aged African Americans living in one
geographic area limits its generalizability to other ages, raceethnicities, and locales. In contrast, its results are consistent
with the prior literature, and we suspect that its major findings
will be replicated in future studies. In addition, we used only
one of several measures of falls efficacy. It is possible that we
would have found more overlap between fear of falling and
other measures of falls efficacy, although the extant literature
would argue against this (3,4).
Conclusion
Fear of falling and fear-related activity restriction were both
surprisingly high in this population of middle-aged African
Americans, particularly in the inner city, and were not well
explained by prior falls or low falls efficacy. These phenomena were already evident by age 50 in a substantial proportion
of participants. Participants with fear of falling alone have
functional status between those without fear and those with
fear and activity restriction. Fear of falling and fear-related
activity restriction deserve more study, including detailed
359
qualitative investigations examining the timing, precursors,
and consequences of these phenomena in minority as well as
majority populations. In the meantime, clinicians should be
aware that fear of falling is common even in middle-aged
patients and that the associated activity restrictions can have
numerous adverse consequences, including premature death
(36–38). Further research is needed to support the extrapolation of our findings to other ethnic populations.
ACKNOWLEDGMENTS
Supported by grant RO1 AG10436 from the National Institute on Aging.
Presented in part at the 2002 Annual Scientific Meeting of the American
Geriatrics Society, May 11, 2002, in Washington, D.C.
Address correspondence to Margaret-Mary G. Wilson, MD, Division
of Geriatric Medicine, St. Louis University School of Medicine, 1402
S. Grand Blvd., M238, St. Louis, MO 53104. E-mail: [email protected]
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Received July 7, 2003
Accepted November 10, 2003
Decision Editor: John E. Morley, MB, BCh