This aim of this study was to investigate the relationship between the clinician-assessed falls risk and self-assessed confidence in completing activities of daily living without falling for older men aged 65 to 74 years old. The findings reported in chapter four indicate that there is a relationship between the two variables; a low relationship at time point one and a moderate relationship at time point two. The results demonstrate that as a falls risk in the clinician- assessment increases, older men between 65 and 74 report less confidence in performing ADLs without falling. The study indicates that the relationship increases over time, and that older men had better awareness of their falls risk when completing complex ADLs compared to basic ADLs. Two possible explanations for the differences in these relationship are considered;
unawareness of falls risk and overconfidence when completing ADLs. Additionally, the possible use of self-rated basic ADLs as predictors of older men’s falls risk will be explored.
Observations of the self-rated assessment tool indicate that some of the ADLs questioned were not gender specific or culturally relevant and the implications of this are explained. The role of occupational therapy within falls will then be discussed to address how specific activity education of could benefit ongoing falls interventions and supports provided to older persons.
Lastly, the studies limitations will be presented followed by future research recommendations to address these limitations identified throughout the project.
5.1- Exploring the relationship
The results of this study highlight mixed results in the relationship between clinician-assessed falls risk and self-assessed confidence in completing ADLs without falling at time points one and two, however, when analysed overall, suggest that older men were more aware of the relationship between their clinician-assessed falls risk and self-assessed confidence levels when completing complex ADLs compared to basic ADLs.
The relationship at time point one identified that largely, older men were not aware of their falls risk when rating their confidence levels when completing most of the ADLs questioned.
While there was a low relationship found overall, across 14 ADLs, eight activities failed to achieve a relationship, four achieved a low relationship, and only two had a moderate relationship. At time point one, this implies that older men were completing activities without
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being aware of their falls risk whilst doing so. Unexpected but insightful findings at time point two found that older men became more aware of their falls risk when rating their confidence levels when completing complex ADLs compared to their risk of falls, but not when completing basic ADLs. Time point two assesses older men’s strength and balance following a six-month falls prevention programme, during this time receiving education on how this aids reducing their risk of falls. This was unexpected as it would be anticipated that older men’s awareness of falls risk would have improved when completing ADLs following education on the topic, however, these findings suggest the relationship predominantly improved in complex ADLs and not as comparably in basic ADLs.
As a single variable, older men self-rated their confidence in ADLs as fairly confident or above on average when completing the 14 ADLs questioned without falling. Thorough examination of self-rated confidence in completing ADLs at both time points reveals that in actual fact, older men reported higher confidence levels when completing basic ADLs compared to complex ADLs. These findings contradict Schepens et al. (2012) who suggested older men were reasonably confident in completing both basic and complex ADLs without falling. Yet, when this study compared the clinician-assessed falls risk and self-assessed confidence in ADLs to determine if there was a relationship, older men demonstrated a stronger relationship between how confident they felt when completing complex ADLs and how this may compare to their falls risk. It is important to note that the relationship between the two variables does not indicate older men were more confident when completing complex ADLs. Rather, this indicates older men were more aware of their falls risk and confidence levels when complex ADLs were completed, even if they did not feel confident in completing the activity. These findings suggest that there is a meaningful relationship for older men’s confidence in complex ADLs that may contribute to their falls risk, and there is a mis-match between how older men rate their confidence in basic ADLs and their risk of falls. Two prominent explanations may answer this; older men being unaware of their falls risk or reporting overconfidence when completing ADLs.
5.1.1- Awareness of falls risk
Firstly, older men may not have been aware of their falls risk when completing the basic ADLs, even if they felt confident whilst doing so. This may be because common activities are completed with greater familiarity throughout the lifespan, whereas complex ADLs are
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completed less frequently and therefore older men may feel less confident in performing these activities. Basic ADLs such as getting in and out of bed, taking a bath or shower, and preparing a meal become ingrained in the daily routine individuals complete, and as the tasks become recurring activities, these are considered less risky and consequently individuals are less likely to identify these activities as contributing to falls risk. While this study did not set out to explore the validity of the mFES, the results of the study suggest that further research investigates the utility of both basic and complex ADLs in a self-rated assessment as this is warranted. This study findings demonstrated that all ten basic ADLs failed to achieve any relationship at time point one, and achieved between a low and no relationship at time point two.
5.1.2- Overconfidence in completing ADLs
Secondly, older men appear to have been overconfident when completing the ADLs that scored a low or no relationship at both time points. In that aspect, the findings of this study are consistent with previously mentioned literature (Jefferis et al., 2015; Kawasaki & Tozawa, 2020) who both similarly reported older persons over-estimating their physical function were just as likely to fall as those who did not feel confident. Overconfidence across the lifespan has been investigated and found individuals, regardless of age, may overestimate their confidence in completing basic tasks (Prims & Moore, 2017). Similarly, Stevens et al. (2018) reported older men felt more capable of managing their falls risk when engaging in activities they chose to do that might be perceived as hazardous, such as using a ladder.
Understanding older men’s overconfidence or unawareness of their falls risk when completing ADLs is important as they may not associate their falls event to the activity completed at the time of the fall. When the risk of falls increases or a falls event occurs, older men may not be recognise that the basic ADLs completed could escalate their falls risk if not appropriately managed. Older men may continue completing the activities that caused the fall which further increases their risk of falling or stop participating in the activity altogether. Stevens et al. (2018) suggests older men may associate falls with external factors such as the environment around them or label their falls as a stumble which minimises the seriousness of the risk. This may be exacerbated by health professionals focus on changing the environment to reduce this risk (Ganz & Latham, 2020) rather than providing older men with sufficient education on how to complete both basic and complex ADLs without increasing their risk of falls. While attention to environmental risks is important, a lack of education to encourage safety in performing
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ADLs may result in reduced activity participation, leading to physical function decline, loss of independence, and diminished quality of life when unable to participate in meaningful occupations. Maintaining older men’s independence and quality of life is vital for healthy ageing and enabling them to remain connected to the occupations that provide a sense of personal autonomy. The findings of this study support the advancement of current literature pertaining to falls and ADL confidence in older men. This study suggests there is a relationship between the clinician-assessed falls risk and older men’s self-rated confidence when completing ADLs, with a more prominent relationship highlighted when completing complex ADLs.
The self-ratings of basic ADLs could be a possible predictor of falls risk for older men, as they reported being fairly confident when assessed on completing basic ADLs individually, however, were not able to demonstrate awareness of their falls risk when compared against their clinician-assessed falls risk level. By understanding that self-rated basic ADLs may possibly correlate to a higher risk of falls, healthcare professionals, support workers, and even whanāu (wider family) could ask screening questions of basic ADLs to older men to swiftly identify if falls supports or assessments are needed to investigate their risk of falls. Further exploration could be beneficial to identify specific ADLs that could be predictors of falls to provide older men with prompt falls assessments and interventions. As older men were more likely to continue completing ADLs if they were unaware of their falls risk, felt a fall event was inevitable, or only discuss falls when asked by a health professional (Cuevas-Trisan, 2019;
Liddle et al., 2019; Stevens et al., 2012), a general screening of ADLs could be useful. A general screening could become a common conversation between older men and several support systems, including healthcare professionals, to identify possible falls risk. However, falls assessments may be averted if older men self-rate higher confidence levels when completing basic ADLs due to overconfidence or unawareness, as aforementioned. Further research into self-rated confidence in completing basic ADLs would be valuable to further refine this statement. Nonetheless, this study has recognised that self-rated confidence in completing basic ADLs could be a useful falls risk predictor for older men.
Other studies have concluded similar recommendations to ADLs predicting falls, although these studies predominantly reviewed if ADLs could predictor falls occurring. Mamikonian- Zarpas and Lagana (2015) attempted to understand the risk of future falls when older persons experienced difficulties in completing basic and complex ADLs. The study found that higher
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reports of ADL difficulty equated to a stronger chance of falls occurring. The ADLs assessed were different than the ADLs questioned in the mFES and examined both genders, however, established that two out of three activities assessed resulted in a high probability of future falls were basic ADLs. Equally, Tsang et al. (2022) found high correlations of balance confidence predicted future falls, but this was predominantly found with a female sample population.
Nevertheless, the findings in this study begin to explore comparable findings to other research and support the recommendations that future research would benefit older men and any future falls risk or falls experiences.
5.2- Falls assessment tools for the older male population
This study on clinician-assessed falls risk and self-assessed falls risk was specific to older men due to the general underrepresentation of older men in falls research (Carmona-Torres et al., 2019; Gustafsson et al., 2013; Schön et al., 2011). With a growing elderly population in New Zealand, where older men equal almost half of the age group above 65 years (Stats NZ, 2022a), falls research would benefit from including a more proportionate male participant sample in falls studies. The wording and relevance of the basic and complex ADLs in the mFES may not be as appropriate to older men, as the ADLs questioned appear to be more relevant to older women. In the mFES, ADLs such as light housekeeping and gardening were questioned using the term ‘light’, however, when applying this to daily activities completed by older men, they reported being more likely to complete the ‘heavier’ aspects of these tasks (Li et al., 2017).
Additionally, older men were more likely to remain independent with their travel rather than using public transportation and were less likely to prepare a meal, use the telephone, or complete simple shopping (Huang et al., 2017; Levin, 2019; Sheehan & Tucker-Drob, 2019) which are four of the basic ADLs examined in the mFES assessment tool (see Appendix E).
These studies provide further rationale into the concerns raised of relevance and appropriateness of terminology used for exploring older men’s self-rated confidence when completing basic and complex ADLs in the mFES assessment tool. Older men may not complete the ADLs for falls-related or health-related reasons, but the questioning of the ADLs, supported by findings from literature, suggest that the relevance of the activities themselves appear to be less appropriate for older men. Additionally, the wording used to describe the ADLs in the mFES assessment requires adjustments to ensure it is general to both older men and women. Presently, these assessment tools are being answered by all older persons, however, if the ADLs are not appropriate for older men, they may be classified as unconfident
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or overconfident of completing ADLs without falling despite the activities not being applicable to them. It is suggested that further study take place to examine common basic and complex activities that older men complete throughout their daily lives and use the results of these common activities to develop a new self-rating questionnaire for older men’s confidence in ADLs without falling.
5.3- Recommendations for the role of an occupational therapist
The POE model provides a clear framework for occupational therapists to assess the ‘fit’
between the person and how they complete their daily activities within their own environment (Clemson et al., 2019). When focusing on older men and their falls risk, occupational therapy interventions aim to support the individual in performing their occupations by either adapting the activity or modifying the environment (Wellecke et al., 2022). Occupational therapists may also recommend than older men attend a falls prevention programme or refer them on to a physiotherapist to improve their strength and balance. A common tool used by occupational therapists in New Zealand is the Live Stronger for Longer home safety checklists (Live Stronger, 2022). This checklist, along with adaptations of the list, provide guidance on how older persons could make adjustments in their home to minimise the risk of falling (Live Stronger, 2022), for example by placing items in closer to reach positions or using a hand reacher equipment, use anti-slip mats over rugs, and remove or downsize furniture to avoid bumping into items (Live Stronger, 2022). This study found older men were more aware of their relationship in completing complex ADLs compared to their falls risk. Yet, while they were still aware of some basic ADLs, including reaching into closets and cabinets and walking around their house, environmental modifications continue to be a leading focus while confidence in completing ADLs is not discussed within resources such as the home safety checklist. Still, there remains minimal focus on supporting older persons confidence when completing ADLs.
With these findings, older men may benefit from occupational therapy services providing more specific activity education on basic ADLs then complex ADLs to enhance their confidence when completing these activities. Occupational therapy education may include supporting older men through an activity, discussing confidence and safety concerns throughout the activities performance to highlight where reduced confidence or unawareness of falls risk may appear and mitigate this by creating a ‘fit’ in the occupation. This may include teaching
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alternative activity performance or developing strategies that enable older men to safely continue in the occupation. It is anticipated that if occupational therapists, or other healthcare professionals also, focus on supporting older men first with their confidence in completing basic ADLs in relation to their level of falls risk, recommendations for occupational and environmental changes to activities may subsequently reduce. If older men received more directed education on their falls risk and confidence when completing ADLs, they may be less reliant on equipment, modifications, or other people to complete ADLs. Focusing on this would be beneficial as it would enable older men to understand what activities that complete daily contribute to their falls risk and if they began to feel unconfident or fearful, occupational therapists could provide the specific, meaningful activity-based education to support them.
Additionally, this would reduce older men’s reliance on equipment for functional mobility, such as a walking aid or walking frame. In turn this may support older men maintaining their independence and physical function for as long as possible if the equipment is not needed.
The recommendation to provide activity support to older men was similarly reflected another study who found older persons wanted to receive support with completing basic ADLs but were not afforded the opportunities of help (Abdi et al., 2019). Older men and older Māori men in New Zealand received higher amounts of home help to complete similar basic ADLs mentioned in the mFES questionnaire compared to the general elderly population (Lapsley et al., 2020). In New Zealand, ‘ageing in place’ is a common theme for older persons as they wish to maintain independence and ability to live in their own home, independently if able to do so, as this connects them with their occupational identity and family (Wiles et al., 2012). Ensuring occupational therapists can provide self-care strategies to older men is important as this enables independence and enhances quality of life, particularly in the later stages of life. Enabling older men to continue completing basic and complex ADLs supports a sense of encouragement and accomplishment in maintaining activities that are often taken for granted in the earlier stages of life. The importance of supporting older men to maintain basic and complex ADLs has been illustrated and should start to be a focus for occupational therapists providing falls and ADL support. With an occupational therapy focus on the POE approach, supporting the person will in turn support participation in occupations and reduced reliance on modifications or environmental adaptations to improve health ageing for older persons. Further, providing support to older men on basic activities can ensure they are aware of their falls risk and confidence levels when completing ADLs, aiming for falls experiences to reduce, and improve confidence in ADL participation with ageing.
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5.4- Influence of ethics and bicultural practice in this research
The initial aim of this study was to focus specifically on older Māori men and their falls risk, however, following consultation with a number of Māori advisors, the researcher, a non-Māori occupational therapist, recognised the potential of the study to compromise and potentially harm Māori. The vulnerability and socio-cultural considerations were able to identify that potential harm could have been apparent if the research was completed by non-Māori without an appropriate level of Māori input. Therefore, a change in focus of the study to the general older male group aged 65 to 74 was decided. Ethical approval was obtained a second time (see Appendix C), alongside written approval from the private health company to collect different data than originally requested. Following this main change in the research topic, no additional ethical concerns became apparent throughout the exploration and discussion of the data. By critically reflecting and following ethical guidelines throughout the research process, this could support any prospective studies taking place as a result of the future research recommendations (Dawson et al., 2019). This research has maintained transparency and sensitivity in how ethical and bicultural considerations impacted the methodologies and analysis of the research, which could in turn positively influence future researchers when considering the same aspects of the topic.
Subsequent to changing the original research topic from older Māori men to the general population of older men, the study was able to include a culturally diverse range of participants.
Māori and Pacifika were included in this study, as well as other ethnicities such as Indian, Asian, and Fijian. Older Māori men were included in this study, however, the bicultural representation of Māori (8.9%) remains lower than the general population of Māori in New Zealand, currently 17.4% (Stats NZ, 2022a). This could be contributed to this study’s participation sample of older persons between 65 to 74 years old rather than encompassing the entire lifespan. This research study contributes to the growing body of literature that include the Māori population when analysing falls in New Zealand, although further research would be beneficial to represent the growing cultural population more accurately.
5.5- Limitations
Several limitations were identified in the study, reported transparently throughout the research process. The study was limited by time as the researcher was completing a master’s project over ten months, and this impacted on the study design. A retrospective study was identified