Discrepancy in falls efficacy and physical functioning

Falls are one of the most common adverse event that could occur to older adults during their daily functioning. Over the last three decades, researchers have identified several factors related to falls and have taken steps mitigating older adults’ falls risk. Yet, falls continue to be a serious safety threat – both for community-dwelling older adults and those staying in hospitals, residential homes, and nursing homes.

Several theories could be applied to explain this phenonmenon. For example, the Protection Motivation Theory proposes that persons who perceive a health threat may form intentions to take action and avoid harm. Research findings have not yet clarified the proposition that adults may not take action to prevent falls if they do not think they are vulnerable to falling, do not perceive a threat of falling, and are not afraid of falling. Another theory, the Social Cognitive Theory proposes that human behaviors are shaped in part by persons’ self-efficacy. Self-efficacy is deterministic of behaviour. Potentially, older adults having varying self-efficacy beliefs leading them to take on risky and hazardous behaviours.

Some studies have shown this assumption that studying falls efficacy is important!

Study 1: Lim et al. (2018) demonstrated that older people in an acute care hospital are poor at recognizing their falls risk.

Study 2: Ickert et al. (2023) showed that older adults are more likely to overestimate their subjective balance confidence.

Study 3: Ko et al. (2009) revealed the discrepancy between balance confidence and physical performance among older adults.

Study 4: Bao et al. (2022) found that over a third of older adults have discrepancy in the falls risk, i.e. either underestimated or overstimated their falls risk.

Employing a strategy to evaluate falls efficacy will add value towards helping older adults to reduce and manage their falls risk.

Dabkowski et al (2022) identified a list of several validated tools to quantify fall perception. Majority are focused on determining the fear of falling and less on falls efficacy. More studies will be needed to investigate the influence of falls efficacy discrepancy and falls.

Measure	Brief Description
Single-item question (SIQ), “are you afraid of falling?” Fall Efficacy Scale International (FES-I)	Beh et al. (2019) applied the Single-item question “Are you afraid of falling?” and Fall-Efficacy Scale-International (FES-I). Both scales relates to the fear of falling. The study concludes that fear of falling did not appear to develop or change during hospitalization. Education and exercise prescription are effective treatments for FOF post-hospitalization.
Falls Risk Awareness Questionnaire (FRAQ)	The Falls Risk Awareness Questionnaire (FRAQ) is a questionnaire that aims to evaluate the perception of the risk for falls in individuals over 65 years old. The instrument was developed at the University of Alberta, Canada and contains 26 multiple-choice closed-ended questions and 2 open-ended questions and is divided into 2 parts.
Falls Efficacy Scale (FES)	Çinarli and Koç et al. (2017) applied Tinetti Falls Efficacy Scale, the Morse Fall Scale, the Nottingham Health Profile (NHP), and the Modified Barthel Index (MBI). The study concludes that older adults seeking care in the emergency department have a higher risk of falling and are more dependent in daily living activities and experience lower quality of life. Falls efficacy should be investigated and older adults can be guided on prevention and management of falls.
Icon FES-I FES-I The Survey of Activities and Fear of Falling in the Elderly (SAFE)	Cox and Vassallo (2015) provided a review on fear of falling assessment in older people with dementia. The Survey of Activities and Fear of Falling in the Elderly (SAFE) was viewed to offer the opportunity for the identification of activity restriction due to fear and the reasons associated with this. The FES-I expanded measurement of fears relating to more demanding activities of daily living (ADLs) and social interactions. The Iconographical Falls Efficacy scale (Icon-FES), which uses pictures to contextualize the questions provide a greater degree of context-specific scenarios, but the added value of iconography could not be established.
Short Fall Efficacy Scale International (Short FES-I) Perceived ability to manage falls scale One-item fear of falling question Fall-related post-traumatic stress symptoms	Eckert et al. (2020) showed that anxiety was modestly correlated with the single-item question on fear of falling and the short FES-I, but not with the Perceived Ability to Manage Falls scale. The path analytic model demonstrated that higher levels of fall-related concerns measured by the Short Falls Efficacy Scale International were only significantly determined by poor physical performance, but not by other psychological dimensions like increased fall-related post-traumatic stress symptoms and psychological inflexibility.
Modified FES (MFES)	Gettens and Fulbrook (2015) applied Hill’s modified Falls Efficacy Scale for this study. The researchers found that an admission MFES score of less than 5 is an effective predictor of patient falls and is associated with a significatnt longer hospital length of stay.
Van Manen’s approach	Gettens et al. (2018) applied a qualitative phenomenological design was used to investigate the experience of falling in hospital. The participants’ perspective of falling included: Feeling safe, Realising the risk and Recovering independence and identity. Healthcare professionals should be aware of these perspective to tailor their discussions and interventions.
Framework analysis	Haines et al. (2012) aimed to understand why older adults take risks that may lead to falls in the hospital setting and in the transition period following discharge home. Five key factors that influence risk taking behaviour were (i) risk compensation ability of the older adult, (ii) willingness to ask for help, (iii) older adult desire to test their physical boundaries, (iv) communication failure between and within older adults, informal care givers and health professionals and (v) delayed provision of help. The study concluded that health professionals and caregivers played a central role in mitigating unnecessary risk taking.
Deductive content analysis	Hill et al. (2016) provides understanding about how falls prevention education can be provided for older hospital rehabilitation patients who have adequate levels of cognition, using a theoretical framework of health behaviour change. Individualised education could assists older hospital rehabilitation patients with good levels of cognition to engage in suitable falls prevention strategies while on the ward. Staff should engage with patients to understand their perceptions about their recovery and support patients to take an active role in planning their rehabilitation.
15-item subscale about patients’ self-efficacy of fall prevention	Huang et al. (2015) developed a 15-item scale for this study to assess the patient’s confidence regarding fall prevention during hospitalization, personal activities of daily living (nine items), and instrumental activities of daily living (six items). The study found that self-efficacy of prevention can be addressed after intervention (i.e. a 20-min fall prevention program). Educating patients about fall prevention and activities associated with falling increases their awareness of the potential of falling and promoting patient safety.
7-item Falls Behavioural Scale-Inpatient (FaB-I)	Kiyoshi-Teo et al. (2019) aimed to identify associations among patient fall risk factors, perceptions, and daily activities to improve patient engagement with fall prevention among hospitalized older adults. The study concluded that addressing patient-centered measures such as perceptions of and daily activities for fall prevention could add value to existing fall prevention programs.
Patients self-reported their perceived risk of falls, their confidence to prevent all and their willingness to ask for assistance	Kuhlenschmidt et al. (2016) aimed to determine the effect of tailored, nurse-delivered interventions as compared to a control group on patient perception of risk for falls, confidence in fall prevention, and willingness to ask for assistance. The study found that about one-third of patients perceived themselves to be at low risk for falls despite a nurse rating of high risk. The study advocated for tailoring education to the patients’ perceived risk for falls in order to help patients become more aware of fall risk.
Self-awareness of falls risk (SAFRM): 31 items	Mihaljcic et al. (2015) attempted to characterize self-awareness in older adults undergoing inpatient rehabilitation and explore factors associated with reduced awareness of falls risk. The study found that of the patients in the sample, 31% to 63% underestimated falls risk and 3% to 10% overestimated falls risk depending on the aspect of awareness measured. Different aspects of reduced self-awareness were correlated with being a man, higher educational attainment, neurologic history, lower cognitive ability, and lower functional ability. The study showed that a proportion of older adults undergoing inpatient rehabilitation underestimate personal falls risk. More research provide greater insights of the contributors to and effects of reduced self-awareness of falls risk. This will help facilitate the development of strategies to increase awareness of falls risk and increase engagement in falls prevention.
Four scales: The fear of falling while hospitalised scale, the confidence to engage in fall prevention scale, the intention to engage in fall prevention scale and the consequences of falling while hospitalised scale	Pena (2019) studied the relationship between patient perception of fall risk and high fall risk screening scores. Confidence was the only perception scale significantly associated with fall risk (r= -0.194, p=.01). The study advocated screening and accurately identifying patients at risk for falls in order to decreased morbidity, mortality, health care cost, and improved patient outcomes. Four scales were developed: (1) Fear scale – The Fear of Falling While Hospitalized Scale (Fear Scale), developed by Twibell and colleagues (2015) was designed to assess a hospitalized adult’s fear of falling. (2) Confidence scale – The Confidence to Engage in Fall Prevention Scale (Confidence Scale), developed by Twibell and colleagues (2015) was designed for assessing an individual’s perception of their confidence they will not fall in the hospital. (3) Intention scale – The Intention to Engage in Fall Prevention Scale (Intention Scale), developed by Twibell et al. (2015) was designed for assessing a high fall risk hospitalized adult’s perception of their intention to ask for help. (4) Consequences scale- The Consequence to Engage in Fall Prevention Scale (Consequence Scale), developed by Twibell et al. (2015) was designed for assessing a hospitalized adult’s perception of the consequences of falling when not calling for help.
The Confidence to Perform Without Falling Scale (Confidence Scale) Fear of Falling While Hospitalised Scale (Fear Scale) Consequences of Falling While Hospitalised Scale (Consequences Scale) Intention to Engage in Fall Prevention scale (Intention Scale) Three single items for perceived likelihood of falling while hospitalised, perceived likelihood of injury if they did fall while hospitalised, and perceived fear of falling	Twibell et al. (2015) developed several scales for their study. These scales have unknown psychometric properties. Confidence scale was designed to measure participants’ perceived confidence that they could perform activities that increased the risk for falling during hospitalization without assistance or falling. Fear scale was designed to measure the degree of concern while performing various task and being hospitalized. Consequences scale was used to measure potential adverse outcomes of falling Intention scale was used to measure participants’ intention to ask for help when performing high-risk behaviors

Reference:

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