It was hypothesized that a possible bidirectional relationship would be found to exist between frailty and fears of falling among a substantive proportion of older community dwelling adults. Moreover, a link for both frailty and falls fears to hip fracture risk would appear to be an apparent, albeit possibly preventable, important disabling pathway.

Frailty, a potentially preventable serious health state and undisputed impediment to well-being among many older populations, not only impacts bone fragility, but overall energy levels, muscle strength capacity, and gait. Frailty also commonly engenders various degrees of anxiety, and depression ⁶ that alone or in combination with one or more of these factors can be expected to not only exacerbate frailty, but also associated levels of serious morbidity and excess rates of premature mortality, as well as possible parallel increases in falls risk, as well as fears of falling.

As such, the excess human as well as fiscal costs of frailty are currently immeasurable, and are likely to increase, rather than decrease, as societies age unless actions are taken to offset this possible cycle of highly adverse events. In particular, falls that often cause severe injury, anxiety and loss of confidence, as well as activity avoidance, depression, and social isolation due to ‘fears of falling’ a collective term denoting a set of negative beliefs that appears to occur in up to 85 percent of older adults who have experienced prior falls ⁷ undoubtedly tends to increase frailty or provoke its multiple manifestations ⁸. In particular, falls leading to hip fractures that occur frequently among the frail elderly not only predict less than desirable outcomes of survivors post hip fracture surgery ⁹, but the persistence of falls fears, anxiety, and low self-efficacy ¹⁰.

Frailty, an age associated syndrome commonly attributed to under nutrition among other factors, appears strongly associated with a progressive decline in several physiological systems that can collectively heighten the older adult’s vulnerability to the risk of multiple adverse health events and outcomes, such as disability or death ¹¹. In this regard, both frailty itself, as well as falls injuries often attributable in part to frailty features such as muscle and bone mass declines, and which often produce an excess of fears, such as falls related fears, can clearly be expected to lower the ability of the affected frail aging adult to adapt to one or more undesirable stresses as well as reducing the chances of successful aging and a high life of quality. Yet, for many older adults living in the community and who may slowly lose their independence, this remains an enormous personal problem, and is one clearly likely to markedly raise the immense and profound social costs associated its well established negative impact on function, as well as social and mental health status ^{12, 13}, particularly if it contributes to a fragility hip fracture ¹¹. In turn, as well as fostering an increased risk for falling or actual fall injuries leading to a fear of falling, fractures and further possible injuries and frailty or the onset of frailty, a deleterious perpetual cycle of adverse health outcomes can be expected to ensue. In this regard, although Malini et al. ¹³ found fear of falling in older adults to occur at high rates in this population, Malini et al. who found use of seven or more medications, having a hearing impairment, being functionally dependent in activities of daily living, diminished walking speed, fair and poor/very poor self-rated health and depressive symptoms to be key related health issues, did not discuss the factor of frailty directly in this respect. However, Crehan et al. ¹⁴ found a quarter of 47 elderly fallers who appeared to exhibit falls fears were also largely frail (75% cases), while in a study of older adults located in four Indian villages, among several associated factors mentioned as salient frailty determinants, such as low education, socioeconomic status and physical activity, age, being female, the frail elderly observed in that study tended to have a higher odds of falls as well as fear of falling compared to those designated as being non-frail, irrespective of the frailty definition ¹⁵. As well as falls, various fear perceptions, which have been studied for some time have shown the specific ‘fear of falling’ may in turn lead to the onset or perpetuation of a state of frailty, poor life quality, and a heightened falls risk and incidence of falls in their own right ¹⁶. Indeed, a fear of falling and/or low falls efficacy appears to be a key risk factor for frailty in older adults with and without diabetes ¹⁷, and is one suggesting this linkage may have a possible profound role to play in terms of clarifying those frailty determinants that might be modifiable, and their role should not be negated, but rather, should arguably be studied further in the future as indicated by Seematter-Bagnoud et al. ¹⁸.

Among the articles relevant to the present topic, although limited in quantity, available data do appear to strongly support the view that many older adults are likely to be frail or in a pre frailty state, a recently constructed term and syndrome employed to characterize those vulnerable older adults who tend to exhibit an increased risk of premature or excess rates of functional declines, institutionalization, hospitalization, and death ^{1, 19}. Other reports indicate that those older adults deemed to be frail, as well as those elderly who are deemed in robust health may yet both exhibit high rates of falling and possible subsequent fears of falling if they have incurred a an injurious fall or believe they are at risk for a future fall. Conceptually, this appears to set the stage for either magnifying the presence of or increasing its risk. In particular, those elderly who restrict their weight bearing activities and others out of falling fears and who may then inadvertently suffer excess muscle mass losses, bone mineral density alterations, weakness and lack of energy, depression, and a heightened medication need, among other negative frailty associated impacts may be highly vulnerable in this regard. Those who have studied this topic thus tend to agree that this series of overlapping events is undoubtedly of high importance to acknowledge in that once a cycle of falls and frailty is established, this situation can be expected to foster a high risk state for serious injuries, adverse health outcomes including falls ³, as well as possible subsequent increments in frailty ²⁰, wherein there may be a further and more permanent loss of the well attuned harmonic interaction between multiple domains or dimensions of wellbeing including those of multiple genetic, biological, functional, cognitive, psychological and functional health domains ²¹.

In light of these highly negatively impactful events, including possible increases in hospitalizations, immense health care costs, and premature mortality rates ³, and the belief that neither frailty nor falls are inevitable, a fair number of current recommendations to offset this adverse cycle of events have been documented. These include the application of early screening as well as efforts to actively intervene to avert this negative cycle of interacting events as well as its various secondary health outcomes and cycle of excess suffering, including comorbidity and falls ^{21, 22}.

​Although frailty is often associated with functional declines, and is said to be distinguishable from aging and to confer a high risk for falls ^{22, 23}, many studies of older adults currently reviewed, such as that by Tomita et al. ²⁴, Makino et al. ²⁵ and Lach et al. ²⁶, did not discuss the attribute of frailty as a possible falls fear predictor in community dwelling elderly adults. In addition, the attribute termed ‘fears of falling’ also closely related to the risk as well as actual prevalence of falls among the elderly, was not mentioned in the context of a study focusing on frailty (eg., 27) As observed by Guedes et al. ²², Esbri-Victor et al. ²⁸ who did assess the association between the attributes of fear of falling and frailty among 183 older Spanish adults with a prior falls history using validated questionnaires the authors found fears of falling to preside in over 76 percent of cases, with 55 percent indicating a high concern. Just over 88 percent of those deemed frail indicated they had a fear of falling with a relative risk of 3.18 compared to those who were not frail. Significant predictors after controlling for other variables were female gender and the presence of depression. Since this was a cross-sectional study, the cause-effect association between frailty and falls fears could not be established, however.

Nonetheless, work conducted in 1994 –did appear to open the door to the possibility that fear of falling, commonly generated in response to an actual fall, could possibly induce or heighten frailty, especially among those in the higher age ranges where falls related fears appear to rise incrementally ²⁹. Again, this study, albeit a cross-sectional one, did tend to support the view that older community dwelling adults who feel depressed or dissatisfied with life, as well as those who experience falls, are likely to be more impacted as far as future falls risk and frailty are concerned ¹⁶. In addition, Ní Mhaoláin et al. ³⁰ found frail fallers to suffer from an increased fear of falling when compared to the more robust faller (p < 0.001). Frail fallers also exhibited higher depression scores than non frail fallers, while fallers at a transitional level of frailty were deemed to represent a particularly vulnerable group psychologically speaking.

Delbaere et al. ³¹ who did conduct a prospective study of older adults from the perspective of falls fears, fears of movement and physical activity, and falling, was able to conclude that fear of falling had possible implications for the development of physical frailty, even though they did not actually assess frailty. They further affirmed those who were female and in the higher age groups were likely to be at most risk.

In their study, Silviera et al. ³², examining elderly fallers with varying frailty designations, found higher fear of falling perceptions in those deemed frail compared to those deemed non frail. As well, Kressig et al. ³³ who noted symptoms of activity related fears of falling to be present among at least 50 percent of older adults deemed to be transitioning to frailty, also found these fears to be associated with depression, as well as prevailing levels of functional ability. Silviera et al. ³² further concluded that frailty is indeed often associated with a heightened fear of falling, as well as reduced muscle strength, and gait abnormalities deemed to possibly lead to falls, while Makino et al. ³⁴ likewise conclude that frailty status may well predict future falls along with the fear of falling in older community-dwelling adults. Fear of falling that induces sedentary behavior is also likely to exacerbate the risk for incurring frailty states or worsening these, as well as falls, regardless of sociodemographic factors ³⁵. Martin et al. ¹¹ too conclude there are close associations between frailty, sarcopenia, osteoporosis and falls that warrant attention especially in cases where older adults have fallen or sustained a fracture or both, as these individuals may not only be frail and require a care plan involving both nutrition and exercises, but also require specific help to prevent future falls. Indeed, Higuchi et al. ⁴ found frail elderly who exhibited falling fears to be worse off physically speaking than those with no fear attributes. Other data reveal the fear of falling can not only contribute to psychological conditions such as depression, but can also impact on the health-related life quality of frail elderly people ³⁶.

In short, therefore, although the literature on the current topic of interest is neither robust, nor conclusive, it appears hard to refute a case for the application of both timely as well as effective intervention strategies to prevent or reduce frailty among older vulnerable adults. This may not only help to reduce the chances of a high falls risk, but may also be beneficial for preventing excess frailty, future falls, as well as future falls fears among frail older adults ³⁷ and should be studied in various contexts, and in diverse groups of older adults. Explicit attention to identifying and intervening upon excess falls fear beliefs where they prevail also seems imperative.

Indeed, a recent study of 175 China based community dwelling older adults from five districts ³⁸ showed those study participants who reported having a fear of falling were 7.2 times more likely to be frail than those reporting no such fear, and among those sixty percent of cases deemed frail, eighty one percent affirmed they had a fear of falling. Similarly, Perez-Ross et al. ³⁹ who examined 564 elderly people with a mean age of 76.05 years; and where 83.9 percent were deemed to be pre frail, among the four factors associated with frailty they included a fear of falling. Further findings of Alcolea–Ruiz et al. ⁴⁰ tend to affirm that fear of falling is significantly elevated in the presence of frailty.

Hence, although frailty represents a highly challenging negative state of wellbeing among many older adults and one that clearly exposes the sufferer to a multitude of potentially preventable adverse health outcomes ⁴¹, it appears safe to say that excess frailty can. possibly be averted in part by multiple approaches that might include taking steps to minimize the onset or perpetuation of excess fears related to future falls among those elderly adults deemed most vulnerable. Conversely, in light of the rapidly ageing global population, and the parallel rise in frailty, as well as falls injuries and resultant possible fears of falling, the current social and economic burden of these two conditions alone will undoubtedly continue to rise exponentially if not addressed in a timely manner. In addition, due to associated increases in numbers of older adults living to higher ages, older adults with multi morbidities and those who survived COVID-19, soaring healthcare and social care costs and suffering can be anticipated if sporadic or belated preventive efforts remain the norm.

To address this issue, it is uplifting to see that while more needs to be done, sufficient research does point to the promise of improved health and social outcomes for the vulnerable elderly, through insightful and carefully tailored preventive approaches ^{42, 43, 44} that do currently exist. These include, but are not limited to multi-component community-based as well as home-based approaches and occupational therapy strategies designed to improve muscle and bone mass and function believed to help reduce both frailty as well as falls risk ^{39, 44, 45, 46, 47}. As well as structured exercises, strength training, or physical activities that involve functional training and coordination exercises ⁴⁸, structured nutrition interventions ⁴⁹, and/or cognitive behavioral intervention approaches to reduce frailty, as well as falls and the fear of falling may similarly help to increase independence, confidence and energy ^{7, 37, 50}. Further efforts directed towards reducing harmful medications, improving calcium and vitamin D status, diabetes control, and desirable home adaptations ^{44, 51, 52}, efforts to provide a person-centered and goal setting approach ⁴⁸ and encouraging social engagement ⁵³ will also likely prove helpful, as will proactive careful screening to identify at risk adults ^{38, 53, 54}. Programs that try to encourage personal development and growth, in spite of aging, and physical, social, emotional, and economic environments that foster wellbeing and active aging appear highly promising as well ⁵⁵.