Falls, fear of falling, and lower body strength in a cohort of community-dwelling older adults with cancer

BACKGROUND

Falls are a major public health issue among older adults (Public Health Agency of Canada, 2014). A fall is an unexpected event in which an individual comes to rest on the ground, floor, or lower level (Montero-Odasso et al., 2022). Falls are attributed as the leading cause of hip fractures, functional decline, and nursing home placement (Public Health Agency of Canada, 2014), and a leading cause of injury-related death among older adults (Kakara et al., 2023). Among older adults with cancer, falls are common (Gomaa et al., 2023; Kenis et al., 2022) and can affect cancer treatment regimen (Sattar et al., 2019). While evidence from the general geriatric setting has demonstrated the links between fear of falling (FOF), lower body muscle strength, and risk of falls in older adults (Asai et al., 2022; Forte et al., 2021; Garbin & Fisher, 2023; Tomita et al., 2018), research specific to falls and fall risks in the geriatric oncology setting is limited (Kenis et al., 2022), despite the aging of the population and increasing number of older adults with cancer. The objectives of this brief report are to explore the associations among history of falls, FOF, and lower body strength at baseline in a cohort of community-dwelling older adults with cancer.

METHODS

This is a secondary analysis of data from an intervention study investigating the feasibility, acceptability, and preliminary efficacy of a virtually delivered exercise training program in older adults with cancer. The results of the intervention study have been published elsewhere (Sattar et al., 2021). Briefly, the intervention study sample included 26 older adults with cancer who participated in an eight-week exercise program entailing three-times weekly resistance and balance training of one-hour sessions. Data on outcome measures were collected at baseline and again at end of intervention, and included fall history, FOF, and lower body strength. Falls were assessed using the question: Have you had any falls in the past six months? The World Health Organization (WHO) definition for falls was applied. FOF was assessed using the Fall Efficacy Scale – International (FES-I). This 16-item instrument was developed to measure FOF related to easy, as well as more challenging, physical and social activities, such as walking on slippery, uneven, or sloping surfaces; going to a social event; and going to a place that has crowds. The level of concern related to undertaking these activities are rated on a four-point Likert scale (from 1 = not at all concerned to 4 = very concerned). Scores >23 indicated high concern about falling (Yardley et al., 2005). Lower body strength was assessed using the five-times chair stand test, which measures the time required to complete five sets of sit-to-stand maneuvers from a standard chair. Time greater than 10 seconds signifies fall risk (Guralnik et al., 2000). Poor lower body muscle strength is associated with increased risk for falls in older adults (Menant et al., 2017; Takada et al., 2024).

For the purposes of this secondary analysis, baseline data on fall history, FOF, and lower body strength were analyzed. Descriptive statistics were used to describe the sample characteristics and the variables of interests. Kendall’s tau was used to examine the bivariate correlations among falls, FOF, and lower body strength.

RESULTS

The sample consisted of 26 older adults (mean age 70.6, SD 4.6) with lung, breast, prostate, or colorectal cancer. Fifty-four percent of the participants were female. Seventeen (65%) were receiving active treatment, of which 15 (88%) were receiving hormone and two (12%) were receiving chemotherapy. Five participants (19.2%) reported having one fall in the past six months, two participants (7.7%) had two falls, and one (3.8%) participant reported having more than two falls. The median FOF score was 18 (IQR 4); 42% (n = 10) had moderate FOF and 4% (n = 1) had high FOF. Median time of the chair-stand test was 9.15 seconds (IQR = 3.05); 23% (n = 6) scored below the cutoff time (>=10 second), indicating being at risk for falls. No statistically significant associations were found between falls in past 6 months and FOF score (p = .69 [τ = 0.71]), fall in past 6 months and chair-stand time (p = .51 [τ = 0.11]), or chair-stand time and FOF score: (p = .12 [τ = 0.24]).

DISCUSSION

In this secondary analysis of a cohort of 26 older adults with cancer taking part in a virtual exercise intervention, we did not find any association among FOF, falls in the past six months, and lower body strength at baseline. The fall rate of 19.2% over a six-month period (or 38.4% over 12 months) is comparable to fall rates in a recent study reported by Kenis et al. (2022). However, our sample appears to have a low FOF compared to a previous cohort of 100 older adults with cancer, who conferred a higher FOF rate of 55% (Sattar et al., 2019). Lower body strength measured by chair stand test was not associated with falls or FOF in this study; although physical performance measures, such as timed-up and go test (TUG), were reported previously to be associated with FOF in the oncology setting (Gomaa et al., 2023). Interestingly, despite the established link between falls and FOF in the general geriatric population, this was not observed in the current sample. However, there is some emerging evidence from the geriatric oncology setting suggesting that FOF measured by FES-I is significantly associated with the number of falls over a 12-month period (p < 0.05; Aburub et al., 2020; Gomaa et al., 2023). Recent evidence also found FOF tends to be high among older patients who have chemotherapy- induced peripheral neuropathy (CIPN; Kang et al., 2021). However, we do not have data in our study to explore this aspect.

Limitations

Our small sample size, and the majority of the sample exhibiting low FOF and good lower body strength, may have rendered this sample a biased sample that was not representative of older adults with cancer; in particular, given the heterogeneity of the older cancer population. More research with greater sample sizes and more representative samples is warranted to continue examining the topic to inform clinical practice and supportive care interventions. Additionally, fall history was based on recall; therefore, we cannot exclude the possibility of recall bias. Participants who choose to engage in exercise programs are often more functional compared to those who do not (de Souto Barreto et al., 2013; Gell et al., 2022), which could have introduced selection bias in our study. Moreover, older adults who are open to engage in technology-based interventions tend to be younger and have greater technology proficiency (Heponiemi et al., 2024; Irvine et al., 2013; Sattar et al., 2021), suggesting that our sample may not be representative of the broader older cancer population.

CONCLUSION

This secondary analysis study did not identify any correlation among FOF, falls in the past six months, and lower body strength at baseline. Given the implications of falls in this population, further research with a greater and more representative sample is needed to continue to investigate the correlations among falls, FOF, and lower body strength in this population which, in turn, can inform interventions and clinical practice in the direction of timely mitigation of risks of falls.