Comprehensive screening and assessment for fall risk
For older adults, the risk of falling is a significant health concern that can profoundly impact independence and quality of life. The evaluation process for fall risk is multifaceted, involving both simple screening tools and more in-depth, clinically-administered assessments. The CDC's STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative provides a valuable framework for this process, broken down into screening, assessing, and intervening.
Screening questionnaires
These initial screening tools are often quick and easy to administer, helping to identify individuals who warrant a more thorough assessment. They are based on self-reported information and medical history.
- CDC's "Stay Independent" Brochure/Tool: A simple, 12-question self-assessment that assigns a risk score. It covers key risk factors like having a fall in the past year, feeling unsteady, worrying about falling, medication use, and issues with footwear. A score of 4 or more indicates a patient is at risk and should be assessed further.
- Three Key Questions: As part of the STEADI program, healthcare providers can ask these three questions to quickly screen for fall risk: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? A 'yes' to any of these indicates increased risk.
Performance-based functional mobility tests
These tests require the individual to perform specific movements or tasks, which are then timed or observed by a trained professional. They provide objective data on a person's balance, gait, and mobility.
- Timed Up and Go (TUG) Test: The patient stands up from a chair, walks 10 feet, turns around, walks back, and sits down. The time taken is measured. A time of 12 seconds or more suggests an increased fall risk. The clinician also observes the quality of the movement, such as gait, balance, and steadiness, to gain further insight.
- Four-Stage Balance Test: This test assesses static standing balance through four progressively more challenging positions: feet side-by-side, semi-tandem, tandem, and single-leg stance. The individual must hold each position for 10 seconds. Failure to hold the tandem stance for 10 seconds is associated with increased fall risk.
- Berg Balance Scale (BBS): A comprehensive, 14-item test that assesses a person's ability to safely perform a range of everyday tasks, such as standing unsupported, transferring, and reaching forward. It takes longer to complete but provides a detailed picture of balance function.
- Short Physical Performance Battery (SPPB): This assessment measures lower extremity function and includes tests for balance, walking speed, and chair stand ability. It is reliable for predicting future disability and nursing home admission.
Clinical and hospital-based scales
These scales are typically used in clinical settings, such as hospitals or long-term care facilities, and are based on a review of the patient's medical history and clinical observations.
- Morse Fall Scale (MFS): A widely used tool in acute care settings to rapidly and systematically assess a patient's risk of falling. It uses six variables, including a history of falling, the presence of a secondary diagnosis, ambulatory aid, IV/heparin lock status, gait, and mental status, to generate a numerical score that classifies risk as low, medium, or high.
- Hendrich II Fall Risk Model: Designed for the acute care setting, this model identifies eight risk factors, including confusion, depression, dizziness, gender, medication usage, and physical ability. Its strength lies in its inclusion of 'risky' medication categories.
- St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY): This tool was designed for use in a hospital setting and identifies specific risk factors like recent history of falls, agitation, visual impairment, and requiring frequent toileting.
Comparison of fall risk assessment tools
| Feature | CDC "Stay Independent" | TUG Test | Morse Fall Scale | Hendrich II Fall Risk Model |
|---|---|---|---|---|
| Primary Use | Community/Initial Screening | Functional Mobility | Acute Care/Hospital | Acute Care/Hospital |
| Assessment Type | Self-report/Questionnaire | Performance-based | Clinical Observation/History | Clinical Observation/History |
| Time to Complete | Very quick (<5 min) | Quick (<10 min) | Quick (<3 min) | Quick (<10 min) |
| Equipment Needed | Paper/Brochure | Stopwatch, chair, tape | None | None |
| Key Factors Assessed | Self-reported history, fear, medications | Gait, balance, mobility | History, gait, mental status, medications | Confusion, depression, medications, physical ability |
| Clinical Focus | Broad screening for general public | Objective measure of functional mobility | Inpatient fall risk prediction | Inpatient fall risk prediction, medication effects |
Conclusion: Choosing the right tool for the right context
Selecting the most appropriate fall risk assessment tool depends on the setting, the level of detail required, and the patient's cognitive and physical status. While simple screening tools like the CDC's questionnaire are excellent for initial identification in a community setting, more complex performance-based tests like the TUG or SPPB offer objective data for functional assessment. In a hospital or clinical environment, the Morse or Hendrich II scales provide a rapid and structured method for evaluating and monitoring inpatient fall risk. The use of any of these tools should be part of a comprehensive fall prevention strategy that includes addressing identified risk factors and implementing tailored interventions.
For more detailed information on preventing falls in older adults, refer to the CDC's STEADI initiative.
Tailored interventions after assessment
Once a fall risk has been identified, the assessment data is used to develop a targeted intervention plan. For example, if the TUG test reveals poor balance, a physical therapy referral might be necessary. If the assessment shows a risk factor like specific medication use, a pharmacist or physician can review the drug regimen. This tailored approach is far more effective than a one-size-fits-all solution and is a hallmark of high-quality senior care.
