In this longitudinal observational study, we investigated the association of FoF with fall occurrence according to fall history in the previous one year (non-fallers, single fallers, and multiple fallers) for community-dwelling older adults. Our results indicate that FoF was significantly associated with the occurrence of falls in community-dwelling older adults. However, the association was not consistent with fall history at baseline.

First, the results of Poisson regression models showed that the FoF was significantly associated with fall occurrences even after controlling for confounders, and the RR was 3.70. These results indicate that FoF is a significant risk factor affecting fall occurrence, and that the assessment of FoF is useful to predict fall occurrences in community-dwelling older adults. These results support previous research, showing FoF as a fall risk factor [5, 28]. A systematic review has shown that screening for FoF should be prioritized to detect high risk older adults, along with fall history [28]. For clinical staff members, the assessment of FoF is strongly recommended to find older adults who are prone to fall. Additionally, our results showed that the ratio of individuals with FoF increased with an increase in past fall experiences. Some studies have reported people developing FoF without fall experiences, and that FoF is not persistent but transient and can be overcome [29, 30]. This indicates that the experience of falling can lead to FoF; thus, preventing a fall is important to break this cycle.

Hereafter, our results showed that the RRs [95% CI] of interaction between FoF and single fallers and multiple fallers were 0.48 [0.19, 1.38] and 0.37 [0.2, 0.68], respectively. Notably, the RRs of the interactions were lower than one and lowered with increased fall history. These results indicate that the association of FoF with fall occurrence may vary with fall history, with multiple fallers showing lower association of FoF with fall occurrence than single fallers and non-fallers. To our knowledge, no study has investigated the association of FoF with the fall occurrence in multiple fallers. This study provides insights into FoF for clinicians and researchers in this field. The results for multiple fallers can be partially explained by their characteristics. In some studies, multiple fallers showed significantly lowered levels in specific physical functions such as vision and stepping movement when turning, which cannot be captured by general physical assessment [12, 13, 15]. Similarly, the results of systematic review suggest that the information on fall history includes psychological and behavior risks [5]. This implies that having a multiple fall history itself may be a strong predictor for falls compared to other factors. Additionally, FoF-associated physical activity restriction might be a crucial factor that helps in explaining our results [31,32,33]. The FoF-associated physical activity restriction tends to occur in multiple fallers [31]. It leads to significant lowered physical function, which may cause the person to suffer a fall again [32, 33]. In the present study, the measurement of physical activity was not included; thus, in the future, a study is needed that includes the same.

As mentioned above, the interaction between single fallers and FoF was not significant in Poisson regression models. This result indicates that one-time fall history does not affect the association of FoF with fall occurrence, that is, FoF possibly affect non-fallers and single fallers equally in terms of fall occurrences. This result can be partly explained by single fallers’ characteristics. Older adults with high physical functions may fall accidentally by exposing themselves to high fall risk situations [34]. Such people may be classified as single fallers in the present study and may show physical performance similar to non-fallers, which is supported by the slower TUG result. Additionally, although the interaction was not significant, a single fall was associated with fall occurrence and the RRs of single fallers were much smaller than those of multiple fallers. These results are reflective of that of other studies, suggesting that single fallers are an important fall risk group, but they are at lower risk than multiple fallers [16,17,18].

There are some limitations to this study. First, the dropout rate was over 30% (271/801, 34%) and selection bias may have occurred. Even though the results of characteristic comparison between individuals who dropped out and those in the final analytical sample did not differ significantly, potential confounders may still exist. Second, we obtained the number of falls in the past year at both baseline and one-year follow-up via a self-administered questionnaire; thus, recall bias may have occurred. Older adults with FoF possibly have a bias regarding their fall history. For example, those who had FoF may have more easily remembered the previous falls. This implies that FoF and fall history may have a mutual relation, which leads to misclassification of the fall history at baseline. This may affect our results. Third, FoF was measured using a one-item questionnaire. This method is an easy and quick way to assess the prevalence of FoF as mentioned in the introduction. However, the influence of FoF on occurrence of fall may vary according to the degree of FoF. Future studies should assess FoF using a one-item questionnaire, and a multiple-item questionnaire which can quantify FoF, such as fall efficacy scale [6]. Fourth, other risk factors such as mental health issues, eye problems, pain, etc. were not measured in our study [5, 35]. These factors may affect our results. Finally, there was a small sample size for multiple fallers; thus, the generalizability is not high. A well-designed study is warranted in the future to overcome the limitations of the present study.

In conclusion, FoF was associated with the occurrence of falls among community-dwelling older adults, and its association was not consistent with fall history at baseline. Compared with non-fallers, the association of FoF with fall occurrence was smaller in multiple fallers. Our results have implications for clinical staff members to interpret the association of FoF with fall occurrence.

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