JAMDA 16 (2015) 1104.e9e1104.

e13

JAMDA
journal homepage: www.jamda.com

Original Study

Effects of Mild Cognitive Impairment on the Development of Fear

of Falling in Older Adults: A Prospective Cohort Study
Kazuki Uemura PT, PhD a, *, Hiroyuki Shimada PT, PhD b, Hyuma Makizako PT, PhD b,
Takehiko Doi PT, PhD b, c, Kota Tsutsumimoto PT, PhD b, Sangyoon Lee PhD b,
Hiroyuki Umegaki MD, PhD d, Masafumi Kuzuya MD, PhD d, Takao Suzuki MD, PhD e
a

Institute of Innovation for Future Society, Nagoya University, Nagoya, Japan

Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
Research Fellow of the Japan Society for the Promotion of Science, Tokyo, Japan
d
Department of Community Healthcare and Geriatrics, Graduate School of Medicine, Nagoya University, Nagoya, Japan
e
National Center for Geriatrics and Gerontology, Obu, Japan
b
c

a b s t r a c t
Keywords:
Falls
cognitive decline
risk factors
elderly

Objectives: The aim of this study was to determine whether mild cognitive impairment (MCI) affects the
development of fear of falling (FoF) in older adults.
Design: Prospective cohort study.
Setting: The Obu Study for Health Promotion in the Elderly, Japan.
Participants: A total of 1700 community-dwelling people aged 65 years or older without FoF at baseline
participated.
Measurements: FoF and related variables, such as physical function, self-rated health, depression, and
total number of medication doses, were investigated at baseline. Participants also underwent cognitive
tests and were divided into cognitive healthy and MCI. Fifteen months after the baseline measurements,
we collected information about the status of FoF and fall incidence during the 15-month follow-up.
Results: At the 15-month follow-up survey, 452 participants (26.5%) reported the development of FoF.
Logistic regression analysis showed that MCI (odds ratio [95% CI] 1.41 [1.07e1.87]) and a fall incident
(3.00 [2.23e4.07]) during follow-up independently predicted the development of FoF, after controlling
for demographic factors, physical function, self-rated health, and depression. The odds ratio for the
development of FoF in participants with both MCI and a fall incident compared with those without them
was 7.34 (4.06e13.3), after controlling for confounding factors.
Conclusion: MCI predicts the new onset of FoF in older adults, especially when they have experience with
falling. Aside from the risk of falling, it is suggested that individuals with MCI are an at-risk population
for FoF and related negative consequences in terms of postfall syndrome.
2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Fear of falling (FoF) has been identied as a common and potentially disabling problem in community-dwelling older adults.
Approximately half of the community-living older population experiences FoF,1,2 and approximately one-third of older adults who had
The authors declare no conicts of interest.
This work was funded by a grant from the Japanese Ministry of Health, Labour,
and Welfare (Project for Optimizing Long-Term Care; B-3) and a grant from the
National Center for Geriatrics and Gerontology (Research Funding for Longevity
Sciences; 22e16).
* Address correspondence to Kazuki Uemura, PT, PhD, Institute of Innovation for
Future Society, Nagoya University, 65 Tsurumai, Showa-ku, Nagoya, Aichi
466e8550, Japan.
E-mail address: uemura@coi.nagoya-u.ac.jp (K. Uemura).

been free from the symptom developed FoF during a year.3 Negative
consequences and a debilitating spiral of FoF have been widely
documented, such as an increased risk for falling, restriction and
avoidance of activities, deteriorated physical and mental performance,
and ultimately, loss of independence as well as decreased quality of
life.4e6 It is reported that FoF may be as harmful psychologically as
falling itself.7 Factors reported to be independently associated with
FoF include older age, female gender, previous falls, decreased physical function or mobility, use of walking aids, poorer self-rated health,
depression, and living alone.1,4 Despite a number of reports regarding
various factors associated with FoF, few studies have examined the
relationship between FoF and cognitive decline, which is strongly
related to the risk of falling.

http://dx.doi.org/10.1016/j.jamda.2015.09.014
1525-8610/ 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

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K. Uemura et al. / JAMDA 16 (2015) 1104.e9e1104.e13

Emerging evidence indicates that cognitive impairment is a risk

factor for falls, that is, dementia and even mild cognitive impairment
(MCI).8,9 MCI is conceptualized to be the earliest feature of cognitive
disorders and a prodromal condition between normal cognitive
functioning and dementia.10 Neuropsychiatric symptoms are also
common in MCI and are reported to occur in 35% to 75% of cases.11,12
Anxiety, depression, and irritability are the most common symptoms.12,13 In particular, anxiety is a clinical predictor of early conversion to Alzheimer disease (AD).14 If individuals with MCI are also
excessively anxious about falling and related injuries, they may be
prone to developing FoF, especially when having a fall experience,
compared with individuals with normal cognition. However, it
remains unclear whether MCI contributes to the development of FoF.
If there is a neuropsychiatric symptom associated with falling in MCI,
we hypothesized that MCI and fall incidents synergistically affect the
development of FoF.
In addition to studying the risk of falling, investigation of FoF may
be important in the medical management of older adults with MCI.
Because of a lack of studies that allow conclusions regarding causality
in the research eld of FoF, little evidence is available on what causes
this fear.15 We have previously reported that individuals with MCI had
higher FoF prevalence than cognitive healthy individuals,2 but causality has not been claried. The purpose of the present study was to
elaborate the inuence of MCI on the new onset of FoF, especially
focusing on the interaction with fall incidents, in a longitudinal study
design.

Methods
Participants
The current prospective cohort study involved communitydwelling older adults who were enrolled in a cohort study called
Obu Study of Health Promotion for the Elderly (OSHPE) from August
2011 to February 2012. Figure 1 shows the owchart of participant
recruitment and screening. Inclusion criteria required that the
participant was aged 65 years or older at examination in 2011 or 2012,
lived in Obu, had not participated in another study, and had not been
certied as needing support or care by the Japanese public long-term
care insurance system (Care Level 3/5). Recruitment was conducted
through letters mailed to 14,313 people, and 5104 people underwent a
baseline assessment including a face-to-face interview and measures
of physical and cognitive function. A follow-up postal survey was

1104.e10

carried out at approximately 15 months after the baseline assessment

(November 2012eMay 2013) with an offer of assistance in completion.
In this prospective study, we included participants who completed
baseline assessments of physical performance and cognitive function
and follow-up assessments of fall incidents and FoF. We excluded
participants with a history of AD, disability in basic activities of daily
living, or Mini-Mental State Examination (MMSE) scores of 23 or
lower in this study. We also excluded participants who had FoF at
baseline so as to focus on the new onset of FoF. Finally, as 3175 were
excluded at baseline and 229 did not complete the follow-up survey,
this prospective cohort study analyzed data from 1700 older adults.
The mean age of the participants was 70.8 (4.7) years, and 62.1%
were men. Informed consent was obtained from all participants before
their inclusion in the study, and the Ethics Committee of the National
Center for Gerontology and Geriatrics approved the study protocol.
Classication of Cognitive Status
The criteria of MCI were those described by Petersen.16 These
criteria involved the following: (1) having subjective memory complaints, (2) having objective cognitive decline, (3) having intact general cognitive function, MMSE score of 24 or lower, (4) having no
clinical criteria for dementia, and (5) being independent in activities of
daily living. Objective cognitive decline was dened as lower cognitive
function in multiple domains more than 1.5 SD from the healthy
database. Cognitive function in multiple domains was assessed using
the National Center for Geriatrics and GerontologyeFunctional
Assessment Tool (NCGG-FAT). NCGG-FAT contains a battery of cognitive tests; the contents of the measurement have been described in
detail in a previous study.17 The battery consists of 8 tasks to assess
memory, attention and execution, processing speed, and visuospatial
skill. The term cognitive healthy in this study was dened as having
cognitive ability intact, and not having objective cognitive
impairment.
FoF/Fall Incidents
FoF was assessed at baseline and follow-up by a closed-ended
question with 4 response choices about participants general FoF.
The question was phrased as follows: Are you afraid of falling?
Participants who responded very much or somewhat were
assigned to the fear group.2 Participants who responded a little or
not at all were assigned to the no-fear group. Participants who had
reported FoF at follow-up were dened as the developed fear group,
whereas those without FoF at both baseline and follow-up were
dened as the never fear group. The participants also completed a
standardized questionnaire, which recorded the number of times they
had fallen during the 15-month follow-up period. A fall was dened as
an unexpected event in which the person comes to rest on the
ground, oor, or lower level.18 The question Do you have any history
of falling within the past year? was used for detecting fallers. Participants who answered yes to the question were considered to be
fallers.
Potential Confounding Factors With FoF

Fig. 1. Flowchart of participant recruitment and screening.

Demographic data were recorded, including age, gender, and

educational history. Participants completed a questionnaire on medical condition, including total medications used. Participants were also
asked about their use of walking aids in daily life.
Walking speed and the Timed Up and Go Test (TUG)19 were used to
assess physical performance. Walking speed was assessed at usual
pace and expressed in meters per second. The TUG involves rising
from a chair, walking 3 meters, turning around, walking back to the
chair, and sitting down. Participants were instructed to complete the

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1104.e11

K. Uemura et al. / JAMDA 16 (2015) 1104.e9e1104.e13

task at their usual walking pace. The score for this test represents the
time (in seconds) that the participant needed to complete the
assessment. Lower times indicate better physical performance.
Depressive symptoms were measured using the 15-item Geriatric
Depression Scale (GDS).20 Self-rated general health was measured
using the question How would you rate your health in general? with
a 4-point scale ranging from bad, fairly bad, fairly good, to very
good. We categorized participants into 2 groups based on their
responses: Poor, which includes bad and fairly bad and Good,
which includes fairly good and very good.21
Statistical Analysis
All analyses were performed using IBM SPSS Version 21 (IBM Corp,
Chicago, IL). Statistical signicance was set at P less than .05 a priori.
We used Student t tests and c2 tests to compare baseline measures
and fall incidents during the 15-month follow-up between the never
fear and developed fear groups. Associations between the incidence of
FoF and other factors were examined by using the logistic regression
models. In the multiple logistic regression analyses, age, gender,
education, MCI, physical performance, use of walking aids, GDS score,
self-rated health, medications at baseline, and fall incidence during
the follow-up period were included in the nal model. Gender, MCI,
fall incidence, use of walking aids, and self-rated health were created
as categorical variables (female 0, male 1; cognitive healthy 0,
MCI 1; nonfaller 0, faller 1; nonuser 0, user 1; good 0,
poor 1). Additionally, to investigate the joint effect of MCI and fall
incidence, participants were classied into groups based on cognitive
status and fall incidence: (1) cognitive healthy/nonfaller, (2) MCI/
nonfaller, (3) cognitive healthy/faller, and (4) MCI/faller. The logistic
regression model was also used to identify whether each classication
was an independent risk factor for the new onset of FoF.

living alone, MCI, fallers, walking aid use, and poor self-rated health,
than the never fear group.
Table 2 presents univariate and multivariate odds ratios (ORs) for
baseline variables and fall incidents during follow-up comparing
those with newly developed FoF with those who never reported FoF.
Univariate logistic models indicated that age (OR 1.05, 95% condence
interval [CI] 1.03e1.08), gender (OR 0.41; 95% CI 0.33e0.51), living
alone (OR 1.54; 95% CI 1.04e2.23), MCI (OR 1.42; 95% CI 1.10e1.83), fall
incidents (OR 3.35; 95% CI 2.53e4.44), walking speed (OR 0.18; 95% CI
0.11e0.32), TUG (OR 1.20; 95% CI 1.12e1.29), walking aids use (OR
5.60; 95% CI 1.68e18.7), GDS score (OR 1.13; 95% CI 1.08e1.18), and
self-rated health (OR 2.05; 95% CI 1.48e2.83) were signicantly
associated with the development of FoF. Factors retained in the
multivariate model were age (OR 1.05, 95% CI 1.02e1.08), gender (OR
0.32; 95% CI 0.25e0.41), educational history (OR 1.06; 95% CI
1.01e1.12), MCI (OR 1.41; 95% CI 1.07e1.87), fall incidents (OR 3.00;
95% CI 2.23e4.07), walking speed (OR 0.31; 95% CI 0.14e0.70), GDS
score (OR 1.11; 95% CI 1.04e1.15), and self-rated health (OR 1.64; 95% CI
1.12e2).
Synergistic Effect of MCI and Fall Incidents
Figure 2 shows ORs and 95% CIs for FoF development classication
based on MCI and fall incidents. Crude logistic models indicated that
OR of MCI/faller and cognitive healthy/faller groups compared with
the cognitive healthy/nonfaller group were 7.15 (95% CI 4.12e12.4) and
2.72 (95% CI 1.96e3.77), respectively. The OR of the MCI/nonfaller
group did not reach signicance. The adjusted model also indicated
that the OR of MCI/faller and cognitive healthy/faller groups compared
with the cognitive healthy/nonfaller group were 7.34 (95% CI
4.06e13.3) and 2.39 (95% CI 1.69e3.34) after controlling for age,
gender, educational history, living alone, MMSE, walking speed, TUG,
walking aids use, GDS, self-rated health, and total number of medication doses.

Results
Discussion
Longitudinal Predictors of New FoF
At the 15-month follow-up survey, 452 participants (26.5%)
reported the development of FoF. The comparisons between groups
are summarized in Table 1. The developed fear group was signicantly
older, had a lower educational history and MMSE score, slower
walking speed and TUG, higher GDS score, and higher rates of women,
Table 1
Comparisons of Demographic and Clinical Variables Between Groups

Age, y
Gender, male
Body mass index, kg/m2
Educational history, y
Living alone
MMSE, points
MCI
Fall incidents, fallers
Cognitive healthy/nonfaller
MCI/nonfaller
Cognitive healthy/faller
MCI/faller
Walking speed (m/s)
Timed Up and Go test, s
Walking aid use
GDS, points
Poor self-rated health
Total no. of medication doses

Never Fear,
n 1248

Developed Fear,
n 452

70.5  4.4
846 (67.8)
23.3  2.6
12.1  2.5
76 (6.1)
27.3  1.8
244 (19.6)
119 (9.5)
905 (72.5)
224 (17.9)
99 (7.9)
20 (1.6)
1.34  0.2
7.9  1.3
4 (0.3)
2.0  2.1
104 (8.3)
1.7  1.9

71.7  5.4
210 (46.5)
23.2  3.1
11.9  2.6
41 (9.1)
27.1  1.9
116 (25.7)
118 (26.1)
259 (57.3)
75 (16.6)
77 (17.0)
41 (9.1)
1.28  0.2
8.3  1.8
11 (2.4)
2.7  2.7
71 (15.7)
1.9  2.1

<.001
<.001*
.82
<.001
.03
.02
.006*
<.001*
<.001*
.49*
<.001*
<.001*
<.001
<.001
<.001*
<.001
<.001*
.05

Values are mean  SD or n (%).

*P values were generated from t test or c2.

The present prospective study involved participants who had been

free of FoF at baseline and investigated the new onset of FoF and its
relationship with MCI. After 15 months of follow-up, 452 participants
(26.5%) developed FoF, which is consistent with previous reports in
community-based samples of older adults.1,3 It is also in line with
available comparable studies in which older age,3,22,23 female
gender,22 fall experience,22,24 depressive symptoms,25 worse physical
function,1,25,26 and poorer self-rated health24 predicted new FoF.
Modiable factors among identied predictors could be applied for
primary prevention interventions in individuals who have not
developed FoF yet.
Table 2
Univariate and Multivariate Predictors of the Development of FoF
OR (95% CI)

Age
Gender, male
Educational history
Living alone
MMSE
MCI
Fall incident
Walking speed
Timed Up and Go test
Walking aids use
GDS
Poor self-rated health
Total no. of medication doses

Univariate

Multivariate

1.05
0.41
0.97
1.54
0.94
1.42
3.35
0.18
1.20
5.60
1.13
2.05
1.05

1.05
0.32
1.06
1.06
0.94
1.41
3.00
0.31
1.11
1.06
1.11
1.64
0.97

(1.03e1.08)
(0.33e0.51)
(0.93e1.02)
(1.04e2.23)
(0.88e0.99)
(1.10e1.83)
(2.53e4.44)
(0.11e0.32)
(1.12e1.29)
(1.68e18.7)
(1.08e1.18)
(1.48e2.83)
(0.99e1.11)

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(1.02e1.08)
(0.25e0.41)
(1.01e1.12)
(0.68e1.64)
(0.91e1.03)
(1.07e1.87)
(2.23e4.07)
(0.14e0.70)
(0.99e1.24)
(0.26e4.35)
(1.04e1.15)
(1.12e2.83)
(0.91e1.03)

K. Uemura et al. / JAMDA 16 (2015) 1104.e9e1104.e13

1104.e12

efforts to improve physical performance and reduce further fall risk

contribute to lowering the likelihood of FoF development. In addition,
clinical management of individuals diagnosed with MCI should
incorporate monitoring of FoF and recommended strategies, including
behavioral therapy, assertiveness training,31 and management of
anxiety and depression through cognitive restructuring to change
patients sense of control over falls,32 which are not commonly contained in fall-prevention efforts.
The main strengths of this study include a large sample size,
comprehensive nature of the assessment, and the prospective design
that can clarify causality between predisposing factors and new onset
of FoF. However, several limitations of the current study should be
noted. First, only a postal survey without face-to-face interview was
conducted and physical or cognitive performance was not measured at
follow-up. It remains unclear how changes in physical or mental status
inuence the development of FoF. Second, fall incidence is measured
via a questionnaire at 15-month follow-up survey. Recommended
prospective methods (ie, fall diary and follow-up telephone calls)
provide more accurate measures of fall frequency.33 Finally, it should
be acknowledged as a limitation that FoF was assessed as a dichotomous response to a single question. Future longitudinal studies should
use more frequent measurements, which can evaluate activity
restriction associated with FoF, such as the Fall-Efcacy Scale.34
Conclusion

Fig. 2. ORs and CIs for FoF development in participants with versus without MCI and
fall incidence: (A) crude model; (B) adjusted for age, gender, educational history, living
alone, MMSE, walking speed, TUG, walking aids use, GDS, self-rated health, and total
number of medication doses.

The present study demonstrated that MCI was independently

associated with FoF development after 15 months, after controlling
potential correlates of FoF, such as physical function and fall incidents.
Furthermore, MCI and fall incidents had a synergistic effect on new
onset of FoF in older adults. Our ndings suggest that individuals with
MCI are an at-risk population for FoF development and related
negative consequences with respect to postfall syndrome.
Acknowledgments

The major new nding from the present study was that MCI was
independently associated with FoF development. This is the rst
prospective study to clarify the relationship between FoF and MCI in
community-dwelling older adults. It is reported that MCI predicts falls,
but that the relationship with falls would not remain after adjusting
for age and education.8 Interestingly, we found that participants with
MCI were more likely to develop FoF than were those with normal
cognition, even after confounding factors were fully adjusted. The
predictors of injurious falls and developing a FoF may differ. Cognitive
factors, such as MCI, may be considered in the prevention of developing an FoF. Aside from increased risk of falling and decreased
physical function,27 excessive concern about falling may be a clinical
characteristic of MCI that should be addressed in medical
management.
Participants with MCI and fall incidents showed approximately 7
times larger risk of FoF development compared with those without.
Originally, FoF was regarded as a result of the psychological trauma of
falling and related injury and also called postfall syndrome,28
although FoF is prevalent in nonfallers. Neuropsychiatric symptoms
of MCI, such as anxiety,12,13 might decrease condence in physical
health status and make them more afraid of subsequent falling, which
may strengthen the relationship between fall experience and consequent FoF development.
Results of the present study suggest that individuals with MCI are a
population at risk not only for dementia10 and falls,8 but also for the
development of FoF, which leads to avoidance of activity, reduction of
social interaction, and further functional deterioration.4,5 FoF in
individuals with MCI may promote conversion to AD, because
restricted life-space29 or reduced physical activity30 are associated
with increased risk of AD and cognitive decline. It is possible that

We thank the Obu city ofce for helping us with participant

recruitment.
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