Research Report

Balance Confidence and Balance Performance,

But Not Fall History Are Associated With
Quality of Life in Community-Dwelling Older
Adults: A Cross Sectional Study
Holly J. Roberts, PT, PhD1,2; Kristen M. Johnson, PT, EdD1,3;
Jane E. Sullivan, PT, DHS4; Carrie W. Hoppes, PT, PhD5

ABSTRACT sion analyses were calculated to determine the relation-

Background and Purpose: Fear of falling (FoF) is highly preva- ship between the outcome measures and domains on the
lent in community-dwelling older adults and is associated with WHOQOL-BREF.
low health-related quality of life (QoL). Low QoL is associated Results and Discussion: Significant correlations were observed
with increased health care utilization and is a predictor of between the WHOQOL-BREF physical health domain and the
future falls, but few studies have examined the relationship ABC, FFABQ, FGA, and CB&M (ρ = 0.524, −0.509, 0.348,
between high-level balance and dynamic gait performance and r = 0.423, respectively), the WHOQOL-BREF psycho-
and QoL in community-dwelling older adults. The purpose logical domain and the ABC (ρ = 0.284) and FFABQ (ρ =
of this cross-sectional study was to determine whether there −0.384), and the WHOQOL-BREF environment domain and
is a relationship between FoF avoidance behaviors, balance the ABC (ρ = 0.343) and FFABQ (ρ = −0.406). No correla-
confidence, performance on measures of high-level mobility, tions were found between WHOQOL-BREF domain scores and
and QoL in community-dwelling older adults. The secondary a history of falls.
purpose was to determine whether older adults who fall have Conclusions: Performance-based outcome measures that
a different QoL than older adults who have not fallen in the measure high-level mobility such as the CB&M and FGA, and
past year. patient-reported outcome measures for balance confidence
Methods: Eighty-nine community-dwelling older adults (76.33 and FoF avoidance behavior such as the ABC and FFABQ, are
± 6.84 years, 54 female, 34 fallers) completed the World correlated with the physical health QoL domain on the WHO-
Health Organization Quality of Life-BREF (WHOQOL-BREF), QOL-BREF. The ABC and FFABQ are correlated with psycho-
Activities-specific Balance Confidence Scale (ABC), Fear of logical and environment QoL. Fall history was not correlated
Falling Avoidance Behavior Questionnaire (FFABQ), Func- with QoL. Interventions to decrease FoF or improve high-level
tional Gait Assessment (FGA), and Community Balance and mobility may improve QoL in community-dwelling older adults.
Mobility Scale (CB&M). Correlation and multiple regres- Key Words: balance, falls, older adults, outcome measures,
quality of life
1Rocky Mountain University of Health Professions, Provo,
Utah. (J Geriatr Phys Ther 2023;46(1):82-89.)
2University of Puget Sound School of Physical Therapy,

Tacoma, Washington.
3Hawaii Pacific University, Honolulu, Hawaii. CLINICAL IMPLICATIONS
4Department of Physical Therapy and Human Movement • Decline in quality of life (QoL) may be related to decreased
performance of high level mobility tasks.
Sciences, Feinberg School of Medicine, Northwestern • Three QoL domains (physical, psychological, and
University, Chicago, Illinois. environment) are related to balance confidence and fear
5Army-Baylor Doctoral Program in Physical Therapy, Joint
of falling avoidance behaviors. Physical health QoL is also
Base San Antonio-Fort Sam Houston, Texas. related to performance on high-level mobility tasks.
This study was partially funded by the Rocky Mountain • Assessment of relatively high-functioning older adults
University of Health Professions Graduate Research Grant should include high-level mobility measures, eg, Functional
and the University of Puget Sound Faculty Research Grant. Gait Assessment or Community Balance and Mobility Scale.
• Increasing high-level mobility abilities and balance
The authors declare no conflicts of interest.
confidence may improve QoL; intervention studies are
Address correspondence to: Holly J. Roberts, PT, PhD, needed to determine this.
University of Puget Sound School of Physical Therapy,
1500 N. Warner St #1030, Tacoma, WA 98416 (hjroberts@
pugetsound.edu). INTRODUCTION
Copyright © 2022 APTA Geriatrics, An Academy of the The World Health Organization (WHO) defines quality of
American Physical Therapy Association. life (QoL) as an “individual’s perception of their position
DOI: 10.1519/JPT.0000000000000349 in life within the context of the culture and value system
82 Volume 46 • Number 1 • January-March 2023
Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

in which they live and in relation to their goals, expecta- and role performance on the SF-36 than individuals who
tions, standards, and concerns.”1(p28) Health-related QoL report being moderately fearful or very fearful of falling.14
is inconsistently defined, but generally refers to QoL in the Conversely, individuals who experience fear of falling report
context of health and disease in the domains of physical, lower levels of QoL.15 This relationship remains true even
mental, emotional, and social functioning.1 when adjusting for other factors such as fall history, age,
Quality of life in older adults is correlated with overall gender, and fall risk16 and regardless of the tool used to
health and health care utilization. Lower scores on health- measure health-related QoL.17 To date, no studies have
related QoL measures have been associated with higher examined the relationship between performance on high-
30-day and 1-year hospitalization rates,2 readmissions,3 level mobility tasks and QoL in community-dwelling older
and mortality.3 Many factors influence QoL in older adults. adults. The purpose of this study was to determine whether
Henchoz et al4 identified 7 domains that older adults there was a relationship between fear of falling avoidance
considered essential to their QoL. Health and mobility were behavior, balance confidence, performance on measures of
rated second only to feeling safe as the most important fac- high-level mobility, and QoL in community-dwelling older
tors contributing to older adults’ overall QoL. Self-reported adults. The secondary purpose of the study was to determine
difficulty with mobility, such as walking 100 m or climb- whether older adults who fall differ in their QoL compared
ing stairs, has been associated with lower perceived QoL.5 with older adults who have not fallen in the past year.
Older adults with higher body mass index (BMI)6-8 and
those who take more medications6 also report lower QoL. METHODS
Few studies have examined the relationship between
physical performance and QoL in community-dwelling Study Design and Participants
older adults. Research has demonstrated that scores on This cross-sectional study included ambulatory commu-
performance-based outcome measures are associated with nity-dwelling older adults. Participants were recruited
QoL. Individuals with faster Timed Up and Go (TUG) between October and December 2019 via posted flyers
times,9,10 longer walking distances on the 6-minute walk and verbal invitations at retirement community wellness
test,10 and stronger handgrip strength9 have better health- centers, service organizations, libraries, churches, senior
related QoL as measured by Euro Quality of Life-5D social groups, and in the waiting room of a physical
(EQ-5F). Slower gait speed is associated with low mental therapy clinic.
component scores on the Medical Outcomes Study Short Participants were included if they were 65 years or older,
Form-36 (SF-36), a multidimensional measure of QoL.7 lived independently, were able to stand without assistance
In addition to gait speed and endurance, balance per- for at least 1 minute, were able to ambulate 20 m without
formance appears to be an indicator of overall QoL and an assistive device or with a single-point cane only, and
is associated with the domains of physical health, psycho- scored at least 23/30 on the Montreal Cognitive Assessment
logical health, environment, autonomy, and social par- (MoCA).18 Participants were excluded if they could not
ticipation on the WHO Quality of Life-OLD.11 Low scores understand written or verbal instructions in English, had
on the Fullerton Advanced Balance Scale are associated a lower extremity orthopedic injury such as a fracture or
with lower physical and mental component scores on the surgery within the past 4 months, had a history of a neu-
SF-36.7 However, no studies have examined the relation- rologic disorder or peripheral neuropathy, had self-reported
ship between higher-level balance or gait performance and unstable angina or uncontrolled cardiovascular problems,
QoL in community-dwelling older adults. The ability to or had pain in any body segment greater than 5 on a
perform high-level balance or gait tasks such as balancing 10-point verbal analog scale (0 = “no pain,” 10 = “worst
with a narrowed base of support, turning, picking objects pain imaginable”). Participants who reported a diagnosis of
up off the ground while walking, walking backward, or diabetes were screened for sensory impairment from periph-
walking while turning the head may influence QoL. eral neuropathy using Semmes-Weinstein monofilament
Balance confidence may also be related to QoL. Self- testing.19 The 5.07/10-g monofilament was applied 4 times
reports of poor balance and difficulty walking are associ- to the dorsum of the great toe of each foot and held for 1
ated with lower QoL in the physical health domain of second while participants had their eyes closed. Participants
the WHO Quality of Life-BREF (WHOQOL-BREF) in indicated the presence of the monofilament by saying,
community-dwelling older adults.12 For example, older “yes.” Participants were excluded if they were unable to
adults with knee osteoarthritis with low balance confidence perceive the monofilament on 5 or more trials.
scores on the Activities-specific Balance Confidence Scale The institutional review boards at Rocky Mountain
(ABC) have lower scores on the SF-36, suggesting a lower University of Health Professions and the University of
perceived health-related QoL.13 Low QoL is also associated Puget Sound approved the studies. Data collection took
with future falls.2 place in a university gait laboratory, a church fellowship
Fear of falling is associated with QoL in community- hall, and a community center. A sample size estimation
dwelling older adults. Community-dwelling older adults was conducted using G-Power 3.1.9.2 (Heinrich-Heine-
who report that they have no fear of falling score higher Universitat Dusseldorf, Dusseldorf, Germany) for a mul-
on the domains of physical functioning, social functioning, tiple regression analysis.20 Using an odds ratio of 2.44 for

JOURNAL OF Geriatric Physical Therapy 83

Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

falls in the previous year,21 prevalence of falls of 0.35,22 Transformed score = [(Actual raw score – lowest
0.80 power, an α level of .05, and an estimated attrition possible raw score)/possible raw score range] × 100
rate of 20%, the sample size needed was 89 participants.
Fear of Falling Avoidance Behavior Questionnaire
Procedures
The FFABQ is a 14-item patient report outcome measure
After volunteers were screened for eligibility and provided
used to assess an individual’s avoidance behavior due to fear
written informed consent, a researcher collected demo-
of falling.26 Total scores range from 0 (high fear avoidance
graphic information and a patient-reported fall history. The
behavior) to 56 (no fear avoidance behavior). The FFABQ
number of total falls and falls requiring medical attention
is valid and reliable (intraclass correlation coefficient [ICC]
in the past 12 months were recorded. Participants then
= 0.812) in community-dwelling older adults.26
completed the ABC, Fear of Falling Avoidance Behavior
Questionnaire (FFABQ), and WHOQOL-BREF. Next,
Activities-specific Balance Confidence Scale
an examiner administered the Community Balance and
The ABC is a patient report outcome measure used to
Mobility Scale (CB&M) and Functional Gait Assessment
measure the degree of balance confidence in household
(FGA). The tests were performed in the participants’ low-
and community activities.27 A minimum score of 0% indi-
heeled shoes, and a safety walking belt was worn around
cates no confidence; a maximum score of 100% indicates
the waist in case of a loss of balance during testing. A roll of
complete confidence. The ABC has excellent test-retest
a die determined the order of testing. The CB&M was per-
reliability (r = 0.92),27 and is a valid measure of balance
formed first when an even number was rolled, and the FGA
confidence in community-dwelling older adults.28 A cut-off
was performed first when an odd number was rolled. The
score of 67% suggests an increased risk for falls.29
test items were administered in their published order.23,24
All testing took place in 1 session and took approximately Community Balance and Mobility Scale
1 hour. Seated rest periods were allowed at any point that The CB&M is a 13-item performance measure used to
the participant wished. assess dynamic balance and mobility.23 The item scores are
All examiners were trained by the primary investigator summed for a total score of 0 to 96. Higher scores indicate
to administer the outcome measures. Training included better mobility. The CB&M is valid and reliable (ICC 0.95-
evaluating video-recorded mock participants to facilitate 0.97) when used with community-dwelling older adults.30
discussion and agreement on evaluation criteria. A cut-off score of 45 or less may identify community-
dwelling older adults with a history of 2 or more falls.30
Outcome Measures
Functional Gait Assessment
World Health Organization Quality of Life-BREF The FGA is a valid performance-based measure to assess
The WHOQOL-BREF is a 26-item patient report outcome balance during gait.24,28 Scores range from 0 to 30; higher
measure available in 19 languages and has been validated scores indicate better balance during gait. The FGA has
cross-culturally.25 The English version of the scale was used good construct validity and excellent reliability (ICC =
for this study. The measure is not reported to have ceiling 0.93) when used with community-dwelling older adults.28
or floor effects and has good internal consistency, construct A cut-off score of 22 or less on the FGA suggests a risk for
validity, discriminant validity, and test-retest reliability future falls for community-dwelling older adults.28
in individuals ranging in age from 12 to 97 years.25 The
domains assessed by the WHOQOL-BREF are presented Statistical Analysis
in Table 1. There is no aggregate score for the measure; Statistical analyses were performed with IBM SPSS Statistics
questions 1 and 2 are reported independently, and the version 25.0 (IBM Corporation, Armonk, New York).
transformed score for each domain is calculated using the Descriptive statistics were reported for the total sample
following formula: and were stratified by fallers and nonfallers. Preliminary

Table 1. Item Description for World Health Organization Quality of Life-BREF

Domain Number of Items Raw Score Range Transformed Score Range
Overall quality of life 1 1-5 Not transformed
(Question 1: “How would you rate your quality of life?”)
Overall health-related quality of life 1 1-5 Not transformed
(Question 2: “How satisfied are you with your health?”)
Physical health 7 7-35 0-100
Psychological health 6 6-30 0-100
Social relationships 3 3-15 0-100
Environment 8 8-40 0-100

84 Volume 46 • Number 1 • January-March 2023

Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

analyses were performed to ensure the assumptions of individuals reported 1 fall that required medical attention.
normality and equal variance were met. If the significance Table 2 shows participant characteristics.
value was greater than .05 in Levene’s Test for Equality of Table 3 displays correlation coefficients for age, number
Variances, equal variances were assumed. χ2 tests for inde- of falls in the past 12 months, outcome measure variables,
pendence were calculated to determine whether sex, resi- and participants’ domain scores on the WHOQOL-BREF.
dence (own or rent a home vs independent living facility), There were large effect sizes for the correlations between
and use of an assistive device differed between fallers and the physical health domain score of the WHOQOL-
nonfallers. Independent t tests were calculated to determine BREF and the ABC and FFABQ scores. The effect sizes
whether fallers and nonfallers were different in age, BMI, for the correlations between the outcome measures and
number of prescribed medications, MoCA score, CB&M the WHOQOL-BREF psychological and environmental
score, and WHOQOL-BREF physical health, psychologi- domain scores were small to medium. The WHOQOL-
cal, and social relationships domain scores. Mann-Whitney BREF social relationships domain score was not correlated
U tests were calculated to determine whether there were with any of the variables.
differences between fallers and nonfallers in the number There were no concerns for multicollinearity; all of
of over-the-counter medications, total falls, falls requiring the variance inflation factors were below 10.32 A multiple
medical attention, ABC score, FFABQ score, FGA score, linear regression was calculated to predict the WHOQOL-
and transformed WHOQOL-BREF environment domain BREF physical health domain score based on age, ABC
score. Mann-Whitney U tests were used because assump- score, FFABQ score, CB&M score, and FGA score. The
tion of normality was not met. χ2 tests for independence model predicted 41.1% of the variance in the physical
were calculated to determine whether there were differenc- health domain score (R2= 0.411, F = 11.560, P < .001).
es between the scores of fallers and nonfallers for question The CB&M score (β = 0.623, P = .005) and age (β =
1 and question 2 on the WHOQOL-BREF. 0.401, P = .001) were significant predictors of the physical
Multiple regression analyses were used to determine health domain score and accounted for 5.86% and 7.78%
whether there was a relationship between total scores on of the total variance in the score, respectively. The ABC
the FGA, CB&M, ABC, and FFABQ, and age, and each score (β = 0.174, P = .127), FFABQ score (β = 0.220, P
domain score of the WHOQOL-BREF. Pearson product = .069), and FGA score (β = 0.209, P = .244) were not
moment correlation coefficients were calculated to deter- significant predictors. The study yielded a regression equa-
mine whether there were independent correlations between tion as follows:
age or CB&M score and the WHOQOL-BREF physical
WHOQOL-BREF physical health domain score =
health, psychological, and social relationships domains.
−10.54 + 0.62 (CB&M score) + 0.40 (age) + 0.127
Spearman correlation coefficients were calculated to deter-
(ABC) – 0.22 (FFABQ) − 0.21 (FGA).
mine whether there were independent correlations between
the number of falls in the past 12 months, ABC score, or A multiple linear regression was calculated to predict
FFABQ score and the WHOQOL-BREF physical health, the WHOQOL-BREF psychological domain score based
psychological, and social relationships domains. Spearman on age, ABC score, FFABQ score, CB&M score, and FGA
correlation coefficients were calculated to determine wheth- score. The model predicted 21.5% of the variance in the
er there were independent correlations between age, falls, psychological health domain score (R2= 0.215, F = 4.550,
or outcome measures and the WHOQOL-BREF environ- P = .001). The FFABQ score (β = −0.431, P = .003) was
ment domain. Spearman correlation coefficients were used the only significant predictor of the psychological domain
to determine whether there was a relationship between age, score and accounted for 9.18% of the total variance in the
number of falls in the past 12 months, or scores on the FGA, score. Age (β = 0.145, P = .303), ABC score (β = 0.027,
CB&M, ABC, and FFABQ and responses to questions 1 P = .205), CB&M score (β = 0.166, P = .794), and FGA
and 2 on the WHOQOL-BREF. After using a Bonferroni score (β = 0.096, P = .642) were not significant predictors.
correction to reduce the risk of a type I error for multiple The study yielded a regression equation as follows:
comparisons, the adjusted significance level for all correla-
tion tests was set at .008. All of the correlation analyses WHOQOL-BREF psychological domain score = 55.70
were 2-tailed. The correlation effect sizes were evaluated as − 0.43 (FFABQ) + 0.03 (ABC) – 0.07 (CB&M) + 0.10
small (0.10-0.29), medium (0.30-0.49), or large (≥0.5).31 (FGA) + 0.15 (age).
A multiple linear regression was calculated to predict
RESULTS the WHOQOL-BREF environment domain score based
Ninety-one individuals volunteered to participate in the on age, ABC score, FFABQ score, CB&M score, and FGA
study and were screened for inclusion. Two individuals score. The model predicted 39.1% of the variance in the
with MoCA scores that were less than 23 points were environment domain score (R2= 0.391, F = 2.994, P =
excluded. Eighty-nine individuals met the inclusion crite- .016). FFABQ score (β = −0.374, P = .011) was the only
ria and agreed to participate in the study (54 female, 76 significant predictor of the environment domain score and
± 7 years). Thirty-four individuals (38.20%) reported at accounted for 26.3% of the total variance in the score. Age
least 1 fall in the 12 months before entering the study. Six (β = 0.043, P = .765), ABC score (β = 0.088, P = .519),

JOURNAL OF Geriatric Physical Therapy 85

Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Research Report

Table 2. Participant Characteristics for 89 Community-Dwelling Older Adults

Total Sample Nonfallers Fallers Comparison
n (%) n (%) n (%) Statistic
Mean ± SD Mean ± SD Mean ± SD (P Value)
Age (range), y 76.33 ± 6.84 (65-93) 76.09 ± 7.28 (66-93) 76.71 ± 6.15 (65-88) −0.410a (.683)
Sex
Female 54 (60.67) 34 (61.82) 20 (58.82)
0.79b (.779)
Male 35 (39.33) 21 (38.18) 14 (41.18)
BMI, kg/m2 27.37 ± 5.04 27.36 ± 4.42 27.37 ± 5.98 −0.007a (.995)
Residence
Own/rent home 88 (98.88) 54 (98.18) 34 (100)
0.625b (.429)
Independent living community 1 (1.12) 1 (1.82) 0 (0)
Assistive device
None 79 (88.76) 51 (92.73) 28 (82.35)
2.267b (.132)
Cane 10 (11.24) 4 (7.27) 6 (17.65)
Number of prescribed medications 3.85 ± 3.12 3.98 ± 3.27 3.63 ± 2.87 0.511a (.611)
Number of over-the-counter medications 2.00 ± 2.57 2.11 ± 2.72 1.81 ± 2.32 841.500c (.834)
Falls in past 12 mo
Total 1.10 ± 2.46 0±0 2.88 ± 3.29 0.000c (<.001)
Injurious 0.07 ± 0.25 0±0 0.17 ± 0.39 770.000c (.001)
MoCA score 26.90 ± 1.82 26.78 ± 1.83 27.09 ± 1.80 −0.772a (.442)
ABC score 86.98 ± 13.47 87.51 ± 13.32 86.13 ± 13.86 889.500c (.701)
FFABQ score 7.29 ± 9.69 5.44 ± 6.69 10.29 ± 12.74 807.000c (.274)
CB&M score 55.99 ± 24.47 58.33 ± 21.86 52.21 ± 28.14 1.083a (.284)
FGA score 24.12 ± 5.60 24.85 ± 4.81 22.94 ± 6.61 783.500c (.199)
WHOQOL-BREF Question 1 4.55 ± 0.66 4.65 ± 0.52 4.38 ± 0.82 790.50c (.151)
WHOQOL-BREF Question 2 3.74 ± 0.97 3.80 ± 0.97 3.65 ± 0.98 858.50c (.477)
WHOQOL-BREF physical health domain 75.52 ± 14.44 77.08 ± 14.01 73.00 ± 14.98 1.298a (.198)
WHOQOL-BREF psychological domain 77.06 ± 12.38 78.33 ± 1.80 75.00 ± 13.18 1.238a (.219)
WHOQOL-BREF social relationships domain 75.09 ± 17.43 76.67 ± 16.07 72.55 ± 19.41 1.084a (.281)
WHOQOL-BREF environment domain 89.40 ± 8.85 90.40 ± 9.18 87.78 ± 8.16 714.500c (.060)
Abbreviations: ABC, Activities-specific Balance Confidence Scale; BMI, body mass index; CB&M, Community Balance and Mobility Scale; FFABQ, Fear of Falling Avoidance Behavior Question-
naire; FGA, Functional Gait Assessment; MoCA, Montreal Cognitive Assessment; WHOQOL-BREF, World Health Organization Quality of Life-BREF.
aIndependent t test.
bχ2 test for independence.
cMann-Whitney U test.

CB&M score (β = −0.001, P = .998), and FGA score did not have an impact on older adults’ social relationships
(β = −0.063, P = .770) were not significant predictors. domain score.
The study yielded a regression equation as follows: Statistically significant positive correlations were
found between the response to the WHOQOL-BREF
WHOQOL-BREF environment domain score = 84.99 question 1 (overall satisfaction with life) and the ABC
− 0.37 (FFABQ) + 0.09 (ABC) – 0.001 (CB&M) − 0.06 score (ρ = 0.294, P = .005, small effect size), CB&M
(FGA) + 0.43 (age). score (ρ = 0.285, P = .007, small effect size), and FGA
The regression analysis for the WHOQOL-BREF social score (ρ = 0.349, P = .001, medium effect size). A statisti-
relationships domain was not statistically significant (R2= cally significant negative correlation was found between
0.039, F = 0.672, P = .646). Results showed that age, FFABQ score and the response to the WHOQOL-BREF
ABC score, FFABQ score, CB&M score, and FGA score question 1 (ρ = −0.354, P = .001, medium effect size).

86 Volume 46 • Number 1 • January-March 2023

Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

Table 3. Correlation Coefficients for the World Health Organization Quality of Life-BREF Domain Scores Amongst 89 Community-
Dwelling Older Adults
Physical Health Domain Psychological Domain Social Domain Environment Domain
Score, Coefficient (P Value) Score, Coefficient (P Value) Score, Coefficient (P Value) Score, Coefficient (P Value)
Age r = 0.054 (.615) r = 0.066 (.540) r = 0.021 (.844) ρ = −0.037 (.734)
Number of falls in past
r = −0.164 (.125) r = −0.154 (.150) r = −0.127 (.236) ρ = −0.244 (.021)
12 months
ABC score ρ = 0.524 (<.001a) ρ = 0.284 (.007a) ρ = 0.103 (.337) ρ = 0.343 (.001a)
FFABQ score ρ = −0.509 (0.001a) ρ = −0.384 (<.001a) ρ = −0.137 (.199) ρ = −0.406 (.001a)
FGA score ρ = 0.348 (.001a) ρ = 0.229 (.031) ρ = 0.079 (.461) ρ = 0.198 (.063)
CB&M score r = 0.423 (<.001a) r = 0.204 (.055) r = 0.081 (.450) ρ = 0.235 (.027)
Abbreviations: ABC, Activities-specific Balance Confidence Scale; CB&M, Community Balance and Mobility Scale; FFABQ, Fear of Falling Avoidance Behavior Questionnaire; FGA, Functional Gait
Assessment.
aDenotes statistical significance at P < .008.

Responses to the WHOQOL-BREF question 1 were not based tests and QoL in community-dwelling older adults.
correlated with age (ρ = 0.025, P = .816) or number of Participants completed the Functional Reach Test (FRT),
falls (ρ = −0.153, P = .153). TUG, single-leg stance, and 6-minute walk test. They
A statistically significant positive correlation was found reported no correlations between the performance-based
between the response to the WHOQOL-BREF question outcome measures and scores on the WHOQOL-BREF.
2 (health-related QoL) and the ABC score (ρ = 0.307, However, their results indicated a ceiling effect for the
P = .003, medium effect size). A statistically significant balance and mobility tests, as the average scores for the
negative correlation was found between the response to FRT and TUG exceeded norms and cut-off scores for each
the WHOQOL-BREF question 2 and the FFABQ score measure. In our study, we measured physical function with
(ρ = −0.288, P = .006, small effect size). Responses to outcome measures that assess higher-level balance and gait
question 1 and question 2 were also significantly correlated tasks and found a positive relationship between scores on
with each other (ρ = 0.500, P < .001, large effect size). the outcome measures and all domains of QoL except
Responses to question 2 on the WHOQOL-BREF were not social relationships.
correlated with age (ρ = 0.169, P = .114) or the number of Our study also demonstrated that community-dwelling
falls in the past 12 months (ρ = −0.064, P = .550). older adults who score higher on the CB&M and FGA
report higher satisfaction with health and higher QoL
scores for the physical health domain of the WHOQOL-
DISCUSSION BREF. In contrast, Bjerk et al15 measured functional perfor-
Our participants reported high satisfaction in all domains mance using the Berg Balance Scale (BBS), gait speed, and
measured by the WHOQOL-BREF and overall satisfac- 30-second sit-to-stand test and correlated these measures
tion with life and satisfaction with their health. We found with health-related QoL. The only correlations they found
significant correlations between scores on the performance- were between gait speed and BBS scores and the physical
based outcome measures and overall life satisfaction for component scale of the SF-36. Other studies have shown
community-dwelling older adults. Individuals who scored that gait speed7 and patient-reported locomotion function5
higher on the CB&M and FGA reported higher levels of are positively correlated with health-related QoL.
life satisfaction. Scores on the patient-reported outcome Interventions to improve physical function in communi-
measures were also significantly correlated with overall life ty-dwelling older adults may improve QoL.34 Our results
satisfaction. Individuals who reported high balance confi- suggest that QoL should be considered when providing
dence on the ABC or low fear avoidance behavior on the physical interventions for community-dwelling older adults
FFABQ reported higher levels of life satisfaction. with low scores on the FGA or CB&M. Future research
To our knowledge, this is the first study to examine should examine whether interventions to improve perfor-
the relationships between scores on high-level mobility mance on high-level mobility tasks will improve QoL in
performance-based outcome measures and overall QoL community-dwelling older adults.
in this population. Previous studies have demonstrated a Previous studies have reported a relationship between
weak association or no association between physical per- falls and health-related QoL. Stenhagen and colleagues35
formance measures and QoL in community-dwelling older reported lower health-related QoL scores in community-
adults. However, the performance measures used may dwelling older adults with a history of at least 1 fall
not have been sensitive enough to detect subtle changes compared with those who had not fallen, and that trend
in balance and mobility in this population. Alexandre remained after a 6-year follow-up. Chang et al36 demon-
et al33 examined the relationship between performance- strated a relationship between falls in the past 12 months
JOURNAL OF Geriatric Physical Therapy 87
Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

and health-related QoL. Having a history of falls appears most significant for participants with depression4,16 or a
to have the strongest correlations with the physical domain diagnosis of at least 2 chronic health conditions.40
of QoL.33,36 In contrast, we found weak, nonstatistically There are limitations to the current study. First, ours
significant correlations between the number of falls experi- was a sample of convenience, and participants reported
enced in the past 12 months and overall satisfaction with high satisfaction in all of the domains measured by the
life, overall satisfaction with health, or QoL measured in WHOQOL-BREF as well as overall satisfaction with life
the physical health, psychological, social relationships, and and satisfaction with their health. Social support from
environment domains of the WHOQOL-BREF. family or friends is associated with high QoL.8 Our par-
Our findings support reports from previous studies that ticipants may have been more active in their community
suggest community-dwelling older adults who report fear or had strong social relationships since one of the recruit-
of falling have lower health-related QoL.15,36,37 Participants ment methods was via advertising with churches and
with high FFABQ scores had lower QoL scores in the phys- community service organizations. We strove to recruit a
ical health, psychological, and environment domains. Our diverse sample by recruiting participants in 3 geographi-
results are in concordance with Chang et al,36 who noted cally distinct communities. However, a random sample
that fear of falling was correlated with mental and physi- of community-dwelling older adults may yield higher
cal component scales on the SF-36 for health-related QoL variability in WHOQOL-BREF scores. Second, QoL may
regardless of the individual’s fall history. In other studies decrease with increasing physical disability.6 Our inclusion
involving community-dwelling older adults who fall, high criteria purposefully selected for participants with minimal
fear of falling is associated with almost all of the compo- disability. However, we still found that participants with
nents of the SF-3615 and EQ-5D.37 Similar to our findings, lower scores on performance-based mobility tests reported
Alexandre and colleagues33 found that older adults with lower QoL. We excluded participants with cognitive
self-reported fear of falling scored lower in the psychologi- impairment. Outcomes may be different for older adults
cal and environment domains on the WHOQOL-BREF. In with mild cognitive impairment.16 Finally, some studies
our study, the overall QoL was lower in all domains except have demonstrated that older adults with depression4,16
social relationships for participants who demonstrated fear or chronic health conditions40 have low QoL scores. We
of falling avoidance behavior. We found that FFABQ scores did not screen for depression or chronic health conditions
also had strong correlations with overall satisfaction with in our participants and cannot determine whether there
health and the WHOQOL-BREF physical domain scores. would have been correlations between these factors and
Since fear of falling has a negative relationship with QoL, QoL in our sample. Further research is needed to determine
interventions aimed at reducing fear of falling in commu- whether community-dwelling older adults who report low
nity-dwelling older adults may also improve QoL. Future QoL and fear of falling have decreased overall activity lev-
research to evaluate the efficacy of interventions to reduce els, which could place them at risk for future falls.
fear of falling should also include QoL outcomes.
To our knowledge, this is the first study to examine
CONCLUSIONS
the relationship between scores on the ABC and QoL in
Community-dwelling older adults reported high satisfac-
community-dwelling older adults without specific chronic
tion in all domains of the WHOQOL-BREF. No differ-
health conditions. As indicated by their score on the ABC,
ences were observed between fallers and nonfallers in
individuals who demonstrated high balance confidence had
QoL measures, and QoL was not associated with age.
higher levels of health-related QoL. Quality-of-life out-
Performance-based outcome measures that assess high-
comes should be considered in future studies that examine
level mobility such as the CB&M and FGA are posi-
interventions to improve balance confidence.
tively correlated with the physical health domain on the
Participants in the Veterans Affairs Normative Aging
WHOQOL-BREF. Patient-reported outcome measures for
Study demonstrated a curvilinear relationship between
balance confidence and fear of falling avoidance behavior
age and life satisfaction, with life satisfaction peaking at
such as the ABC and FFABQ are also correlated with the
age 65.38 However, they found individual variability and
physical health, psychological, and environment domains
noted that extroverted participants reported less decline
on the WHOQOL-BREF. Interventions to decrease fear of
in life satisfaction as they age. In our study, age was not
falling or improve high-level mobility may improve QoL in
correlated with overall life satisfaction, health-related
community-dwelling older adults.
QoL, or the physical health, psychological, social relation-
ships, or environment domains of the WHOQOL-BREF.
These findings are consistent with other studies that have REFERENCES
1. WHOQOL Group. Development of the WHOQOL: rationale and current
demonstrated that QoL does not decrease as one ages, a status. Int J Ment Health. 1994;23(3):24-56. doi:10.1080/00207411.1994.
phenomenon that has been termed the “paradox of well- 11449286
2. Bilotta C, Bowling A, Nicolini P, et al. Older People’s Quality of Life (OPQOL)
being.”39 Tseng and colleagues39 demonstrated that age scores and adverse health outcomes at a one-year follow-up. A prospective
was not associated with health-related QoL, and QoL in cohort study on older outpatients living in the community in Italy. Health
Qual Life Outcomes. 2011;9:72. doi:10.1186/1477-7525-9-72
the psychosocial domain actually increased with age. Other 3. Andreasen J, Gobbens RJJ, Eriksen HH, Overvad K. Health-related quality of
studies have found that age-related declines in QoL were life at hospital discharge as a predictor for 6-month unplanned readmission

88 Volume 46 • Number 1 • January-March 2023

Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

and all-cause mortality of acutely admitted older medical patients. Qual Life 23. Howe JA, Inness EL, Venturini A, Williams JI, Verrier MC. The Community
Res. 2019;28(11):3015-3024. doi:10.1007/s11136-019-02259-w Balance and Mobility Scale—a balance measure for individuals with
4. Henchoz Y, Meylan L, Goy R, et al. Domains of importance to the quality traumatic brain injury. Clin Rehabil. 2006;20(10):885-895. doi:10.1177/
of life of older people from two Swiss regions. Age Ageing. 2015;44(6):979- 0269215506072183
985. doi:10.1093/ageing/afv130 24. Wrisley DM, Marchetti GF, Kuharsky DK, Whitney SL. Reliability, internal
5. Neri AL, Borim FSA, Fontes AP, et al. Factors associated with perceived quality consistency, and validity of data obtained with the Functional Gait
of life in older adults: ELSI-Brazil. Rev Saude Publica. 2018;52(suppl 2): Assessment. Phys Ther. 2004;84(10):906-918. doi:10.1093/ptj/84.10.906
16s. doi:10.11606/S1518-8787.2018052000613 25. Skevington SM, Lotfy M, O’Connell KA, WHOQOL Group. The World Health
6. Blanco-Reina E, Valdellós J, Ocaña-Riola R, et al. Factors associated with Organization’s WHOQOL-BREF quality of life assessment: psychometric
health-related quality of life in community-dwelling older adults: a multinomial properties and results of the international field trial. A report from the
logistic analysis. J Clin Med. 2019;8(11):1810. doi:10.3390/jcm8111810 WHOQOL group. Qual Life Res. 2004;13(2):299-310. doi:10.1023/
7. Sartor-Glittenberg C, Lehmann S, Okada M, Rosen D, Brewer K, Bay RC. B:QURE.0000018486.91360.00
Variables explaining health-related quality of life in community-dwelling 26. Landers MR, Durand C, Powell DS, Dibble LE, Young DL. Development of
older adults. J Geriatr Phys Ther. 2014;37(2):83-91. doi:10.1519/ a scale to assess avoidance behavior due to a fear of falling: the Fear of
JPT.0b013e3182a4791b Falling Avoidance Behavior Questionnaire. Phys Ther. 2011;91(8):1253-
8. Gouveia ÉRQ, Gouveia BR, Ihle A, et al. Correlates of health-related quality 1265. doi:10.2522/ptj.20100304
of life in young-old and old-old community-dwelling older adults. Qual Life 27. Powell L, Myers A. The Activities-specific Balance Confidence (ABC) scale.
Res. 2017;26(6):1561-1569. doi:10.1007/s11136-017-1502-z J Gerontol A Biol Sci Med Sci. 1995;50A(1):M28-M34. doi:10.1093/
9. Yang S, Li T, Yang H, et al. Association between muscle strength and health- gerona/50a.1.m28
related quality of life in a Chinese rural elderly population: a cross-sectional 28. Wrisley DM, Kumar NA. Functional Gait Assessment: concurrent,
study. BMJ Open. 2020;10(1):e026560. doi:10.1136/bmjopen-2018-026560 discriminative, and predictive validity in community-dwelling older adults.
10. Olivares PR, Gusi N, Prieto J, Hernandez-Mocholi MA. Fitness and health- Phys Ther. 2010;90(5):761-773. doi:10.2522/ptj.20090069
related quality of life dimensions in community-dwelling middle aged and 29. Lajoie Y, Gallagher SP. Predicting falls within the elderly community:
older adults. Health Qual Life Outcomes. 2011;9:117. doi:10.1186/1477- comparison of postural sway, reaction time, the Berg Balance Scale and
7525-9-117 the Activities-specific Balance Confidence (ABC) scale for comparing fallers
11. Haider S, Luger E, Kapan A, et al. Associations between daily physical and non-fallers. Arch Gerontol Geriatr. 2004;38(1):11-26. doi:10.1016/
activity, handgrip strength, muscle mass, physical performance and quality s0167-4943(03)00082-7
of life in prefrail and frail community-dwelling older adults. Qual Life Res. 30. Balasubramanian CK. The Community Balance and Mobility scale
2016;25(12):3129-3138. doi:10.1007/s11136-016-1349-8 alleviates the ceiling effects observed in the currently used gait and balance
12. Gobbens RJJ. The prediction of quality of life by physical, psychological and assessments for the community-dwelling older adults. J Geriatr Phys Ther.
social components of frailty in community-dwelling older people. Qual Life 2015;38(2):78-89. doi:10.1519/JPT.0000000000000024
Res. 2014;23(8):2289-2300. doi:10.1007/s11136-014-0672-1 31. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed.
13. Bobić Lucić L, Grazio S. Impact of balance confidence on daily living Lawrence Erlbaum Associates; 1988.
activities of older people with knee osteoarthritis with regard to balance, 32. Hair J, Anderson R, Tatham R, Black W. Multivariate Data Analysis. 3rd ed.
physical function, pain, and quality of life—a preliminary report. Clin Macmillan; 1995.
Gerontol. 2018. 41(4):357-365. doi:10.1080/07317115.2018.1453907 33. Alexandre T da S, Cordeiro RC, Ramos LR. Factors associated to quality of
14. Suzuki M, Ohyama N, Yamada K, Kanamori M. The relationship between life in active elderly. Rev Saude Publica. 2009. 43(4):613-621. doi:10.1590/
fear of falling, activities of daily living and quality of life among elderly s0034-89102009005000030
individuals. Nurs Health Sci. 2002;4(4):155-161. doi:10.1046/j.1442- 34. Bocalini DS, Serra AJ, Rica RL, Dos Santos L. Repercussions of
2018.2002.00123.x training and detraining by water-based exercise on functional fitness
15. Bjerk M, Brovold T, Skelton DA, Bergland A. Associations between health- and quality of life: a short-term follow-up in healthy older women.
related quality of life, physical function and fear of falling in older fallers receiving Clin Sao Paulo Braz. 2010;65(12):1305-1309. doi:10.1590/s1807-
home care. BMC Geriatr. 2018;18(1):253. doi:10.1186/s12877-018-0945-6 59322010001200013
16. Lin S-I, Chang K-C, Lee H-C, Yang Y-C, Tsauo J-Y. Problems and fall risk 35. Stenhagen M, Ekström H, Nordell E, Elmståhl S. Falls in the general elderly
determinants of quality of life in older adults with increased risk of falling. population: a 3- and 6- year prospective study of risk factors using data from
Geriatr Gerontol Int. 2015;15(5):579-587. doi:10.1111/ggi.12320 the longitudinal population study “Good ageing in Skane.” BMC Geriatr.
17. Erdoğanoğlu Y, Yalçin B, Külah E, Kaya D. Is there a relationship between 2013;13:81. doi:10.1186/1471-2318-13-81
plantar foot sensation and static balance, physical performance, fear 36. Chang N, Chi L, Yang N, Chou P. The impact of falls and fear of falling on
of falling, and quality of life in hemodialysis patients? Hemodial Int. health-related quality of life in Taiwanese elderly. J Community Health Nurs.
2019;23(2):273-278. doi:10.1111/hdi.12724 2010;27(2):84-95. doi:10.1080/07370011003704958
18. Carson N, Leach L, Murphy KJ. A re-examination of Montreal Cognitive 37. Nguyen LH, Thu Vu G, Ha GH, et al. Fear of falling among older patients
Assessment (MoCA) cutoff scores. Int J Geriatr Psychiatry. 2018;33(2):379- admitted to hospital after falls in Vietnam: prevalence, associated factors
388. doi:10.1002/gps.4756 and correlation with impaired health-related quality of life. Int J Environ Res
19. Shaffer S, Harrison A, Brown K, Brennan K. Reliability and validity of Public Health. 2020;17(7):2493. doi:10.3390/ijerph17072493
Semmes-Weinstein monofilament testing in older community-dwelling 38. Mroczek DK, Spiro A. Change in life satisfaction during adulthood: findings
adults. J Geriatr Phys Ther. 2005;28(3):112-113. from the Veterans Affairs normative aging study. J Pers Soc Psychol.
20. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical 2005;88(1):189-202. doi:10.1037/0022-3514.88.1.189
power analysis program for the social, behavioral, and biomedical sciences. 39. Tseng H-Y, Löckenhoff C, Lee C-Y, et al. The paradox of aging and health-
Behav Res Methods. 2007;39(2):175-191. doi:10.3758/bf03193146 related quality of life in Asian Chinese: results from the Healthy Aging
21. Tomita Y, Arima K, Tsujimoto R, et al. Prevalence of fear of falling and associated Longitudinal Study in Taiwan. BMC Geriatr. 2020. 20(1):91. doi:10.1186/
factors among Japanese community-dwelling older adults. Medicine s12877-020-1446-y
(Baltimore). 2018;97(4):e9721. doi:10.1097/MD.0000000000009721 40. Lee H-J, Yun J. Health-related quality of life in South Korean community-
22. Lavedán A, Viladrosa M, Jürschik P, et al. Fear of falling in community- dwelling older adults with multimorbidity: a convergent parallel mixed-
dwelling older adults: a cause of falls, a consequence, or both? PLoS One. methods approach. Qual Life Res. 2020. 29(3):721-732. doi:10.1007/
2018;13(3):e0194967. doi:10.1371/journal.pone.0194967 s11136-019-02360-0

JOURNAL OF Geriatric Physical Therapy 89

Copyright © 2022 APTA Geriatrics, An Academy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.