A concept analysis of fear of falling in older adults: insights from qualitative research studies. — TEI-tagged view

Dayeon LeepersName, Sunghee H TakpersName (2023date). “A concept analysis of fear of falling in older adults: insights from qualitative research studies..” BMC Geriatricstitle·j.

Object of study — the concept of fear of fallingterm·dom faced by older adultsterm·key

Research question — what the attributes, antecedents and consequences of older adultsterm·key' fear of fallingterm·dom are

Contribution — four attributes, two antecedents and five consequences of fear of fallingterm·dom, and a definition as an emotional state

Full text — tagged

A concept analysisterm·key of fear of fallingterm·dom in older adultsterm·key: insights from qualitative research studies.

Abstract Fear of fallingterm·dom is a persistent concern about fallsterm·dom that commonly occur in older adultsterm·key. Recently, it has been argued that fear of fallingterm·dom doesn’t simply mean a state of low falls efficacyterm, but is a concept distinct from falls efficacyterm. However, the two concepts are still indistinguishable. Therefore, it is necessary to understand the unique characteristics of the fear of fallingterm·dom. This study aims to analyze the concept of ‘fear of fallingterm·dom’ faced by older adultsterm·key.

This study is designed as a concept analysisterm·key. A concept analysisterm·key was conducted by Walker & Avant’s eight-step concept analysisterm·key method. A total of 16 pieces of literature were selected by inclusion and exclusion criteria from those published in Pubmed and Scopus between 1993 and 2022 on 8 November 2022.

Two antecedents, four attributes, and five consequences were identified. Apprehension caused by the unpredictable nature of fallsterm·dom, unease related to one’s vulnerabilityterm·key, high vigilance-related to the environment, and concern about potential harm after fallterm·dom events were presented as attributes of fear of fallingterm·dom in older adultsterm·key. There were two antecedents of fear of fallingterm·dom which were awareness of fallsterm·dom and near fallsterm·key, and direct/indirect experience about fallsterm·dom and near fallsterm·key. As consequences of fear of fallingterm·dom, protective effect, activities curtailment, reduction in radius of living, restricted freedom, and limited social activities were reported.

It was confirmed that fallsterm·dom and the fear-inducing process were fused to constitute the unique characteristics of the fear of fallingterm·dom. This can be presented as an important basis for future research on the fear of fallingterm·dom or dealing with various aspects of the fear of fallingterm·dom in the clinical field.

Keywords: Concept Analysisterm·key, Fear of fallingterm·dom, Older adultsterm·key, Nursing Summary statement There has been confusion in defining and using the concept of fear of fallingterm·dom. This study clarifies the unique attributes, antecedents, and consequences of fear of fallingterm·dom.

This will establish the concept of fear of fallingterm·dom in future studies and will serve as the basis for dealing with various attributes of fear of fallingterm·dom in the clinical field.

No patient of public contribution The articles used for analysis were searched through several search engines, and there was no direct contact with patients or general older adultsterm·key during the entire study. Since the analysis was conducted based on the contents of the published articles, there is no direct contribution from various users, however since these documents were based on interviews with various patients or older adultsterm·key, it can be seen that there is an indirect contribution.

Introduction The fear of fallingterm·dom is a common problem for older adultsterm·key. The persistent concern about fallsterm·dom has the potential to have serious consequences, making older adultsterm·key avoid activities they can perform [ 1 – 3 ]. The fear of fallingterm·dom occurs in 20–85% of older adultsterm·key, of which 20–55% experience restrictions on daily activities. About 30–50% of older adultsterm·key, who live independently, experience fear of fallingterm·dom regardless of whether they fallterm·dom or not [ 2 , 4 ]. In a previous study, fear of fallingterm·dom was defined as persistent concern about fallsterm·dom that prevent individuals from performing activities they are capable of [ 5 ], which meant having low self-efficacy to avoid fallsterm·dom during harmless activities that were essential for daily life [ 1 ].

In particular, fear of fallingterm·dom is related to fallsterm·dom and gait disorders [ 3 , 6 ]. It was also suggested that excessive fear of fallingterm·dom can lead to decreased confidence, activity, and muscle strength, and can lead to decreased physical function [ 2 , 3 , 7 ]. A previous study showed that older adultsterm·key who experience fear of fallingterm·dom were two to seven times more likely to exhibit decreased physical function and showed a higher dependence on ADL and IADL activities such as walking outside than those who didn’t [ 8 ]. In another previous study, it was reported that the fear of fallingterm·dom was associated with activity avoidance, decreased independence, diminished confidence, depression, and a lower quality of life. As a result of the fear of fallingterm·dom, older adultsterm·key experienced physical, social, and psychological impacts [ 9 ].

As such, there is a correlation between fallterm·dom and fear of fallingterm·dom, and in some previous studies, both of them reported as important predictors of each other. However, there is inconsistent evidence regarding which one causes the other [ 10 – 14 ]. Fear of fallingterm·dom is often used interchangeably with the concepts of falls efficacyterm, balance confidence, and gait confidence [ 15 ]. For example, it is unclear what unique attributes distinguish fear of fallingterm·dom from falls efficacyterm. Due to this ambiguity, each concept was used interchangeably in previous studies, and similar scales were used to measure each concept [ 15 ]. The use of the scales developed to measure other concepts to measure fear of fallingterm·dom is related to the underlying theory that assesses the process of perceived fear of fallingterm·dom. For example, Tinetti et al. [ 16 ] developed Falls Efficacy Scaleterm (FESterm) after defining fear of fallingterm·dom as a state of low falls efficacyterm based on Bandura’s self-efficacy theory [ 10 , 16 ]. Recently, it has been argued that fear of fallingterm·dom doesn’t simply mean a state of low falls efficacyterm, but that fear of fallingterm·dom and falls efficacyterm are distinct concepts [ 10 , 17 ]. Evidence suggests that falls efficacyterm acts as a mediator between fear of fallingterm·dom and fallsterm·dom [ 10 ]. Therefore, before understanding and intervening fear of fallingterm·dom in older adultsterm·key, it is necessary to understand the unique characteristic of the fear of fallingterm·dom which distinguishes it from other concepts. Thus, this study aims to identify the attributes, antecedents, and consequences of older adultsterm·key’ fear of fallingterm·dom, based on the contents of previous studies.

Methods Data sources Documents related to the keywords below, published between 1993 and 2022, were searched in Pubmed and Scopus on 8 November 2022. The keywords employed were (“Fear of fallingterm·dom” or “FOF,” “Post-fall syndrome” or “Post fallterm·dom,” “Anxiety,” “Fear”) and “Fallterm·dom” and (“Older*,” “Elder*,” or “Geriatric*”) and (“Qualitative” or “Interview”). To provide specific and detailed explanations of the concept, the search was limited to qualitative studies or studies containing interviews. As a result, 93 documents from Pubmed, and 363 documents from Scopus were searched. Among them, 77 documents were removed because of duplication, and some of the remaining 379 documents were removed after checking the title and manuscript. After that, two documents were added through a manual search.

Data selection The inclusion criteria are as follows. (1) A study described in Korean or English and accessible as the full text. (2) A study was conducted to identify the concept, characteristics, or attributes of fear of fallingterm·dom.

The exclusion criteria are as follows. (1) A study that uses fear of fallingterm·dom only as a variable to describe a specific object, variable, or program and doesn’t explain related concepts or characteristics. (2) A study that doesn’t have a clear conceptual definition, referring only to repetitive concepts or scale identification and evaluation.

To explore the universal experience of fear of fallingterm·dom in older adultsterm·key, the literature was included without imposing restrictions based on specific disease conditions. Literature that was not about fear of fallingterm·dom (n = 261), used fear of fallingterm·dom as a variable without mentioning its characteristics (n = 75), didn’t have a clear conceptual definition, and referred only to repetitive concepts or scale evaluation (n = 16), didn’t investigate the participants’ fear of fallingterm·dom (n = 3), investigated the perception of fear of fallingterm·dom after the intervention in the randomized controlled trial (n = 1), weren’t written in Korean or English (n = 8), and were unavailable to access as full text (n = 1) were all removed. A total of 365 documents were removed, and 16 documents were used for the final analysis (Fig. 1 ).

Flow diagram of the study selection Concept analysisterm·key process This study was designed as a concept analysisterm·key for clarifying the concept of fear of fallingterm·dom in older adultsterm·key and the analysis was conducted by Walker & Avant’s eight-step conceptual analysisterm·mth method [ 18 ]. Each step is as follows. (1) Concept selection, (2) Establishing the purpose of concept analysisterm·key, (3) Identifying all use of concepts, (4) Identifying the proper attributes of concepts, (5) Presenting a model case of the concept, (6) Presenting a borderline, related, contrary case of the concept, (7) Identifying the antecedents and the consequences, and (8) Presenting the empirical referents.

When deriving the attributes, antecedents, and results of the concept, all the contents mentioned about the fear of fallingterm·dom in the selected literature were identified. Common items were confirmed, and even if they were not found in common, important contents were also reviewed. In particular, during this process, not only the results presented in the selected articles but also the direct words and expressions of the subjects presented by each researcher were verified. After that, the contents revealed in the results of each study were classified into each attribute and collected through a content analysis process [ 19 ]. The above process was carried out multiple times, and each time the decisions were made through discussions and agreements between researchers. Then, based on the identified attributes of the fear of fallingterm·dom, three cases were presented, including the model case, a borderline case, and a contrary case. The authors’ clinical and research backgrounds were used to construct these case scenarios.

Results Dictionary definition The definition of the term “fear of fallingterm·dom” wasn’t found, but “fear” was defined as “the bad feeling that you have when you are in danger or when a particular thing frightens you” and “fallterm·dom” was explained as “to drop down from a higher level to a lower level” or “to suddenly stop standing” in Oxford dictionary [ 20 , 21 ]. Also, a fallterm·dom was defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” by World Health Organization (WHO) [ 22 ]. As such, the meaning of the fear of fallingterm·dom may be derived from the definitions of ‘fallterm·dom’ and ‘fear’.

Use of the concept There are various scales for measuring fear of fallingterm·dom, and each scale defines fear of fallingterm·dom using different concepts. Fear of fallingterm·dom was initially operationalized as a state of ‘low perceived self-efficacy at avoiding fallsterm·dom during essential, non-hazardous activities of daily living’ by Tinetti et al. [ 16 ] and was then measured by the Falls Efficacy Scaleterm (FESterm), which investigates the degree of perceived self-efficacy when performing a particular activity [ 16 ]. Additionally, Lachman et al. [ 23 ] developed the Survey of Activities and Fear of Fallingterm·dom (SAFFE), which measures fear of fallingterm·dom that doesn’t lead to negative consequences such as activity curtailmentterm·key or fatality [ 23 ]. There is also the Falls Efficacyterm Scale-International (FES-I), which was developed from FESterm and includes question items about concerns regarding falling while performing various activities [ 24 , 25 ]. Lastly, Dayhoff et al. [ 26 ] developed the Fear of Falling Questionnaireterm (FFQterm) to measure fear of fallingterm·dom as harm outcomes, coping potential, degree of threat, and future expectancy based on Lazarus’s cognitive appraisal model of emotion [ 26 ].

Recently, the term ‘concern about fallingterm·dom’ has emerged, as suggested by The World Fallsterm·dom Guidelines Concern about Fallsterm·dom and Falling Working Group [ 27 , 28 ]. They recommended using the term ‘concern about fallingterm·dom’ instead of ‘fear of fallingterm·dom’, citing that older adultsterm·key prefer the term ‘concern’ over ‘fear’ and that ‘concern’ is more suitable and acceptable to older adultsterm·key because it is perceived as ‘less intense and emotional’ than ‘fear’ [ 27 , 28 ].

In one previous study presenting a new perspective on falls efficacyterm, researchers defined falls efficacyterm as “perceived self-efficacy to perform activities of daily living without falling” and fear of fallingterm·dom as “lasting concerns about falling that lead to individuals avoiding activities they are still capable of performing” [ 17 ]. Thus, there has been increasing research that distinguishes fear of fallingterm·dom from falls efficacyterm.

Attributes of fear of fallingterm·dom in older adultsterm·key In this study, four decisive attributes of fear of fallingterm·dom were presented based on the contents of several previous studies, especially qualitative studies expressing the fear of fallingterm·dom by the participants: Apprehension caused by the unpredictable nature of fallsterm·dom, unease related to own vulnerabilityterm·key, high vigilance-related to the environment, and concern about potential harm after fallterm·dom events (Table 1 ).

Literature included in the concept analysisterm·key Apprehension caused by the unpredictable nature of fallsterm·dom It refers to an anxious feeling caused by the unpredictable character of the fallterm·dom. As a characteristic that affects the occurrence of fear of fallingterm·dom, the concept that the occurrence of fallsterm·dom cannot be predicted has emerged. Due to the nature of fallsterm·dom, the participants thought that they could fallterm·dom at any time [ 29 ], which resulted in increased fear [ 30 ]. Fear of fallingterm·dom increased when they were alone because they felt that they couldn’t cope with fallsterm·dom by themselves [ 31 ]. Also, the fear of fallingterm·dom tended to decrease when someone was around or accompanied by others, but the attitude of others or the help provided by others sometimes increased the fear of fallingterm·dom [ 31 ].

In previous studies, it was said that fear of fallingterm·dom was caused by not being sure of the cause of instability related to fallsterm·dom or thinking that it was out of one’s control [ 32 ]. It was reported that these self-uncontrollable instabilities were frequent but unpredictable, and for this reason, they expected themselves to fallterm·dom every moment they took a step [ 30 , 32 ]. Also, they thought that they don’t fallterm·dom every day but the fallsterm·dom could happen suddenly, anytime, anywhere [ 29 , 33 ]. Along with these characteristics of fallsterm·dom, unpredictable outside characteristics such as weather increased this fear [ 34 , 35 ].

Unease related to own vulnerabilityterm·key It means one’s vulnerabilityterm·key to falling occurrences and the ability to deal with fallsterm·dom, such as the possibility of fallterm·dom occurrences, recovery after fallsterm·dom, coping with fallsterm·dom, etc. For individuals, being careful not to fallterm·dom relates to knowing about their safety and avoiding perceived threats around them [ 30 , 35 ]. In previous studies, the participant explained that fear of fallingterm·dom meant being careful when taking steps [ 30 ]. Fear of fallingterm·dom was associated with discomfort from not being able to fully coordinate themselves and was more frequent when they were tired or stressed [ 29 ]. They also expressed concerns about how to get up and recover from fallterm·dom events [ 36 , 37 ], and this was related to their perception of their inability to cope with fallsterm·dom.

They said they were conscious of their instability, and expressed that they were not the same as before and they should walk slower now [ 38 ]. Also, they thought that they fallterm·dom because they weren’t paying enough attention, and they said they should be more cautious and careful [ 34 ]. They were more conscious of the activities they could perform and places they could visit because of their fear of fallingterm·dom [ 39 ] and reported that they strictly planned every day to maintain a good balance [ 34 ]. They recognized that their bodies are aging and expressed that this aging process made them more vulnerable to fallsterm·dom [ 35 , 39 , 40 ]. Reduced balance control, decreased vision and hearing, dizziness-related instability, and osteoporosis due to aging were associated with a fear of fallingterm·dom, and the older, lonely, and weaker they were, the stronger their fear of fallingterm·dom became [ 32 , 34 , 35 , 39 , 40 ]. These feeling of weakness and vulnerabilityterm·key was caused by the lack of trust in their body. The gap between what the brain wants and what the body performs causes fear and anxiety [ 34 ].

High vigilanceterm·key related to the Environment It means paying more attention to the surrounding environment. They explained that fear of fallingterm·dom always makes them more vigilant or careful, and search for hazards that exist in the environment [ 29 ].

The design of the surrounding environment played an important role in the fallterm·dom occurrence, and they expressed that they were highly vigilant to avoid fallsterm·dom and that they need to know better about the surroundings [ 39 ]. They explained that they fallterm·dom because of the physical environment and so, they avoided visiting places with slippery surfaces or stairs [ 29 , 36 ]. They also argued that they felt unsafe in the crowd, and the fear of fallingterm·dom made the environment look dangerous and overbearing [ 29 , 32 ]. In previous studies, participants said that if the floor is hard, they feel fear because they think that they will get severely injured when they fallterm·dom, and if the floor is shiny they think that the floor is slippery, and feel scared even if it is not [ 29 ]. In addition, they cannot stand the mess of the environment, especially the floor, and to prevent fallsterm·dom, they organize the surroundings and implement behavioral adjustments such as drying the floor off, to remove risk factors [ 35 ].

Concern about potential harm after fallsterm·dom It refers to a wide range of physical, functional, and emotional damage that may occur to an individual after experiencing a fallterm·dom. Concerns about physical damage in future fallsterm·dom, including injuries, pain, and disabilities had been most often found [ 29 ]. In previous studies, many participants thought that fallsterm·dom could result in injuries or fractures, and if they have bad fallsterm·dom, they could injure their heads or break their necks, and become permanently disabled or die [ 29 – 38 , 41 , 42 ]. They thought of fallsterm·dom as a link to possible physical damage [ 38 ] and were concerned about post-fall pain and the possibility that they couldn’t get up again [ 29 ]. Some previous studies reported that the fear of fallingterm·dom was a concept developed based on physical damage and loss of function and that the participants experienced fear of possible injury [ 42 ].

Also, the participants often mentioned that they were afraid of becoming incompetent, being a burden, or being useless [ 42 ], and being incompetent meant a situation in which they had to rely on others for their needs. They expressed fear that they would lose their independence and become dependent on wheelchairs and were worried that they would have to leave their residence and become institutionalized [ 30 , 42 ].

The persistent fear of fallingterm·dom acted as a psychological pressure on older adultsterm·key, because of which they became more sensitive, and this heightened sensitivity made them complain about bad moods [ 35 ]. In addition, they explained that the fallterm·dom experience was related to social embarrassment. They were not only embarrassed by the fact that they fell, but also felt humiliated in public when others came and helped them [ 34 , 42 ]. They reported that they hated being seen and being helped by others, and this affected their confidence [ 42 ]. Some of them also mentioned that they heard others laugh when they fell, so they felt uneasy and concerned [ 34 ].

Model case A 65-year-old woman visited her friend who fell on the street and was hospitalized a few days ago, and she almost fell in the bathroom on the previous day. She felt anxious. After all, she couldn’t predict when the fallterm·dom will occur and is worried. She thought herself vulnerable to falling because she is old and can’t move as before. In addition, she thinks she would break her leg or be hospitalized if she fell, and she thinks that she should take a closer look at the surroundings when using stairs or doing outdoor activities.

Borderline case A 70-year-old woman almost slipped on her way home on a rainy day. She was worried about the thought that she could get seriously injured if she fell. Also, she thought that it was more dangerous because there were many solid objects on the porch. In addition, she was anxious because she thought that a fallterm·dom could happen to anyone at any time, especially on such a rainy day, so she put an anti-slip mat on the floor.

There is no mention of ‘unease related to own vulnerabilityterm·key’.

Contrary case A 75-year-old man almost fell yesterday while using stairs. However, he thought that he wouldn’t fallterm·dom and that he wouldn’t be seriously injured if he fell. In addition, he thought that if he paid attention, he wouldn’t fallterm·dom on the stairs and that he should exercise in the future to develop his leg muscles more.

Antecedents and consequences Similarities were identified in terms of the antecedents or consequences of fear of fallingterm·dom between the experiences of community-dwelling healthy older adultsterm·key and patients with various diseases, with the exception of individuals with Parkinson’s Disease. Due to the disease-specific nature of Parkinson’s Disease and the progressive deterioration of their physical condition, their experiences tended to be distinct and specific to the disease.

Antecedents Awareness of Fallsterm·dom and Near Fallsterm·key. It means knowing that fallsterm·dom are dangerous. Various opinions were suggested as to whether encountering other people’s fallterm·dom experiences increases the participants’ fear of fallingterm·dom [ 29 , 30 , 43 ], but it was confirmed that recognizing how dangerous a fallterm·dom is, including the consequences that may occur after a fallterm·dom, is the base of the fear of fallingterm·dom. They also expressed that fallsterm·dom could have negative consequences, or that they should be careful to avoid fallsterm·dom [ 30 , 35 ].

Direct/Indirect Experience about Fallsterm·dom and Near Fallsterm·key. The antecedent factors of fear of fallingterm·dom identified through previous studies were direct and indirect experiences of fallsterm·dom, threats perceived through near-fall experiences where they almost fell but managed to restore balance and changes in the environment [ 10 , 29 ]. Fear of fallingterm·dom also occurred after experiencing fallsterm·dom or depression or anxiety related to fallsterm·dom, or serious fallsterm·dom requiring medical intervention [ 30 , 36 , 40 , 42 ], friends’ or relatives’ experiences of bad fallsterm·dom [ 29 , 36 ].

Consequences Moderate fear of fallingterm·dom has a fallterm·dom prevention effect, but excessive fear of fallingterm·dom has resulted in increased fallterm·dom risk, decreased physical activity, decreased social activity, instability, loss of independence, unsafe environment/place/activity avoidance, weakened muscle strength, and poor quality of life [ 30 , 38 ].

Protective Effect. It was said that worrying thoughts have a protective effect because they attract attention to potential risks, which can increase concentration on the task and maintain the correct movements required to maintain safety [ 32 ]. In addition, it is said that they are more positive and actively engaged in life so that negative thoughts don’t encroach their life [ 34 , 42 ], and prepare strategies to reduce the probability of fallsterm·dom, such as improving the home environment or using aids [ 35 , 36 ].

Activities Curtailment. It is reported that fear of fallingterm·dom forces individuals to avoid actions that are thought to perform without falling, thereby reducing the number of safe activities available to participate in, which eventually leads to avoidance and immobility [ 32 ]. They avoided activities they enjoyed in the past [ 39 , 42 ], partially, temporarily, or completely abandoned activities such as using stairs, or taking walks, and restricted themselves to perform only activities they felt confident in [ 36 , 40 , 44 ].

Reduction in the Radius of Living. They thought their lives were shrinking. They moved less, and reduced activities in their daily lives [ 29 , 30 , 45 ]. They also described themselves as not leaving the house because they prefer to sit or lie on the sofa, making themselves lazy [ 41 ].

Restricted Freedom. They described their freedom as limited to living complete and undisturbed lives [ 34 ], and said that they would have been free to live more actively in public if there were no fear of fallingterm·dom [ 29 ].

Limited Social Activities. They expressed that fear of fallingterm·dom affects socializing with others, and they have difficulty spending time with friends and relatives [ 34 ]. It is said that social activities decrease, resulting in social isolation (Fig. 2 ) [ 29 , 40 , 41 ].

Conceptual Structure of the Fear of Fallingterm·dom in Older Adultsterm·key Empirical referents Identifying empirical referents is a crucial process for validating the actual manifestation of a concept in the real world [ 18 ]. It should be noted that empirical referents refer not only to the measurement tools of the concept but also to the means of assessing its attributes, often aligning with the identified attributes [ 18 ]. Thus, in order to achieve this objective, we examined how well the factors comprising the Fear of Falling Questionnaireterm (FFQterm), a tool developed for measuring fear of fallingterm·dom, corresponded to the attributes of fear of fallingterm·dom identified in this study.

In the FFQterm developed by Dayhoff et al. [ 26 ], the harm outcomes factor measured the anticipated physical and existential harm and fear associated with these anticipations. The statements for measuring this factor included that they would not be able to easily recover from injuries caused by fallsterm·dom, and they would have to stop doing some activities if they fell [ 26 ]. Also, in the case of the degree of threat factor, it meant the amount of anxiety caused by the expected threat, and statements measuring this included that their lives would change if they fell [ 26 ]. It can be seen that these are in line with the ‘concern about potential harm after fallterm·dom events’ of this study. Another factor of FFQterm, coping potential, referred to an evaluation of an individual’s ability to cope with a change, and as a measure of this, statements that they believe that they would not fallterm·dom, and they might make a change not to fallterm·dom included [ 26 ]. This is related to the ‘unease related to own vulnerabilityterm·key’ and ‘high vigilance-related to the environment,’ mentioned in this study. However, it was difficult to find factors or items related to ‘apprehension caused by the unpredictable nature of fallsterm·dom.’

Discussion As discussed in this study, four attributes make up the fear of fallingterm·dom: apprehension caused by the unpredictable nature of fallsterm·dom, unease related to own vulnerabilityterm·key, high vigilanceterm·key related to the environment, and concern about potential harm after fallterm·dom events. There are two antecedents of fear of fallingterm·dom which are awareness of fallsterm·dom and near fallsterm·key, and direct/indirect experience about fallsterm·dom and near fallsterm·key, and five consequences of fear of fallingterm·dom which are protective effect, activities curtailment, reduction in radius of living, restricted freedom, and limited social activities. This is in line with the cognitive vulnerabilityterm·key model of the etiology of fear proposed by Armfield [ 46 ]. Armfield [ 46 ] suggested the vulnerabilityterm·key schema as an important factor in the outbreak of fear [ 46 ]. It was proposed that this vulnerabilityterm·key schema included the uncontrollability and unpredictability of fear stimuli, and was also associated with the possibility that these fear stimuli can lead to negative consequences which are related to danger and disgust [ 46 ]. Also, the vulnerabilityterm·key schema was associated with learning experiences related to the fear stimuli or individual characteristics [ 46 ]. After activation of the vulnerabilityterm·key schema, two processes induced fear: the first is to elicit immediate fear with an automatic response, and the second is to include the relatively slow, automatic, semi-automatic, and non-automatic aspects, leading to cognitive fear along with the evaluation process [ 46 ]. It was stated that this overall process could lead to emotional, physiological, and behavioral reactions, and the interaction of these results goes back and influence the vulnerabilityterm·key schema [ 46 ].

Among the results of this study, ‘apprehension caused by the unpredictable nature of fallsterm·dom’ which is one of the attributes of fear of fallingterm·dom is said to be associated with unpredictability among the vulnerabilityterm·key schema. In previous studies, unpredictability was related to Spatio-temporal unpredictability, perceived risk, and viability [ 46 , 47 ], and when looking at animal-related fears as examples, the inability to predict animals’ movement, encounters, or willingness to attack was included in the unpredictability [ 46 , 48 ]. Therefore, if this is applied to fallsterm·dom, it is related to the aspect of uncertainty which includes that it is hard to know when fallsterm·dom will occur. Since this attribute to psychological anxiety occurs with the uncertainty and unpredictability of fallterm·dom events, it is related to the unpredictability of this theory. A prior study mentioned that the fear of fallingterm·dom increases because people were unable to anticipate their next fallterm·dom. This finding aligns with the unpredictability emphasized in theory [ 28 ].

Subsequently, ‘concern about potential harm after fallterm·dom events’ seems to be related to unpredictability, danger, and disgust among vulnerabilityterm·key schema. One of the properties of unpredictability presented in the literature is the ‘unpredictability of suffering actual harm if attacked’ [ 46 ]. If this aspect is put into a situation related to fallsterm·dom, it can be said that it is impossible to know how many injury outbreaks when a fallterm·dom occurs. In addition, participants reported that they were worried about various physical and functional difficulties that could occur after fallterm·dom events, which can be seen as reflecting the aspect of danger among vulnerabilityterm·key schema because it is related to the risk of falling. Also, one of the injuries that participants were worried about was emotional damage, which they expressed as the social embarrassment they would experience as they fallterm·dom, and expressed that they would be humiliated [ 34 , 42 ]. This aspect seems to reflect the disgust among vulnerabilityterm·key schema.

In the previous studies, the perceived vulnerabilityterm·key was explained to be an uncomfortable emotion related to capacity or an inability related to stimuli, to which an unexpected and unaffordable shock had a detrimental effect [ 46 , 49 ]. The attribute ‘unease related to own vulnerabilityterm·key’ identified in this study could also be related to this aspect, because the participants reported that they thought they were susceptible to fallsterm·dom or they were easily injured when exposed to fallsterm·dom. This aspect could be related to the possibility of participants encountering more frequent fallsterm·dom or greater risk concerning the attribute of danger among the vulnerabilityterm·key schema.

Lastly, ‘high vigilanceterm·key related to the environment’ can be associated with the notion of uncontrollability in the vulnerabilityterm·key schema. A prior study suggested that when explaining uncontrollability in relation to fear of certain animals, one factor is the inability to control encounters with the animal or to avoid them altogether [ 46 ]. If we apply this perspective to fallsterm·dom, it includes scenarios where the occurrence of fallsterm·dom cannot be managed, and the start and end of a fallterm·dom cannot be controlled. This attribute elucidates that vigilanceterm·key towards the hazardous environment increases due to the uncontrollable nature of fallsterm·dom, which establishes a connection to the concept of uncontrollability in fallsterm·dom. Moreover, this component, previously identified as “feeling out of control” and “lack of perceived control”, supports the notion of uncontrollability in this theory [ 31 ].

Furthermore, personality factors and learning experiences were said to be factors influencing the vulnerabilityterm·key schema in this theory [ 46 ]. Similarly, ‘awareness of fallsterm·dom and near fallsterm·key’, and ‘direct/indirect experience about fallsterm·dom and near fallsterm·key’ were suggested as antecedents of the fear of fallingterm·dom in this study, which could be seen as learning experiences of this theory. It was suggested that various reactions could occur due to the progress of the activated vulnerabilityterm·key schema, and similarly, this study confirmed that psychological, behavioral, and social reactions appeared as a result of fear of fallingterm·dom.

Although this study was not conducted based on this theory, there was a correspondence when considering each attribute and concept in this theory. Through this, it can be seen that the results of this study reflect the overall aspect of fear occurrence, while also encompassing the characteristics related to fallsterm·dom.

In the previous study, falls efficacyterm was identified as corresponding to the cognitive domain, while fear of fallingterm·dom was associated with the emotional domain [ 17 ]. This indicates that all attributes related to various aspects of emotion are important components of fear of fallingterm·dom. Specifically, four attributes can be distinguished based on the causes of fear, which include characteristics of fallterm·dom occurrences, the subject’s vulnerabilityterm·key, environmental risks, and the outcomes of fallsterm·dom. Various triggers can evoke the emotion of fear. Among these attributes, two that stand out as differentiating fear of fallingterm·dom from falls efficacyterm are ‘appreciation caused by the unpredictable nature of fallsterm·dom’ and ‘concern about potential harm after fallsterm·dom’.

‘Appreciation caused by the unpredictable nature of fallsterm·dom’ is characterized by the realization that a fallterm·dom can happen suddenly anywhere, irrespective of the subject’s abilities or confidence. This awareness of the potential risk of falling evokes strong emotions in individuals. Additionally, ‘concern about potential harm after fallsterm·dom’ generates fear due to the possibility of various damages that may occur following a fallterm·dom. It is distinctly different from confidence or efficacy in preventing fallsterm·dom. Notably, it can be seen as an attribute that sets fear of fallingterm·dom apart from falls efficacyterm, as the perception of falling risk by an individual directly contributes to the experience of fear.

Overall, fear of fallingterm·dom is a complex concept that encompasses various environmental and situational factors in addition to individual factors. This unique characteristic distinguishes it from other concepts.

Limitation Most of the studies included in the analysis investigated the fear of fallingterm·dom in older adultsterm·key, but some studies included participants under the age of 65 with more focus on specific diseases such as stroke, Parkinson’s disease, and dizziness. However, many studies focused on older adultsterm·key, and certain disease-specific factors revealed in some studies were excluded because they weren’t commonly revealed in several studies, so it was unlikely to have affected the overall characteristics of fear of fallingterm·dom in older adultsterm·key.

In addition, there is a limitation in that the number of documents used in the analysis isn’t large. However, all literature has the advantage of being able to confirm deep and diverse opinions on the concept of fear of fallingterm·dom by using qualitative approaches, which seems to compensate for the limitation.

Implications Understanding the antecedents, attributes, and consequences of fear of fallingterm·dom is crucial for clinicians when developing strategies for fallterm·dom prevention in older adultsterm·key. Based on the study’s findings, the fear of fallingterm·dom is rooted in individual recognition of the potential danger posed by a fallterm·dom. Therefore, clinicians should gather data on direct and indirect experiences of fallsterm·dom, as these experiences can influence the degree of fear.

The findings reveal that fear of fallingterm·dom in older adultsterm·key manifest in four distinct aspects: apprehension arising from the unpredictability of fallsterm·dom, unease related to personal vulnerabilityterm·key, heightened vigilanceterm·key concerning the environment, and concern about potential harm following fallterm·dom events. The extent to which individuals experience each aspect may differ. Consequently, interventions should be tailored to address these aspects on a personalized level. Implementing effective fallterm·dom prevention programs can assist in reducing apprehension, enhancing perceived control, promoting physical strength through exercise, addressing emotional vulnerabilityterm·key, improving environmental safety, and increasing knowledge about fallsterm·dom.

Considering that an excessive fear of fallingterm·dom can result in activity restriction, limited mobility, reduced independence, and decreased social engagement, it is imperative to evaluate the nature and scope of fear of fallingterm·dom in order to enhance the overall quality of life for older adultsterm·key. Fallterm·dom prevention programs should incorporate these aspects of fear of fallingterm·dom, particularly by providing education and counseling interventions to older adultsterm·key experiencing the negative consequences of excessive fear. Additionally, public awareness campaigns and policy implementation are necessary to foster safe indoor and outdoor environments for older adultsterm·key.

Conclusion In this study, to understand the fear of fallingterm·dom, which is important for older adultsterm·key, the attributes, antecedents, and consequences of this concept were explored. It was confirmed that the unique characteristics of fallsterm·dom and the fear-inducing process were fused to form the fear of fallingterm·dom. Based on the identified attributes, the fear of fallingterm·dom is an emotional state characterized by apprehension stemming from the unpredictable nature of fallsterm·dom, coupled with unease regarding one’s vulnerabilityterm·key. It entails a state of high vigilanceterm·key towards the environment and is accompanied by significant concern about the potential harm that may occur following fallterm·dom events. Thus, the fear of fallingterm·dom involves not only emotional responses (apprehension, unease, concern) but also cognitive response (vigilanceterm·key) to a perceived threat. This is believed to be the basis for developing scales that measure various aspects of fear of fallingterm·dom in the elderly in future studies. In addition, it is possible to present what aspects should be identified and considered when identifying or intervening in the fear of fallingterm·dom, which is expected to be an important basis for future research on the fear of fallingterm·dom or for dealing with the fear of fallingterm·dom in the clinical field.

Acknowledgements Not applicable.

Author contributions DL performed the data selection, analyzed the concept, integrated separated components into one concept, and wrote the original draft preparation of the manuscript. ST read selected articles, analyzed the concept and integrated separated components into one concept, and substantively revised the manuscript. Both authors have made substantial contributions to the conception, design of the work and interpretation of data. All of authors read and approved the final manuscript.

Funding The first author received a scholarship from the BK21 education program(Center for Human-Caring Nurse Leaders for the Future). The second and corresponding author was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT) (No. 2023R1A2C1006362).

Data Availability All data generated or analysed during this study are included in this published article.

Declarations Ethics approval and consent to participate Not applicable.

Consent for publication Not applicable.

Competing interests The authors declare that they have no competing interests.

Footnotes References Associated Data Data Availability Statement All data generated or analysed during this study are included in this published article.