Common tools for fall risk assessment
Identifying a patient's risk of falling is a multi-faceted process that depends on their health status, environment, and specific risk factors. As a result, no single "best" tool exists; instead, healthcare providers select the most appropriate assessment for their setting.
The Morse Fall Scale (MFS)
The Morse Fall Scale is a quick and straightforward tool widely used in acute care and hospital settings. It evaluates six variables, assigning a point value to each to determine the patient's overall risk level: low, medium, or high.
Key variables of the MFS:
- History of falling within the last three months
- Presence of a secondary diagnosis
- Use of an ambulatory aid (cane, crutches, walker, or furniture)
- Use of an IV or heparin lock
- Gait status (normal, weak, or impaired)
- Mental status (alert and oriented versus forgetting limitations)
The total score helps clinicians implement immediate interventions, such as adjusting the care plan, providing assistive devices, or increasing supervision.
The Timed Up and Go (TUG) test
The Timed Up and Go (TUG) is a simple performance-based test for assessing mobility and dynamic balance. It requires the patient to perform a series of movements that are timed with a stopwatch.
Steps for the TUG test:
- The patient starts seated in a chair with armrests.
- On the command "Go," they stand up.
- They walk a distance of 10 feet (3 meters) at a normal pace.
- They turn around.
- They walk back to the chair.
- They sit down again.
Taking 12 seconds or longer to complete the test suggests an increased risk of falling among older adults. The test also offers an opportunity for a qualitative assessment of the patient's gait and stability.
The Berg Balance Scale (BBS)
The Berg Balance Scale is a more comprehensive, 14-item performance-based tool that assesses an individual's static and dynamic balance. It is commonly used in physical therapy to measure a patient's ability to safely balance during specific tasks.
Example tasks in the BBS include:
- Sitting to standing and standing to sitting
- Standing unsupported with eyes closed
- Reaching forward with an outstretched arm
- Picking up an object from the floor
- Turning 360 degrees
- Standing on one leg
Each task is scored on a scale from 0 to 4, with a maximum score of 56. A total score of 45 or less may indicate a greater risk of falling. The BBS does not evaluate gait, so it is often used in combination with other tests.
Comparison of common fall risk assessment tools
Choosing the right tool depends on the setting and the patient's specific needs. The following table highlights the differences between the three most common fall risk assessment tools.
| Feature | Morse Fall Scale (MFS) | Timed Up and Go (TUG) | Berg Balance Scale (BBS) |
|---|---|---|---|
| Type of Assessment | Questionnaire-based and observation | Performance-based and timed | Performance-based and scored |
| Evaluation Area | History of falls, secondary diagnosis, ambulatory aid, IV use, gait, and mental status | Functional mobility, dynamic balance, gait | Static and dynamic balance |
| Administration Time | Quick (typically 3 minutes or less) | Very quick (just a few minutes) | Longer (around 15–20 minutes) |
| Setting | Acute care and hospital settings | Wide range of settings, including primary care and home care | Physical therapy and rehabilitation settings |
| Equipment | None needed besides the assessment form | Standard chair, stopwatch, and tape measure | Standard chairs (with and without arms), stopwatch, step/stool, and ruler |
| Cut-off Score | >45 high risk; 25-45 moderate risk | ≥12 seconds indicates increased risk | <45 indicates increased risk; 41–56 low risk |
Using the appropriate tool for effective intervention
After a tool is selected, the assessment is performed, and the risk level is determined, the information gathered is used to create a targeted fall prevention plan. This can include a range of interventions tailored to the specific risk factors identified.
For example, if the TUG test reveals gait or balance issues, a physical therapist may focus on strength and balance exercises. If the MFS identifies cognitive impairments, additional supervision or environmental modifications may be necessary to ensure patient safety. For higher-functioning individuals, the BBS may provide more detailed insights into balance deficits.
Comprehensive fall prevention also involves educating the patient and their caregivers. Understanding the specific risk factors and how to manage them can empower individuals to take proactive steps to ensure safety at home and in other care settings. Resources such as the CDC's STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative provide a comprehensive, multi-step approach for healthcare providers to screen, assess, and intervene effectively.
Conclusion
Multiple assessment tools are available for identifying a patient's risk of falling, each with a unique focus and application. The Morse Fall Scale is ideal for quick, systematic evaluation in hospital settings, while the Timed Up and Go test offers a fast, practical way to screen for mobility and balance issues. The Berg Balance Scale provides a detailed, performance-based assessment of static and dynamic balance, particularly useful in rehabilitation. By choosing the appropriate tool for the individual and setting, healthcare providers can accurately assess risk and implement effective, personalized interventions to reduce the likelihood of falls and improve patient safety. No single tool is perfect, but when used appropriately, these assessments are invaluable in promoting proactive fall prevention strategies.
