Abstract
Background
Falls and physical inactivity increase with age. However, physical activity, falls and their associations in older people born at different times are unclear.
Methods
Women born 1921–26 and 1946–51 who completed follow-up questionnaires in 1999 (n = 8 403, mean (SD) age: 75 (1) years) and 2019 (n = 7 555; 71 (1) years) in the Australian Longitudinal Study on Women’s Health. Self-reported noninjurious and injurious falls in the previous 12 months and weekly amounts and types of physical activity (brisk walking, moderate- and vigorous-intensity) were compared between the cohorts using Chi-square tests. Associations between physical activity, and noninjurious and injurious falls were estimated using multinomial logistic regressions informed by a directed acyclic graph.
Results
A greater proportion of the later (1946–51) cohort (59%) reached 150–300 minutes of weekly physical activity, as recommended by the World Health Organization, compared to the earlier (1921–26) cohort (43%, p < .001). A greater proportion of the later cohort reported noninjurious falls (14% vs 8%). Both cohorts reported similar proportions of injurious falls (1946–51:15%, 1921–26:14%). In both cohorts, participation in 150–300 minutes of physical activity was associated with lower odds of noninjurious falls (adjusted Odds Ratio, 95% CI: 1921–26: 0.66, 0.52–0.84; 1946–51: 0.78, 0.63–0.97) and injurious falls (1921–26: 0.72, 0.60–0.87; 1946–51: 0.78, 0.64–0.96).
Conclusions
Participation in recommended levels of physical activity was associated with reduced falls in both cohorts. However, generational differences were found with more falls and more physical activities in the women born later. Future studies could examine the reasons contributing to the generational differences.
Keywords: Accidental falls, Directed acyclic graph, Older adults, Physical activity, Women
Background
Falls prevention in older adults is a worldwide challenge as projections indicate that 1 in 4 people will be aged 65+ by 2050 (1). At least 1 in 3 community-dwelling older adults experiences at least 1 fall each year (2), and the frequency of falls and fall-related injuries increases with age (3,4). The incidence of falls is higher among older women than men (5). Falls are the leading cause of hospitalized injuries and death among older people in Australia (6). The consequences of falls include fall-related injury hospitalization, reduced physical function, loss of autonomy, and increased dependency (6,7).
Being physically active is widely promoted for health benefits including reduction of all-cause mortality, the risk of noncommunicable disease, improvement of physical, psychological, and social outcomes (8). Structured exercise, a form of physical activity, reduces falls (9,10). The World Health Organization (WHO) recommends older adults undertake 150–300 minutes of moderate-intensity physical activity (8,11). However, 1 in 4 adults globally are insufficiently active (12). Levels of physical activity decrease with increasing age, with women reporting lower physical activity levels than men (13).
With increases in life expectancy, monitoring and understanding health behaviors between different generations is important for preventive measures and future planning. Birth cohorts experience unique environments across their lifespan, which could impact physical activity level, and falls (14,15). Previous systematic reviews examined the associations between physical activity and falls in older people (16,17). However, to our knowledge, no study has examined physical activity and falls in older people born at different times. The Australian Longitudinal Study on Women’s Health (ALSWH), a longitudinal study ongoing since 1996, provides a unique opportunity to explore differences in falls and physical activity in older women from 2 different cohorts of similar age 20 years apart. This study aims to:
describe and compare the proportion of older women who reported noninjurious and injurious falls in the 2 birth cohorts;
describe and compare the amounts and types of physical activity participation in the 2 birth cohorts;
explore and compare the association between physical activity and noninjurious and injurious falls in the 2 birth cohorts.
Method
Data Source
The ALSWH is a prospective longitudinal study with 3 samples of women born within the years 1921–26 (aged 70–75 years in 1996), 1946–51 (aged 45–50), and 1973–78 (aged 18–23), randomly drawn from the national Medicare health insurance database (18–20). Initial response rates were 37%–40%, 53%–56%, and 41%–42%, respectively. To understand falls and physical activity participation in older women of similar age in 2 different generations, we used the 1999 survey (survey 2, aged 73–78 years) in the 1921–26 cohort and the 2019 survey (survey 9, aged 68–73 years) in the 1946–51 cohort (20). In the 1921–26 cohort, 10 434 (84%) of the 12 432 women returned a 1999 survey. In the 1946–51 cohort, 7 956 (58%) of the 13 714 women returned a 2019 survey. Figure 1 shows details of the included sample.
Figure 1.
Sample selection flowchart of the 1921–26 and the 1946–51 born women.
Physical Activity
Using the validated version of the Active Australia National Physical Activity survey, participants self-reported frequency and total duration of physical activity that lasted for ≥10 minutes in the past week including: Walking briskly (for recreation or exercise or to get from place to place); moderate (eg, social tennis, moderate exercise classes, recreational swimming); a vigorous activity that makes one breathe harder or puff and pant (eg, aerobics, vigorous cycling, running, and swimming) (21).
We summed the total duration of brisk walking, moderate and vigorous activity to describe the amount of physical activity participation in the past week (22). Participants were categorized into 4 groups of physical activity duration: zero; 1 to <150 minutes; 150 ≤ 300 minutes; ≥300 minutes. The 150- and 300-minute cut-off was used according to the targeted duration of moderate-intensity activity in the WHO guideline on physical activity (11). Participation in the different types of physical activity specified above was dichotomized (yes/no), depending on whether participants had a nonzero response in either the frequency or duration of the corresponding type of physical activity.
Falls
Participants were considered to have experienced a fall if they had a positive response to any 3 questions about the past year (1) had a fall to the ground, (2) been injured because of a fall; and (3) sought medical attention for an injury from a fall. Participants were considered to have experienced a noninjurious fall if they had reported a fall to the ground without any positive response to either the second or third questions. Participants were considered to have experienced an injurious fall if they had a positive response to either the second or third question.
Potential Covariates
To identify potential covariates, a directed acyclic graph (DAG) was developed before any analysis using DAGitty software (version 3.0) based on expert knowledge and the literature (Supplementary Figure 1) (23). A DAG forms a hypothesized theoretical framework to select a minimally sufficient set of variables confounding the exposure-outcome relationship to the statistical model. The minimal sufficient set of variables was identified to avoid over-adjustment and thus not all the variables in the DAG were required for adjusting the exposure-outcome relationship (24). Supplementary Methods explains the DAG and the variables considered. These variables include age, housing situation, Accessibility Remoteness Index of Australia (ARIA+), education, and ability to manage income.
Statistical Analyses
We described the reported noninjurious, injurious falls, and amounts and types of physical activity participation. As physical activity and falls were the variables of interest, the proportions of women who reported noninjurious and injurious falls and amounts and types of physical activity were compared between the 2 birth cohorts using Chi-squared tests. We used descriptive statistics to describe the characteristics of those who reported no falls, noninjurious and injurious falls by possible confounders and described the presence of frailty and physical function limitation because these factors may have an impact on falls. Multinomial logistic regression was used to examine the association between amounts and types of physical activity and falls. All models were adjusted for the potential confounders as identified in the DAG, and we reported the estimate using the recommended approach of the DAG-implied adjustment set (23,25). Analyses were conducted using Statistical Analysis System (SAS) 9.4 software (SAS Institute Inc., Cary, NC, USA). Two-sided p < .05 was considered statistically significant.
Results
Of the 1921–26 cohort participants who returned 1999 survey, 8 403 were included in the final analytical sample, after excluding women with missing responses in physical activity (n = 1 045), falls (n = 340), and other covariates (n = 646). Of the 1946–51 cohort participants who returned the 2019 survey, 7 555 were included in the final analytical sample, after excluding women with missing responses in physical activity (n = 131), falls (n = 110), and other covariates (n = 160). Figure 1 shows the sample selection flowchart and Supplementary Table 1 shows the characteristics of included and excluded participants.
Compared to the 1921–26 cohort at an average age of 75 years, a smaller proportion of the 1946–51 cohort at an average age of 71 years reported no formal education (31% vs 12%), frailty (21% vs 13%), and physical function limitation (47% vs 28%; Table 1). The 2 cohorts had similar distributions of living location, housing situation and ability to manage on income (Table 1).
Table 1.
Characteristics of the 1921–26 and 1946–51 Born Cohorts by Status of Falls
| 1921–26 | 1946–51 | |||||||
|---|---|---|---|---|---|---|---|---|
| Total n = 8 403 |
People had no falls n = 6 537 |
People had noninjurious falls n = 701 |
People had injurious falls n = 1 165 |
Total n = 7 555 |
People had no falls n = 5 393 |
People had noninjurious falls n = 1 050 |
People had injurious falls n = 1 112 |
|
| Age, years, mean (SD) | 75 (1) | 75 (1) | 75 (1) | 75 (1) | 71 (1) | 71 (1) | 71 (1) | 71 (1) |
| Location (ARIA+), n (%) | ||||||||
| Majorities of Australia | 3 298 (39) | 2 550 (39) | 259 (37) | 489 (42) | 2 982 (39) | 2 194 (41) | 359 (34) | 429 (39) |
| Inner regional of Australia | 3 450 (41) | 2 710 (41) | 279 (40) | 461 (40) | 3 113 (41) | 2 198 (41) | 450 (43) | 465 (42) |
| Regional (Outer regional, remote and very remote Australia) | 1 655 (20) | 1277 (20) | 163 (23) | 215 (18) | 1 460 (19) | 1 001 (19) | 241 (23) | 218 (20) |
| Housing situation, n (%) | ||||||||
| House/unit/apartment/villa/townhouse | 7 745 (92) | 6042 (92) | 638 (91) | 1065 (91) | 7 093 (94) | 5 081 (94) | 982 (94) | 1 030 (93) |
| Caravan/mobile home/retirement village/hostel/residential aged care | 658 (8) | 495 (8) | 63 (9) | 100 (9) | 462 (6) | 312 (6) | 68 (6) | 82 (7) |
| Education, n (%) | ||||||||
| No formal education | 2 568 (31) | 1 977 (30) | 235 (34) | 356 (31) | 896 (12) | 618 (11) | 134 (13) | 144 (13) |
| School, certificates | 5 474 (65) | 4 293 (66) | 436 (62) | 745 (64) | 4 982 (66) | 3 603 (67) | 679 (65) | 700 (63) |
| University degrees or above | 361 (4) | 267 (4) | 30 (4) | 64 (5) | 1 677 (22) | 1 172 (22) | 237 (23) | 268 (24) |
| Ability to manage on income, n (%) | ||||||||
| Impossible | 48 (1) | 37 (1) | 3 (0.4) | 8 (1) | 110 (1) | 65 (1) | 24 (2) | 21 (2) |
| Difficult always | 411 (5) | 294 (5) | 45 (6) | 72 (6) | 473 (6) | 296 (5) | 83 (8) | 94 (8) |
| Difficult sometimes | 1 627 (19) | 1 226 (19) | 137 (20) | 264 (23) | 1 410 (19) | 956 (18) | 204 (19) | 250 (22) |
| Not too bad | 4 342 (52) | 3 400 (52) | 372 (53) | 570 (49) | 3 670 (49) | 2 661 (49) | 480 (46) | 529 (48) |
| Easy | 1 975 (24) | 1 580 (24) | 144 (21) | 251 (22) | 1 892 (25) | 1 415 (26) | 259 (25) | 218 (20) |
| People who were frail, n (%) | 1 775 (21) | 1 245 (19) | 198 (28) | 332 (29) | 967 (13) | 550 (10) | 176 (17) | 241 (22) |
| People who had physical functioning limitationa, n (%) | 3 918 (47) | 2 885 (45) | 391 (56) | 642 (56) | 2 084 (28) | 1 295 (24) | 359 (34) | 430 (39) |
Notes: ARIA+ = Accessibility Remoteness Index of Australia scale.
Survey 2 (1999, n = 8 403) and survey 9 (2019, n = 7 555) was used for the 1921–26 and 1946–51 born cohort, respectively.
Proportion of people who were frail or had physical function limitation were described in the table to show the characteristics of each cohort.
People who were classified as frail if there were 2 of more positive components in fatigue, resistance, ambulation, illness, and loss of weight.
People who were classified as having physical function limitation if they reported limitation in walking 100 meters or dealing with 1 flight of stairs.
aMissing data in the 1921–26 n = 92; 1946–51 n = 15.
There was a significant difference in physical activity participation between the 2 cohorts (p < .0001, Figure 2). Compared to the 1921–26 cohort, a greater proportion of the 1946–51 cohort reported ≥150 minutes of physical activity (43% vs 59%; Figure 2), and more reported participating in each of the different types of physical activity (Supplementary Figure 2).
Figure 2.
Physical activity participation in the 1921–26 and 1946–51 born women.
There was a significant difference in falls between the 2 cohorts (p < .0001, Figure 3). Compared to the 1921–26 cohort, a greater proportion of the 1946–51 cohort reported noninjurious falls (8% vs 14%), however, women in both cohorts reported similar proportions of injurious falls (14% vs 15%; Figure 3). Among those who fell, a greater proportion of the 1921–26 cohort reported injuries from falls than the 1946–51 cohort at a similar age (62% vs 51%).
Figure 3.
Noninjurious and injurious falls in the 1921–26 and 1946–51 born women.
Associations Between Amounts of Physical Activity and Falls
For both cohorts, in both crude and adjusted models, compared to no physical activity, 1 to <150 minutes of physical activity participation was associated with significantly lower odds of injurious falls, but not noninjurious falls (Figure 4). In both cohorts, 150 ≤ 300 and ≥300 minutes of physical activity participation was associated with lower odds of noninjurious and injurious falls (Figure 4). In the 1921–26 cohort, the reduction in falls associated with more physical activity participation was of a greater magnitude for noninjurious falls (150 ≤ 300 minutes: 0.66, 95% CI: 0.52–0.84; ≥300 minutes: 0.67, 95% CI: 0.54–0.84), than for injurious falls (150 ≤ 300 minutes: 0.72, 95% CI: 0.60–0.87; ≥300 minutes: 0.73, 95% CI: 0.62–0.86). In the 1946–51 cohort, similar magnitudes of association were seen between participation in 150 ≤ 300 minutes and both noninjurious and injurious falls. Participation in ≥300 minutes of physical activity was associated with greater reductions in injurious falls (0.64, 95% CI: 0.54–0.78), than noninjurious falls (0.75, 95% CI: 0.62–0.91).
Figure 4.
Associations between different amounts and types of physical activity, and noninjurious and injurious falls.
Associations Between Types of Physical Activity and Falls
In both cohorts, brisk walking was associated with lower odds of noninjurious and injurious falls on crude analysis. After adjusting for potential confounders, brisk walking was significantly associated with lower odds of noninjurious falls in the 1946–51 cohort (0.79, 95% CI: 0.67–0.93). A protective effect was also seen in the 1921–26 cohort, although this was not statistically significant (0.86, 95% CI: 0.73–1.01). Lower odds of injurious falls were found among those who participated in brisk walking in both cohorts. In both cohorts, for both crude and adjusted models, moderate-intensity physical activity was associated with lower odds of noninjurious and injurious falls (Figure 4). In the 1946–51 cohort, in both crude and adjusted models, vigorous, and moderate-vigorous intensity physical activity were associated with lower odds of noninjurious and injurious falls, but nonsignificant associations were found in the 1921–26 cohort (Figure 4).
Discussion
To our knowledge, this is the first study to compare physical activity, noninjurious and injurious falls, and their associations in older women of similar ages 20 years apart. We found that women born later (ie, 1946–51 cohort) undertook more physical activity, and experienced more noninjurious falls, but reported similar experiences of injurious falls, compared with the 1921–26 cohort. In both cohorts, physical activity participation was associated with a lower risk of noninjurious and injurious falls. This apparent contradiction suggests that factors other than physical activity are contributing to more falls in this cohort born more recently.
Differences between the 2 cohorts were seen for reported physical activity participation. Compared to the 1921–26 cohort in 1999, a greater proportion of the 1946–51 cohort in 2019 reached the recommended level from the WHO physical activity guideline (ie, ≥150 minutes) and participated in different types of physical activity. The finding of the increasing trend of physical activity participation was similar to a previous systematic review that reported an increase in leisure-time physical activity in the past 20 years among adults aged 18+ years (26), and older adults in Canada, Spain, and the United Kingdom (27–29). The physical activity recommendations in the 2 periods were the same (30–32). Adults were recommended to “accumulate 30 minutes of moderate-intensity physical activity on most, preferably all, days of the week” (30–32), so this does not explain the differences seen. However, there have been increased global physical activity promotion initiatives including the 2004 Global Strategy for Diet and Physical Activity and the 2010 Global Recommendations on Physical Activity for Health (33,34). Therefore, the awareness of physical activity recommendations in the 2 cohorts might differ.
The other difference found between the 2 cohorts was the report of falls. Compared to the 1921–26 cohort in 1999, a higher proportion of people in the 1946–51 cohort in 2019 reported falls (ie, both noninjurious and injurious falls; 22% vs 29%) in the past year. The frequency of fall-related injuries increases with age (3,4), and so the slightly younger age of the 1946–51 cohort (mean 71 years) may suggest that our findings underestimate this apparent generational difference. The prevalence of falls found in the 1946–51 cohort (29%) is similar to the recent global reports of falls regardless of injuries in older people according to a systematic review of 104 studies (26.5%; 95% CI: 23.4%–29.8%) (35).
Factors including body function may contribute to the differences in the reports of physical activity participation and falls between the 2 cohorts (36,37). For instance, a previous cohort study in the United States showed that community-dwelling adults aged 50+ (n = 3 146) who were frail were more likely to have higher levels of sedentary behavior (38). Similarly, our study found a greater proportion of women born 1921–26 had frailty or physical function limitation compared to the 1946–51 cohort. Furthermore, women who were better educated may have better access to information and were found to be more adhere to preventive services (39,40). With higher educational levels in the 1946–51 cohort, a greater proportion of women in this cohort achieved the recommended level of physical activity. Other factors, such as differences in daily activities or health conditions, may also contribute to observed differences in falls and physical activity participation between the 2 cohorts. Although a full exploration of the reasons influencing the different proportions of people reporting falls and physical activity participation between the 2 cohorts is beyond the scope of this study, such exploration is warranted in future studies.
Some similarities were found between the 2 cohorts. The proportions of women reporting injurious falls were similar between the 2 cohorts (1921–26:14%; 1946–51: 15%). In both cohorts, more than half of the falls resulted in injuries among those who had fallen. This proportion was higher compared to the previously reported proportion of 37.5% among the American older population who had fallen (41). This could possibly be due to the inclusion of any injuries in our study rather than injuries that only required medical treatment (41). Increasing trends in absolute numbers and/or rates of fall-related injury hospitalization and mortality have also been reported globally including in Australia, Brazil, Spain, and the United States (6,42–45). With the increase in life expectancy in the population globally, the increase in an absolute number of falls-related injury hospitalizations and mortality globally may be due to a greater proportion of older people in the population, and greater disability at the same age. However, trends of aged-standardized fall-related injury hospitalization and mortality over time have been inconsistent (6,45). Globally, there has been a slight decrease of age-standardized falls-related mortality rate (45). In Australia, age-standardized rates of fall-related hospitalizations and mortality increased from 2010 to 2020, indicating an increase beyond that expected of an aging population (6). The similar proportions of reports of injurious falls in the 2 cohorts with 20 years apart suggest the ongoing challenge in preventing fall-related injuries for the emerging generation of older people.
The other similarity found between the 2 cohorts was the association between weekly physical activity participation and falls in both cohorts. Participation in 1 to <150 minutes of physical activity weekly was associated with significantly lower risks of injurious falls, but not noninjurious falls, compared to no physical activity. Participation in physical activity at the level recommended by the WHO guidelines (ie, 150–300 minutes per week) was associated with a lower risk of both noninjurious and injurious falls in both cohorts. A previous systematic review examined the associations between physical activity and falls but did not examine injurious falls (17), our study extends the understanding of the association between physical activity and injurious falls and the difference in magnitude of association in the 2 cohorts of similar age. In addition, our study showed that physical activity of ≥300 minutes weekly, walking briskly or moderate-intensity physical activity was associated with a lower risk of noninjurious and injurious falls in both cohorts. These findings are contradictory to some previous evidence that reported a potential U-shaped association between physical activity and falls, with a higher fall risk found among older adults with higher physical activity levels due to an increase in exposure (17,46,47). An increase in exposure to risky environments such as uneven surfaces during physical activity participation could possibly increase the risk of falling. Environment is one of the influential factors on participation (36), and thus participating in some types of physical activities may lead to a higher fall risk than some other activities (eg, mountain biking vs brisk walking at a park). The similarity of associations found in the 2 different cohorts of similar age affirms the benefits of physical activity, and that a higher amount of physical activity is not associated with more fall-related injuries in older Australian women.
Strengths of the Study
The main strength of our study is the comparison of the 2 generations of similar age using the same study design 20 years apart, using a large population-based sample of Australian women (18), which has not been done previously. The use of the same questionnaire in the 2 different cohorts allows us to compare and understand any differences in falls and physical activity participation. The large sample also allows for more precise estimates. A further strength of the study is our adjustment for potential covariates, identified from the DAG developed before any analyses. This reduces the potential bias in an exposure-outcome relationship.
Limitations and Recommendations for Future Studies
There are limitations in this study. Physical activity and falls were self-reported, which may be subject to recall bias. However, recall of physical activity in the past week has acceptable psychometric properties (48). In addition, the questionnaire asked for each type of physical activity with a duration of at least 10 minutes. Therefore, we were unable to capture bouts of self-reported physical activity shorter than 10 minutes or any incidental activities, which may contribute to increased exposure to fall risk, particularly among people with impaired gait and balance (49). In addition, as both cohorts responded to the set questions about physical activity, we are unable to identify the exact type of activity (eg, tennis or recreational swimming grouped under moderate-intensity activity) that has contributed to the lower risk of noninjurious and injurious falls. Future research could further investigate the association between the different types of physical activity and falls. Although our study found similar fall prevalence as the prevalence reported worldwide (3), retrospective self-reported falls may also be subject to under-reporting (50). Furthermore, the prevalence of self-reported injurious falls may differ from studies reporting injurious falls requiring medical care from general practitioners and hospitals. Future research could use administrative data to investigate the association between physical activity and injurious falls that result in health service use.
In addition, the DAG was constructed following the expert knowledge to account for confounding in the exposure-outcome relationship, and we acknowledge the presence of other potential pathways and missing variables of the concepts within the DAG. Future research could examine the prospective associations between physical activity and noninjurious and injurious falls in older adults from different generations, and explore the potential effect modifications of such associations in different generations. Another limitation is the inevitable difference in proportions of original survey respondents included in the complete case analyses (68% of 1921–26 and 55% of 1946–51 cohorts) that may have influenced the results. Participants in both cohorts were recruited in 1996 and followed up thereafter. Therefore, the relatively lower response rate in the 1946–51 cohort compared to the 1921–26 cohort may be due to the longer follow-up period (ie, in the 1921–26 cohort, survey 2 was used and was 1 survey post recruitment whereas, in the 1946–51 cohort, survey 9 was used and was 8 surveys post recruitment). However, participants in both cohorts were initially randomly selected from the national health insurance database that included Australian citizens and permanent residents in 1996. The large sample provides a good representation of Australian women (18). Finally, our findings may not be generalized to older men. Future research could also examine if there are any generational differences in falls and physical activity participation in men.
Conclusion
This is the first study to compare physical activity and falls in older women of similar ages 20 years apart. More women from the ALSWH 1946–51 cohort reported noninjurious falls in 2019 than from the 1921–26 cohort in 1999, with similar proportions of women from both cohorts reporting injurious falls. This highlights the ongoing challenge of preventing falls and fall-related injuries in older people. Compared to the 1921–26 cohort, a greater proportion of the 1946–51 cohort reported physical activity participation at the level recommended by WHO. Despite the different reports of physical activity and falls in the 2 cohorts, in both cohorts, the recommended level of physical activity participation, brisk walking, or moderate-intensity physical activity were associated with lower risks of noninjurious and injurious falls. Physical activity participation should therefore be encouraged in older people. The 20-year time difference between the 2 cohorts in our study indicates generational differences in falls or amounts and types of physical activity participation. Future studies could examine the reasons and other individual characteristics contributing to the different proportions of people reporting falls and physical activity participation.
Supplementary Material
Acknowledgments
The research on which this study is based was conducted as part of the Australian Longitudinal Study on Women’s Health by the University of Queensland and the University of Newcastle. We are grateful to the Australian Government Department of Health and Aged Care for funding and to the women who provided the survey data.
Contributor Information
Wing S Kwok, Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
Saman Khalatbari-Soltani, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; ARC Centre of Excellence in Population Aging Research (CEPAR), University of Sydney, Sydney, New South Wales, Australia.
Xenia Dolja-Gore, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.
Julie Byles, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.
Juliana S Oliveira, Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
Marina B Pinheiro, Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
Catherine Sherrington, Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
Lewis A Lipsitz, (Medical Sciences Section).
Funding
W.K. was supported by the National Health and Medical Research Council Center of Research Excellence Prevention of Falls injuries (project no. APP1198371); the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. S.K.S. was supported by the Australian Research Council Centre of Excellence in Population Aging Research (project no. CE170100005); the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. M.P. receives salary funding from the Australian National Health and Medical Research Council; the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict of Interest
None.
Ethical Approval
The ALSWH survey has ongoing ethical approval from the Human Research Ethics Committees of the Universities of Newcastle and Queensland, with approval numbers of H-076-0795 and 2004000224, respectively.
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