Balance bridges upstream deficits associated with falls in older adults: evidence from the National Health and Aging Trends Study Round 13 cohort.

BACKGROUND AND OBJECTIVES: Falls in older adults are a major public health concern, but the mechanistic pathways linking sensory, cognitive, and vascular deficits to falls are poorly understood. We hypothesized that balance acts as a critical mediator, channeling these upstream deficits into functional fall risk. METHODS: Using cross-sectional data from 4805 community-dwelling adults (≥ 65 years) in the National Health and Aging Trends Study (NHATS) Round 13, we examined predictors of a composite fall-risk score (self-reported past falls and worry about falling). Survey-weighted multiple regression identified direct predictors, while mediation analyses tested the indirect effects of hearing, cognition, and vascular conditions through subjective (self-reported problems) and objective (performance-based) balance measures. RESULTS: Subjective balance was the strongest direct predictor of fall risk (β = 0.53, p < .001), with additional direct effects from objective balance, depression, anxiety, and heart disease. Notably, hearing ability, cognitive function, and hypertension were not direct predictors of fall risk; their influence was fully or partially mediated by balance, establishing postural control as the primary pathway through which these upstream factors contribute to falls. DISCUSSION AND IMPLICATIONS: These findings identify a dual-pathway fall risk model driven by subjective and objective balance. While psychological factors and heart disease directly influence fall risk, upstream sensory, cognitive, and hypertensive deficits operate through balance as a convergent mediating pathway. Clinical fall prevention must prioritize subjective and objective balance measures, while managing mental health as a direct threat and addressing sensory and cognitive function as foundational to postural control.