Falls are a complex, multifactorial issue, and a thorough risk assessment is the cornerstone of any effective fall prevention strategy. The process extends beyond a single tool, requiring a synthesis of clinical judgment, validated scales, and patient-centered evaluation. By addressing both intrinsic (patient-specific) and extrinsic (environmental) factors, healthcare providers can identify key areas for intervention and create personalized care plans.
The Multifactorial Nature of Fall Risk Assessment
Effective fall risk assessment requires a holistic view of the client's condition, recognizing that risks arise from a combination of factors. The evaluation should cover both intrinsic and extrinsic elements that contribute to a person's risk of falling.
Intrinsic Risk Factors
These are factors related to the client's own health and physical condition.
- History of falls: A client who has fallen previously is at a significantly higher risk of falling again. Inquiring about the number and circumstances of past falls is crucial.
- Chronic conditions: Diseases such as Parkinson's disease, dementia, arthritis, and diabetes can cause impaired gait, balance problems, or cognitive deficits.
- Muscle weakness and gait deficits: Reduced lower-body strength and changes in walking patterns are significant predictors of falls.
- Balance impairment: Age-related decline in balance control, as well as vestibular disorders, can increase fall risk.
- Sensory deficits: Poor vision, reduced night vision, and hearing impairment can affect spatial awareness and the ability to detect hazards.
- Orthostatic hypotension: A sudden drop in blood pressure when standing can cause dizziness, leading to falls.
- Cognitive impairment and mental status: Confusion, poor judgment, or an inability to remember physical limitations increases risk, especially in unfamiliar environments like a hospital.
Extrinsic Risk Factors
These are external and environmental factors that can increase a client's risk.
- Medications: Polypharmacy (taking multiple medications) or specific drugs like sedatives, psychoactive medications, and some blood pressure drugs can cause side effects like dizziness, drowsiness, or impaired balance.
- Environmental hazards: Clutter, loose rugs, poor lighting, slippery floors, and lack of grab bars in bathrooms are common tripping hazards.
- Improper footwear: Shoes with poor traction or that fit improperly can increase the risk of slips.
- Improper use of assistive devices: Canes or walkers that are the wrong size or used incorrectly can cause instability.
Standardized Screening and Assessment Tools
Healthcare professionals use validated screening tools to systematically quantify a client's risk level. These tools provide objective data to guide care planning and intervention.
Morse Fall Scale (MFS)
The MFS is a widely used, rapid assessment tool for hospitalized and ambulatory patients. It evaluates six variables, assigning a point value to each, which are then summed to determine a risk level (low, moderate, or high). The categories include:
- History of falling
- Secondary diagnosis
- Ambulatory aid use
- IV therapy presence
- Gait status
- Mental status
Timed Up and Go (TUG) Test
The TUG test assesses functional mobility, balance, and gait. The client is timed as they stand up from a chair, walk 3 meters (10 feet), turn, walk back, and sit down. An older adult who takes 12 seconds or more to complete the test is at an increased risk for falls.
Berg Balance Scale (BBS)
The BBS is a 14-item, 56-point scale that objectively measures a client's static and dynamic balance. It includes tasks such as standing unsupported, sitting with eyes closed, reaching forward, and transferring. A score of 45 or less indicates a greater risk of falling.
The Comprehensive Fall Risk Evaluation Process
Beyond standardized scales, a holistic assessment includes a thorough history, physical exam, and environmental review.
The Clinical Interview and Patient History
This is a critical first step. The healthcare provider should engage the client in a conversation about their health and lifestyle.
- Fall history: Ask about the number, timing, location, and circumstances of any falls or near-falls.
- Medical history: Review all chronic and acute conditions, especially neurological, musculoskeletal, and cardiovascular issues.
- Medication review: Systematically review all prescription and over-the-counter drugs for potential side effects or interactions that increase fall risk.
- Activity level: Discuss the client's daily activities and any functional limitations or assistive devices they use.
- Fear of falling: Evaluate if the client has a fear of falling, which can lead to reduced activity and subsequent muscle deconditioning.
The Physical Examination
A focused physical exam can identify many of the intrinsic risk factors. Key components include:
- Gait and balance assessment: Observe the client's walking style for instability, shuffling, or other abnormalities. The TUG test is often used here.
- Orthostatic blood pressure: Measure the client's blood pressure while lying, sitting, and standing to detect orthostatic hypotension.
- Vision and hearing screening: Basic tests can identify sensory deficits that affect balance.
- Musculoskeletal and neurological exam: Evaluate muscle strength, range of motion, and sensory function, especially in the lower extremities.
The Environmental Assessment
This involves evaluating the client's living space for potential hazards. An occupational therapist can perform this for in-home care.
- Inspect pathways for clutter and cords.
- Check lighting levels, especially in hallways and bathrooms.
- Look for loose rugs or uneven floor surfaces.
- Assess the need for assistive devices like grab bars in bathrooms or handrails on stairs.
Comparison of Key Fall Risk Assessment Tools
| Feature | Morse Fall Scale (MFS) | Timed Up and Go (TUG) Test | Berg Balance Scale (BBS) |
|---|---|---|---|
| Focus | Multi-component score based on history, diagnosis, ambulation, etc. | Functional mobility, gait, and balance during a timed task. | Static and dynamic balance ability through 14 standardized tasks. |
| Method | Paper-based or digital questionnaire; score is calculated. | Observational, timed test where patient rises, walks 3m, turns, and sits. | Observational, clinician-scored performance on 14 balance tasks. |
| Setting | Acute care, long-term care facilities. | Wide application in clinical, residential, and community settings. | Clinical settings, often used by physical/occupational therapists. |
| Key Score Indicator | Total score classifies risk as low, moderate, or high (e.g., >45 is high risk). | Time taken. ≥12 seconds indicates increased fall risk. | Total score out of 56. <45 suggests a higher fall risk. |
| Strengths | Quick, easy to use, and widely adopted. | Simple, requires minimal equipment, and provides a functional measure. | Objective measure of balance, identifies specific balance deficits. |
| Limitations | Doesn't assess gait quality directly; can be reactive (relies on history). | Time-based metric may be influenced by patient effort; doesn't evaluate specific balance deficits. | More time-consuming to administer; not a perfect predictor of falls on its own. |
Conclusion: The Path Forward for Fall Prevention
Assessing a client for fall risk is a dynamic and ongoing process that requires careful attention to detail and collaboration across the care team. By moving beyond simple checklists and adopting a multifactorial assessment approach, healthcare providers can gain a clearer understanding of a client's unique vulnerabilities. Regular screening using validated tools like the Morse Fall Scale, combined with functional tests such as the TUG test and Berg Balance Scale, creates a robust framework for identifying risk. Ultimately, a systematic evaluation—integrating patient history, physical examination, and environmental review—enables the development of targeted, individualized interventions that promote mobility, independence, and overall safety.
Learn more about the CDC's STEADI initiative for fall prevention.
