In this study, we investigated the relationship between falls and the self-rated health status and anxiety symptoms of elderly chronic multimorbid patients and the moderating role played by psychological resilience using a cross-sectional data from the CLHLS, and our findings showed that falls were significantly negatively correlated with the self-rated health status of elderly chronic multimorbid patients in China and were significantly positively associated with anxiety symptoms in Chinese elderly chronic multimorbidity patients. Among the moderating effects, there is a moderating role of psychological resilience between falls and anxiety symptoms. In addition, we further confirmed the heterogeneity of falls with both self-rated health and anxiety status across gender and residence groups.
First, the present study found that falls were negatively associated with self-rated health in Chinese elderly chronic multimorbid patients. This result is consistent with past related studies. Previous studies have shown that falls interact with older adults' health levels, with more falls predicting poorer physical health, more negative emotions, and less physical activity in the near future for older adults living in the community[27]. In turn, more poor health also promotes the occurrence of falls in the elderly. Some medical studies have shown that the decline in muscle function of the lower extremities is a significant contributor to falls in older adults, and that this state is not an inevitable consequence of aging, but is related to an individual's underlying chronic health condition[28–31]. Therefore, elderly patients with chronic multimorbidity are more prone to falls, and the health problems that may be associated with falls, such as limb injuries (e.g. hip fracture), deterioration of physical and cognitive functioning, and poor trajectory of recovery from chronic diseases, These will directly affect patients' assessment of their own health and lead to a low self-rated of their health status.
Another correlation result of this study showed that falls were positively correlated with anxiety symptoms in Chinese elderly with chronic multimorbidity. This finding is generally consistent with previous studies, indicating that falls contribute to anxiety symptoms and adversely affect the mental health of older adults[4, 21, 32]. It has been noted that anxiety symptoms are commonly associated with four psychological disorders triggered by falls, including fear of falling, fall-related self-efficacy, balance confidence, and outcome expectations[18]. For elderly patients with chronic multimorbidity, they are inherently prone to poor mental health due to suffering from multiple chronic conditions over time[33]. The occurrence of falls also puts patients at risk for recurrent falls and physical impairment, which in turn triggers a fear of repeated falls and a reduced sense of self-efficacy. Previous studies have shown that it becomes more difficult for the elderly to recover from fall-related injuries[34], so after experiencing a fall older patients are more likely to develop a fear of falling again, which can be manifested as a loss of confidence in the ability to perform everyday behaviors, limiting and avoiding participation in certain activities, which contributes to the development of anxiety symptoms, and the stronger the fear, the more severe the anxiety symptoms[35]. In addition, the impaired health, functional deterioration, and decreased independence caused by falls may lead to a gradual resistance to social participation, which not only reduces the exchange of daily information, but also does not facilitate the venting of negative emotions, and has a serious negative impact on all areas of the patient's life, thus eroding the patient's sense of self-efficacy[36], and triggering the emergence of anxiety symptoms.
Furthermore, the present study revealed the existence of the moderating role of psychological resilience. It has been previously shown that psychological resilience as a moderator is effective in reducing anxiety and depression after falls in older adults, and improving psychological resilience may be an effective way to intervene and prevent fall-related anxiety and depression symptoms[18]. In addition to this, many studies have confirmed the assertion that the moderating effects of psychological resilience can modify the impact of risk factors on psycho-social functioning[37], and are reflected in different groups. For example, soldiers exposed to military operations[38], COVID-19 experiencers[39], and groups of children and adolescents[40, 41]. Therefore, a high level of psychological resilience is also effective in regulating one's own state of mind and suppressing anxiety symptoms triggered by negative events such as falls for a group of Chinese elderly chronic multimorbid patients. But in the relationship between falls and self-rated health of elderly patients with chronic multimorbidity, our study showed that psychological resilience did not play a significant moderating role, and we speculate that positive mental status is not sufficient to influence patients' assessment of their physical health status. Self-rated health is a reliable and effective indicator of an individual's own health[42], and has been regarded as an important reference factor for determining morbidity, hospitalization and mortality[43], which reinforces the need for patients to ensure objectivity and truthfulness in assessing their own health status. Therefore, psychological resilience fails to play a moderating role between falls and self-rated health as it is difficult to influence patients' assessment of their objective conditions such as disease, functional status, and other health problems through changes in mindset.
Finally, this study found that the effects of falls on self-rated health and anxiety symptoms of Chinese elderly chronic multimorbid patients varied by gender and place of residence. First, from the gender perspective, the female patient group was more likely to have poorer self-rated health and more severe anxiety symptoms in the future after a fall. The moderating effect of psychological resilience was similarly more pronounced in female patient group compared to males. A study showed that the prevalence of post-fall fear was higher in women and increased with age[44]. This suggests that the significant presence of post-fall fear in female patients means that they are more likely to develop anxiety symptoms after a fall. It has also been shown that women are generally more emotional than men, and are more susceptible to external influences on a mental level[45]. Therefore, the female chronic multimorbid group may experience greater fluctuations in their psychological state and level of cognition about themselves compared to males after experiencing fall behavior, resulting in poorer self-rated health and more severe anxiety symptoms, and psychological resilience as a positive mental state, may also play a stronger moderating role in the female patient group. From the perspective of place of residence, the results of the study showed that elderly chronic multimorbid patients living in urban areas were more likely to experience anxiety after a fall and that psychological resilience had a more significant moderating effect, whereas patients living in rural areas were more likely to experience poorer self-rated health after a fall. A possible explanation for this is that urban and rural patients experience different health shocks after falls. For older urban patients, the relatively higher level of education leads to higher expectations of educational rewards, and thus the fluctuations in psychological state may be greater in the event of a setback similar to a fall. Moreover, life in towns and cities is richer than in rural areas, which leads to greater life changes after a fall, which can have a more severe negative impact on mental health. In addition, in the relationship between falls and self-rated health, many studies have shown that Chinese rural residents generally have worse self-rated health outcomes than their urban counterparts due to unequal health opportunities and uneven utilization of healthcare services [46]. On the basis of this assertion, we can further confirm that rural elderly patients with chronic diseases are more likely to have a poorer assessment of their own health after experiencing an adverse event of a fall.
The strengths of this study are the selection of a sample from the National Population Survey which provided sufficient data to explore the relationship between falls and self-rated health and anxiety symptoms in older people with chronic multimorbidity, and the focus on older people with chronic multimorbidity, which provided insight into the impact of falls on their physical and mental health, and the role of psychological resilience in this. Limitations of this study are as follows: First, the study was analyzed based on a cross-sectional data set. Therefore, our predicted results cannot be explained in depth in terms of causality and can only be understood statistically, and further research on falls and Chinese elderly chronic multimorbid patients' self-rated health and anxiety symptoms needs to be explored with longitudinal data. Second, the present study used a self-rated approach for the identification of falls, in which participants were asked to recall whether a fall had occurred in the past year; this approach may be subject to recall bias, and further research should also take a more accurate approach to the recording of falls.