Pathways to Falls Among Community-Dwelling Older Women: The Mediating Role of Cognitive Decline and Fear of Falling

Background and Objectives Falls are a critical health concern, with fear of falling and cognitive function recognized as key factors in the complex network of causes leading to falls. Yet, their mediating roles in urban settings of low- and middle-income countries remain underexplored. Research Design and Methods This study was conducted among 9,117 women aged ≥60 years in Iran (Dec 2024–Jan 2025), using stratified sampling across eleven municipal zones. Validated tools assessed fear of falling, cognitive function, loneliness, anxiety, depression, and frailty. Analyses included logistic regression, mediation, and survival models, adjusting for age, education, and assistive device use. Results Higher fear of falling increased the odds of falling (OR = 1.04, p < .001). In contrast, better cognitive function reduced fall risk by about 1% per unit increase (OR = 0.99, p < .001). The oldest-old reported greater fear and loneliness ( p < .05). Mediation analysis showed cognitive function partially explained the pathway from frailty to fear of falling (z = −6.6, p < .001). Survival analysis indicated that less lonely participants had lower fall risk (HR = 0.99, p