Falls are a critical health concern, with fear of falling and cognitive function recognized as key factors in the complex network of causes leading to falls. Yet, their mediating roles in urban settings of low- and middle-income countries remain underexplored.
Research Design and Methods
This study was conducted among 9,117 women aged ≥60 years in Iran (Dec 2024–Jan 2025), using stratified sampling across eleven municipal zones. Validated tools assessed fear of falling, cognitive function, loneliness, anxiety, depression, and frailty. Analyses included logistic regression, mediation, and survival models, adjusting for age, education, and assistive device use.
Results
Higher fear of falling increased the odds of falling (OR = 1.04, p < .001). In contrast, better cognitive function reduced fall risk by about 1% per unit increase (OR = 0.99, p < .001). The oldest-old reported greater fear and loneliness (p < .05). Mediation analysis showed cognitive function partially explained the pathway from frailty to fear of falling (z = −6.6, p < .001). Survival analysis indicated that less lonely participants had lower fall risk (HR = 0.99, p <.001).
Discussion and Implications
Stronger cognitive ability and reduced fear of falling are protective against falls. Interventions targeting these domains can enhance safety and resilience, offering guidance for policymakers and urban planners.
AtchisonK.WuP.SamiiL.WalshM.IsmailZ.IaboniA.GoodarziZ. (2024). Detection of anxiety symptoms and disorders in older adults: A diagnostic accuracy systematic review. Age and Ageing, 53(7), afae122. https://doi.org/10.1093/ageing/afae122
2.
BilginY. O. U.KoskdereliogluA.GedizliogluM. (2023). Fall risk is related to cognitive functioning in ambulatory multiple sclerosis patients. Neurological Sciences, 44(9), 3233–3242. https://doi.org/10.1007/s10072-023-06770-4
ChenH.HuangL.XiangW.LiuY.XuJ. W. (2023). Association between cognitive frailty and falls among older community dwellers in China: A Chinese longitudinal healthy longevity survey-based study. Frontiers in Aging Neuroscience, 14, Article 1048961. https://doi.org/10.3389/fnagi.2022.1048961
5.
GoslingC. J.ColleR.CartignyA.JollantF.CorrubleE.FrajermanA. (2024). Measuring loneliness: A head-to-head psychometric comparison of the 3-and 20-item UCLA loneliness scales. Psychological Medicine, 54(14), 3821–3827. https://doi.org/10.1017/S0033291724002083
6.
HeidenblutS.ZankS. (2020). Screening for depression in old age with very short instruments: The DIA-S4 compared to the GDS5 and GDS4. Gerontology and Geriatric Medicine, 6, 2333721420981328. https://doi.org/10.1177/2333721420981328
7.
HusseinS. (2023). Reflections on the intersectionality of gender and ageing in the Middle East. Journal of the British Academy, 11(S2), 55–70. https://doi.org/10.5871/jba/011s2.055
8.
KlimaD. W.RabelM.MandelblattA.MiklosovichM.PutmanT.SmithA. (2021). Community-based fall prevention and exercise programs for older adults. Current Geriatrics Reports, 10(2), 58–65. https://doi.org/10.1007/s13670-021-00354-w
9.
LeeE. S.KimB. (2024). The impact of fear of falling on health-related quality of life in community-dwelling older adults: Mediating effects of depression and moderated mediation effects of physical activity. BMC Public Health, 24(1), 2459. https://doi.org/10.1186/s12889-024-19802-1
10.
LinP.WanB.ZhongJ.WangM.TangF.WangL.DengL.YeY.LiuX.PengL. (2024). Risk of fall in patients with chronic kidney disease: Results from the China Health and Retirement Longitudinal Study (CHARLS). BMC Public Health, 24(1), 499. https://doi.org/10.1186/s12889-024-17982-4
11.
McGarrigleL.YangY.LasradoR.GittinsM.ToddC. (2023). A systematic review and meta-analysis of the measurement properties of concerns-about-falling instruments in older people and people at increased risk of falls. Age and Ageing, 52(5), afad055. https://doi.org/10.1093/ageing/afad055
12.
PalmateerG.LukeW.BraunschweigA.SchmeusserB.MidenbergE.PatilD.ImtiazN.PatelS.MumfordS.KearnsE.VashiK.HajiahM.GrajalesV.JoshiS. S.NarayanV. M.OganK.MasterV. A. (2025). Assessing the ability of timed up and Go and modified frailty Index-5 compared to fried frailty index to objectively identify frail patients undergoing evaluation for surgery. Surgical Oncology Insight, 2(3), Article 100183. https://doi.org/10.1016/j.soi.2025.100183
13.
RosenblattN. J.MajorM. J.ManeshB.SchneiderK.MillerS. A. (2024). Validating a fear‐of‐falling–related activity avoidance scale in lower limb prosthesis users. PMR, 16(5), 462–473. https://doi.org/10.1002/pmrj.13063
14.
SalisF.PiliD.ColluM.SerchisuL.LaconiR.MandasA. (2023). Six-item Cognitive Impairment Test (6-CIT)’s accuracy as a cognitive screening tool: Best cut-off levels in emergency department setting. Frontiers in Medicine, 10, Article 1186502. https://doi.org/10.3389/fmed.2023.1186502
15.
ShengY.WangC.WangY.PanL.ZhangM.LiuD.GaoW. (2025). An umbrella review of physical-activity therapy and cognitive behavioral therapy in reducing fear of falling among community-dwelling older adults: Insights on intervention intensity and duration. Frontiers in Public Health, 12, Article 1498451. https://doi.org/10.3389/fpubh.2024.1498451
16.
SmithM. L.HanG. (2024). Effectiveness of evidence-based fall prevention programs to reduce loneliness in the United States. Frontiers in Public Health, 12, Article 1459225. https://doi.org/10.3389/fpubh.2024.1459225
17.
United Nations Department of Economic and Social Affairs. (2024). World population ageing 2023: Challenges and opportunities of population ageing in the least developed countries. (Statistical Papers, Series A, Population and Vital Statistics Report). https://doi.org/10.18356/9789213586747
18.
XiongW.WangD.RenW.LiuX.WenR.LuoY. (2024). The global prevalence of and risk factors for fear of falling among older adults: A systematic review and meta-analysis. BMC Geriatrics, 24(1), 321. https://doi.org/10.1186/s12877-024-04882-w
19.
XuD.WangY.ZhuS.ZhaoM.WangK. (2024). Relationship between fear of falling and quality of life in nursing home residents: The role of activity restriction. Geriatric Nursing, 57, 45–50. https://doi.org/10.1016/j.gerinurse.2024.03.006
20.
XuQ.OuX.LiJ. (2022). The risk of falls among the aging population: A systematic review and meta-analysis. Frontiers in Public Health, 10, Article 902599. https://doi.org/10.3389/fpubh.2022.902599
21.
YaoS.ChenX. W. (2024). The association between depressive symptoms with fear of falling and cognitive decline in older adults in the Korean community: An analysis of the Korean Longitudinal Study of Aging (KLoSA), 2006–2020. Archives of Gerontology and Geriatrics, 117, Article 105177. https://doi.org/10.1016/j.archger.2023.105177
22.
YosefT.PascoJ. A.TemboM. C.WilliamsL. J.Holloway-KewK. L. (2024). Falls and fall-related injuries: Prevalence, characteristics, and treatment among participants of the Geelong osteoporosis study. Frontiers in Public Health, 12, Article 1454117. https://doi.org/10.3389/fpubh.2024.1454117
23.
YoshikawaA.RamirezG.SmithM. L.LeeS.OryM. G. (2020). Systematic review and meta-analysis of fear of falling and fall-related efficacy in a widely disseminated community-based fall prevention program. Archives of Gerontology and Geriatrics, 91, Article 104235. https://doi.org/10.1016/j.archger.2020.104235
