The relationship between fear of falling and frailty in older adults undergoing hemodialysis

Document Type : Original Article


1 Student Research Committee, Nursing Care Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

2 Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran


Background: Frailty and fear of falling (FOF) are highly prevalent in older adults undergoing hemodialysis (HD). However, there is no reliable evidence of the association between FOF and frailty in older adults undergoing HD.
Objectives: This study aimed to determine the association between FOF and frailty in older adults undergoing HD.
Methods: This cross-sectional study was conducted on 194 older adults undergoing HD in the east of Mazandaran province, Iran. Data were collected using of demographic and clinical characteristics questionnaire, Edmonton Frail Scale (EFS), and Falls Efficacy Scale–International (FES-I). Independent t-test, analysis of variance, Pearson’s correlation coefficient, and stepwise multiple regression were used to analyze the data.
Results: The mean score of the FOF was 34.41±12.20, and most of the participants (38.4%) had moderate FOF. The mean score of the frailty was 6.91±3.12 and most of older adults (34.3%) were vulnerable to frailty. There was a positive and significant association between FOF and frailty in older adults undergoing HD (r=0.802, P<0.001).
Conclusion: The majority of older adults receiving chronic HD have moderate to high FOF and are prone to frailty. Therefore, it is necessary to perform appropriate educational, behavioral, and cognitive interventions to reduce the FOF in these patients.


Zahra Jannat Alipoor [Pubmed] [Google Scholar]


  1. Siriwardhana DD, Hardoon S, Rait G, Weerasinghe MC, Walters KR. Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis. BMJ open 2018; 8:e018195. doi:10.1136/bmjopen-2017-018195 PMid:29496895 PMCid:PMC5855322
  2. Venturini C SR, de Souza Moreira B, Ferriolli E, Neri AL, Lourenço RA, et al. A multidimensional approach to frailty compared with physical phenotype in older Brazilian adults: data from the FIBRA-BR study. BMC Geriatr 2021;21:246-49. doi:10.1186/s12877-021-02193-y PMid:33853524 PMCid:PMC8045180
  3. Garcia-Canton C, Rodenas A, Lopez-Aperador C, Rivero Y, Anton G, Monzon T, et al. Frailty in hemodialysis and prediction of poor short-term outcome: mortality, hospitalization and visits to hospital emergency services. Ren Fail 2019;41:567-75. doi:10.1080/0886022X.2019.1628061 PMid:31234684 PMCid:PMC6598473
  4. Wongrakpanich S, Susantitaphong P, Isaranuwatchai S, Chenbhanich J, Eiam-Ong S, Jaber BL. Dialysis therapy and conservative management of advanced chronic kidney disease in the elderly: a systematic review. Nephron 2017;137:178-89. doi:10.1159/000477361 PMid:28538218
  5. Chao CT, Chiang CK, Huang JW, Hung KY, COGENT study group. Self-reported frailty among end-stage renal disease patients: A potential predictor of dialysis access outcomes. Nephrology (Carlton) 2017;22:333-334. doi:10.1111/nep.12961 PMid:28247523
  6. Fitzpatrick J, Sozio SM, Jaar BG, Estrella MM, Segev DL, Parekh RS, et al. Frailty, body composition and the risk of mortality in incident hemodialysis patients: the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease study. Nephrol Dial Transplant 2019; 34:346-54. doi:10.1093/ndt/gfy124 PMid:29868775 PMCid:PMC6365769
  7. Yadla M, John JP, Mummadi M. A study of clinical assessment of frailty in patients on maintenance hemodialysis supported by cashless government scheme. Saudi J Kidney Dis Transpl 2017;28:15-22. doi:10.4103/1319-2442.198102 PMid:28098098
  8. De Souza LF, Canever JB, Moreira BS, Danielewicz AL, de Avelar NCP. Association between Fear of Falling and Frailty in Community-Dwelling Older Adults: A Systematic Review. Clin Interv Aging 2022; 17:129-140. doi:10.2147/CIA.S328423 PMid:35173427 PMCid:PMC8843349
  9. Thiamwong L, Suwanno J. Fear of falling and related factors in a community-based study of people 60 years and older in Thailand. Int J Gerontol 2017;11:80-84. doi:10.1016/j.ijge.2016.06.003
  10. da Silva de Jesus LA, Pinheiro BV, Koufaki P, Lucinda LMF, Gravina EPL, Barros FS, et al. Factors associated with fear of falling in hemodialysis patients. Int Urol Nephrol 2021; 53:2159-2166. doi:10.1007/s11255-021-02856-0 PMid:33881702
  11. Mane AB, Sanjana T, Patil PR, Sriniwas T. Prevalence and correlates of fear of falling among elderly population in urban area of Karnataka, India. J Midlife Health 2014;5:150-55. doi:10.4103/0976-7800.141224 PMid:25317002 PMCid:PMC4195189
  12. Kim JH, Bae SM. Association between Fear of Falling (FOF) and all-cause mortality. Arch Gerontol Geriatr 2020; 88: 104017. doi:10.1016/j.archger.2020.104017 PMid:32044524
  13. Bahat Öztürk G, Kılıç C, Bozkurt ME, Karan MA. Prevalence and associates of fear of falling with frailty among community-dwelling older adults. J Nutr Health Aging 2021;25:433-439. doi:10.1007/s12603-020-1535-9 PMid:33786559
  14. Alcolea-Ruiz N, Alcolea-Ruiz S, Esteban-Paredes F, Beamud-Lagos M, Villar-Espejo MT, Pérez-Rivas FJ. Prevalence of fear of falling and related factors in community-dwelling older people. Aten Primaria 2021; 53: 101962. doi:10.1016/j.aprim.2020.11.003 PMid:33446358 PMCid:PMC7910690
  15. Kuo CT, Chen DR, Chen YM, Chen PY. Validation of the short falls efficacy scale-international for Taiwanese community-dwelling older adults: associations with fall history, physical frailty, and quality of life. Geriatr Nurs 2021;42:1012-1018. doi:10.1016/j.gerinurse.2021.06.006 PMid:34256149
  16. Pérez-Ros P, Vila-Candel R, López-Hernández L, Martínez-Arnau FM. Nutritional status and risk factors for frailty in community-dwelling older people: a cross-sectional study. Nutrients 2020;12: 1041. doi:10.3390/nu12041041 PMid:32290060 PMCid:PMC7231056
  17. Gesualdo GD, Zazzetta MS, Say KG, Orlandi FS. Factors associated with the frailty of elderly people with chronic kidney disease on hemodialysis. Cien Saúde Colet 2016;21:3493-3498. doi:10.1590/1413-812320152111.18222015 PMid:27828582
  18. Fadavi-Ghaffari M, Azad A, Meimandi M, Arani-Kashani Z, Ghorbanpoor H. The Psychometric Properties of Falls Efficacy Scale in the Elderly Iranian Residents of Nursing Homes. Iran Rehabil J 2019;17:197-206. doi:10.32598/irj.17.3.197
  19. Perna S, Francis MD, Bologna C, Moncaglieri F, Riva A, Morazzoni P, et al. Performance of Edmonton Frail Scale on frailty assessment: its association with multi-dimensional geriatric conditions assessed with specific screening tools. BMC Geriatr 2017;17:2. doi:10.1186/s12877-016-0382-3 PMid:28049443 PMCid:PMC5209899
  20. Dehesh M, Rejeh N, Tadrisi SD, Tayebi A. Fear of Falls and Related Factors in The Elderly Undergoing Dialysis Referred to Hospitals in Tehran 2021. Qom Univ Med Sci J 2021;15:640-649. doi:10.32598/qums.15.9.2466.1
  21. Shirai N, Yamamoto S, Osawa Y, Tsubaki A, Morishita S, Nitami S, et al. Fear of falling and physical activity in hemodialysis patients: a pilot study. Ren Replac Ther 2021; 7:1-7. doi:10.1186/s41100-021-00383-3
  22. Takeuchi H, Uchida HA, Kakio Y, Okuyama Y, Okuyama M, Umebayashi R, et al. The prevalence of frailty and its associated factors in Japanese hemodialysis patients. Aging Dis 2018;9:192-207. doi:10.14336/AD.2017.0429 PMid:29896410 PMCid:PMC5963342
  23. Orlandi FS, Gesualdo GD. Assessment of the frailty level of elderly people with chronic kidney disease undergoing hemodialysis. Acta Paul Enferm 2014;27:29-34. doi:10.1590/1982-0194201400007
  24. McAdams-DeMarco MA, Law A, Salter ML, Boyarsky B, Gimenez L, Jaar BG, et al. Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis. J Am Geriatr Soc 2013; 61:896-901. doi:10.1111/jgs.12266 PMid:23711111 PMCid:PMC3938084
  25. Asadi A, Habibi Soola A, Iranpour S. The Relationship between Frailty and Polypharmacy in the Elderly Re-ferred to the Emergency Departments of Ardabil, 2020. Iran J Ageing 2022;16:550-563. doi:10.32598/sija.2021.2999.2
  26. Lee HJ, Son YJ. Prevalence and associated factors of frailty and mortality in patients with end-stage renal disease undergoing hemodialysis: A systematic review and meta-analysis. Int J Environ Res Public Health 2021;18:3471. doi:10.3390/ijerph18073471 PMid:33801577 PMCid:PMC8037521
  27. Hoogendijk EO, van Hout HP, Heymans MW, van der Horst HE, Frijters DH, Broese van Groenou MI, et al. Explaining the association between educational level and frailty in older adults: results from a 13-year longitudinal study in the Netherlands. Ann Epidemiol 2014; 24: 538-44. doi:10.1016/j.annepidem.2014.05.002 PMid:24935466
  28. Jiao J, Wang Y, Zhu C, Li F, Zhu M, Wen X, et al. Prevalence and associated factors for frailty among elder patients in China: a multicentre cross-sectional study. BMC Geriatr 2020;20:100. doi:10.1186/s12877-020-1496-1 PMid:32164595PMCid:PMC7068995
  29. Liang YD, Zhang YN, Li YM, Chen YH, Xu JY, Liu M, et al. Identification of frailty and its risk factors in elderly hospitalized patients from different wards: a cross-sectional study in China. Clin Interv Aging 2019;14:2249-59. doi:10.2147/CIA.S225149 PMid:31908435 PMCid:PMC6927496
  30. Auais M, French S, Alvarado B, Pirkle C, Belanger E, Guralnik J. Fear of falling predicts incidence of functional disability 2 years later: a perspective from an international cohort study. J Gerontol A Biol Sci Med Sci 2018;73:1212-1215. doi:10.1093/gerona/glx237 PMid:29220420 PMCid:PMC6093362
  31. Qin Y, Li J, McPhillips M, Lukkahatai N, Yu F, Li K. Association of fear of falling with frailty in community‐dwelling older adults: A cross‐sectional study. Nurs Health Sci 2021;23:516-524. doi:10.1111/nhs.12840 PMid:33825287 PMCid:PMC8217326
  32. Veronese N, Stubbs B, Noale M, Solmi M, Pilotto A, Vaona A, et al. Polypharmacy is associated with higher frailty risk in older people: an 8-year longitudinal cohort study. J Am Med Dir Assoc 2017;18:624-628. doi:10.1016/j.jamda.2017.02.009 PMid:28396180 PMCid:PMC5484754
  33. Khanian ZS, Ghaffari F, Alipoor ZJ, Fotokian Z. Designing and validating the empowerment scale for the older individuals with chronic obstructive pulmonary disease (ESOCOPD). Heliyon. 2020; 6(5). doi: 10.1016/j.heliyon.2020.e03909