What is the name of the scale used to assess fall? And How It Works

According to the CDC, over one in four older adults experiences a fall each year, and less than half report it. Clinicians rely on specific assessment tools, such as the scale used to assess fall risk, to proactively identify and manage this significant health concern in seniors. Knowing which scales are used and how they work can empower both patients and caregivers in preventing falls.

Quick Summary

The Morse Fall Scale (MFS) is a widely used tool for assessing a patient's risk of falling, particularly in clinical settings. The article will also cover other vital assessment scales, including the Berg Balance Scale and the Timed Up and Go (TUG) test.

Key Points

• Morse Fall Scale (MFS): A quick, six-component tool commonly used in hospital and long-term care settings to assess a patient's risk of falling.

• Berg Balance Scale (BBS): A detailed, 14-item performance-based test that objectively measures a person's static and dynamic balance abilities.

• Timed Up and Go (TUG) Test: A fast and simple test measuring functional mobility and gait, suitable for screening purposes in various settings.

• Multi-Factorial Assessment: Combining different scales provides a more comprehensive view of an individual's fall risk, as no single tool is universally perfect.

• Beyond Assessment: Effective fall prevention involves more than just scales; it includes exercise, medication management, home modifications, and regular health check-ups.

• Empowerment through Knowledge: Understanding these scales helps individuals, caregivers, and clinicians to proactively identify risks and implement strategies to prevent falls.

Introduction

Falls among older adults are not an inevitable part of aging but a significant health risk that can lead to injury, decreased independence, and fear of falling. Assessing and managing this risk is a critical component of senior care. To do this effectively, healthcare professionals use a variety of validated instruments. While the Morse Fall Scale is one of the most prominent, a comprehensive approach often involves a combination of tools to gain a complete picture of an individual’s fall risk factors.

The Morse Fall Scale (MFS)

The Morse Fall Scale is a quick and straightforward tool used by nurses and other healthcare professionals to determine the likelihood of a patient falling. It is especially common in acute care and hospital settings. The MFS evaluates six key components, with points assigned to each based on the patient's condition. The total score helps classify a patient's risk as low, moderate, or high, guiding the implementation of tailored preventative measures.

The Six Components of the MFS

1. History of Falling: A recent fall (within 3 months) adds 25 points. This is a crucial indicator as a past fall significantly increases the risk of another.
2. Secondary Diagnosis: A patient with more than one medical diagnosis that could increase fall risk (e.g., chronic conditions affecting mobility or cognition) is assigned 15 points.
3. Ambulatory Aid: The type of support a patient needs to walk affects their score. A score of 0 is given for bedrest or needing nurse assistance, 15 for using a cane or walker, and 30 for relying on furniture.
4. IV/Heparin Lock: The presence of intravenous therapy is a risk factor due to impaired mobility and potential entanglement with tubing, adding 20 points.
5. Gait: The patient's walking pattern is evaluated. A normal gait scores 0, a weak gait (stooped, unsteady) scores 10, and an impaired gait (shuffling, balance issues) scores 20.
6. Mental Status: This assesses the patient's awareness of their limitations. A patient who is oriented to their abilities scores 0, while one who overestimates their capabilities or is forgetful scores 15.

Interpreting the MFS Score

After summing the points, the total score determines the risk level:

• 0–24 points: Low Risk
• 25–45 points: Moderate Risk
• Over 45 points: High Risk

The Berg Balance Scale (BBS)

In contrast to the MFS's focus on rapid clinical assessment, the Berg Balance Scale is a 14-item performance-based test that objectively measures an individual's static and dynamic balance abilities. A healthcare provider observes the patient performing tasks and scores them on a scale of 0 to 4 for each item.

Tasks Assessed by the BBS

The 14 tasks increase in difficulty, starting with simpler actions and progressing to more challenging ones. Examples include:

• Sitting to standing
• Standing unsupported
• Reaching forward with an outstretched arm
• Standing on one foot
• Turning 360 degrees

Interpreting the BBS Score

The highest possible score is 56, indicating excellent balance. The lower the score, the greater the balance impairment and risk of falling. It is important to note that while the BBS is a valuable measure of balance, it has limitations in predicting falls on its own and is often used in conjunction with other assessments.

The Timed Up and Go (TUG) Test

The Timed Up and Go test is a simple and quick assessment of basic functional mobility and balance. It is suitable for a wide range of settings, including community health programs and clinics. The test is easy to administer and requires minimal equipment.

How the TUG Test is Performed

1. The patient sits in a standard chair.
2. On the command “go,” they stand up.
3. They walk a distance of 3 meters (10 feet).
4. They turn and walk back to the chair.
5. They sit down again.

Interpreting the TUG Test Score

The time it takes for the patient to complete the task is measured. A score of 12 seconds or more has been shown to indicate a high risk for falls in older adults. However, the TUG also offers valuable qualitative observations about a patient's gait, stability, and speed that can provide additional insights.

Comparing Fall Assessment Scales

Feature	Morse Fall Scale (MFS)	Berg Balance Scale (BBS)	Timed Up and Go (TUG)
Setting	Acute care, hospitals, long-term care	Rehab, outpatient therapy, clinics	Community, clinics
Focus	Multi-factorial risk (history, medications, gait)	Performance-based balance tasks	Functional mobility and gait speed
Time	Very quick, typically <3 minutes	Approx. 15–20 minutes	Very quick, <1 minute
Requires	Clinician observation, patient interview	Stopwatch, chair, tape measure, object	Stopwatch, chair, tape measure
Predicts	Clinical fall risk level (low, moderate, high)	Balance deficits, mobility limitations	High risk of falls and mobility problems
Strengths	Fast, easy to use in busy settings	Detailed, objective balance measure	Simple, effective for a quick screening
Limitations	Subjective, may not capture all risks	Not a perfect fall predictor alone	Less detailed than other tests

Comprehensive Fall Prevention Beyond the Scales

Assessment scales are only the first step. A comprehensive fall prevention plan should address the multifactorial causes of falls. This includes intrinsic factors, like an individual's physical condition, and extrinsic factors, like environmental hazards.

• Physical Activity: Regular strength and balance exercises are essential. Programs like Tai Chi have been proven to reduce the risk of falling.
• Medication Management: Many medications can cause side effects like dizziness, drowsiness, or confusion that increase fall risk. A pharmacist or doctor should regularly review medications.
• Environmental Modifications: Removing trip hazards such as throw rugs, improving lighting in hallways and stairs, and installing grab bars in bathrooms are key modifications to enhance home safety.
• Regular Check-ups: Vision and hearing impairments can contribute to falls. Routine checks with an optometrist and audiologist are important. Addressing foot pain or ensuring proper footwear can also have a major impact.

For more in-depth information on fall prevention strategies and resources, the Centers for Disease Control and Prevention (CDC) offers a comprehensive STEADI (Stopping Elderly Accidents, Deaths, & Injuries) program, which can be a valuable resource for both healthcare professionals and the public.

Conclusion

While the Morse Fall Scale is a well-known answer to the question, "What is the name of the scale used to assess fall?", it's important to recognize that multiple tools serve this purpose. The MFS, BBS, and TUG test each offer unique perspectives on a person's fall risk. By utilizing these tools for a thorough assessment and combining the results with comprehensive prevention strategies, healthcare providers can significantly improve the safety and independence of older adults, helping them maintain their quality of life as they age.

Frequently Asked Questions

What does a high score on the Morse Fall Scale indicate?

A higher score on the Morse Fall Scale (typically above 45 points) indicates a higher risk of falling. The score is calculated from six factors and helps clinicians determine appropriate fall prevention interventions.

Is the Berg Balance Scale reliable for predicting future falls?

While the Berg Balance Scale (BBS) is a reliable and valid measure of balance abilities, studies show it is not a perfect predictor of future falls when used alone. It is most effective as part of a total balance evaluation, complemented by other tests and clinical judgment.

What is considered a high-risk time for the TUG test?

An older adult who takes 12 seconds or more to complete the Timed Up and Go (TUG) test is generally considered to be at a high risk for falling. It also allows observation of gait and balance issues during the test.

How often should a fall risk assessment be performed?

Fall risk assessments should be conducted on admission to a care facility, after a change in health condition, following a fall event, and periodically during a patient's care. Frequent reassessment is key for high-risk individuals.

Besides scales, what are other factors that contribute to falls?

Other significant factors include environmental hazards (poor lighting, clutter), medication side effects (drowsiness, dizziness), poor vision, lower body weakness, and fear of falling, which can lead to reduced activity and increased weakness.

What is the difference between the MFS and the BBS?

The Morse Fall Scale (MFS) is a quick screening tool based on patient history and observation, commonly used in hospitals. The Berg Balance Scale (BBS) is a longer, performance-based test focusing on objective measures of balance. They are often used in different settings to address different aspects of fall risk.

Can exercise help lower my fall risk?

Yes, regular exercise, especially focusing on strength, balance, and flexibility, is one of the most effective strategies for preventing falls. Programs like Tai Chi and specific balance training can help improve stability and reduce risk.