Globally, falls are a major public health problem in terms of both mortality and morbidity, and adults aged 60 years and older suffer the greatest number of fatal falls.1 Even when falls are not immediately fatal, they significantly increase the risk of disability, higher medical care costs, institutionalization, and early mortality.2, 3, 4, 5, 6 Fear of falling (FOF) is the most common psychological consequence related to falls and is highly prevalent among older adults, irrespective of whether they have actually experienced falls.7 FOF has been variously defined as including a cautious concern about falling, a lack of confidence in maintaining balance during normal activities, and low perceived self-efficacy in avoiding falls during essential, non-hazardous activities of daily living.7, 8, 9 A mild level of FOF is very common and can be viewed as a normal part of life. However, a strong and ongoing FOF may become a major problem and create a vicious cycle.10 FOF may lead older adults to withdraw from activities they enjoy and lose confidence in performing daily activities, which can worsen their muscle strength and gait balance. This all puts older adults at an increased risk of falling and makes future falls more likely. Falls with serious consequences can further increase the level of FOF.11,12 Moreover, FOF limits older adults’ daily activities as much as having had multiple previous falls does.10

Besides limiting activities and increasing the risk of futural falls, FOF can also affect older adults’ mental health.13 FOF reduces older adults’ confidence and makes them feel vulnerable and incompetent, which may lead to depression and reduced quality of life.12,14 In a large cohort of community-dwelling older adults, a previous study found that FOF and activity restriction were associated with the prevalence and incidence of late-life depression, respectively.9 FOF was significantly related to declines in the Short Form 36 Health Survey (SF-36) scores and even non-fallers who reported FOF had a greater risk of nursing home admission.15 A systematic review of the consequences of FOF among older persons found consistent results on reduction in social activities, depression, and diminished quality of life.13

Restriction in physical and social activities has adverse effects on health outcomes. Previous research indicated that activity restriction significantly decreased the quality of life and increased depressive symptoms among older adults with chronic conditions.16, 17, 18 On the one hand, physical exercise can affect the onset of depression by affecting central function, or by stimulating endorphin levels.19 Exercise can prevent a variety of cardiovascular and cerebrovascular diseases, diabetes, and other health conditions, maintain functional independence, and improve quality of life. Social activities, on the other hand, may influence depression by increasing self-esteem. People improve their quality of life by engaging in social activities, building social relationships, and experiencing positive emotions.20

Prior research provides an essential understanding of older adults’ FOF; however, most studies have been focused on community-dwelling older adults, with less attention on nursing home residents. Nursing home residents fall at about three times the rate of older adults in the community.21 They also have a higher risk of death or serious injury arising from a fall22 and are more likely to adopt a sedentary lifestyle. Therefore, more studies are needed to investigate FOF among the nursing home population. While existing studies have shed light on the relationships between FOF and activity restriction,10 between activity restriction and quality of life or mental health,16, 17, 18, 19, 20 and even between FOF and quality of life or mental health,9,12, 13, 14, 15,23,24 the simultaneous interrelationship between these factors has not yet been thoroughly explored. One study, which explored the mediating role of activity restriction played in the relationships between FOF and late-life depression in a cohort of community-dwelling older adults, found that activity restriction accounted for 45.8 % of the effect of FOF on depression.9 Therefore, there is a critical need for research endeavors that delve into the interrelationships among FOF, activity restriction, quality of life, and mental health outcomes specifically within the nursing home population. To address gaps in knowledge, this study aims to investigate (1) the mediating role of activity restriction in the relationships between FOF and quality of life, and (2) the mediating role of activity restriction in the relationships between FOF and depression among nursing home residents. This study will enhance our understanding of FOF and activity restriction among nursing home residents and its implications for their quality of life and mental health, thereby informing targeted interventions and improving care practices in these settings.