INTRODUCTION

In Korea, the 2023 National Survey on the Elderly reported that 5.6% of seniors aged 65 and older experienced falls in the prior year, with an average of 1.9 falls per person. The survey also showed that the incidence of falls increased with age [1]. Previously, the transition from the 2017 data (displaying a fall rate of 15.9% and an average of 2.1 falls/person) to the 2020 figures (exhibiting a fall rate of 7.2% and an average of 1.6 falls/person) could be viewed as a positive trend. However, this decline may result from limitations on social activities among the elderly due to social distancing measures, which became part of daily life starting in February 2020 in response to the coronavirus disease 2019 pandemic. Falls pose a serious health risk for the elderly and represent a major social and economic burden in aging societies [2-4]. Deaths from falls are often unrecorded, or the cause of death is attributed to a complication of the fall [5], potentially leading to an underestimation of fall-related fatalities. Falls in older adults frequently result in fractures or serious physical injuries [6,7]. Due to slower recovery times in this population, such injuries can make independent daily living challenging, adversely impacting physical and mental functions and quality of life [8]. Moreover, healthcare costs associated with injuries impose a financial burden on older adults, and related activity restrictions can limit their economic activities [9]. Risk factors for fall-related injuries can be categorized into exogenous and endogenous factors [10]. Exogenous factors include environmental hazards such as inadequate lighting, slippery floors, and obstacles like electrical wires and stairs [11]. In comparison, endogenous factors include age-related changes and chronic diseases such as myasthenia, other musculoskeletal disorders, cardiovascular disease, dementia, and other neurological conditions [12,13]. Certain medications, such as sleeping pills, antidepressants, and diuretics, are known to increase the risk of falls [14].

Physical impairment in older adults can limit not only their social lives but also their ability to perform activities of daily living (ADLs), potentially leading to social withdrawal and compromised adaptation. Such withdrawal can cause older adults to become isolated, which may precipitate psychiatric illness. Moreover, decreased physical activity can exacerbate mental health issues, establishing a cycle of deterioration [15,16]. Depression in older adults is believed to increase the risk of falls. It is associated with diminished cognitive function and reduced physical activity, both of which are fall risk factors [17]. In turn, physical injuries from falls can themselves exacerbate social isolation, further diminishing quality of life and mental health [18]. Previous studies have indicated that depression can lead to impaired cognitive function and reduced physical activity [19], while reduced physical activity and cognitive function are linked to a higher risk of gait disorders and falls [20,21]. Older adults who have experienced multiple falls may develop a fear of falling again; this fear can contribute to a loss of independence in activities, intensifying feelings of social isolation [22]. Research has also demonstrated that experiencing a fall and consequently developing a fear of falling can increase depression [23].

This study was performed to examine the association between falls and mental health using data from the Korean Community Health Survey (KCHS). The survey comprises a questionnaire with over 200 health-related items, enabling a comparative analysis of falls and various mental health indicators. Through this analysis, the present study seeks to understand the prevalence of fall experiences, mental health issues, and health behaviors, focusing on exploring the relationship between multiple falls and mental health status among older adults.

METHODS

Study Design

A cross-sectional analysis was performed using data from the KCHS conducted in 2017, 2019, and 2021 to analyze risk factors for falls among older adults (≥65 years old).

Participants

In this study, we utilized data from the KCHS, conducted by the Korea Disease Control and Prevention Agency (KDCA), for the years 2017, 2019, and 2021. The KCHS is designed to provide health statistics at the city, county, and district levels and to generate foundational data for regional public health initiatives. Beginning in 2008, the survey has been carried out annually on a nationwide scale, organized by region [24]. Participants include adults aged 19 years and older who live in residential buildings within the sampled locations. The population is stratified by administrative divisions such as dong, eup, or myeon, as well as by the type of residence. The average sample size is 900 individuals per public health center. Complex sampling is employed for sample selection. Probability proportional systematic sampling is conducted by tong, ban, or ri, followed by secondary systematic sampling to choose households for the final sample (Figure 1).

In the KCHS, trained surveyors visit selected households to conduct one-on-one interviews using a laptop. A total of 686 722 individuals participated in the 2017, 2019, and 2021 KCHS, among whom 216 874 were older adults aged 65 years or older. After excluding 19 098 persons with missing data regarding the questions used in this study, the remaining 197 776 persons were included in the final analysis.

Measures and Scales

Socio-demographic characteristics

For socio-demographic characteristics, we examined participants’ age, sex, marital status, educational level, income level, type of residence, employment status, and receipt of Basic Livelihood Security benefits. All participants were considered elderly (65 years or older). Educational level was classified as “uneducated,” “elementary school,” “middle school,” “high school,” “university,” or “higher than university.”

Health behavior-related characteristics

Parameters related to health behaviors included body mass index (BMI), frequency of alcohol consumption, current smoking status, subjective oral health status, hypertension, diabetes, walking, moderate physical activity, vigorous physical activity, stretching, and subjective health status.

Mental health-related characteristics

Parameters related to mental health included sleep duration, subjective stress perception, the presence of depression, and depression severity based on the Patient Health Questionnaire-9 (PHQ-9). Sleep duration was classified as “insufficient” for less than 6 hours, “excessive” for 9 hours or more, and “appropriate” for 6 hours to 8 hours. Regarding subjective stress perception, participants answered the question, “How much stress do you usually experience during daily living?” with options of “significant,” “moderate,” “slight,” or “none.” The PHQ-9 consists of 9 items, each scored on a scale from 0 points to 3 points. Based on the total score, depression was categorized as “severe” (20 to 27 points), “moderate” (10 to 19 points), “mild” (5 to 9 points), or “no depression” (0 to 4 points).

Fall experience

For participants who responded “yes” regarding whether they had experienced falls, we investigated the number of falls experienced per year. Based on their responses, participants were categorized as having had “no falls,” “a single fall,” or “multiple falls.”

Statistical Analysis

The data collected in this study were analyzed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA) and SPSS version 21 (IBM Corp., Armonk, NY, USA). To examine general and health behavior-related characteristics, the chi-square test was employed. Multiple logistic regression was used to examine risk factors for falls and associated relationships. Prior to this analysis, linear regression was applied to identify related variables, including age, marital status, education level, type of residence, employment status, Basic Livelihood Security status, BMI, smoking status, subjective oral health status, hypertension, diabetes, walking, and vigorous physical activity. These were applied as moderating variables in the subsequent analysis (Figure 2).

Ethics Statement

The data used in this study were obtained from the Community Health Survey, which was conducted in accordance with the Personal Information Protection Act. All data that could potentially identify individual participants were excluded. The survey instruments and procedures were approved by the Institutional Review Board of the KDCA. The raw data from the KCHS are publicly available and may be used for general research purposes. For this study, anonymized data were obtained through an official request via the KDCA KCHS website. After the completion of this study, the related thesis was reviewed and granted exemption from ethical review by the Institutional Review Board of Dong-A University.

RESULTS

Associations Between Socio-demographic Characteristics and Fall Experience

The mean age of the participants was 74.14 years, and 56.7% were female (Supplemental Material 1). Regarding fall history, 83.0% had not experienced any falls, 11.3% had fallen once, and 5.7% had fallen multiple times. Among female, 13.5% had fallen once and 6.6% had fallen multiple times, while among male, 8.3% had experienced one and 4.5% had experienced multiple falls, indicating a higher incidence of falls in female. Participants without a spouse exhibited higher rates of falls, with 13.7% in the single-fall group and 7.3% in the multiple-fall group, compared to those with a spouse. Lower educational level was linked to higher rates of both single fall and multiple falls. Excluding the highest monthly household income bracket (≥4 million Korean won), a lower income was associated with a greater incidence of both single fall and multiple falls. Regarding type of residence, individuals living in houses exhibited a higher rate of falls than those in apartments, although this difference was less pronounced than with other factors. Unemployed participants had higher rates of falls than their employed counterparts, with 12.1% experiencing a single fall and 6.5% multiple falls. Among recipients of Basic Livelihood Security benefits, 14.0% had experienced a single fall and 9.7% multiple falls, exceeding the rates of non-recipients (Supplemental Material 2).

Associations Between Mental Health Characteristics and Fall Experience

The mean rate of fall incidents among participants was 17.0%, with 11.3% of participants experiencing a single fall and 5.7% reporting multiple falls. This overall rate exceeds the mean fall incidence reported in the 2020 Statistics Korea data among individuals aged 65 years and older, at 7.2% (Figure 3).

The mean rate of depression among all participants was 18.3%, while the depression rates for participants in the single fall and multiple fall groups were 16.5% and 16.7%, respectively. Compared to the 13.5% rate of depression among older adults reported in Statistics Korea for 2020, our participants exhibited a higher rate of depression (Figure 4).

Among mental health-related characteristics, the group with insufficient sleep (≤5 hours) had the highest rate of experiencing a single fall, at 13.4%, followed by those with excessive sleep (≥9 hours), at 11.8%. Multiple falls were most common in the group with excessive sleep (≥9 hours), at 8.4%, followed by the group with insufficient sleep (≤5 hours), at 7.5%. Rates of both single fall and multiple falls were higher among participants who perceived higher levels of subjective stress. Additionally, among those who had experienced depressive mood, high rates of single fall (16.0%) and multiple falls (13.1%) were noted. Similarly, the rates of single fall and multiple falls were higher for participants with severe depression, as indicated by the PHQ-9, followed by those with moderate and then mild depression (Supplemental Material 3).

Association Between Mental Health Status and Fall Experience

Based on multiple logistic regression analysis, participants with a sleep duration of 5 hours or less faced an elevated risk of experiencing a single fall (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10 to 1.17), as did participants with a sleep duration of 9 hours or more (OR, 1.14; 95% CI, 1.07 to 1.21). The risk of a single fall was also higher among participants who reported stress at a “significant” (OR, 1.25; 95% CI, 1.14 to 1.38) or “moderate” (OR, 1.32; 95% CI, 1.27 to 1.38) level. Participants who indicated slight stress had an OR of 1.11 (95% CI, 1.07 to 1.15). For those who had experienced depressive mood, the OR for experiencing a single fall was 1.21 (95% CI, 1.15 to 1.28). Participants with severe depression had an OR of 1.41 (95% CI, 1.18 to 1.68) for a single fall, while those with moderate depression had an OR of 1.43 (95% CI, 1.33 to 1.53). Participants with mild depression also had higher odds of fall history compared to those without depression (OR, 1.34; 95% CI, 1.29 to 1.40).

In the multiple-fall group, participants with a sleep duration of 5 hours or less displayed an OR of 1.14 (95% CI, 1.09 to 1.19) for experiencing multiple falls, while those with a sleep duration of 9 hours or more had an OR of 1.48 (95% CI, 1.37 to 1.59). Participants who reported “significant” stress faced an elevated risk of multiple falls (OR, 1.79; 95% CI, 1.61 to 1.99), as did those who were moderately (OR, 1.75; 95% CI, 1.65 to 1.85) or slightly stressed (OR, 1.23; 95% CI, 1.17 to 1.29). For participants who had experienced depressive mood, the OR for experiencing multiple falls was 1.39 (95% CI, 1.31 to 1.48). Compared to participants with no depression, individuals with severe depression had an OR of 2.82 (95% CI, 2.38 to 3.34) for multiple falls, while those with moderate depression had an OR of 2.60 (95% CI, 2.41 to 2.80). Participants with mild depression displayed an OR of 1.98 (95% CI, 1.89 to 2.09) for experiencing multiple falls (Supplemental Material 4).

DISCUSSION

In this study, we investigated the rate of falls among older adults and identified significant relationships between falls and mental health variables. The fall rate among participants was 17.0%, which exceeds the 7.2% rate among older respondents (≥65 years old) reported by Statistics Korea for 2020. Considering that the Statistics Korea data were based on the National Survey of Older Koreans, which included proxy responses, the fall rate could have been underestimated due to misreporting. Moreover, our large sample size and integration of data from 3 years of the KCHS distinguish the present results from those of Statistics Korea. Both our study and the Statistics Korea report collected information on involuntary, non-injurious falls by asking participants if they had experienced any falls (slips or trips) in the past year. The definition of a fall can vary; in the present research, falls were defined as “involuntary falls, including slips and trips, that occurred in the last year.”

When examining the rate of depression among participants based on the frequency of falls, we found slightly higher rates of depression in the “multiple-falls” group (16.7%) relative to the “single-fall” group (16.5%). These rates exceed the mean depression rate of 13.5% reported by Statistics Korea based on the 2020 National Survey of Older Koreans. The rate of depression in the National Survey was assessed using the Short Geriatric Depression Scale, which consists of 30 questions. This differs from the 9-question PHQ-9 used in the KCHS and thus in our study, complicating direct comparisons. Furthermore, according to the Consumer Injury Surveillance System of the Korea Consumer Agency, a total of 3474 elderly fall accidents were reported in 2021, representing 65% of elderly safety accidents [25]. These fall accidents included cases of physical injury due to trips or falls and encompassed not only trips and slips but also falls from height. This discrepancy makes it challenging to directly compare these data with the fall rates in our study. Nevertheless, even when considering only slips and falls, there were 2795 reported cases, accounting for over 50% of safety accidents. The study also reported a rate of fall accidents that was approximately twice as high for female compared to male, aligning with our findings.

We observed a significant association between falls and scores on the PHQ-9, a scale used to assess depression. The PHQ-9 is a self-report tool developed to facilitate the detection of mental health disorders and the diagnosis of depression. In the present study, when participants were grouped based on their PHQ-9 scores, correlations were observed with both single fall and multiple falls experiences. Logistic regression analysis revealed that greater depression severity (as indicated by a higher PHQ-9 score) was associated with a greater risk of multiple falls, indicating a strong association between depression and fall recurrence. Notably, single fall and multiple falls are reported to involve different mechanisms. While single fall may occur due to moments of carelessness, multiple falls are often the result of persistent issues [26]. Patients with depression exhibit gait instability, reduced gait speed, and increased stride length variability, all of which increase the risk of falling [27]. In a study investigating the relationship between depression and fractures, depressed female aged 65 years and older displayed a 40% higher risk of recurrent falls than their counterparts without depression [28]. Recent research has also identified a relationship between cerebral white matter lesions and depression in older adults. Elderly patients with depression and white matter lesions are at elevated risk of gait instability, potentially leading to recurrent falls.

Cerebral white matter lesions are typically associated with the loss of myelin sheaths in the brain, a process often linked to aging. Damage to the frontal lobe and the circuits that connect various cortical regions significantly impacts movement, and research has demonstrated a strong relationship between white matter lesions and the frontal cortex [29]. Furthermore, white matter lesions in the frontal and temporal cortices are directly associated with depression [30], age-related brain injuries may lead to depression as well as gait dysfunction, increasing the risk of falls. The use of antidepressants, such as selective serotonin reuptake inhibitors, is also closely associated with both single fall and multiple falls, regardless of the presence of depressive symptoms [14,31]. Known adverse effects of antidepressants, such as orthostatic hypotension, sleep disorders, and sedative effects, can also contribute to falls [32]. Among elderly patients with depression, the use of antidepressants has been linked to falls due to dizziness and other side effects. Therefore, future studies should consider not only depressive symptoms but also variables related to the use of antidepressants or other psychiatric drugs.

Sleep is a key factor associated with mental health in the elderly [33], and persistent sleep disorders can exacerbate mental health issues, including symptoms of depression [34]. Sleep disorders may also compromise the physical ability to perform ADLs and instrumental ADLs [35]. Diminished physical function increases the risk of falls, which can instill a fear of falling and lead to social withdrawal, ultimately decreasing quality of life [36]. This study further revealed an elevated risk of falls among participants with either insufficient or excessive sleep, aligning with prior studies. Subjective stress perception was another mental health factor linked to falls. Previous research has indicated that highly stressful environments trigger the release of stress hormones. The resulting physiological dysregulation can lead to adverse physical outcomes, including falls [37]. Stress-induced inflammation has also been implicated in muscle mass loss and impaired physical function, which may make falling more likely [38]. Furthermore, stressful environments can exacerbate social isolation and reduce both quality of life and physical activity levels, all of which may increase the likelihood of falls [39].

In our study, the “single-fall” and “multiple-fall” groups exhibited lower rates of alcohol consumption and smoking compared to the “no-fall” group. Given that both groups with a fall history exhibited higher levels of hypertension and diabetes than the group without prior falls, these findings may result from patients with these diseases adopting healthier lifestyle habits. In contrast, when examining walking and moderate to vigorous physical activity, those in the fall groups engaged in these activities less frequently than the “no-fall” group. This finding suggests a decline in quality of life, regardless of the severity of fall injuries [4]. The fear of falling that may arise after a fall can cause individuals to avoid physical activity, diminishing quality of life and potentially leading to depression. The lower rates of physical activity observed in the fall groups could be a consequence of this fear, potentially resulting in social isolation and depression.

This study has several limitations. First, the research relied on cross-sectional data, limiting our capacity to determine causal relationships. Mental health may influence the likelihood of falls, while conversely, experiencing a fall might impact mental health. In other words, the relationship between these factors could be bidirectional, highlighting the need for additional research in this area. Second, our lack of data on the use of psychotropic medications prevented us from investigating the relationship between falls and psychiatric drugs. Furthermore, the mechanisms linking falls and depression could involve multiple neural systems; however, our analysis was limited to the relationships between pairs of individual variables, which represents another limitation of our work. Nevertheless, we utilized nationwide survey data derived from probabilistic sampling and aggregated information from the 2017, 2019, and 2021 KCHS, which included indices of fall experiences. Thus, our findings are valuable, as they identify current factors associated with fall experience and mental health, while integrating 3 years of data to examine the relationship between these variables.

In this study, we examined the associations between depression and both single fall and multiple falls. We observed a higher risk of falls among participants with more severe depression and considered the effects of antidepressant use as a potential explanation. Additionally, given the established link between depression and white matter lesions, it is plausible that multiple falls could be caused by white matter lesions leading to gait instability. Consequently, we suggest the implementation of combined programs, aimed at improving physical and mental health, that fully consider the bidirectional relationship between multiple falls and mental health.

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

This study is based on the first author’s master’s thesis completed at Dong-A University.

Author Contributions

Conceptualization: Lim C, Hong YS. Data curation: Hong YS, Kim BG, Son HJ. Formal analysis: Lim C, Hong YS, Kim BG, Son HJ. Funding acquisition: None. Methodology: Lim C, Hong YS, Kim BG, Son HJ. Project administration: Lim C. Visualization: Lim C. Writing – original draft: Lim C, Hong YS. Writing – review & editing: Lim C, Hong YS, Kim BG, Son HJ. Yu BC, Kim J.

Figure. 1.

Flow diagram of the participants.

Figure. 2.

Methodological flow diagram. PHQ-9, Patient Health Questionnaire-9; BMI, body mass index.

Figure. 3.

The fall experience rate of the participants.

Figure. 4.

The depression experience rate of the participants.

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Figure & Data

References

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