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. 2026 Oct 6;13(10):e70900. doi: 10.1002/nop2.70900

Sarcopenia, Depression, Fatigue, and Fear of Falling in Middle‐Aged and Older Adults With Visual Impairment: Empirical Research Quantitative

Eunjin Yang 1, Young‐Shin Joo 2, Jee‐Hye Yoo 3,✉
PMCID: PMC13639707  PMID: 42834865

ABSTRACT

Aim

To examine whether depression and fatigue mediate the association between sarcopenia and fear of falling in middle‐aged and older adults with visual impairment, based on the biopsychosocial model.

Design

Cross‐sectional secondary data analysis.

Methods

Data from 211 community‐dwelling adults aged 50 years and older with visual impairment in South Korea, collected between September 2024 and March 2025, were analysed. The risks of sarcopenia, depression, fatigue, and fear of falling were measured. Serial mediation was tested using Hayes' PROCESS macro (Model 6).

Results

Sarcopenia was positively associated with depression, fatigue, and fear of falling, and its direct effect on fear of falling was significant. Depression alone did not mediate the association, whereas fatigue showed a significant indirect effect, including a serial pathway through depression and fatigue.

Conclusions

Fatigue was a key pathway linking sarcopenia to fear of falling, whereas depression alone was not. Screening for sarcopenia risk, fatigue, and depression, along with tailored interventions, is warranted.

Implications for the Profession and/or Patient Care

When assessing fall risk in middle‐aged and older adults with visual impairment, nurses should screen not only for physical function but also for sarcopenia risk, fatigue, and depression. Nurse‐led interventions combining strength and balance training with fatigue and mood management may help reduce fear of falling in this population.

Impact

This study addressed how, and why, sarcopenia relates to fear of falling in adults with visual impairment. Fatigue emerged as the key pathway. The findings can help nurses and other providers develop integrated fall‐prevention care for this population.

Reporting Method

To strengthen the validity of the research, it was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

Patient or Public Contribution

No patient or public contribution, as this study involved a secondary analysis of de‐identified data.

Keywords: depression, fatigue, fear of falling, sarcopenia, visually impaired individual

1. Introduction

Population aging is a growing public health concern worldwide, and South Korea is one of the countries undergoing the fastest demographic transitions (Baek et al. 2021; Hong et al. 2023). Population aging includes a growing number of individuals with disabilities, whose age‐related health needs are often more complex and remain underrecognized (Molton and Ordway 2019). Older adults with visual impairment tend to have poorer physical and mental health than their non‐disabled counterparts, suggesting that health problems may be worsened by the dual challenges of aging and disability (Swenor et al. 2020). Therefore, research on healthy aging that reflects the specific needs of individuals with visual impairment is important for supporting their independent living and quality of life (Jaiswal et al. 2023).

Sarcopenia refers to age‐related loss of muscle mass and muscle strength (Rosenberg 1997). It is associated with physical frailty, impaired gait, reduced balance, and an increased risk of falling (Lim and Kong 2022). Visual impairment is a major risk factor for falls, but sarcopenia is also important in this population (Chen and Liao 2022; Ehrlich et al. 2019; Metanmo et al. 2022; Woo and Kim 2014). When visual input is limited, muscle strength and balance play important roles in maintaining safe mobility and are potentially modifiable through targeted interventions. Middle‐aged and older adults with visual impairment tend to rely more heavily on non‐visual sensory systems, such as musculoskeletal proprioception and hearing, to maintain their balance (Zarei et al. 2023). Consequently, sarcopenia‐related declines in muscle strength may have a disproportionate impact on balance and fall risk in this population compared to their sighted counterparts. Older adults with visual impairment exhibit weaker muscle strength and poorer physical function than those without visual impairment (Miyata et al. 2021; Smith et al. 2021).

In a population‐based study of US Medicare beneficiaries, 27.6% of older adults with visual impairment reported more than one fall in the past year, approximately twice the rate observed among those without visual impairment (13.2%) (Ehrlich et al. 2019). Falls among individuals with visual impairment result in both physical injury and psychological distress, which can contribute to the fear of falling (White et al. 2015). Although fear of falling is common among older adults and can develop even without a prior fall, its consequences may be more pronounced among individuals with visual impairment (Wang et al. 2012). As visual loss constrains independent mobility and orientation, fear‐driven activity avoidance in this population may further restrict already limited opportunities for exercise and social participation, compounding physical deconditioning and social isolation to a greater extent than typically seen among sighted older adults. Nearly half of older adults with visual impairment reported a fear of falling, and this prevalence is much greater than that observed in their non‐disabled counterparts (48.3% vs. 26.7%) (Ehrlich et al. 2019).

Previous studies have demonstrated an association between sarcopenia and fear of falling, particularly in relation to impaired balance, frailty, and the risk of falling (Gadelha et al. 2018; Merchant et al. 2020). However, the role of depression and fatigue in this relationship, particularly among middle‐aged and older adults with visual impairments, remains unclear. In this population, the prevalence of depression is considerably higher than that in the general population, and reduced physical activity due to sarcopenia may exacerbate helplessness (Virgili et al. 2022). In addition, individuals with visual impairment tend to devote more cognitive and physical effort to daily activities, such as walking or reading. When muscle strength and endurance are reduced, these activities may become highly fatiguing, contributing to chronic fatigue (Schakel, Bode, Elsman, et al. 2019; Schakel, Bode, Van De Ven, et al. 2019).

Depressive symptoms can contribute to fatigue by reducing physical and psychological energy (Schakel, Bode, Van De Ven, et al. 2019). Fatigue may increase the fear of falling by reducing confidence in safe mobility and increasing anxiety about falling (He et al. 2022; Martínez‐Arnau et al. 2021). Therefore, among older adults with visual impairment, sarcopenia may influence the fear of falling both directly and indirectly through depression and fatigue as mediators. However, few studies have examined these structural relationships in this population. Based on Engel's biopsychosocial model, which suggests that health outcomes emerge from dynamic interactions among biological, psychological, and social domains, this study conceptualized sarcopenia as a biological factor, depression and fatigue as psychological mediators, and fear of falling as a social‐behavioural outcome (Engel 1977). Although fear of falling is psychological in nature, it has been conceptualized as a social‐behavioural outcome because it is associated with activity restriction and loss of independence.

Nurses, particularly those working in community, primary care, and rehabilitation settings, contribute to fall‐risk assessment, monitoring, education, and referral for older adults with visual impairment. Previous research supports nurses' involvement in delivering evidence‐based fall prevention education for older adults (Ong et al. 2021). Current fall prevention guidance emphasizes multidimensional assessment, including mobility, balance, vision, depressive symptoms, fear of falling, and sarcopenia‐related vulnerability (Montero‐Odasso et al. 2022). However, modifiable contributors such as sarcopenia, fatigue, and depression have seldom been examined together in relation to fear of falling among adults with visual impairment. Clarifying whether these factors are interrelated is relevant to nursing because it would indicate whether they should be assessed together and which represents the more actionable target for integrated fall‐related assessment and intervention planning. Thus, this study examined the direct and indirect associations between sarcopenia and fear of falling, with depression and fatigue specified as sequential mediators, among middle‐aged and older adults with visual impairment. We included middle‐aged and older adults because age‐related health problems can appear earlier in individuals living with disabilities than in those without (Campbell and Putnam 2017; Molton and Yorkston 2017). The research hypothesis was that a higher sarcopenia risk would be associated with greater fear of falling, and that this relationship could be explained by indirect pathways involving depression and fatigue.

1.1. Theoretical Framework

As the theoretical framework for this study, we adopted Engel's biopsychosocial model (Engel 1977), which proposes that health and illness are understood through interactions among the biological, psychological, and social domains. This model helps overcome the limitations of the traditional biomedical model and emphasizes the need to understand health within a broader contextual framework (Borrell‐Carrió et al. 2004; Engel 1977). The model is appropriate for understanding individuals with visual impairment because it affects multiple domains of function, including physical, psychological, and social domains. For example, visual impairment can limit physical activity, increase depressive symptoms, and reduce social participation. These domains interact with one another; reduced physical activity can worsen depressive symptoms, and a depressed mood can further restrict physical activity and social participation.

In this study, sarcopenia was conceptualized as a biological domain because it reflects physical vulnerability associated with reduced muscle mass. Depression and fatigue were conceptualized as psychological‐domain mediators; they represent emotional responses to physical vulnerability and the increased effort required by visual impairment (Engel 1977). Although fear of falling is psychological in nature, it has been conceptualized as a social domain because it is closely related to activity restriction and loss of independence (Engel 1977). Although bidirectional relationships between depression and fatigue have been documented (Brown et al. 2009), depression has often been modelled as preceding fatigue on theoretical grounds (Azizoddin et al. 2020). Therefore, in this study, we examined the influence of the biological domain (sarcopenia) on the social domain (fear of falling) through psychological mediators (depression and fatigue) in middle‐aged and older adults with visual impairments.

2. Methods

2.1. Study Design, Participants, and Data Collection

This cross‐sectional study was a secondary analysis of data from a parent study that examined the relationship between intrinsic capacity profiles and frailty among visually impaired middle‐aged and older adults legally registered as persons with disabilities in South Korea. The parent study recruited legally registered individuals aged 50 years and older using convenience and snowball sampling methods between September 2024 and March 2025, yielding a final sample of 211 participants. Data were collected from accessible community settings.

The present secondary analysis specifically examined the serial mediating roles of depression and fatigue in the association between sarcopenia and fear of falling. As this study involved a secondary analysis of de‐identified data, additional informed consent was waived.

As this study was a secondary analysis of a pre‐existing dataset (N = 211), a formal a priori power analysis was not conducted; therefore, the sample size was determined by the parent study rather than by statistical requirements.

2.2. Variables and Measures

2.2.1. Demographic Characteristics

Demographic characteristics of the participants were assessed, including age, sex, education level, marital status, living arrangement, and subjective economic status. Vision‐related variables included visual impairment severity (severe vs. mild), which was evaluated using the Korean government criteria for legal‐blindness registration and visual impairment duration. Participants were asked whether they received assistance from a disability support worker.

2.2.2. Independent Variable: Sarcopenia

Sarcopenia was measured using the strength, assistance walking, rising from a chair, climbing stairs, and falls (SARC‐F) questionnaire, a self‐reported screening tool widely used to identify individuals at risk of sarcopenia (Kim et al. 2018; Malmstrom and Morley 2013). Each item was scored on a 3‐point scale (0: no difficulty, 1: some difficulty, 2: a lot of difficulty or inability to do so), with the total score ranging from 0 to 10. A score of 4 or higher on the SARC‐F indicated a risk of sarcopenia. Although SARC‐F is a screening instrument rather than a diagnostic tool, it has been widely used to identify individuals at risk of sarcopenia and sarcopenia‐related adverse outcomes (Lian et al. 2023; Malmstrom et al. 2016). Accordingly, the total SARC‐F score was treated as a continuous indicator of the sarcopenia symptom burden in this study. Therefore, all findings should be interpreted as reflecting sarcopenia risk rather than clinically confirmed sarcopenia, and the term “sarcopenia” is used hereafter for the sake of brevity.

2.2.3. Mediation Variables: Depression

The Korean version of the Short Form of the Geriatric Depression Scale was used to assess depression (Kee 1996; Yesavage et al. 1982). The scale consists of 15 dichotomous items (Yes/No). Total scores range from 0 to 15, with scores < 5 indicating a normal range, scores of 5–9 indicating a possible depression risk, and scores ≥ 10 indicating depressive symptoms. Higher scores reflect greater depression severity, and the total score was used in this study. Previous studies reported a Cronbach's α of 0.88 (Kee 1996), and the internal consistency reliability in the present study, assessed using the Kuder–Richardson Formula 20, was 0.908.

2.2.4. Mediation Variables: Fatigue

A modified Korean version of the Chalder Fatigue Scale (Chalder et al. 1993) was used to assess fatigue (Ahn et al. 2020). This instrument consists of 11 items scored on a 10‐point Likert scale (0 = “not at all” to 9 = “unbearably severe”). The scale includes two subdomains: physical fatigue (items 1–7) and mental fatigue (items 8–11). The scores range from 0 to 99, with higher scores indicating greater fatigue. In a previous study, Cronbach's α values were 0.963 for physical fatigue and 0.958 for mental fatigue (Ahn et al. 2020). In the present study, Cronbach's α was 0.888, 0.848, and 0.910 for physical, mental, and total fatigue, respectively.

2.2.5. Dependent Variable: Fear of Falling

Fear of falling was measured using the Korean Version of the Short Falls Efficacy Scale‐International (Ko et al. 2022), which is a translation of the original version of the scale (Kempen et al. 2008). The tool consists of seven items: going up or down stairs, taking a bath or shower, going out for a social event, getting dressed or undressed, reaching for something above the head or on the ground, walking up or down a slope, and getting into or out of a chair (Ko et al. 2022). Responses were scored on a four‐point Likert scale (1 = not concerned at all, 2 = slightly concerned, 3 = moderately concerned, and 4 = very concerned). Higher scores indicate greater fear of falling. The internal consistency reliability of the scale assessed using Cronbach's α was 0.93 and test–retest reliability was 0.95 in the previous Korean validation study (Ko et al. 2022). Cronbach's α was 0.87 in this study.

2.2.6. Covariates

Age, sex, education level, living arrangement (alone vs. with others), perceived economic status, chronic disease, severity of visual impairment (mild vs. severe), and visual impairment duration were included in the model as covariates. Previous studies have reported associations between these covariates and fear of falling (Birhanie et al. 2021; Iaboni and Flint 2013; Singh and Maurya 2022).

2.3. Data Analysis

General and vision‐related participant characteristics are presented as means and standard deviations or numbers and percentages, depending on the variable type. Prior to computing Pearson's correlation coefficients, the assumption of normality was examined for all study variables. Skewness values ranged from 0.253 to 1.760, and kurtosis values ranged from −0.812 to 3.114, all within the accepted thresholds for approximate normality (i.e., skewness values below 2 and kurtosis values below 7) (Kim 2013). In addition, the scatterplots for each pair of variables indicate approximately linear relationships. Therefore, Pearson correlation coefficients were calculated to examine the correlations between the variables. The PROCESS macro model 6 was used to test serial multiple mediation by depression and fatigue in the association between sarcopenia and fear of falling (Hayes 2017). Sarcopenia was specified as the independent variable and fear of falling as the dependent variable, with depression and fatigue as the primary and secondary mediators, respectively. To improve the estimation precision, age, sex, education level, living arrangement (alone vs. with others), perceived economic status, chronic disease, severity of visual impairment (mild vs. severe), and duration of visual impairment were included as covariates. Statistical significance was evaluated using bootstrapping with 5000 resamples and 95% confidence intervals (CIs), and was considered present when the CI did not include zero.

2.4. Ethical Considerations

This study was exempted from the Institutional Review Board (IRB) of the researcher's affiliated university, as it involved secondary data analysis of an existing dataset for which the primary study had already obtained full IRB approval. This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. In the primary study, all participants received a detailed explanation of the research purpose and procedures, their rights as research participants, personal information protection, and their right to withdraw from the study at any time, without penalty. Written informed consent was obtained from all participants during primary data collection.

3. Results

3.1. Participant Characteristics

A total of 211 participants were included (mean age = 68.39 years; standard deviation [SD] = 8.26), of which 53.6% were female and 38.4% had a middle school or lower education level. Nearly half of the participants were married (49.8%), 55.9% did not live alone, and 43.6% reported a low economic status. Most participants had severe visual impairment (77.7%), with a mean duration of 36.33 years (SD = 21.60), and 68.2% had received support from disability support workers. The detailed participant characteristics are presented in Table 1.

TABLE 1.

Demographic characteristics of the participants (N = 211).

Characteristics Mean (SD) n (%)
Age 68.39 (8.26)
Sex
Female 113 (53.6)
Male 98 (46.4)
Level of education
≤ Middle school 81 (38.4)
High school 74 (35.1)
> High school 56 (26.5)
Marital status
Married 105 (49.8)
Others (single, widowed, separated, divorced, or bereaved) 106 (50.2)
Living alone
Yes 93 (44.1)
No 118 (55.9)
Subjective economic status
Low 92 (43.6)
Lower‐middle 41 (19.4)
Middle 69 (32.7)
Upper‐middle 7 (3.3)
High 2 (0.9)
Visual impairment severity
Severe 164 (77.7)
Mild 47 (22.3)
Duration of visual impairment 36.33 (21.60)
Support from disability support worker
Yes 144 (68.2)
No 67 (31.8)
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Abbreviation: SD, standard deviation.

3.2. Bivariate Correlations

Pearson's correlations were calculated to examine the associations between the main study variables, and the results are presented in Table 2 and Figure S1. Sarcopenia was significantly and positively correlated with depression (r = 0.422, p < 0.01), fatigue (r = 0.455, p < 0.01), and fear of falling (r = 0.432, p < 0.01), indicating that higher sarcopenia scores were associated with higher levels of depression, fatigue, and fear of falling. Moreover, depression was strongly and positively associated with fatigue (r = 0.640, p < 0.01) and fear of falling (r = 0.377, p < 0.01). Fatigue was significantly positively correlated with fear of falling (r = 0.381, p < 0.01), suggesting that greater fatigue was associated with greater fear of falling.

TABLE 2.

Correlation between all variables (N = 211).

Variable Mean SD Sarcopenia Depression Fatigue Fear of falling
Sarcopenia 1.84 2.00 1
Depression 5.00 4.55 0.422** 1
Fatigue 38.07 21.86 0.455** 0.640** 1
Fear of falling 10.76 4.35 0.432** 0.377** 0.381** 1
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Abbreviation: SD, standard deviation.

**

p < 0.01.

3.3. Mediation Analyses

The hypothesized serial multiple‐mediation model is shown in Figure 1. After controlling for age, sex, education level, living arrangement (alone vs. with others), perceived economic status, chronic disease, severity of visual impairment (mild vs. severe), and visual impairment duration, the total effect of sarcopenia on fear of falling was significant (total effect = 0.8687, 95% CI [0.5890, 1.1483]). The individual path coefficients and 95% CIs for all paths in the serial mediation model are presented in Table 3.

FIGURE 1.

FIGURE 1

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Serial multiple mediation model (N = 211). Coefficients are unstandardized. Covariates are included but not shown. *p < 0.05, ***p < 0.001.

TABLE 3.

Individual path coefficients and mediation analysis results (N = 211).

Effect BootSE t p BootLLCI BootULCI
Individual paths
Sarcopenia → Depression 0.9487 0.1498 6.3343 < 0.001 0.6534 1.2441
Sarcopenia → Fatigue 2.8085 0.6469 4.3416 < 0.001 1.5329 4.0841
Depression → Fatigue 2.6169 0.2781 9.4084 < 0.001 2.0684 3.1653
Depression → Fear of falling 0.1204 0.0779 1.5456 0.124 −0.0332 0.2739
Fatigue → Fear of falling 0.0334 0.0165 2.0252 0.044 0.0009 0.0659
Total, direct, indirect effects
Total effect 0.8687 0.1418 6.1243 < 0.001 0.589 1.1483
Direct effect 0.5779 0.1577 3.6637 < 0.001 0.2668 0.8889
Total Indirect effect 0.2908 0.0987 0.1193 0.5051
Sarcopenia → Depression → fear of falling 0.1142 0.0726 −0.0237 0.2623
Sarcopenia → Fatigue→ fear of falling 0.0937 0.0559 0.0049 0.2276
Sarcopenia → Depression → Fatigue→ fear of falling 0.0829 0.0461 0.0044 0.1875
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Note: p < 0.05, the covariates included age, sex, educational level, living arrangement (alone vs. with others), perceived economic status, chronic disease, severity of visual impairment (mild vs. severe), and duration of visual impairment.

Abbreviations: BootLLCI, Bootstrap Lower Level Confidence Interval; BootSE, Bootstrap Standard Error; BootULCI, Bootstrap Upper Level Confidence Interval.

Sarcopenia was significantly associated with both depression (effect = 0.9487, 95% CI [0.6534, 1.2441]) and fatigue (effect = 2.8085, 95% CI [1.5329, 4.0841]), and depression was, in turn, associated with fatigue (effect = 2.6169, 95% CI [2.0684, 3.1653]). After the mediators were included, the direct effect of sarcopenia on fear of falling remained significant (effect = 0.5779, 95% CI [0.2668, 0.8889]). Among the mediators, fatigue was significantly associated with fear of falling (effect = 0.0334, 95% CI [0.0009, 0.0659]), whereas depression was not (effect = 0.1204, 95% CI [−0.0332, 0.2739]). This finding indicates that sarcopenia had a significant independent association with fear of falling even after the effects of depression and fatigue were taken into account.

Three indirect pathways from sarcopenia to fear of falling were examined (Table 3). Simple mediation via depression (sarcopenia → depression → fear of falling) was not statistically significant (effect = 0.1142, 95% CI [−0.0237, 0.2623]), indicating that depression alone did not mediate this association. Conversely, the pathway via fatigue (sarcopenia → fatigue → fear of falling) was statistically significant (effect = 0.0937, 95% CI [0.0049, 0.2276]), as was the serial pathway via both depression and fatigue (sarcopenia → depression → fatigue → fear of falling; effect = 0.0829, 95% CI [0.0044, 0.1875]). The total indirect effect of sarcopenia on fear of falling, summed across these three pathways, was 0.2908, with a 95% CI of [0.1193, 0.5051], which did not include zero.

Thus, the total effect of sarcopenia on fear of falling comprised both a significant direct effect (effect = 0.5779, 95% CI [0.2668, 0.8889]) and a significant total indirect effect (effect = 0.2908, 95% CI [0.1193, 0.5051]). The significant indirect pathways involved fatigue, either as a single mediator or as part of a sequential pathway with depression, whereas depression alone did not constitute a significant mediating pathway. These findings indicate that the association between sarcopenia and fear of falling was partially mediated by fatigue alone and through the sequential pathway of depression and fatigue.

4. Discussion

This study examined whether depression and fatigue serially mediate the association between sarcopenia and fear of falling. Sarcopenia was directly associated with fear of falling and was associated with fear of falling through two indirect pathways: (1) a serial mediation pathway in which sarcopenia was associated with higher depression, which in turn was associated with greater fatigue, and ultimately with greater fear of falling; and (2) a single‐mediator pathway through fatigue alone. These findings suggest that among middle‐aged and older adults with visual impairment, the association between sarcopenia and fear of falling may extend beyond physical impairment to involve interrelated depressive and fatigue symptoms.

The observed association between sarcopenia and depression is consistent with previous studies, indicating that reduced muscle mass is associated with greater depressive symptoms (Luo et al. 2021; Qiu et al. 2024). Although the mechanisms underlying this association remain incompletely understood, a plausible explanation is that reduced muscle mass may be associated with decreased physical activity and increased depression (Kong et al. 2022; Li et al. 2022). Reduced physical activity can exacerbate depression by limiting outdoor mobility, social interaction, and sunlight exposure while simultaneously eliminating the mood‐stabilizing benefits of exercise (Pearce et al. 2022). As middle‐aged and older adults with visual impairment often experience mobility limitations, sarcopenia may further restrict their physical activity and contribute to greater depression symptoms and fatigue. Therefore, the association between sarcopenia and depression is particularly pronounced in this population.

Depression has been associated with fatigue through psychological (e.g., sleep disturbance and reduced motivation) and physical pathways (e.g., decreased physical activity) (Schakel, Bode, Van De Ven, et al. 2019). Older adults with visual impairment tend to report higher levels of depressive symptoms than those without visual impairment because of disability‐related stressors and the greater effort required for daily tasks (Choi et al. 2018). Although the participants in this study reported relatively low levels of depression and fatigue—likely because of the self‐selected community‐dwelling participants—the association between the two remained statistically significant. This finding suggests that even subclinical depressive symptoms may contribute to fatigue in this population. This pattern is consistent with previous studies that reported similar findings in adults with visual impairment (Schakel, Bode, Van De Ven, et al. 2019; Schakel et al. 2024).

Furthermore, fatigue may increase the fear of falling by reducing the physical capacity for safe mobility, including gait performance, balance, and confidence in walking (Blain et al. 2021; Grobe et al. 2017). The finding that fatigue alone may mediate this association suggests that sarcopenia may be associated with a greater fear of falling through energy depletion, even without clinically salient depressive symptoms (Merchant et al. 2020). Although depression and fear of falling were significantly correlated at the bivariate level, depression alone did not significantly mediate this association in the serial model, likely because of its strong correlation with fatigue, which meant that fatigue accounted for much of the shared variance between depression and fear of falling. This suggests that depression's contribution to fear of falling in this population may operate largely through fatigue or that fear of falling may be more strongly related to functional and sensory limitations than to mood symptoms alone. These findings suggest that the relationship between sarcopenia and fear of falling in middle‐aged and older adults with visual impairment should be understood within the broader interactions among the biological, psychological, and social domains of the biopsychosocial model.

From a nursing perspective, this study extends current knowledge by showing that factors related to fear of falling may be interrelated rather than acting independently in middle‐aged and older adults with visual impairment. Fatigue was involved in both significant indirect associations between sarcopenia and fear of falling, whereas the indirect association through depression alone was not significant. This finding implies that fatigue can be an important symptom in understanding the relationship between physical vulnerability and fear of falling. It also suggests that depression needs to be understood together with fatigue rather than as a separate problem. Therefore, this study provides nursing‐relevant evidence for viewing physical vulnerability, fatigue, and emotional symptoms as related aspects of the health experiences of adults aging with visual impairment.

These findings also have implications for nursing education and policy. Nursing curricula and continuing‐education programs for nurses in community, primary‐care, and rehabilitation settings could help nurses recognize sarcopenia risk, fatigue, and depressive symptoms as interconnected contributors to fear of falling among people aging with visual impairment. In addition, it also helps build the competencies needed to assess and address these factors together. At the policy level, fall‐prevention guidelines and community health programs for this population could be strengthened by explicitly incorporating multidomain assessment including sarcopenia risk, fatigue, and mood alongside existing vision and balance evaluation, and by supporting accessible referral pathways to mental‐health services, consistent with current multidomain falls‐prevention guidance (Montero‐Odasso et al. 2022).

Findings have several implications for nurse‐led fall prevention and rehabilitation in middle‐aged and older adults with visual impairments. First, because sarcopenia is directly associated with fear of falling, nurses can add a brief sarcopenia check to their usual fall‐risk evaluation and connect at‐risk patients to strength‐ and balance‐training programs adapted to low‐vision environments. Second, as fatigue emerged as a key mediator, both alone and in sequence with depression, fatigue itself warrants regular assessment, with nurses guiding patients in pacing daily activity and conserving energy as a first‐line measure. Third, although depression did not directly mediate the association, it operated as an upstream contributor to fatigue; therefore, nurses should remain alert to even mild depressive symptoms and arrange timely referral for mental health support.

4.1. Limitations

This study had some limitations. First, because this was a cross‐sectional study in which all variables were measured at a single time point, the proposed sequential pathway from sarcopenia through depression and fatigue to fear of falling remains theoretical and cannot establish temporal or causal relationships. Accordingly, longitudinal studies are warranted to examine the changes in sarcopenia, depression, fatigue, and fear of falling over time. Second, participants were recruited through convenience and snowball sampling approaches, which are non‐probability sampling methods that may have introduced selection bias. For example, individuals who were more socially connected, functionally independent, or engaged in social activities may have been overrepresented, whereas more isolated or frail individuals may have been underrepresented. This may limit the generalizability of the findings to a broader population of middle‐aged and older adults with visual impairment. Third, sarcopenia was assessed using a self‐reported measure (SARC‐F), which may not adequately capture the objective muscle mass or strength. Future studies should incorporate objective diagnostic criteria, such as grip strength assessment and muscle mass measurement, to confirm sarcopenia status. Fourth, as the data were collected from a small sample in South Korea, the findings may have limited generalizability to the broader population of middle‐aged and older adults with visual impairment. Future studies with larger and more diverse samples across multiple regions are required to confirm the robustness of these findings.

5. Conclusions

This study provides preliminary evidence supporting the psychological pathways underlying fear of falling among middle‐aged and older adults with visual impairment, offering insights that may inform strategies to promote safer, healthier aging in this population. Building on these findings, future research should develop and evaluate integrated fall prevention programs that address the physical and psychological characteristics of visually impaired middle‐aged and older adults.

Author Contributions

Eunjin Yang: conceptualization, investigation, methodology, validation, funding acquisition, writing – original draft, writing – review and editing, formal analysis, data curation. Young‐Shin Joo: writing – original draft, methodology, formal analysis. Jee‐Hye Yoo: writing – original draft, methodology, validation, writing – review and editing.

Funding

This research was supported by the National Research Foundation of Korea (NRF) grant funded by the South Korean Government (MSIT) (No. RS‐2023‐00214446).

Ethics Statement

This study received an exemption from the Institute Review Board (no. 1044396‐202512‐HR‐265‐01). The present study is a secondary data analysis of data originally collected for a different research purpose, for which the parent study had obtained Institutional Review Board approval (no. 1044396‐202404‐HR‐073‐02). Written informed consent was obtained from all participants at the time of the primary data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1: Heatmap of Pearson correlation coefficients among sarcopenia, depression, fatigue, and fear of falling (N = 211).

NOP2-13-e70900-s001.docx (37.2KB, docx)

Acknowledgements

The authors are sincerely grateful to the older adults with visual impairment who participated in this study for their valuable time and meaningful contributions. During the preparation of this work, the authors used ChatGPT (OpenAI) and Claude (Anthropic) to improve readability and grammar. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Yang, E. , Joo Y.‐S., and Yoo J.‐H.. 2026. “Sarcopenia, Depression, Fatigue, and Fear of Falling in Middle‐Aged and Older Adults With Visual Impairment: Empirical Research Quantitative.” Nursing Open 13, no. 10: e70900. 10.1002/nop2.70900.

Statistician: TaeJin Hwang

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S1: Heatmap of Pearson correlation coefficients among sarcopenia, depression, fatigue, and fear of falling (N = 211).

NOP2-13-e70900-s001.docx (37.2KB, docx)

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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