The Fear of Falling, Physical Activity, and Quality of Life in Elderly After COVID-19

The COVID-19 negatively affected the physical and mental health of elderly due to pandemic-related restrictions. This study aimed to investigate the influences on fear of falling, physical activity level, and quality of life in older people living in the community after the COVID-19. Falls Efficacy Scale-International (FES-I), Physical Activity Scale for the Elderly (PASE), and Nottingham Health Profile (NHP) were used to study. One hundred fifty individuals older than 65 years. Results indicated that 69.3% of the individuals had fallen in the past 6 months. FES-I showed that the elderly had moderate FES-I (31.95 ± 10.55), and PASE showed that this cohort had severe activity limitation (85.42 ± 56.45) and low NHP (213.62 ± 143.45). There was negative association between FES-I and PASE levels (ρ = .000, r = −0.291) and a moderate negative association between. FES-I and NHP (ρ = .000, r = 0.577). The variables for the number of falls and FES-I were included in the multiple linear regression analysis and model formed with FES-I that predicted PASE level was statistically significant. As a result, it is important to raise awareness about older individuals’ concerns regarding falling to implement essential measures that can effectively alleviate such fears.. In this context, it is advisable to explore innovative clinical and policy strategies that can facilitate the seamless integration of interdisciplinary preventive care for vulnerable elderly individuals, with the overarching aim of enhancing their overall quality of life. Plain Language Summary Plain Language Summary - SO-23-1238 In the current study, it was determined that the fear of falling decreased the level of activity and negatively affected the quality of life. The current study, unlike the previous literature, was carried out after the removal of prohibitions such as the curfew related to Covid-19. For this reason, after these prohibitions, it provides new information about the fear of falling and the level of physical activity of elderly individuals. Studies on elderly individuals during the Covid-19 period provide limited information about the fear of falling and the level of physical activity of these individuals. It is important to increase the awareness of the elderly about the fear of falling, to determine the risks of falling and to take the necessary precautions to eliminate the fear of falling. The older ageing people can be educated in order to reduce the risk and fear of falling and to increase physical activity levels. It is possible to increase the social participation and physical activity levels of the older ageing by making environmental planning, not only indoors but also outdoors.


Introduction
The coronavirus , which emerged in 2019 in Wuhan, China, spread globally and was declared a pandemic by the World Health Organization (WHO) on March 1, 2020 (Huang et al., 2020).On March 11, 2020, the first cases were detected in Turkey.Consequently, the government took measures to restrict social life (Wang et al., 2020).The COVID-19 pandemic had a detrimental impact on the physical and mental well-being of elderly individuals aged 65 and above, as well as those with chronic illnesses.These individuals experienced social isolation and were restricted to their residences during the period spanning from 2020 to 2022 (Saldıran et al., 2022).This resulted in a decline in their ability to engage in daily activities and routines, as highlighted by Nguyen et al. (2022).During this period, physical activity levels also decreased because of social isolation, leading to physical and functional deterioration (Schmidt et al., 2021).This situation increases the vulnerability of older people and the risk of falling (Goswami, 2017).
Falls and related traumas are significant health problems for the elderly (Division of Unintentional Injury Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention, 2017).Considering the fact that 28% to 42% of individuals older than 65 fall at least once a year (Bor et al., 2017), and approximately 50% of elderly individuals have a fear of falling (Kocic et al., 2017), it is no wonder that older people who have a fear of falling increasingly avoid daily, social participation and physical activities, and as a result, their life quality is negatively affected by the reduction in activity level (Nguyen et al., 2022).The fear of falling is defined as the fear and avoidance of activity and physical movement arising from the feeling of sensibility to painful and repetitive injury (Sapmaz & Mujdeci, 2021).Advanced age, solitude and isolation, chronic diseases, insufficient physical activity, and mobility problems have been defined as the main factors that increase the fear of falling (Kocic et al., 2017).Additionally, we need to consider the influence of social distancing on the interactions between elderly individuals and their caregivers.Insufficient awareness among family members or caregivers regarding circumstances that could lead to falls, as well as the necessary preventive measures, might elevate the likelihood of falls among older adults (S xent€ urk, 2020).The increased risk of falls could stem from the inadequate capacity of the individuals cohabiting with older adults to provide the necessary support for self-care activities within the household.Looking into the outcomes of fall prevention initiatives centered on educating both older adults and caregivers about protective and preventive measures could offer valuable insights.Gathering evidence regarding the effectiveness of such programs in reducing the occurrence of falls and associated risk factors among older adults living independently in the community could provide guidance.Furthermore, it is crucial to document the strategies employed by institutions and individuals in the management of elderly health.This documentation can play a pivotal role in enhancing our understanding of effective approaches for ensuring the well-being of older individuals (S xent€ urk, 2020; Vahia et al., 2020).
The elderly with a history of falling develop a fear of movement or falling; therefore, they feel more insecure and choose a less active lifestyle (Ahangari & Abdolrahmani, 2020).Serious injuries, fractures, inadequacy in activities of daily living, and a decrease in quality of life may occur after a fall (Awale et al., 2017).The fear of falling has been associated with falling again (S xent€ urk, 2020), depression (Sapmaz & Mujdeci, 2021), decreased social participation (Ahangari & Abdolrahmani, 2020), and quality of life (Akosile et al., 2021;Kahraman et al., 2020).
Only a few publications (Merchant et al., 2020;Quach & Burr, 2021) have mentioned the problems associated with fear of falling in elderly who have experienced social isolation.In addition, the painrelated problems of older people have been described in only a few publications (Hoffman et al., 2022;Saldıran et al., 2022).Furthermore, the number of studies on fear of falling and changes in physical activity in the elderly during the COVID-19 pandemic is limited (Hoffman et al., 2022;Nascimento et al., 2021;Siefkas et al., 2022).In addition, only a few studies have investigated the consequences of social isolation, the negative effects of fear of falling, and the risk of falling on physical activity levels in the elderly (Hoffman et al., 2022;Lach & Parsons, 2013).In the changing demography, old age is increasing worldwide (Altın, 2020;World Health Organization [WHO], 2011).Quality of life is important in care services provided to the elderly (Singhal et al., 2021).The fear of falling in the elderly may limit physical activity and affect quality of life due to social isolation (D 'Cruz et al., 2021).However, no study in the Turkish population addressed the relationship between these issues in the geriatric population in the disadvantaged group after COVID-19.Therefore, this study aimed to investigate the influences on fear of falling, physical activity, and quality of life in older people over 65 who experienced social isolation after COVID-19.Hence, the primary objective of this research was to examine the factors that contribute to the fear of falling, activity levels, and quality of life among individuals aged 65 and above who have encountered social isolation subsequent to the COVID-19 pandemic.
This research makes a valuable contribution to the existing body of literature by investigating the potential impact of fear of falling on both activity levels and quality of life.The results of our present research have the potential to enhance our comprehension of the impact of fear of falling on physical activity levels and quality of life among older individuals the fast environmental changes seen during the COVID-19 period.

Design
Data were collected online using Google Forms with individuals during July 2021.
Participants were reached using the convenience sampling method.Participants aged 65 and over who could walk independently, read and understand Turkish, and use computer technologies were included in the study.Persons with complete hearing or vision loss, participants with a serious psychiatric or neurological diagnosis, and persons who refused to participate or did not sign informed consent were excluded.In the questionnaire section, the participants were asked which diseases they had or did not have.Psychiatric and neurological disease groups were also included in this section.A total of 183 people completed the online questionnaires, but these data were not included in the study because 15 had a psychiatric or neurological diagnosis, and 18 had missing survey data.The reliability of the data was verified by this method.

Sample
Sample size calculation was done with the G*Power 3.2.9.4 package program.The software tool G*Power (Version 3.2.9.4) was used for the purpose of determining the appropriate sample size in this research (Faul et al., 2007(Faul et al., , 2009)).The number of participants required for the study was calculated as 150 (with medium effect size, Type I error, and 90% power).

Ethical Consideration
Necessary ethics committee approval was obtained before starting the study.XXXXX University .. and .
Research Ethics Committee approved the study (date;., number; .. ).The study was carried out according to the Helsinki Declaration (Nguyen et al., 2022).Before the study, the individuals were informed about the study, and an individual consent form was obtained.Participation in the study was done voluntarily.

The Self-Directed Questionnaires
A socio-demographic information questionnaire, Falls Efficacy Scale-International (FES-I), Physical Activity Scale for the Elderly (PASE), and Nottingham Health Profile (NHP) were employed.The socio-demographic information questionnaire was used to record the data such as age, gender, marital status, and fall experience during COVID-19.
Falls Efficacy Scale-International (FES-I): The FES-I scale, which was developed by Tinetti et al. in 1990(Tinetti et al., 1990), measures the confidence rate of older people in their daily living activities and shows the level of fear of falling.The scale's reliability and validity have been published in the Turkish version (Ulus et al., 2012).The scale consists of 16 items, each with a score between 1 and 4 points (not at all concerned: 1 point, slightly concerned: 2 points, quite concerned: 3 points, very concerned: 4 points).The total score is between 16 and 64.Higher scores indicate an increased fear of falling (Ulus et al., 2012).
Physical Activity Scale for the Elderly (PASE): PASE was developed by Washburn in 1993 to evaluate physical activities (Washburn et al., 1993).The scale's validity and reliability in Turkish were established by Ayvat et al. in 2017(Ayvat et al., 2017).The total mark of PASE is a combination of scores that include recreational activities, walking, housework, gardening, and caring for others.It examines intensity, frequency, and duration.The items consist of walking/light, moderate, strenuous sports and recreational activities/muscle strengthening and endurance exercises/work-related physical activities/lawn and garden care/caring for another person/home repairs/ heavy and light household activities.The total mark is between 0 and 400.Higher scores indicate a better level of physical activity (Ayvat et al., 2017).
Nottingham Health Profile (NHP): The NHP is a measurement tool that assesses individuals' health problems and how they affect their daily activities.NHP was developed in England in 1985 and translated into many languages (Hunt et al., 1985).The Turkish version was prepared by K€ uc x€ ukdeveci et al. in 2000 and is used to evaluate the quality of life of older people (K€ uc€ ukdeveci et al., 2000).The scale consists of six sub-scales and 38 items in total.The sub-scales are: Energy (three items), pain (eight items), emotional reactions (nine items), sleep (five items), social isolation (five items), and physical activity (eight items).Each sub-scale is scored between 0 and 100, with a different score for each question.As the score decreases, the health status improves.

Statistical Analysis
Data were analyzed using the IBM SPSS 21 ver.(IBM Corp. Released 2012.IBM SPSS Statistics for Windows, Version 21.0.Armonk, NY: IBM Corp.) package program.Numerical variables were summarized as mean 6 standard deviation and median [Min-Max] values, and categorical variables were summarized as numbers and percentages.The Kolmogorov-Smirnov test was used to determine whether the numerical variables were normally distributed.Spearman correlation analysis was employed to analyze the relationship between variables, and the Mann-Whitney U test was utilized to analyze the differences between genders.The statistical significance level was taken as p \ .05.

Regression Analysis
The effects of both the fear of falling and the number of falls on physical activity level and quality of life were analyzed using a multiple regression model.The regression model for the predictors of PASE and NHP variables was obtained by Multiple Linear Regression using the Backward Elimination method.Multicollinearity was checked by the Variance Inflation Factor (VIF), and Autocorrelation between errors was checked by the Durbin-Watson test.The adequacy of the model was assessed by examining the effective and distant observations through case statistics, that is, Cook's distance and Mahalanobis distance.Residual plots were used to examine the normal distribution of errors, homoscedasticity of variance, and outlier observations (cases) (Alpar, 2011).

Demographic Characteristics of the Participants
The study was completed with 150 individuals with a mean age of 69.32 6 11.70 years.Of the participants, 117 (78%) were between the ages of 65 and 80, 80.7% were female, 46.7% were married, and 70% lived in the city.

Fear of Falling, Physical Activity, and Quality of Life
Mean score for FES-I was 31.95 6 10.55; and 69.3% of the elderly had fallen within the past year, and 58.9% had fallen at least twice (Table 1).Descriptive characteristics of the individuals are presented in Table 1.
Mean scores of the individuals showed a statistically significant association between the fear of falling and gender (p = .001).The average FES-I scores of female participants were higher than males.Female participants feared falling more than males (p = .001)(Table 2).
Mean PASE score was 85.42 6 56.45, which was considered low.There was no statistically significant difference between the male and female participants in terms of physical activity (PASE) levels (p = .845;Table 3).Analysis of quality of life according to gender showed that the mean NHP scores of female participants were higher than male participants (p = .003;Table 3).After evaluating the participants' quality of life, NHP's total score mean was 213.62 6 143.45.Regarding the subscales, the highest mean score was recorded in the ''energy'' sub-scale, while the lowest was determined in the ''social isolation'' sub-scale.According to these results, the quality of life of the elderly was the best in ''social isolation,'' while the worst was in ''energy'' (Table 4).
Association between the variables showed a weak negative correlation between fear of falling and physical activity levels (r=20.291,p = .000)and a moderate negative correlation between fear of falling and quality of life (r = 0.577, p = .000).There was a weak positive correlation between the fear of falling and the number of falls (r = 0.340, p = .007;Table 5).
Table 5 shows a correlation between the participants' age, fear of falling, and the number of falls.Age and the number of falls were risk factors for the fear of falling in the elderly (Table 5).

Regression Results
The residual plots for the model obtained in Table 6 show that the errors are normally distributed, and no heteroscedasticity problem exists.As a result of the Durbin-Watson test (1.983), it was seen that there was no autocorrelation between the errors (Jobson, 2012).As a result of the analysis performed with the Backward Subtraction method, the regression model created with the number of falls and FES-I variables predicting NHP was found significant (F [2;146] = 47,793, p \ .001).No     Go ¨ktas x et al.
The analysis with independent variables demonstrated that the number of falls and the variables of FES-I significantly affect the quality of life (F [2;146] = 47.793,p \ .001;Table 6).The contribution of the number of falls and FES-I variables to the model was statistically significant (p = .002,respectively).Based on the standardized regression coefficients, the greatest contribution to the model was made by FES-I (0.531), followed by the number of falls (0.212).The established model explains 39.6% of the variation in the NHP score variable (Alpar, 2011).A 1-unit increase in the number of falls and the FES-I increases 18.781 and 7.049 units in the NHP variable, respectively (Table 6).
The residual plots for the model obtained in Table 7 show that the errors are normally distributed, and no heteroscedasticity problem exists.As a result of the Durbin-Watson test (2.342), it is seen that there is no autocorrelation between the errors (Jobson, 2012).
The number of falls and FES-I variables were included in the Multiple Linear Regression Analysis.As a result of the analysis performed with the Backward Subtraction method, the regression model created with the FES-I variable predicting the PASE Score was found significant (F[1;145] = 38.483,p \ .001).No multicollinearity was found (VIF\10).Three influential observations (7, 49, and 66) were removed from the data set.The contribution of the FES-I variable to the model is statistically significant (p \ .001).
The contribution of the FES-I variable to the model was statistically significant (p \ .001).Multiple regression analysis showed that FES-I's number of falls and variables explained 21.0% of the change in PASE scores (p \ .001).A 1-unit increase in the FES-I variable caused a 2.371-unit decrease in the PASE variable (Table 7).

Discussion
In the current study, we demonstrated that more than half (69.3%) of the older people had fallen within the past 6 months, and more than half (58.9%) of them had fallen twice or more.Okuyan and Bilgili (2018) stated that 49.2% of the elderly had fallen within the last year, and 75.4% had fallen at least once.Approximately onethird of people over 65 fall every year, and more than half are repeated falls (Pohl et al., 2018).The rates in our study were higher than the rates given in previous publications.This situation can be related to the isolation and decrease in physical activity levels during COVID-19.A problem that is as important as falling and negatively affects the lives of the elderly is the fear of falling.Therefore, the pre-COVID-19 period studies report the prevalence of fear of falling in the elderly as between 20% and 85% (Chang et al., 2016;Okuyan & Bilgili, 2017).Hoffman et al. (2022) stated that the COVID-19 pandemic, which greatly impacts individuals with social isolation and reduced physical activity, is associated with decreased physical functionality and falls.Our results are similar to Hoffman's study and support the thesis that almost all older people fear falling, and that falls and fear of falling have become common problems of the elderly after the COVID-19 quarantine period.
In a study conducted by Cruz et al. (2017), an examination was undertaken to determine the prevalence of fear of falling and its association with age.The researchers discovered that the prevalence of fear of falling was 95.2%, and further observed a positive link between fear of falling and age (Cruz et al., 2017).Oliveira et al. (2019) reported that physical capacity decreases with age, and falls are observed more frequently.Our results showed a significantly high number of falls and fear of falling in women due to social isolation.The women aged 65 and over had experienced fear of falling more often than  men.A recent study has reported a lower risk of falling in older men than older women (Caner & Avci, 2022;Saldıran et al., 2022).Domaradzki et al. (2017) discovered that the risk of falling is twice in women who have muscular weakness.Considering the results of the current study, since age-related falls have a greater negative impact on women, the fear of falling may have increased in women.According to our results, the participants' physical activity levels were not different among men and women.Similarly, Saldıran et al. (2022) found no significant difference between genders.The lack of difference in both genders may be because of the social isolation due to COVID-19 and the limited physical activities were limited since it can be thought that both genders decreased their activities such as leisure time activities, walking, exercise, housework, gardening during COVID-19 and performed only the care activities that they were obliged to perform (Callow et al., 2020).Activity participation in both genders may have decreased similarly during COVID-19.Upon scrutinizing the quality of life of both men and women within our investigation, a notable disparity emerged between the genders regarding their quality of life.Specifically, the quality of life for women was established to be lower compared to that of men.In a similar vein, a study conducted by S xims xek et al. in 2011 aimed at assessing the influence of mental, mobility, and functional status on the quality of life among elderly individuals.Notably, this study found that gender did not exert a significant impact on the quality of life of elderly individuals (S xims xek et al., 2011).
In terms of the quality-of-life levels, previous studies, such as U ¨n et al. (2011), which have used NHP to evaluate older people's life quality, have demonstrated that ''energy'' and ''sleep'' sub-scales had the highest average scores, while ''social isolation'' had the lowest.In general, the quality of life in older people is low.This result has generally been attributed to low energy levels, fear of falling, and affected mental health due to the COVID-19 pandemic.Previous publications (Ahangari & Abdolrahmani, 2020;Kahraman et al., 2020;Sapmaz & Mujdeci, 2021;S xent€ urk, 2020;Stubbs et al., 2014) noted that the prevalence of fear of falling in older people is high, which increases health expenditures at least as much as falls affects the emotions of the elderly negatively and reduces their participation in daily living activities.
Our study showed that physical activity decreased as the fear of falling and the risk of falling increased.The study by Saldıran et al. (2022) stated that the fear of falling can explain 49.5% of participation in physical activity.Fear of falling significantly affects the level of physical activity (Saldıran et al., 2022).A study investigating the effects of COVID-19 restrictions has found an association between the increased fear of falling and worsened physical mobility (Hoffman et al., 2022).Our results showed that the fear of falling could explain 21.0% of participation in physical activity.A 1unit increase in the Falls Efficacy Scale variable caused a 2.371-unit decrease in the physical activity variable.
According to Korhonen et al. (2013), there is a positive association between the rise in falls and the fear of falling.They also found that when the danger of falling rises, people's levels of physical activity decline (Korhonen et al., 2013).A similar positive correlation in our study supports the literature finding.Studies showed that adopting social isolation policies due to the COVID-19 pandemic has increased solitude and sedentary behavior in the elderly (Korhonen et al., 2013;Vahia et al., 2020).Only a few studies have examined the relationship between social isolation and falls (Schrempft et al., 2019;Siefkas et al., 2022).A recent cohort data analysis has predicted a decrease in social isolation in the following year (Korhonen et al., 2013;Quach & Burr, 2021;Saldıran et al., 2022;Siefkas et al., 2022;).
Our study found a negative and moderately significant relationship between fear of falling and quality of life.The regression model created with the number of falls and fear of falling variables predicting quality of life was found to be significant.According to the regression model, fear of falling and number of falls predicted 39.6% of quality of life.In the study conducted by D 'Cruz et al. (2021), the elderly were evaluated in terms of functional status, ADL participation, and psychological aspects during the COVID-19 period, and it was reported that deterioration in these factors caused low quality of life.The health policies to control the epidemic and protect the elderly population should be planned carefully and take into consideration that social isolation, decrease in activity level, and falling are all related concepts in geriatric patients (Akosile et al., 2021;Drummond et al., 2020)

Limitations
The study had certain limitations, notably the absence of inquiries into specific details like the utilization of assistive devices, the nature of the living environment, and the type of housing (such as detached houses or apartments) among the study participants.Furthermore, there is a suggestion to consider conducting upcoming research endeavors that incorporate evaluations tailored to distinct age groups.In this regard, future investigations could encompass a comprehensive analysis of the activities undertaken by individuals residing in diverse residential settings.
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Conclusion
In conclusion, our research revealed a high frequency and persistence of falling fear in older persons in the COVID-19 years, demonstrating that this condition is significant to their life and should always be addressed as part of a comprehensive evaluation.Along with worsening physical activity and poor quality of life in the elderly, we showed how the frequency of falls and fear of falling interact.This situation is intricately tied to a diminished quality of life, warranting significant attention not only within the scope of falls, which have already been extensively addressed in existing literature but also within the domains of public health and gerontology.Innovative clinical and policy instruments that can help integrate interdisciplinary preventive care for the elderly at risk should be addressed.Considering the results of the current study, older people can be educated to reduce the risk and fear of falling and increase physical activity levels.In addition, it is of prime importance to provide training activities to individuals living with the elderly and their caregivers to increase awareness.
-I = Falls Efficacy Scale-International; PASE = Physical Activity Scale for the Elderly; NHP = Nottingham Health Profile.

Table 1 .
Socio-Demographic Characteristics of the Elderly People.

Table 2 .
Comparison of Fear of Falling Scores (FES-I) by Gender.

Table 3 .
Comparison of PASE and NHP Scores by Gender.
Note.T test: two independent samples, significance level: p\.05.PASE = Physical Activity Scale for the Elderly; NHP = Nottingham Health Profile; min-max = minimum-maximum; X = mean.

Table 5 .
The Association Between the Scores of the Elderly.

Table 6 .
Multiple Linear Regression Analysis of Nottingham Scores.

Table 7 .
Multiple Linear Regression Analysis of PASE.