Fear of falling can be defined as an exacerbated concern about falling during daily activities (Jung, 2008) and its current prevalence in community-dwelling older adults differs in different countries, with variations between 41.7% in Spain (Lavedán et al., 2018), 48.40% in Brazil (Canever et al., 2021), and 75.6% in Korea (Oh et al., 2017). Fear of falling is associated with a higher occurrence of falls (Young & Mark Williams, 2015), constituting a public health problem due to its high prevalence worldwide (Almeida et al., 2019), and also the consequences resulting from this condition (Vieira et al., 2018).
Fear of falling and a history of falling are associated with several predisposing conditions, among which gender (Moreira et al., 2020; Vitorino et al., 2019), health perception (Ferreira et al., 2018; Vitorino et al., 2017), multimorbidity (Lavedán et al., 2018; Moreira et al., 2020), environmental factors (Ambrose et al., 2013; Canever et al., 2021), and cognitive decline stand out (Akyol et al., 2018; Jung, 2008). In addition, fear of falling and a history of falls may predispose an individual to adverse health events, such as increased depressive symptoms (Afrin et al., 2020; Hajek & König, 2020), reduced physical activity (Lopes et al., 2009; Pimentel & Scheicher, 2009), functional decline (Auais et al., 2018; Zusman et al., 2019), hospitalizations (Khow & Visvanathan, 2017), and mortality (Kim & Bae, 2020).
It is already established in the literature that physical inactivity is associated with fear of falling (Kendrick et al., 2014; Kumar et al., 2016; Pimentel & Scheicher, 2009). However, the association with sedentary behavior (SB) still remains understudied (Kotlarczyk et al., 2020; Stubbs et al., 2014). The SB can be defined as any behavior which has an energy expenditure of <1.5 metabolic equivalent in a sitting, lying, or reclining position (Sedentary Behaviour Research Network, 2012). It is worth noting that the concept of SB differs from physical inactivity as coexisting behavior profiles can be observed, since an individual can have SB and be physically active (Omorou et al., 2016). However, physical activity can delay, but not compensate for the deleterious effects of SB (Biswas et al., 2018). Moreover, it is noteworthy that SB is prevalent in older adults; a review study which analyzed data from six countries (Australia, Canada, Norway, Spain, United Kingdom, and United States) found that this behavior affects 67% of older adults, and they spend more than 8.5 hr a day in SB (Harvey et al., 2013). Similarly, Brazilian studies suggest that this population spends about 4.5 hr per day in a sitting position (Leão et al., 2020).
The SB is associated with several chronic health conditions (Gennuso et al., 2013), reduced self-esteem (Rezende et al., 2014), increased risk of cardiovascular disease (Grøntved & Hu, 2011; Thorp et al., 2011), and functional decline (Brandão et al., 2019). Previous studies have defined SB cutoff points for different outcomes, such as musculoskeletal pain (3.5 hr in SB per day; Stubbs et al., 2014), mental disorder (about 5 hr in SB per day; Silva et al., 2017), and increased mortality (12.5 hr in SB per day; Diaz et al., 2017). However, the SB time for predicting fear of falling and falls is still unknown.
The World Health Organization (World Health Organization, 2020) highlights the importance of reducing SB time in older adults, but does not present reference values that can be used for education/guidance to this population. Furthermore, no studies were found that defined average weekly discriminative values to be oriented to reduce SB in community-dwelling older adults and which verified the association of this behavior with fear of falling and history of falls. The definition of this discriminative value may serve as a parameter to reduce such behavior in older adults, aiming to reduce these health problems. Thus, the objectives of this study were: (a) to establish SB cutoff values that discriminate falls and fear of falling in community-dwelling older adults and (b) to verify the association between SB and fear of falling and falls according to the established cutoff point.
Materials and Methods
Study Design
This was a cross-sectional study with a probabilistic sample, carried out with older adults (60 years or more) from the municipality Balneário Arroio do Silva/SC, Brazil. This study was approved by the Ethics Committee on Human Research of the Federal University of Santa Catarina under CAAE number 87776318.3.0000.0121. All participants provided written informed consent. This study is in accordance with the ethical principles contained in the Declaration of Helsinki.
Population and Sample
The sample size calculation took into account the total number of older adults registered in the municipality’s health system (n = 2,833) according to the following parameters: unknown prevalence for the outcomes of 50%, confidence level of 95%, sampling error of six percentage points, and 20% for expected losses, thus estimating the need for 302 volunteers for the study. The study inclusion criteria were men and women aged 60 years or more living in the urban area of the municipality of Arroio do Silva. The individuals participating in the study had to be registered with the primary care system in the municipality of Balneário Arroio do Silva. In this context, information about the address and name of the individual was collected. Later, the researchers randomly selected individuals and went to their homes to ask about their interest in participating in the study. Individuals who agreed to participate in the study and were able to answer the questions promptly were included in this study.
We excluded the older adults who were bedridden, hospitalized, dependent, or who could not answer the questionnaires, who lived in long-term care institutions, or who had changed their residential address.
Independent Variable
The SB was assessed by two questions on time spent sitting on a weekday and a weekend day from the International Physical Activity Questionnaire (IPAQ). The IPAQ was validated for the Brazilian older adult population (Benedetti et al., 2004, 2007) and used in several previous studies to evaluate SB (Cleland et al., 2018; Tomioka et al., 2011). This questionnaire showed reasonable to substantial (r = .26–.70) validity for SB in U.K. older adults (Cleland et al., 2018). The intraclass correlation coefficient in the study by Tomioka et al. (2011) ranged from .39 to .66 in men and .30 to .67 in older adult women. Spearman’s correlation coefficient regarding the validity data ranged from .42 to .53, indicating that IPAQ has adequate validity to assess SB in older adults.
The following formula was used to obtain the average time spent sitting: ([sitting time weekday × 5 + sitting time weekend × 2]/7) (Cleland et al., 2018).
Outcomes
History of Falls
The older adults were asked about their history of falls in the past 12 months, being categorized dichotomously with or without a history of falls (yes or no). The occurrence of a fall was defined as an event characterized by the unintentional displacement of the body from the standing position to a lower level, determined by multifactorial circumstances (Liu-Ambrose et al., 2019).
Fear of Falling
Fear of falling was assessed by Falls Efficacy Scale International (FES-I; Yardley et al., 2005) translated and adapted by Camargos et al. (2010) for use in Brazil (FES-I Brazil). This scale assesses the concern about suffering falls when performing 16 daily life tasks, from performing simple activities, such as dressing, undressing, and bathing, to more complex activities, such as walking on uneven surfaces, going up and down ramps, and walking on slippery surfaces. The score ranges from 1 to 4 for each task, and the total scale score can vary from 16 to 64 points (Camargos et al., 2010). The cutoff point established to discriminate high fear of falling in older adults in Brazil is ≥23 points (Camargos et al., 2010).
Adjustment Variables
The receiver-operating-characteristic curve was initially calculated to determine the SB cutoff points related to fear of falling and history of falls, and then logistic regression was performed to explain the relationship between a binary dependent variable and other independent variables (Wang et al., 2011). After calculating the SB cutoff points related to fear of falling and history of falling, multivariable logistic regression analysis was performed to verify the association between these conditions. Thus, the following adjustment variables were used: sex (female and male; Ambrose et al., 2013; Oh et al., 2017), age group (60–69 years, 70–79 years, and over 80 years; Ambrose et al., 2013; Danielewicz et al., 2018), presence of multimorbidity by considering the presence of two or more self-reported medical conditions (spinal disease, arthritis or rheumatism, cancer, diabetes, bronchitis or asthma, heart or cardiovascular disease, chronic renal failure, tuberculosis, cirrhosis, stroke/cerebrovascular ischemia, osteoporosis, hypertension, labyrinthitis, and sphincter incontinence; Deandrea et al., 2010; Lavedán et al., 2018), and physical activity. The physical activity level was assessed by the IPAQ, which was developed in 1998 by the World Health Organization and validated in Brazil by (Benedetti et al., 2004, 2007). The instrument presents 27 questions related to physical activities performed in a normal week with vigorous, moderate, and light intensity, with a minimum duration of 10 continuous minutes, distributed in four dimensions of physical activity (work, transportation, domestic activities, and leisure), and the time spent per week in a sitting position. The physical activity level for leisure was categorized as sufficiently active (>150 min) and insufficiently active (<150 min) (Pimentel & Scheicher, 2009; World Health Organization, 2020).
Statistical Analysis
Data were independently tabulated by two researchers in Microsoft Excel software (2019) and later entered into the statistical program SPSS (version 23.0; IBM Corp., Chicago, IL). The significance level adopted was 5%. Descriptive analyses were performed and the values of proportions (in percentage) and respective 95% confidence intervals (95% CI) were presented.
Receiver-operating-characteristic curves were constructed for the analysis of sensitivity, specificity, Youden index, odds ratio for positive (+LR), negative (−LR) tests, positive predictive value (+PV), and negative predictive value (−PV) for the outcome variable. Subsequently to the establishment of the cutoff point in the SB to discriminate fear of falling and history of falls, an association analysis was carried out between the variables, through multivariable logistic regression, estimating the crude and adjusted odds ratios, with their respective CIs. The multicollinearity test required for binomial logistic regression was performed using the variance inflation factor whose value adopted as the cutoff point was >10 (Maranhão et al., 2015). The test showed an absence of multicollinearity between the independent variables studied, since the highest variance inflation factor value observed was 1.45.
Results
Of the 2,883 older adults registered in the primary care system, 540 older adults were randomly selected. However, 232 were excluded from the study for the following reasons: 24 deaths, 68 losses, 64 changes of address, 16 exclusions for being bedridden or dependent older adults, 29 refusals, and 31 for incomplete registrations. Thus, a total of 308 community-dwelling older adults participated in the study (Figure 1).
—Study flowchart.
Citation: Journal of Aging and Physical Activity 30, 5; 10.1123/japa.2021-0175
—Study flowchart.
Citation: Journal of Aging and Physical Activity 30, 5; 10.1123/japa.2021-0175
—Study flowchart.
Citation: Journal of Aging and Physical Activity 30, 5; 10.1123/japa.2021-0175
The majority of the full participating group was female (57.8%), in the age group 60–69 years (54.7%), with multimorbidity (61.9%) and insufficiently active (87.2%). Of the 299 participants who completed the FES-I—Brazil, 140 (46.8%) were classified as having “High fear of falling.” A reason for not completing the FES-I—Brazil was the participant’s refusal to answer any of the 16 items on the scale. Among those who presented high fear of falling, most were women (72.9%), with multimorbidities (77.7%) and insufficiently active (91.3%). Regarding the history of falls, 306 participants answered this item and 32.7% of community-dwelling older adults had a history of falls. Among the older adults with a history of falls, the majority were women (72.0%), with multimorbidities (71.0%) and insufficiently active (87.0%). The data characterizing the sample according to fear of falling and history of falls are described in Table 1.
Sociodemographic and Clinical Characteristics of the Evaluated Older Adults
| Variables | All participants 308 (100) | High fear of falling 140 (46.8) | Low fear of falling 159 (53.2) | With history of falls 100 (32.7) | Without history of falls 206 (67.3) |
|---|---|---|---|---|---|
| Gender | |||||
| Women | 178 (57.8) | 102 (72.9) | 73 (45.9) | 72 (72.0) | 105 (51.0) |
| Men | 130 (42.2) | 38 (27.1) | 86 (54.1) | 28 (28.0) | 101 (49.0) |
| Age group | |||||
| 60–69 years | 168 (54.7) | 77 (55.0) | 88 (55.7) | 61 (61.0) | 106 (51.7) |
| 70–79 years | 109 (35.5) | 50 (35.7) | 54 (34.2) | 33 (33.0) | 75 (36.6) |
| ≥80 years | 30 (9.8) | 13 (9.3) | 16 (10.1) | 6 (6.0) | 24 (11.7) |
| Multimorbidity | |||||
| No | 117 (38.1) | 31 (22.3) | 83 (52.2) | 29 (29.0) | 86 (42.0) |
| Yes | 190 (61.9) | 108 (77.7) | 76 (47.8) | 71 (71.0) | 119 (58.0) |
| Physical activity | |||||
| Insufficiently active | 266 (87.2) | 126 (91.3) | 132 (83.5) | 87 (87.0) | 177 (87.2) |
| Sufficiently active | 39 (12.8) | 12 (8.7) | 26 (16.5) | 13 (13.0) | 26 (12.8) |
Note. The frequency values are given in parentheses.
The cutoff point in SB to discriminate fear of falling was >4.14 hr per day (area under curve [AUC] = 0.60, 95% CI [0.54, 0.65]); sensitivity, 49.29% (95% CI [40.7, 57.9]); specificity, 67.30% (95% CI [59.4, 74.5]); Youden J statistic, 0.17 (95% CI [0.08, 0.24]), +LR, 1.51 (95% CI [1.10, 2.00]), −LR, 0.75 (95% CI [0.60, 0.90]), +PV, 57.00 (95% CI [50.10, 63.70]); and −PV, 60.10 (95% CI [55.4, 64.70]).
The cutoff point for history of falls was >3.90 hr per day (AUC = 0.59, 95% CI [0.53, 0.64]); sensitivity, 58.00% (95% CI [47.70, 67.80]); specificity, 58.25% (95% CI [51.20, 65.10]); Youden J statistic, 0.17 (95% CI [0.07, 0.24]), +LR, 1.39 (95% CI [1.10, 1.80]); −LR, 0.72 (95% CI [0.60, 0.90]); +PV, 40.30 (95% CI [34.80, 46.00]); and –PV, 74.10 (95% CI [68.80, 78.70]) (Table 2).
Analysis of the Area Under the ROC Curve and General and Specific Predictive Values of SB in Community-Dwelling Older Adults
| Variables | Predictive values | AUC | Sensitivity (%) | Specificity (%) | +LR | −LR | Youden J statistic | +PV | −PV |
|---|---|---|---|---|---|---|---|---|---|
| Fear of falling | >4.14 | 0.59 [0.53, 0.65] | 49.29 [40.70, 57.90] | 67.30 [59.4, 74.50] | 1.51 [1.10, 2.00] | 0.75 [0.60, 0.90] | 0.17 [0.07, 0.24] | 57.00 [50.10, 63.70] | 60.10 [55.4, 64.70] |
| History of falls | >3.90 | 0.58 [0.52, 0.64] | 58.00 [47.70, 67.80] | 58.25 [51.20, 65.10] | 1.39 [1.10, 1.80] | 0.72 [0.60, 0.90] | 0.17 [0.07, 0.24] | 40.3 [34.80, 46.00] | 74.1 [68.80, 78.70] |
Note. ROC = rate of change; AUC = area under the ROC curve; SB = sedentary behavior; +LR = OR for positive test; −LR = OR for a negative test; +PV = positive predictive value; −PV = negative predictive value; OR = odds ratio.
The association between the SB, fear of falling, and history of falls variables is described in Table 3. The multivariable logistic regression analysis showed that older adults with SB had 1.76 (95% CI [1.06, 2.89]) and 1.71 (95% CI [1.03, 2.84]) higher odds of having a history of falls and fear of falling, respectively, compared with those without this condition, even after adjusting for gender, age group, multimorbidity, and physical activity.
Association Between Fear, History of Falls, and SB in Community-Dwelling Older Adults
| SB | ||
|---|---|---|
| Variables | Raw OR [95% CI] | Adjusteda OR [95% CI] |
| Fear of falling | ||
| <4.1 hr/day | 1.00 | 1.00 |
| >4.1 hr/day | 2.05 [1.28, 3.28] | 1.71 [1.03, 2.84] |
| History of falls | ||
| <3.9 hr/day | 1.00 | 1.00 |
| >3.9 hr/day | 1.85 [1.14, 3.00] | 1.76 [1.06, 2.90] |
Note. OR = odds ratio; CI = confidence interval; SB = sedentary behavior.
aAdjusted for the variables sex, age group, multimorbidity, and physical activity.
Discussion
The main findings of this study suggest that the discriminative points associated with fear of falling and history of falls for community-dwelling older adults were 4.1 and 3.9 hr per day, respectively. In addition, older adults who spent more time in SB than the suggested values were more likely to have a fear of falling and history of falling, respectively, when compared with older adults without this behavior.
Some studies have shown that fear of falling can contribute to increased SB time (Kotlarczyk et al., 2020; Stubbs et al., 2014). However, there is no research that proves that SB could increase fear of falling. The present study demonstrated that community-dwelling older adults who spent longer than 4.1 hr per day on SB showed a higher fear of falling. This association may be justified because SB contributes to developing depressive symptoms (Zhu et al., 2018), functional decline (Brandão et al., 2019), and falls (Rezende et al., 2014). These factors predispose community-dwelling older adults to fear of falling. In addition, fear of falls leads to the belief that sitting is safer than standing or walking, and thus significantly contributes to older adults remaining seated, consequently increasing the time spent in SB (Kotlarczyk et al., 2020).
The present study also found that older adults with SB were about 1.71 (95% CI [1.03, 2.84]) more likely to be afraid of falling than older adults without this condition, which may be directly related to the consequences of SB. Padoin et al. (2010) carried out a comparative analysis between older adults who practiced physical exercises and older adults with SB, and concluded that sedentary older adults had a greater fear of falling. A possible hypothesis would be the association of fear of falling with reductions in mobility, balance, and restrictions in functional activities (Padoin et al., 2010; Vellas et al., 1997). Thus, a vicious cycle begins in which the consequences of SB can contribute to the fear of falling, and the fear of falling can lead to important functional restrictions (Ambrose et al., 2013), increasing SB.
There are studies regarding SB and history of falls which state that falls can contribute to an increase in SB in older adults (Rezende et al., 2014). In the present study, it was found that staying more than 3.9 hr per day in SB may increase the risk of the older person falling. The SB is associated with reduced bone mass (Zusman et al., 2019), decline in balance (Thibaud et al., 2012), muscle weakness (Gianoudis et al., 2015), increased risk for sarcopenia (Gianoudis et al., 2015), reduction in instrumental activities (Pimentel & Scheicher, 2009), gait disturbances (Pimentel & Scheicher, 2009), decrease in functional capacity (Gianoudis et al., 2015), and consequently may contribute to the occurrence of falls.
Furthermore, the present research showed that older adults with SB presented 1.76 (95% CI [1.06, 2.89]) higher chances of suffering falls than those without this condition. These findings corroborate the study by Pimentel and Scheicher (2009), which verified that sedentary older adults have 15.6 times more risk of suffering falls when assessed by the Berg scale. The possible explanation for this result is the fact that physical activity contributes to a lower incidence of falls in older adults and because SB causes important physiological, social, and psychological changes (Pimentel & Scheicher, 2009).
As already mentioned, previous studies have aimed to find SB cutoff points for different health outcomes, such as musculoskeletal pain (Stubbs et al., 2014), developing mental disorder (Silva et al., 2017), fragility (Silva et al., 2018), and increased mortality (Diaz et al., 2017). Silva et al. (2018) also assessed SB using IPAQ and found a mean time of 8.25 hr per day (AUC 0.74, 95% CI [0.67, 0.81]) in SB for men and 8.9 hr per day (AUC 0.58, 95% CI [0.52, 0.64]) for women to discriminate frailty among Brazilian older adults, with these AUC values being similar to those found in the present study.
Identifying SB cutoff points is of utmost importance, since practicing physical activity and reducing SB improves muscle strength, increases independence, and can reduce injuries in older adults (Zusman et al., 2019). There is evidence that physical activity prevents falls in older adults (Gillespie et al., 2012). Thus, the knowledge of SB time, which is a predictor of fear of falling and falls, can help health professionals, especially physical therapists in the health education of their patients, encouraging them to stop SB before reaching these cutoff points and consequently reduce the SB time. Knowledge of these cutoff points can also be useful for developing health policies and actions which can propose interventions (booklets, programs, and lectures) for the older adult population about the importance of preventing and reducing SB, and about the risks they will be subjected to when they remain in SB for long periods.
Although it is possible to investigate several variables concomitantly in a case-control study, this design is a limitation of the study since it prevents an evaluation of the cause and effect relationship between the variables. Even though validated questionnaires, such as the FES-I and IPAQ were applied, we point out that another limitation of the present study is self-report. Variables collected through self-report are subject to the subjects’ honesty and introspective abilities, that is, community older adults may not be able to accurately assess themselves and may not clearly understand the questions. Although the sample of this study is randomly selected, another limitation of the study is that it is composed only of community-dwelling elderly people from the southernmost part of Santa Catarina (Brazil), and may be susceptible to cultural, ethical, and health differences from other regions of Brazil and the world. Finally, we highlight that the potential refinement of the model with additional dimensions of SB may lead to an underestimation or overestimation of the time spent on this behavior; thus, being another limitation of this study.
We emphasize that the findings of the present study can assist clinicians in using these cutoff points as a recommendation to reduce SB as well as its negative health outcomes. Furthermore, the results of the present study can help public health agencies to promote policies aiming to reduce SB and outcomes, such as fear of falling and history of falls. It is worth mentioning that the strengths of this study were the sample size and the fact that the sample was randomized, reducing possible selection biases. As well as the robust association analysis, using several adjustment variables, reducing the risk of bias, therefore, enabling better identification of the associations of SB and fear of falling and history of falls in community-dwelling older adults.
Conclusion
Values higher than 4.1 and 3.9 hr/day in SB are associated with fear of falling and suffering falls in community-dwelling older adults. These findings may contribute to developing rehabilitation protocols by health professionals and strategies to raise awareness by older adults promoted by public policies and other health actions.
Acknowledgments
The authors are grateful to the Municipal Health Secretariat and the professionals who work in the Basic Health Units of the municipality Balneário Arroio do Silva de Santa Catarina for their assistance in conducting the project and facilitating contact with the sampled older adult population.
References
Afrin, N., Honkanen, R., Koivumaa-Honkanen, H., Sund, R., Rikkonen, T., Williams, L., & Kröger, H. (2020). Depression, falls, and fractures. Osteoporosis International, 31(6), 1173–1174. https://doi.org/10.1007/s00198-020-05348-6
Akyol, Y., Ulus, Y., Tander, B., Tomak, L., Zahiroğlu, Y., Bilgici, A., & Kuru, Ö. (2018). Falls, fear of falling, and associated factors in ambulatory patients with rheumatoid arthritis: A comparative study with healthy controls. Turkish Journal of Physical Medicine and Rehabilitation, 64(3), 213–221. https://doi.org/10.5606/tftrd.2018.1687
Almeida, L.M.S., Meucci, R.D., & Dumith, S.C. (2019). Prevalence of falls in elderly people: A population based study. Revista Da Associacao Medica Brasileira, 65(11), 1397–1403. https://doi.org/10.1590/1806-9282.65.11.1397
Ambrose, A. F., Paul, G., & Hausdorff, J. M. (2013). Risk factors for falls among older adults: A review of the literature. Maturitas, 75(1), 51–61. https://doi.org/10.1016/j.maturitas.2013.02.009
Auais, M., French, S., Alvarado, B., Pirkle, C., Belanger, E., & Guralnik, J. (2018). Fear of falling predicts incidence of functional disability 2 years later: A perspective from an international cohort study. The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 73(9), 1212–1215. https://doi.org/10.1093/gerona/glx237
Benedetti, T.B., Mazo, G.Z., & Barros, M.V.G. (2004). Aplicação do Questionário Internacional de Atividades Físicas para avaliação do nível de atividades físicas de mulheres idosas: validade concorrente e reprodutibilidade teste-reteste. Revista Brasileira de Ciência e Movimento, 12(1), 25–34. https://doi.org/10.18511/rbcm.v12i1.538
Benedetti, T.R.B., Antunes, P.C., Rodriguez-Añez, C.R., Mazo, G.Z., & Petroski, É.L. (2007). Reprodutibilidade e validade do Questionário Internacional de Atividade Física (IPAQ) em homens idosos. Revista Brasileira de Medicina do Esporte, 13(1), 11–16. https://doi.org/10.1590/S1517-86922007000100004
Biswas, A., Oh, P.I., Faulkner, G.E., & Alter, D.A. (2018). A prospective study examining the influence of cardiac rehabilitation on the sedentary time of highly sedentary, physically inactive patients. Annals of Physical and Rehabilitation Medicine, 61(4), 207–214. https://doi.org/10.1016/j.rehab.2017.06.003
Brandão, T.L., Lago, K.N., & Rocha, S.V. (2019). Sedentary behavior and functional disability in older adults with low economic status: Monidi study. Revista Brasileira de Cineantropometria & Desempenho Humano, 21, Article e55944. https://doi.org/10.5007/1980-0037.2019v21e55944
Camargos, F.F.O., Dias, R.C., Dias, J.M.D., & Freire, M.T.F. (2010). Cross-cultural adaptation and evaluation of the psychometric properties of the falls efficacy scale-international among elderly Brazilians (FES-I-BRAZIL). Revista Brasileira de Fisioterapia, 14(3), 237–243. https://doi.org/10.1590/S1413-35552010000300010
Canever, J.B., Danielewicz, A.L., Leopoldino, A.A.O., & de Avelar, N.C.P. (2021). Is the self-perception of the built neighborhood associated with fear of falling in community-dwelling older adults? Archives of Gerontology and Geriatrics, 95(January), Article 104395. https://doi.org/10.1016/j.archger.2021.104395
Cleland, C., Ferguson, S., Ellis, G., & Hunter, R.F. (2018). Validity of the international physical activity questionnaire (IPAQ) for assessing moderate-to-vigorous physical activity and sedentary behaviour of older adults in the United Kingdom. BMC Medical Research Methodology, 18(1), 176. https://doi.org/10.1186/s12874-018-0642-3
da Silva, P.A.S., Rocha, S.V., Vasconcelos, L.R.C., & dos Santos, C.A. (2017). Comportamento sedentário como discriminador dos transtornos mentais comuns em idosos. Jornal Brasileiro de Psiquiatria, 66(4), 183–188. https://doi.org/10.1590/0047-2085000000169
da Silva, V.D., Tribess, S., Meneguci, J., Sasaki, J.E., Santos, D.A.T., Carneiro, J.A.O., & Virtuoso Júnior, J.S. (2018). Time spent in sedentary behaviour as discriminant criterion for frailty in older adults. International Journal of Environmental Research and Public Health, 15(7), Article 1336. https://doi.org/10.3390/ijerph15071336
Danielewicz, A.L., d’Orsi, E., & Boing, A.F. (2018). Association between built environment and the incidence of disability in basic and instrumental activities of daily living in the older adults: Results of a cohort study in southern Brazil. Preventive Medicine, 115, 119–125. https://doi.org/10.1016/j.ypmed.2018.08.016
de Rezende, L.F.M., Rodrigues Lopes, M., Rey-López, J.P., Matsudo, V.K.R., & Luiz, O.C. (2014). Sedentary behavior and health outcomes: An overview of systematic reviews. PLoS One, 9(8), Article e105620. https://doi.org/10.1371/journal.pone.0105620
Deandrea, S., Lucenteforte, E., Bravi, F., Foschi, R., La Vecchia, C., & Negri, E. (2010). Risk factors for falls in community-dwelling older people: A systematic review and meta-analysis. Epidemiology, 21(5), 658–668. https://doi.org/10.1097/EDE.0b013e3181e89905
Diaz, K.M., Howard, V.J., Hutto, B., Colabianchi, N., Vena, J.E., Safford, M.M., Blair, S.N., & Hooker, S.P. (2017). Patterns of sedentary behavior and mortality in U.S. middle-aged and older adults: A national cohort study. Annals of Internal Medicine, 167(7), 465–475. https://doi.org/10.7326/M17-0212
Ferreira, F.R., César, C.C., de Andrade, F.B., de Souza Junior, P.R.B., Lima-Costa, M.F., & Proietti, F.A. (2018). Aspects of social participation and neighborhood perception: ELSI-Brazil. Revista de Saude Publica, 52, 1–11. https://doi.org/10.11606/S1518-8787.2018052000647
Gennuso, K.P., Gangnon, R.E., Matthews, C.E., Thraen-Borowski, K.M., & Colbert, L.H. (2013). Sedentary behavior, physical activity, and markers of health in older adults. Medicine & Science in Sports & Exercise, 45(8), 1493–1500. https://doi.org/10.1249/MSS.0b013e318288a1e5
Gianoudis, J., Bailey, C.A., & Daly, R.M. (2015). Associations between sedentary behaviour and body composition, muscle function and sarcopenia in community-dwelling older adults. Osteoporosis International, 26(2), 571–579. https://doi.org/10.1007/s00198-014-2895-y
Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M., & Lamb, S.E. (2012). Interventions for preventing falls in older people living in the community. The Cochrane Database of Systematic Reviews, 9, Article CD007146. https://doi.org/10.1002/14651858.CD007146.pub3
Grøntved, A., & Hu, F.B. (2011). Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: A meta-analysis. Journal of the American Medical Association, 305(23), 2448–2455. https://doi.org/10.1001/jama.2011.812
Hajek, A., & König, H.-H. (2020). What are the psychosocial consequences when fear of falling starts or ends? Evidence from an asymmetric fixed effects analysis based on longitudinal data from the general population. International Journal of Geriatric Psychiatry, 35(9), 1028–1035. https://doi.org/10.1002/gps.5325
Harvey, J.A., Chastin, S.F.M., & Skelton, D.A. (2013). Prevalence of sedentary behavior in older adults: A systematic review. International Journal of Environmental Research and Public Health, 10(12), 6645–6661. https://doi.org/10.3390/ijerph10126645
Jung, D. (2008). Fear of falling in older adults: Comprehensive review. Asian Nursing Research, 2(4), 214–222. https://doi.org/10.1016/S1976-1317(09)60003-7
Kendrick, D., Kumar, A., Carpenter, H., Zijlstra, G.A.R., Skelton, D.A., Cook, J.R., Stevens, Z., Belcher, C.M., Haworth, D., Gawler, S.J., Gage, H., Masud, T., Bowling, A., Pearl, M., Morris, R.W., Iliffe, S., & Delbaere, K. (2014). Exercise for reducing fear of falling in older people living in the community. The Cochrane Database of Systematic Reviews, 2014(11), Article CD009848. https://doi.org/10.1002/14651858.CD009848.pub2
Khow, K.S.F., & Visvanathan, R. (2017). Falls in the aging population. Clinics in Geriatric Medicine, 33(3), 357–368. https://doi.org/10.1016/j.cger.2017.03.002
Kim, J.-H., & Bae, S.M. (2020). Association between fear of falling (FOF) and all-cause mortality. Archives of Gerontology and Geriatrics, 88, Article 104017. https://doi.org/10.1016/j.archger.2020.104017
Kotlarczyk, M.P., Hergenroeder, A.L., Gibbs, B.B., Cameron, F.A., Hamm, M.E., & Brach, J.S. (2020). Personal and environmental contributors to sedentary behavior of older adults in independent and assisted living facilities. International Journal of Environmental Research and Public Health, 17(17), Article 6415. https://doi.org/10.3390/ijerph17176415
Kumar, A., Delbaere, K., Zijlstra, G.A.R., Carpenter, H., Iliffe, S., Masud, T., Skelton, D., Morris, R., & Kendrick, D. (2016). Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis. Age and Ageing, 45(3), 345–352. https://doi.org/10.1093/ageing/afw036
Lavedán, A., Viladrosa, M., Jürschik, P., Botigué, T., Nuín, C., Masot, O., & Lavedán, R. (2018). Fear of falling in community-dwelling older adults: A cause of falls, a consequence, or both? PLoS One, 13(3), Article e0194967. https://doi.org/10.1371/journal.pone.0194967
Leão, O.A.A., Knuth, A.G., & Meucci, R.D. (2020). Comportamento sedentário em idosos residentes de zona rural no extremo sul do Brasil. Revista Brasileira de Epidemiologia, 23, Article e200008. https://doi.org/10.1590/1980-549720200008
Liu-Ambrose, T., Davis, J.C., Best, J.R., Dian, L., Madden, K., Cook, W., Hsu, C.L., & Khan, K.M. (2019). Effect of a home-based exercise program on subsequent falls among community-dwelling high-risk older adults after a fall: A randomized clinical trial. Journal of the American Medical Association, 321(21), 2092–2100. https://doi.org/10.1001/jama.2019.5795
Lopes, K.T., Costa, D.F., Santos, L.F., Castro, D.P., & Bastone, A.C. (2009). Prevalência do medo de cair em uma população de idosos da comunidade e sua correlação com mobilidade, equilíbrio dinâmico, risco e histórico de quedas. Revista Brasileira de Fisioterapia, 13(3), 223–229. https://doi.org/10.11606/S1518-8787.2017051007098
Maranhão, T.A., Gomes, K.R.O., Nunes, L.B., & Moura, L.N.B. (2015). Fatores associados ao aleitamento materno exclusivo entre mães adolescentes. Cadernos Saúde Coletiva, 23(2), 132–139. https://doi.org/10.1590/1414-462X201500020072
Moreira, B.S., Andrade, A.C.S., Xavier, C.C., Proietti, F.A., Braga, L.S., Friche, A.A.L., & Caiaffa, W.T. (2020). Perceived neighborhood and fall history among community-dwelling older adults living in a large Brazilian urban area: A multilevel approach. International Journal of Environmental Health Research, 1–13. https://doi.org/10.1080/09603123.2020.1782354
Oh, E., Hong, G.R.S., Lee, S., & Han, S. (2017). Fear of falling and its predictors among community-living older adults in Korea. Aging and Mental Health, 21(4), 369–378. https://doi.org/10.1080/13607863.2015.1099034
Omorou, A.Y., Coste, J., Escalon, H., & Vuillemin, A. (2016). Patterns of physical activity and sedentary behaviour in the general population in France: Cluster analysis with personal and socioeconomic correlates. Journal of Public Health, 38(3), 483–492. https://doi.org/10.1093/pubmed/fdv080
Padoin, P.G., Gonçalves, M.P., Comaru, T., & da Silva, A.M.V. (2010). Comparative analysis of old people practicing physical exercises and sedentary ones regarding the risk of falling. O Mundo Da Saúde, 34(2), 158–164.
Pimentel, R.M., & Scheicher, M.E. (2009). Comparação do risco de queda em idosos sedentários e ativos por meio da escala de equilíbrio de Berg. Fisioterapia e Pesquisa, 16(1), 6–10. https://doi.org/10.1590/S1809-29502009000100002
Sedentary Behaviour Research Network. (2012). Letter to the editor: Standardized use of the terms “sedentary” and “sedentary behaviours.” Applied Physiology, Nutrition, and Metabolism, 37(3), 540–542. https://doi.org/10.1139/h2012-024
Stubbs, B., Patchay, S., Soundy, A., & Schofield, P. (2014). The avoidance of activities due to fear of falling contributes to sedentary behavior among community-dwelling older adults with chronic musculoskeletal pain: A multisite observational study. Pain Medicine, 15(11), 1861–1871. https://doi.org/10.1111/pme.12570
Thibaud, M., Bloch, F., Tournoux-facon, C., Brèque, C., Rigaud, A.S., Dugué, B., & Kemoun, G. (2012). Impact of physical activity and sedentary behaviour on fall risks in older people : A systematic review and meta-analysis of observational studies. European Review of Aging Physical Activity, 9, 5–15. https://doi.org/10.1007/s11556-011-0081-1
Thorp, A.A., Owen, N., Neuhaus, M., & Dunstan, D.W. (2011). Sedentary behaviors and subsequent health outcomes in adults a systematic review of longitudinal studies, 1996-2011. American Journal of Preventive Medicine, 41(2), 207–215. https://doi.org/10.1016/j.amepre.2011.05.004
Tomioka, K., Iwamoto, J., Saeki, K., & Okamoto, N. (2011). Reliability and validity of the International Physical Activity Questionnaire (IPAQ) in elderly adults: The Fujiwara-kyo Study. Journal of Epidemiology, 21(6), 459–465. https://doi.org/10.2188/jea.je20110003
Vellas, B.J., Wayne, S.J., Romero, L.J., Baumgartner, R.N., & Garry, P.J. (1997). Fear of falling and restriction of mobility in elderly fallers. Age and Ageing, 26(3), 189–193. https://doi.org/10.1093/ageing/26.3.189
Vieira, L.S., Gomes, A.P., Bierhals, I.O., Farías-Antúnez, S., Ribeiro, C.G., Miranda, V.I.A., Lutz, B.H., Barbosa-Silva, T.G., Lima, N.P., Bertoldi, A.D., & Tomasi, E. (2018). Falls among older adults in the south of Brazil: Prevalence and determinants. Revista de Saude Publica, 52, 1–12. https://doi.org/10.11606/S1518-8787.2018052000103
Vitorino, L.M., Marques-Vieira, C., Low, G., Sousa, L., & Cruz, J.P. (2019). Fear of falling among Brazilian and Portuguese older adults. International Journal of Older People Nursing, 14(2), 1–8. https://doi.org/10.1111/opn.12230
Vitorino, L.M., Teixeira, C.A.B., Boas, E.L.V., Pereira, R.L., dos Santos, N.O., & Rozendo, C.A. (2017). Fear of falling in older adults living at home: Associated factors. Revista Da Escola de Enfermagem, 51, 1–6. https://doi.org/10.1590/S1980-220X2016011803215
Wang, J.-C., Huan, S.K., Kuo, J.-R., Lu, C.-L., Lin, H., & Shen, K.-H. (2011). A multivariable logistic regression equation to evaluate prostate cancer. Journal of the Formosan Medical Association, 110(11), 695–700. https://doi.org/10.1016/j.jfma.2011.09.005
World Health Organization. (2020). Diretrizes da OMS para atividade física e comportamento sedentário: num piscar de olhos. https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf. Accessed March 26, 2021.
Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age and Ageing, 34(6), 614–619. https://doi.org/10.1093/ageing/afi196
Young, W.R., & Mark Williams, A. (2015). How fear of falling can increase fall-risk in older adults: Applying psychological theory to practical observations. Gait & Posture, 41(1), 7–12. https://doi.org/10.1016/j.gaitpost.2014.09.006
Zhu, Y., Blumenthal, J.A., Shi, C., Jiang, R., Patel, A., Zhang, A., Yu, X., Gao, R., & Wu, Y. (2018). Sedentary behavior and the risk of depression in patients with acute coronary syndromes. The American Journal of Cardiology, 121(12), 1456–1460. https://doi.org/10.1016/j.amjcard.2018.02.031
Zusman, E.Z., Dawes, M., Fleig, L., Mcallister, M.M., Cook, W.L., Guy, P., Brasher, P.M.A., Mckay, H.A., Khan, K.M., & Ashe, M.C. (2019). Older adults sedentary behavior and physical activity after hip fracture: Results from an outpatient rehabilitation randomized controlled trial. Journal of Geriatric Physical Therapy, 42(2), 32–38. https://doi.org/10.1519/JPT.0000000000000193
