In these analyses from the BHS, women who fell only once during each 6-month follow-up time period reported similar levels of social activities as those who did not fall; however, those who fell more than once reported participation in fewer social activities than those who did not fall at each of the 6 and 12 month evaluations. Adjustment for a global measure of lower extremity functional performance did not attenuate this association, suggesting that the decreased social participation in this group was not explained by worse lower extremity function. Adjustment for depressive symptoms, as measured by the GDS scale, did however result in an attenuation of this association by ~11–14%, suggesting that the observed association may be explained, in part, by an increase in depressive symptoms in those with multiple falls.
The association of multiple (>1) falls with decreased social participation is consistent with previous studies that found that in community-dwelling elders, multiple falls, but not a single fall, were associated with the increased risk for activity avoidance, including avoidance of social activities [3
Although poorer physical functioning has been associated with physical activity restriction [27
], in the analyses presented here, the association of multiple falls with social activity participation persisted even after adjusting for lower extremity functioning, suggesting that another mechanism may explain this relationship.
Depressive symptoms and depression are also believed to negatively impact functional recovery after hip fracture surgery [28
], and in our analyses, adjustment for depressive symptoms resulted in an attenuation of the observed relationship. This suggests that an increase in depressive symptoms in those with multiple falls may play a role. Multiple fallers are believed to also be at greater risk for fear of falling than those with one or fewer falls [3
], and fear of falling has been seen to have a significant impact on activity restriction in both individuals who have and have not fallen [29, 30
]. This fear, that may be present for those who fall, especially those who fall more than once, may be a factor in the causal pathway to social activity restriction. Because individuals who are fearful of falling are also believed to be more likely to show depressive symptoms or a depressed mood [4
], this may explain why depressive symptom scores partially attenuated the association in the current analysis.
The lack of a measure of fear of falling in the BHS-3 dataset is a limitation of these analyses, and re-evaluation of these results in hip fracture patients, in whom a validated measure of fear of falling is used, would be important. Also all of the subjects included in these analyses were white women and thus we are unable to assess whether similar associations exist in men or in women of other ethnicities. Another limitation is that the social functioning measure is not a standard measure that has been rigorously validated. Further research would benefit from the use of a standard measure of social functioning in order to compare the results more effectively to the current literature. We also have no information on pre-fracture depression or depressive symptoms and are therefore unable to assess how pre-existing depression might influence the observed associations. The age of the data can be viewed as a potential limitation to the interpretation of the analyses; however, although there have been significant changes to in-hospital care of hip-fracture patients in the years since 1995, analyses of more recent cohorts from the BHS suggests that the post-discharge pattern of recovery remains very similar. As a result, it is unlikely that the association of falls with the recovery of social functioning has changed during this time and the interpretation of the main analyses presented here are likely to still be of relevance today.
In conclusion, we found that in women, the presence of multiple falls was associated with participation in fewer social activities in the year post-hip fracture independent of lower extremity function. An increase in depressive symptoms in those with multiple falls may explain, in part, this relationship. Future research on social activity recovery using a specific measure of fear of falling is needed to further evaluate these associations.