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Fall Risk Assessment Scales: A Systematic Literature Review
1 Clinical Research Unit, University-Hospital of Padua, 35128 Padua, Italy; moc.liamg@inirtsacinorev
2 Continuity of Care Service-University-Hospital of Padua, 35128 Padua, Italy; [email protected]
3 Independent Research, University-Hospital of Padua, 35128 Padua, Italy
Background: Falls are recognized globally as a major public health problem. Although the elderly are the most affected population, it should be noted that the pediatric population is also very susceptible to the risk of falling. The fall risk approach is the assessment tool. There are different types of tools used in both clinical and territorial settings. Material and methods: In the month of January 2021, a literature search was undertaken of MEDLINE, CINHAL and The Cochrane Database, adopting as limits: last 10 years, abstract available, and English and Italian language. The search terms used were “Accidental Falls” AND “Risk Assessment” and “Fall Risk Assessment Tool” or “Fall Risk Assessment Tools”. Results: From the 115 selected articles, 38 different fall risk assessment tools were identified, divided into two groups: the first with the main tools present in the literature, and the second represented by tools of some specific areas, of lesser use and with less supporting literature. Most of these articles are prospective cohort or cross-sectional studies. All articles focus on presenting, creating or validating fall risk assessment tools. Conclusion: Due to the multidimensional nature of falling risk, there is no “ideal” tool that can be used in any context or that performs a perfect risk assessment. For this reason, a simultaneous application of multiple tools is recommended, and a direct and in-depth analysis by the healthcare professional is essential.
The phenomenon of falls is recognized globally as a major public health problem. Falling down is globally the number-one health problem, and a common problem of evaluation by healthcare professionals. A fall is defined as a “sudden, not intentional, and unexpected movement from orthostatic position, from seat to position, or from clinical position” [ 1 ]. Falls involve elderly people for two main reasons: (1) the decrease of functional reserves that are used to maintain the orthostatic position; (2) the following vulnerabilities or pathologies caused by factors that occur simultaneously, pathological processes, and adverse pharmacological incentives. People over 65 have the highest probability of falling down: 30% of them fall down at least once per year, while the percentages become higher, (about 50%) on people over 80 [ 2 ]. Even if elderly people run the highest risk of falling down, it is necessary to point out that the pediatric population runs quite a high risk of downfall as well. About three million children are victims of wounds related to annual falls [ 3 ]. Although nearly 40% of the total daily falls worldwide occur in children, this measurement may not accurately reflect the impact of fall-related disabilities for older individuals who have more disabling outcomes and are at greater risk of institutionalization [ 1 ].
The financial costs of fall injuries are substantial. For people aged 65 and over in Finland and Australia, it was calculated at USD 3611 and USD 1049, respectively. Evidence from Canada suggests implementing effective prevention strategies with a subsequent 20% reduction of the incidence of falls among children under 10 could create net savings of more than USD 120 million annually [ 1 ]. The Joint Commission International for Accreditation Standards for Hospitals specifies that hospitals should aim to reduce the risk of injury from falls to inpatients and outpatients, including appropriate screening or assessment of fall risk tools, a process for re-evaluation, especially if there are changes in the patient’s condition; and implement interventions to reduce the risk of falling [ 4 ]. For this reason, risk assessment is important. The expression of risk assessment is based on the following: checklists drafted of different risk factors for fall and numerical indexes to predict the risk. The checklists help the staff to identify the most common factors, while the numerical index is used to predict the risk of an individual using a numerical score that is proportional to the number of risk factors included [ 5 ].
However, the characteristics of the patient for a fall risk tool are varied: age, cognitive state, state of health in general, particular comorbidities, hospital or home context. These are just a few features. In fact, in recent studies, particular risk factors have been evaluated such as being hospitalized, being hospitalized in neuropsychiatry, suffering from dementia and delirium, and going to the bathroom [ 6 ].
Currently in the literature, there is no study that summarizes the tools available to healthcare professionals according to the different contexts in which they operate. Knowing the fall assessment tools, through the analysis of their characteristics, allows to identify the most suitable scale for each individual patient and to prevent the risk. As described in NICE, 2004, the patients should be cared for by personnel who have undergone appropriate training and who know how to initiate and maintain correct and suitable preventative measures. Staffing levels and skill mix should reflect the needs of patients [ 6 ].
This review aims to analyze different fall risk assessment tools present in the literature with the aim of supporting healthcare professionals in choosing the tool best suited to their operational context and the characteristics of the patients.
2. Material and Methods
A literature search was undertaken from MEDLINE, CINHAL and The Cochrane Database in the month of January 2021.
The present review of literature followed the PRISMA guidelines [ 7 ]. The PICO method was adopted [ 8 ] as shown below to find the correct research terms to use:
- Population: individuals who are in hospital environments or who stay in the territory, without any age limit.
- Intervention: application of instruments to evaluate the risk of falling.
- Comparison: none.
- Outcomes: measurement of the downfall risk.
For every database, the following search terms were used: “Accidental Falls” and “Risk Assessment”, “Fall Risk Assessment Tool” or “Fall Risk Assessment Tools”.
The limits applied to each study were: year of publication 2010–2020 (last ten years); abstract available, Italian and English languages. Specific criteria of inclusion and exclusion were defined as shown below:
Inclusion Criteria: Revision and research studies (experimental, observational and descriptive studies) focused on the presentation, creation, validation, or critique of instruments of fall risk evaluation.
Exclusion criteria: articles that report evaluations measuring the risk of falling with medical parameters or criteria (ex. Laboratory data), or evaluations made through movement sensors; articles without abstract or not available in Italian or English languages.
The review was not registered in any database or similar, and it was conducted by two separate reviewers who then compared the results on the basis of the limits and eligibility criteria chosen. The agreement was found as shown in Figure 1 .
PRISMA flow diagram.
Figure 1 is an illustrative example of the selection process with the final total number of articles included (n = 115). Most selected studies are prospective cohort studies or transverse studies, focused on the validation of an instrument in a different environment from the original one. In the other articles: retrospective studies, descriptive studies, methodical studies, and systematic reviews are present. Some instruments of evaluation have been compared to analyze their properties in relation to each other.
For the selected scales, the history and any important changes over the years have been reconstructed. Each scale, in fact, belongs to different populations or contexts, for the purpose of presenting the entire scenario of the tolls for assessing the risk of falling.
Tools identified by the analysis of the articles are 38, divided into two groups.
The first group is represented by the main 21 risk assessment tools, described in Table 1 .
Risk of falling evaluation tools.
Table 2 describes the second group, with 17 additional assessment tools specific to some areas, but of lesser use and with less supporting literature. The tools divided by scope are the following: psychiatric field: “Baptist Health High Risk Falls Assessment (BHHRFA)”, “Wilson-Sims Fall Risk Assessment Tool (WSFRAT)”; pediatric field: “4-item Little Schmidy Pediatric Hospital Fall Risk Assessment Index”, “Humpty Dumpty Fall Scale (HDS)”, “Bayındır Hospital Risk Evaluation Scale for In-hospital Falls of Newborn Infants”; emergency department: “KINDER 1 Fall Risk Assessment Tool”, “Memorial Emergency Department (MED-FRAT)”; rehabilitation field: “Casa Colina Fall Risk Assessment Scale (CCFRAS)”, “Predict_FIRST”, “Marianjoy Fall Risk Assessment Tool (MFRAT)”, scope of home care: “Simple clinical scale”, “Home Falls and Accidents Screening Tool (HOME FAST)”; patients affected by stroke: “Stroke Assessment of Fall Risk (SAFR)”, “Royal Melbourne Hospital Falls Risk Assessment Tool (RMH FRAT)”, “Sydney Fall Risk Screening Tool”, “Outdoor Falls Questionnaire”, “Questionnaire for Fall Risk Assessment in the Elderly”.
Specific tools for given contests/population.
The vast majority of the proposed tools have been developed for use in acute and geriatric settings, in which there are numerous factors that expose individuals to this risk. The target most subjected to the assessment is the elderly population (>65 years), followed by people suffering from pathologies that alter walking and balance skills (e.g., Parkinson’s disease, mental disabilities, stroke outcomes, etc.).
Falls Efficacy Scale—International (FES-I). The FES-I scale is the most used tool in literature for the “fear of falling” evaluation, a factor closely related to the genesis of falls [ 22 ]. This scale refers only to basic daily activities of frail elderly people or people with disabilities. The FES-I includes 16 daily life activities, and the individual must report the perceived degree of concern in implementing each of the activities listed. It is the ideal tool for investigating the “fear of falling” of the elderly in normal daily activities.
The Activities-specific Balance Confidence Scale (ABC Scale) was developed to assess the perceived degree of confidence in maintaining balance or not becoming unstable in performing various functional tasks. It is a structured questionnaire that measures the confidence of an individual in carrying out activities and consists in attributing a percentage value, between “insecurity” and “complete security”, to the 16 proposed activities [ 14 ]. The ABC scale is simple to complete, and the time required for filling out can be as much as 20 min, which is why a simplified version has been proposed that includes six of the most challenging activities of the previous scale. The scale has been validated for use with different ratings including people with Parkinson’s Syndrome, post-stroke, with lower limb amputations and vestibular disorders; it has also been translated into several languages besides English such as Swedish, Chinese, Canadian French and Arabic [ 47 ].
Comparing the two scales, it emerged that the FES-I scale has a greater appropriateness of use in clinical settings than the ABC Scale, whose use is recommended mainly in the elderly living at home [ 22 ].
The STRATIFY scale is a predictive tool for the risk of falls in hospitalized patients. The compilation of the scale is not performed through direct observation of the patient, but the evaluator reports the score based on information obtained from the previous observation or from other caregivers. STRATIFY has been extensively studied in intensive care units in Australia, Europe and Canada [ 48 ] and has also been applied in numerous geriatric and rehabilitation departments [ 49 ]. In these contexts, it has long been considered the “Gold standard” tool to be used at patient admission thanks to the high sensitivity value demonstrated by numerous studies (between 73.7% and 93.0%) and the simplicity and speed of application (3 min).
At the same time, some studies criticize its reduced specificity, or identify its scarce usefulness if applied in different or specific contexts such as rehabilitation from traumatic brain injury, or in patients younger than 65 years old. The Hendrich II Fall Risk Model (HIIFRM) was designed to identify adult patients at risk of falling in acute care hospitals [ 25 ]. Unlike the STRATIFY scale, the history of previous falls was not considered as a risk factor. They are also taken into account due to drug categories that are at greater risk for falls and side effects than other drug categories. The time required for its compilation is approximately similar to that of the STRATIFY scale. The scale was tested on acute phase patients with different diagnoses (diabetes mellitus, stroke, heart failure), demonstrating that its effectiveness varies according to the patient group, the healthcare professional’s skill level and the clinical units in which is applied.
The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) was used for the multi-factorial assessment of the risk of falling in departments for acute patients [ 23 ]. The JHFRAT scale is a tool that makes possible to implement a multi-factorial assessment of the risk of falling in a simple way, which requires an average of 5 min for its completion and is widely used in adult departments in the acute phase [ 50 ]. However, there are discordant results in the literature regarding its statistical characteristics: in some studies, a high sensitivity is reported, but a low specificity, vice versa in other studies, which consider it weak if used in specific contexts, such as in the departments of medicine [ 50 , 51 ].
The Tinetti Mobility Test (TMT) or the Performance-Oriented Mobility Assessment (POMA) consists of the combined use of the useful components drawn from both approaches [ 9 ]. The total POMA (POMA-T) consists of two sub-scales: the balance rating scale (“balance scale” or POMA-B) and the gait rating scale (“gait scale” or POMA-G) [ 52 ]. The scale is also used in different clinical contexts: its effectiveness was analyzed on patients with Parkinson’s disease, with amyotrophic lateral sclerosis, Huntington’s disease and community-resident elderly [ 52 ]. The time taken is 5–10 min, but it requires training for the examiner as a prerequisite and requires some equipment (stopwatch, chair, 5-pound object = about 2.5 kg and a space to walk 15 feet = about 5 m). It can also be burdensome for patients. There is a “long” version of the scale consisting of a total of 40 points that assesses the individual in more depth, but consequently requires more time for its application [ 6 ].
The Aachen Falls Prevention Scale was developed in order to allow the elderly to perform a self-assessment of their risk of falling [ 19 ]. The Aachen Fall Prevention Scale is an easy-to-understand tool that investigates various factors that contribute to the genesis of falls and introduces a quick and safe test; it allows the individual to perform a self-assessment and increase the degree of self-perception. The authors have also created an evaluation index, the “Aachen Mobility and Balance Index” to measure the physiological risk of falling in the elderly at home; this includes the execution of performances characterized by the progressive increase of difficulty in the components of balance, mobility and grip strength required for the completion of the test. The index demonstrated a strong correlation with the Tinetti POMA Scale and a good degree of discrimination between individuals at risk of falling and not, but the time required to execute the performances and the necessary equipment make it more complex.
The Fullerton Advanced Balance (FAB) Scale is a multidimensional tool for assessing balance developed for functionally independent seniors. It aims to identify highly active seniors who are at increased risk of suffering fall-related injuries due to sensory impairments [ 24 ]. The validity of its contents is based on a theoretical analysis of the components of the static and dynamic balance, the reception and integration of the sensory components and the anticipatory and reactive postural control. Berg Balance Scale (BBS) was developed for the evaluation of both static and dynamic balance capacity. It provides a detailed balance assessment and has been extensively tested in various contexts: United States, Canada, Brazil, Australia, China, Japan, Korea and United Kingdom. It has shown accuracy in predicting falls in different types of population (elderly living in communities or suffering from chronic diseases or with intellectual and visual disabilities) and a greater sensitivity was highlighted when applied in populations affected by diseases that affect the balance (e.g., neuromuscular pathologies) both in clinical and home settings [ 53 ]. Compared to the FAB scale, it has a “ceiling effect” that does not allow it to be administered to physically active elderly people [ 54 ]. It also requires a much longer application time, about 20 min.
The Balance Evaluation Systems Test (BESTest) aims to identify the disordered systems underlying postural control responsible for poor functional balance in adults. It is widely used to evaluate six balance control systems; however, it is difficult to apply in clinical situations due to the long administration time (approximately 20–30 min). The BESTest has two shorter versions: the Mini-BESTest [ 18 ], developed in 2010, allows the evaluation of four balance control systems (compared to the six total of the original) and has been used with different clinical populations and has shown particular psychometric properties in individuals with Parkinson’s syndrome [ 55 ]. The test, however, requires a moderate amount of equipment to be completed and, moreover, it focuses on dynamic balance, without evaluating all the stability control systems; while the Brief-BESTest, developed in 2012, is a reduced version, consisting of eight items that allow an analysis of all six balance control systems evaluated by the BESTest; moreover, it requires even less time and material to complete it [ 56 ]. The comparison of the two tests shows that the Brief-BESTest is recommended as a guide for planning interventions, while the Mini-BESTest is more appropriate as a screening tool for the dynamic balance of patients [ 55 ].
The 5 Times-Sit to Stand Test (5T-STS) was developed and validated in America to establish the ability of individuals with balance disorders to perform transitional movements. A simple and quick test provided an objective measurement of the level of balance and coordination of individuals subject to various health alterations such as Sdr. Parkinson’s disease or chronic stroke [ 56 ]. Subsequently, the restriction of use of the 5T-STS test defined as unable to evaluate a population of individuals with different degrees of motor ability was criticized, which is essential if a tool is to be applied within institutionalized geriatric contexts. Similar to 5T-STS is the Dynamic Gait Index (DGI), that verifies the participant’s ability to maintain the equilibrium of walking by responding to different requests. Some studies demonstrated the high reliability of the assessment in elderly people, subjects suffering from vestibular dysfunction, multiple sclerosis and post-stroke [ 15 ]. It can be performed in both hospital and home settings, as it does not require any special equipment. It evaluates all aspects of gait, but takes a long time to administer (15 min) [ 15 ].
The Timed Up and Go (TUG) test is simple and effective, and seeks functional mobility: it provides a quick assessment of the individual’s strength, mobility capacity and dynamic balance [ 11 ]. Numerous studies have attested its validity by applying it in different contexts such as wards for acute patients or community residents [ 57 ], or to individuals with different health alterations such as Parkinson’s syndrome [ 58 ] or mental disabilities [ 59 ]. It is a simple test to implement, therefore applicable in clinical situations where the time available to the healthcare professional is a fundamental resource. Compared to the 5T-STS and the DGI, it presents multiple variables that can alter the result of the test (such as the support foot while getting up from the chair, the moment in which the stopwatch starts, the clear understanding of the tasks to be performed by the individual), has also shown reduced efficacy when administered to people with high or normal functional mobility [ 45 ]. Finally, the different cut-off values must be considered based on the age, context and pathological condition of the population being tested.
The Downton Fall Risk Index (DFRI) detects the risk of falling. The tool has been used in several studies with different purposes: to evaluate the effectiveness of a program for the elderly in post-stroke rehabilitation aimed at muscle strengthening, or to discriminate in a population of elderly who had experienced previous episodes of falls. The Tool has been extensively analyzed in contexts that do not include acute patients such as nursing homes, while when applied to the hospital environment, its ability to predict falls significantly decreases [ 60 ].
The Conley Scale assesses the risk of falls. The scale has been inserted and used in various Italian hospital contexts (mainly medicine and surgery). It is quick to use (about 2 min) and is easily understood; it is usually administered upon admission of the patient to the ward. However, the inability to identify patients not at risk of falling due to the low specificity value was contested [ 61 ]; therefore, it is recommended to use it as a preliminary evaluation to identify subjects who need a more in-depth clinical evaluation [ 62 ].
The Minimal Chair Height Standing Ability Test (MCHSAT) involves measurements of the minimum height of the chair from which the person is able to stand up. The tool has been used in several studies with different purposes: to evaluate the effectiveness of a program for the elderly in post-stroke rehabilitation aimed at muscle strengthening, or to discriminate in a population of elderly people who had experienced previous episodes of falls. The test showed, if administered in a standardized way, a high sensitivity (75%), which, combined with its simplicity of execution and speed of administration, makes it an appropriate tool for screening the risk of falling in healthcare settings [ 63 ]. From the comparison performed between the MCHSAT test and the 5T-STS, it emerged that both are less effective if performed by patients with heart disease or stroke, while in patients suffering from arthritis of the lower limbs, the 5T-STS is more effective [ 63 ].
Stopping Elderly Accidents, Deaths, and Injuries (STEADI) was created to help health professionals integrate fall risk assessment into routine practice. The tool also includes a list of fall prevention interventions for clinical use. The STEADI algorithm provides valid, unique information on the risk of falling, independently of traditional indicators based on a low level of physical health [ 28 ].
Morse Fall Scale (MFS) is a quick and easy way to assess the likelihood of a patient falling. It was developed in acute patient, rehabilitation and nursing home departments. The scale was computer tested in a simulated population and was subsequently applied to the populations of the previously mentioned departments. The Morse scale takes a few minutes to complete (approximately 2 min), allows for three different risk categories (low, medium and high) and is used in hospital settings [ 64 ]. This tool, however, does not investigate factors relevant to the risk of falls such as sensory deficits and the intake of certain drugs that can affect the mechanisms involved in the genesis of falls. For this reason, some studies have implemented a more accurate stratification of the areas investigated by the items.
A scale concerning the presence of drugs is the medication fall risk score (RxFS). It was developed as part of the pharmacist-coordinated falls prevention program in America to compensate for the lack of various drug therapy risk assessment tools [ 65 ]. The US Agency for Healthcare Research and Quality (AHRQ) has approved and recommended its use in conjunction with various nurse-administered rating scales, such as MFS and STRATIFY. The retrospective cohort study by Yazdani and Hall evaluated the efficacy of the association of RxFS with the MFS scale [ 26 ].
Falls Risk for Older People-Community Setting Screening Tool (FRHOP Com Screen) was developed by a multidisciplinary team of experts and tested in the wards of subacute patients. The Thai version of the scale has demonstrated satisfactory reliability and validity in hospitalized elderly subjects. Sensitivity and specificity are, respectively, 57% and 68%. By applying modifications to the FRHOP, the Western Health Fall Risk Assessment (WHeFRA) scale was developed by Walsh et al. and demonstrated efficacy comparable to the STRATIFY scale [ 20 ]. Austin Health Falls Risk Screening Tool (AHFRST) was developed for acute or subacute patients. This tool is administered to all patients upon entering the ward for a preliminary identification of those at risk of falling; it is fast and easy to use [ 29 ]. Comparison with the TNH-STRATIFY scale performed in the original study showed that both are unable to identify individuals not at risk of falling. Therefore, they demonstrate a low degree of “predictivity” if applied in this type of population [ 29 ].
The main elements that distinguish the assessment tools shown in the review are: the risk factors investigated (intrinsic and/or extrinsic), the sample subjected to analysis (hospital population and/or resident at home) and the way the test is used (questions to be answered and/or physical actions to be performed). Between the instruments presented between the discussion and Table 2 , eight involve the execution of one or multiple physical actions, with the aim of evaluating the mechanisms that regulate the maintenance of balance and coordination in the individual (“Performance”); 26 investigate different risk factors through questions directed to the patient or elements on which the attention of the professional using the instrument is guided (“Self-report”), and finally, three scales include both the investigation of some risk factors through questionnaire, and the execution of one or more physical activities. The RxFS is excluded from this distribution, as it guides the attribution of a score exclusively based on the type of drugs taken by the individual. The risk factors investigated by the “Self-report” tools are mainly intrinsic, which means referred to the person; among these, there are: the identification of previous episodes of falls (present in 23 scales); the evaluation of the cognitive state aimed at identifying confusion, disorientation, agitation, impulsiveness or mnemonic difficulties (present in 18 scales), alterations of organs or systems and intake of drugs linked or not to specific pathological conditions, and other intrinsic variables such as age and gender. Regarding extrinsic factors, only 5 tools evaluate them in a specific way, paying attention to the context in which the individual lives. Instead, the environmental factor represented by walking aid devices is investigated by almost all the instruments presented.
Each scale, before being applied in a specific clinical context or on a population other than that for which it was created, must be properly tested, to verify its effectiveness and reliability [ 61 ]; in fact, the same instrument can have variable values of sensitivity and specificity if used in different contexts or with different populations. For example, the combined application of a test with high and stable sensitivity (e.g., TUG test) and one with a high and stable specificity (e.g., BBS) allows increasing the diagnostic precision in predicting the risk of falling. The use of a scale that evaluates the state of illness or the alterations individual (e.g., STRATIFY or HIIFRM) simultaneously with a test that evaluates the physical ability to maintain balance (e.g., BBS) can permit greater accuracy in identifying those at risk, even in different contexts [ 53 ].
This revision has the following limitations: only the articles of the last 10 years were analyzed, the entire scenario of fall risk assessment tools present in the literature, there is not sufficient information available on the statistical characteristics of the different instruments to compare the tools or their parameters.
This study presents the entire scenario of fall risk assessment tools present in the literature. Between most of the tools analyzed, 23 tools target hospitalized patients, eight are used for risk assessment in home residents, while seven are applicable to both populations. The primary purpose of using a fall risk assessment tool is not to reduce falls, but to identify individuals at high and low risk [ 53 ]. In this way, the subjects that need a more in-depth analysis are identified, and the healthcare professional’s attention is focused on the main risk factors responsible of falls. To these subjects should be offered a multifactorial falls risk assessment [ 6 ].
According to some studies, to maximize the predictability characteristics of each instrument, it would be recommended to use two tests in combination.
Indeed, due to the multidimensional nature of the risk of falling, there is no “ideal” a single tool that can be used in any context or that performs a perfect risk assessment. A simultaneous application of several instruments is recommended and a direct and in-depth analysis by the healthcare professional is essential [ 6 ]. The results of the risk assessment should be discussed within the multi-professional team in order to identify the most effective interventions for preventing falls, especially among people with cognitive disorders, where the risk of fall is very common and have different etiologies [ 66 ].
Thanks to Giosuè Bacchin for his precious assistance in translation.
All authors contributed to the same and review of the work. Conceptualization, V.S., R.S. and A.P.; methodology, V.S., R.S. and A.P.; software, V.S., R.S. and A.P.; validation, V.S., R.S. and A.P.; formal analysis, V.S., R.S. and A.P.; investigation, V.S., R.S. and A.P.; resources, V.S., R.S. and A.P.; data curation, V.S., R.S. and A.P.; writing—original draft preparation, V.S., R.S. and A.P.; writing—review and editing, V.S., R.S. and A.P.; visualization, V.S., R.S. and A.P.; supervision, V.S., R.S. and A.P.; project administration, V.S., R.S. and A.P.; funding acquisition, V.S., R.S. and A.P. All authors have read and agreed to the published version of the manuscript.
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The authors declare that they have no conflict of interest. The authors declare that they have not used any source of funding.
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Fall Risk Assessment
What is a fall risk assessment.
Falls are common in adults 65 years of age and older. In the United States, about a third of older adults who live at home and about half of people living in nursing homes fall at least once a year. There are many factors that increase the risk of falling in older adults. These include mobility problems, balance disorders , chronic illnesses , and impaired vision . Many falls cause at least some injury. These range from mild bruising to broken bones , head injuries , and even death. In fact, falls are a leading cause of death in older adults.
A fall risk assessment checks to see how likely it is that you will fall. It is mostly done for older adults. The assessment usually includes:
- An initial screening. This includes a series of questions about your overall health and if you've had previous falls or problems with balance, standing, and/or walking .
- A set of tasks, known as fall assessment tools. These tools test your strength, balance, and gait (the way you walk).
Other names: fall risk evaluation, fall risk screening, assessment, and intervention
What is it used for?
A fall risk assessment is used to find out if you have a low, moderate, or high risk of falling. If the assessment shows you are at an increased risk, your health care provider and/or caregiver may recommend strategies to prevent falls and reduce the chance of injury.
Why do I need a fall risk assessment?
The Centers for Disease Control and Prevention (CDC) and the American Geriatric Society recommend yearly fall assessment screening for all adults 65 years of age and older. If the screening shows you are at risk, you may need an assessment. The assessment includes performing a series of tasks called fall assessment tools.
You also may need an assessment if you have certain symptoms. Falls often come without warning, but if you have any of the following symptoms, you may be at higher risk:
- Irregular or rapid heartbeats
What happens during a fall risk assessment?
Many providers use an approach developed by the CDC called STEADI (Stopping Elderly Accidents, Deaths, and Injuries). STEADI includes screening, assessing, and intervention. Interventions are recommendations that may reduce your risk of falling.
During the screening , you may be asked several questions including:
- Have you fallen in the past year?
- Do you feel unsteady when standing or walking?
- Are you worried about falling?
During an assessment , your provider will test your strength, balance, and gait, using the following fall assessment tools:
- Timed Up-and-Go (Tug). This test checks your gait. You'll start in a chair, stand up, and then walk for about 10 feet at your regular pace. Then you'll sit down again. Your health care provider will check how long it takes you to do this. If it takes you 12 seconds or more, it may mean you are at higher risk for a fall.
- 30-Second Chair Stand Test. This test checks strength and balance. You'll sit in a chair with your arms crossed over your chest. When your provider says "go," you'll stand up and sit down again. You'll repeat this for 30 seconds. Your provider will count how many times you can do this. A lower number may mean you are at higher risk for a fall. The specific number that indicates a risk depends on your age.
- Position 1: Stand with your feet side-by-side.
- Position 2: Move one foot halfway forward, so the instep is touching the big toe of your other foot.
- Position 3 Move one foot fully in front of the other, so the toes are touching the heel of your other foot.
- Position 4: Stand on one foot.
If you can't hold position 2 or position 3 for 10 seconds or you can't stand on one leg for 5 seconds, it may mean you are at higher risk for a fall.
There are many other fall assessment tools. If your provider recommends other assessments, he or she will let you know what to expect.
Will I need to do anything to prepare for a fall risk assessment?
You don't need any special preparations for a fall risk assessment.
Are there any risks to a fall risk assessment?
There is a small risk that you may fall as you do the assessment.
What do the results mean?
The results may show you have a low, moderate, or high risk of falling. They also may show which areas need addressing (gait, strength, and/or balance). Based on your results, your health care provider may make recommendations to reduce your risk of falling. These may include:
- Exercising to improve your strength and balance. You may be given instructions on specific exercises or be referred to a physical therapist.
- Changing or reducing the dose of medicines that may be affecting your gait or balance. Some medicines have side effects that cause dizziness, drowsiness, or confusion.
- Taking vitamin D to strengthen your bones.
- Getting your vision checked by an eye doctor.
- Looking at your footwear to see if any of your shoes might increase your risk of falling. You may be referred to a podiatrist (foot doctor).
- Reviewing your home for potential hazards. These may include poor lighting, loose rugs, and/or cords on the floor. This review may be done by yourself, a partner, an occupational therapist, or other health care provider.
If you have questions about your results and/or recommendations, talk to your health care provider.
- American Nurse Today [Internet]. HealthCom Media; c2019. Assessing your patients' risks for falling; 2015 Jul 13 [cited 2019 Oct 26]; [about 3 screens]. Available from: https://www.americannursetoday.com/assessing-patients-risk-falling
- Casey CM, Parker EM, Winkler G, Liu X, Lambert GH, Eckstrom E. Lessons Learned From Implementing CDC's STEADI Falls Prevention Algorithm in Primary Care. Gerontologist [Internet]. 2016 Apr 29 [cited 2019 Oct 26]; 57(4): 787–796. Available from: https://academic.oup.com/gerontologist/article/57/4/787/2632096
- Centers for Disease Control and Prevention [Internet]. Atlanta: U.S. Department of Health and Human Services; Algorithm for Fall Screening, Assessment and Intervention; [cited 2019 Oct 26]; [about 4 screens]. Available from: https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf
- Centers for Disease Control and Prevention [Internet]. Atlanta: U.S. Department of Health and Human Services; Assessment: The 4-Stage Balance Test; [cited 2019 Oct 26]; [about 4 screens]. Available from: https://www.cdc.gov/steadi/pdf/STEADI-Assessment-4Stage-508.pdf
- Centers for Disease Control and Prevention [Internet]. Atlanta: U.S. Department of Health and Human Services; Assessment: 30-Second Chair Stand; [cited 2019 Oct 26]; [about 4 screens]. Available from: https://www.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf
- Mayo Clinic [Internet]. Mayo Foundation for Medical Education and Research; c1998–2019. Evaluating patients for fall risk; 2018 Aug 21 [cited 2019 Oct 26]; [about 4 screens]. Available from: https://www.mayoclinic.org/medical-professionals/physical-medicine-rehabilitation/news/evaluating-patients-for-fall-risk/mac-20436558
- Merck Manual Consumer Version [Internet]. Kenilworth (NJ): Merck & Co., Inc.; c2019. Falls in Older People; [updated 2019 Apr; cited 2019 Oct 26]; [about 2 screens]. Available from: https://www.merckmanuals.com/home/older-people%E2%80%99s-health-issues/falls/falls-in-older-people
- Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am [Internet]. 2015 Mar [cited 2019 Oct 26]; 99(2):281–93. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Fall Risk Assessment
Identify patients who may be at risk of a fall and implement interventions to prevent falls before they happen, with our simple Fall Risk Assessment, based on the Peninsula Health FRAT.
What Is A Fall Risk Assessment?
For children or young adults, a fall might mean nothing more than a scrape or a few stitches, but for older people, a fall can be a severe health setback that can lead to long-term disability or significantly reduced quality of life.
Falling is a particular concern for elderly patients due to the increased risk of falling with age and the increased risk of serious fall-related problems. This is especially for those over the age of 65, as well as those who suffer from walking, balance, and vision issues. This is in addition to heart palpitations, and low blood pressure.
Contrary to popular belief, falls are often not the random occurrence we assume they are. The likelihood of falls increases with factors such as diabetes, cognitive impairment, postural hypotension, incontinence, and mental health. Many of these risk factors for falls can be screened for and incorporated into a , a valuable tool for practitioners to identify individuals at risk of falling to implement preventative strategies.
To help standardize this process and ensure clinicians can consistently identify their patients at risk of falling, we have created an interactive PDF version of the commonly used FRAT (Fall Risk Assessment Test). To see how you can implement this handy assessment to ensure your patients receive the interventions they need to prevent falls before they happen, just keep reading.
Lowering Fall Risk
To help, it is also recommended to take on board the following tips to reduce the risk of falling.
- Get up slowly to prevent feeling dizzy
- Use assistive devices, such as a cane
- Modify your home with bars to hold onto, and if possible, live within a one-level home
- Take vitamin D supplements
- Try group exercise classes
- Wear glassess if suffering from poor vision
Printable Fall Risk Assessment
Download this Fall Risk Assessment to assess your client’s risk of falling.
How To Use This Fall Risk Assessment
This simple Fall Risk Assessment is based on the first part of the full Fall Risk Assessment Tool (FRAT) developed by Peninsula Health in 1999. This assessment is split into different risk factors that can contribute to an increased likelihood of falling. Follow the step-by-step guide below to gain confidence in administering this invaluable assessment.
Recent Falls Risk Factor
The first risk factor to assess is if your patient has fallen recently. Falling in the past is a good indicator that a patient may be at risk of falling again. This risk factor gives the lowest score of 2 if the patient has not had a fall in the last year and the highest score of 8 if they have fallen in the previous three months while they were an inpatient or resident at a hospital or rehabilitation centre.
Medication Risk Factors
Another risk factor for falling is being on certain medications. The Fall Risk Assessment includes examples of medications that should be counted for this section, including anti-depressants, hypertensives, sedatives, diuretics or hypnotics.
Psychological Risk Factors
Certain psychological factors can contribute to a patient's risk of falling, such as depression, poor insight or judgment, or anxiety.
Cognitive Status Risk Factors
The cognitive status risk factor is assessed using a separate assessment called the Hodkinson Abbreviated Mental Test Score. This is a rapid questionnaire which is designed to determine the presence of dementia in elderly patients. This is a commonly used and validated tool you can read more about in the reference provided at the end of this article.
Automatic High-Risk Factors
In addition to these four risk factor categories, there are two questions that, if applicable to the patient, automatically give them a high fall risk status.
Tally Final Score and Determine Fall Risk Status
Once you have completed each assessment section, assigning a score to each, it’s time to tally up the scores and determine the final risk status. A score of 5-11 gives a low-risk status, 12-15 is a medium-risk status, and above 16 is a high-risk status. Additionally, if either automatic high-risk status factor is selected, the fall risk status is high regardless of the total score.
Determine Interventions Based on Fall Risk Status
Once the assessment is completed, it’s time to determine the next steps for your patient. Depending on their fall risk status, you may recommend a different intervention level from no intervention required to additional home support, mobility aids, changes to their medication regime, mental health interventions, or referral to a specialist geriatrician to optimize their care.
Save and store securely
The last step is to store the fall risk assessment securely as part of your patient’s medical record . This assessment contains confidential and important information which other members of their care team may need to access in the future. As such, it’s important this assessment is stored both securely and accessibly.
Fall Risk Assessment Example (Sample)
To see an example of how this Fall Risk Assessment can help identify patients at greater risk of falls, just look at our example Fall Risk Assessment. This example is a completed version of the interactive PDF assessment designed to illustrate a sample patient’s response. Read our example Fall Risk Assessment below, or download the sample PDF if you prefer.
Download this Fall Risk Assessment Example (Sample) here:
When Would You Typically Use This Fall Risk Assessment Assessment?
A Fall Risk Assessment is a concise enough assessment that it can be undertaken at any stage of a patient’s care but would typically be administered upon the intake of a potentially susceptible patient to a new healthcare provider. This could be upon admission to a new healthcare centre, upon hospitalization for any reason- whether related to a fall or not, or for any patient who fits a threshold for fall risk screening, whether that is age or mobility-level-related.
Patients admitted to rehabilitation centres, such as post-stroke rehabilitation, may also have a fall risk assessment to identify any additional interventions they require while they are an inpatient.
Who Can Use This Printable Fall Risk Assessment?
Although a relatively straightforward assessment, the interpretation of the Fall Risk Assessment and the treatment decisions in response to the Fall Risk Assessment result require the expertise of a trained healthcare practitioner. These might include:
- Nurses and nurse practitioners
- Physical Therapists
- Occupational Therapists
Why Is This Assessment Popular With Nurses?
Concise Assessment Tool
This tool is quick to administer and requires no additional equipment other than knowledge of the ten questions comprising the Hodkinson AMTS. This means it can be performed with minimal prior arrangement and can quickly determine a quantitative fall risk factor for your patient to inform their future interventions.
Simple scoring system
The result of this fall risk assessment is a simple numerical score and a categorization of Low, Medium, or High risk of falling. This simple scoring system is beneficial for quickly communicating a patient’s risk status to others in their care team and ensuring they get the treatment they need as soon as possible to prevent future falls.
Benefits Of Free Fall Risk Assessment
Standardize your fall risk assessments.
Ensure you give all your patients the same level of care by using the same Fall Risk Assessment every time. Having a standardized process for fall risk assessment is a great way to ensure you don’t miss any key risk factors for your patient. It also allows you to compare scores between patients and for the same patient over time.
Keep your Assessments Digital
Another great benefit of this Fall Risk Assessment is that it can be kept entirely digital , meaning you can fill it out, share it, and store it entirely digitally. This saves time printing and scanning and allows you to utilize digital encryption to enhance your data security.
Structure your Appointment
This Fall Risk Assessment can also provide a structure for your appointment with your patient, separating each risk factor into different sections, which you can use as a framework for your discussion in their session with you.
Keep comprehensive records
Keeping comprehensive records is crucial to meeting your legal medical documentation requirements. Having a copy of the type of Fall Risk Assessment you used for your patient (and for all of your patients!) is a great way to ensure you keep precise and complete medical records.
Improve communication within your patient’s team
Using a standardized fall risk assessment ensures that other members of your patient’s care team can quickly understand the assessment that was administered, and interpret the results.
Why Use Carepatron For Fall Risk Assessment Software?
Carepatron is an intuitive and comprehensive software guaranteed to save you time on your practice’s administration work. Automate your email or SMS appointment reminders, utilize our smart dictation software, and offer your patients their own Carepatron portal to book appointments with you and access their medical records.
You can access this Fall Risk Assessment, assign it to your patients, and store it securely all from within Carepatron- and rest assured that your patient's data will be safe with Carepatron’s HIPAA-compliant, bank-level data security.
In addition to security, with Carepatron’s mobile and desktop platforms, you’ll be able to access the information you need- wherever you need it.
Fall Risk Assessment Tool (FRAT) - Peninsula Health (1999)
Commonly asked questions
The Hodkinson AMTS score is the result of a separate, short questionnaire designed to assess the presence of dementia in the elderly patient. The AMTS is scored out of 10, with a score of 9 or above contributing a low risk to the patient’s overall fall risk status.
There are two aspects that need to be considered in order to designate a fall risk status (low, medium or high) to a patient. This is the sum of each of the risk factors, giving a total out of 20 and the result of the automatic high-risk status questions. Assuming neither of these questions are answered in the affirmative, the final score out of 20 can be interpreted as low risk: 5-11, medium risk: 12-15, and high risk: 16 or above.
The two automatic high-risk status questions are two extra questions at the end of the fall risk assessment. If either is answered in the affirmative, they put your patient into the high-risk status regardless of their total score.
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