What should a fall assessment include? A comprehensive guide to senior fall prevention

Over one in four people aged 65 and older fall each year, with many falls causing serious injury. Understanding exactly what should a fall assessment include is the first and most critical step toward proactive fall prevention, addressing the many factors that can contribute to instability and risk.

Quick Summary

A comprehensive fall assessment evaluates an individual's history of falls, current medications, balance and gait, vision, cognitive function, environmental hazards, and fear of falling to identify and mitigate significant risk factors.

Key Points

• History Review: An assessment starts with a detailed review of past falls, medical conditions, symptoms before falling, and functional ability to understand an individual's baseline risk.

• Physical Testing: Standardized tests like the Timed Up-and-Go (TUG) and 30-Second Chair Stand test are used to evaluate and quantify gait, balance, and lower body strength objectively.

• Medication Check: A critical step involves reviewing all medications and supplements, as certain types can increase fall risk by causing dizziness, sedation, or orthostatic hypotension.

• Sensory and Cognitive Screening: Regular checks for vision and hearing impairment, along with cognitive screening, are vital, as these can affect balance, navigation, and awareness.

• Home Safety Scan: The assessment includes identifying and modifying environmental hazards in and around the home, such as removing clutter, improving lighting, and installing grab bars.

• Psychological Factors: Evaluating a person's fear of falling is important, as it can lead to activity restriction and further physical decline, creating a vicious cycle of risk.

The Core Components of a Multifactorial Fall Assessment

For seniors and their caregivers, a fall assessment is not a single test but a thorough, multifactorial evaluation designed to pinpoint specific risks. The Centers for Disease Control and Prevention (CDC) provides a framework known as STEADI (Stopping Elderly Accidents, Deaths & Injuries), which outlines a three-step process: Screen, Assess, and Intervene. The assessment phase is particularly crucial, delving into a patient’s health and environment to create a personalized prevention plan. Below are the key areas of focus.

Medical and Fall History

This initial review provides the foundational information needed to understand a patient's risk profile. It goes beyond simply asking if a fall has occurred.

• History of Falls: A detailed account of any falls within the past year, including frequency, location, time of day, circumstances (e.g., did they trip, or did they lose balance?), and any resulting injuries.
• Medical Conditions: A review of chronic illnesses such as Parkinson's disease, arthritis, diabetes, stroke, and cardiovascular issues that can affect balance and mobility.
• Symptoms Prior to a Fall: Did the patient feel dizzy, lightheaded, or faint before the fall? This can indicate underlying issues like heart problems or orthostatic hypotension.
• Functional Ability: Evaluation of the patient's ability to perform activities of daily living (ADLs) and their current activity level.

Physical and Functional Examination

This hands-on portion of the assessment uses standardized tests to objectively measure balance, strength, and mobility.

• Gait and Balance Assessment: Healthcare professionals use a variety of tests to observe a patient’s walking pattern and stability.
  • Timed Up-and-Go (TUG) Test: The patient is timed as they stand up from a chair, walk 10 feet, turn around, walk back, and sit down. Taking 12 seconds or more indicates a higher risk of falling.
  • 30-Second Chair Stand Test: Assesses lower body strength by counting how many times the patient can stand up and sit down from a chair in 30 seconds.
  • 4-Stage Balance Test: Evaluates static balance by having the patient hold four progressively difficult standing positions.
• Musculoskeletal and Neurological Check: Examines muscle bulk, tone, strength, reflexes, range of motion, and proprioception.
• Postural Blood Pressure: Measures blood pressure while the patient is lying down and then standing to check for orthostatic hypotension, a common cause of dizziness and falls in older adults.

Medication and Sensory Review

Some medications and changes to sight and hearing can dramatically impact stability and awareness.

• Comprehensive Medication Review: A crucial step where all medications—prescription, over-the-counter, and supplements—are reviewed. Certain classes of drugs, including psychoactive medications, sedatives, and antihypertensives, are known to increase fall risk. The goal is to identify potentially inappropriate medications and reduce dosage or discontinue them when possible.
• Vision and Hearing Screening: Impaired vision or hearing can significantly affect a person’s ability to navigate their environment safely. An annual eye exam and regular hearing checks are recommended.

Cognitive and Psychological Evaluation

Mental state and emotional well-being play a role in fall risk.

• Cognitive Screening: A brief test, such as the Mini-Cog, can assess for cognitive impairment, which is a known risk factor for falls.
• Fear of Falling (FOF): FOF can lead to activity restriction, which in turn causes deconditioning and increases the risk of falls. Standardized tools like the Falls Efficacy Scale-International (FES-I) measure this concern.

Environmental and Home Safety Assessment

A professional evaluation of the home environment can identify and mitigate trip hazards, poor lighting, and other risks.

• Clear Walkways: Removing clutter, loose rugs, and electrical cords from high-traffic areas.
• Adequate Lighting: Ensuring proper lighting, especially in hallways, stairways, and bedrooms.
• Bathroom Safety: Installing grab bars in showers and next to toilets, and using non-slip mats.
• Stairway Precautions: Checking that handrails are sturdy, on both sides, and that stairs are free of clutter and have secure, non-slip treads.
• Appropriate Footwear: Recommending shoes with non-skid soles and avoiding loose-fitting slippers.

Comparison of Common Fall Risk Assessment Tools

Assessment Tool	What It Measures	Target Population	Key Features
Timed Up-and-Go (TUG)	Gait speed, balance, mobility	Adults 65+	Quick, simple to administer; high score (≥12s) indicates high risk
Morse Fall Scale	Patient-specific risk factors	Hospitalized patients	Widely used in clinical settings; assesses history, secondary diagnosis, gait, mental status
Berg Balance Scale	Balance during tasks	Older adults with impaired balance	Standardized, 14-item test evaluating static and dynamic balance
Falls Efficacy Scale-International (FES-I)	Fear/concern of falling	Community-dwelling older adults	16-item questionnaire assessing concern during daily activities

Implementing Your Fall Prevention Plan

Based on the comprehensive assessment, an individualized intervention plan can be developed. This may involve referrals to specialists like physical or occupational therapists for strength and balance training, medication adjustments by a physician, home safety modifications, and counseling for fear of falling. Staying active through exercise programs like Tai Chi can also significantly improve balance. For more detailed information on preventing falls, a helpful resource is the CDC's STEADI materials.

Conclusion

A thorough fall assessment is an essential part of healthy aging, helping to reduce the risk of injury and maintain independence. By systematically evaluating medical history, physical function, medications, sensory abilities, mental health, and the home environment, healthcare providers can identify specific risk factors. The results empower individuals to take proactive steps, such as making necessary home modifications, engaging in targeted exercises, and adjusting medications. This comprehensive approach is the most effective strategy for preventing falls and safeguarding the well-being of seniors.

Frequently Asked Questions

Who should receive a fall assessment?

Anyone aged 65 or older, or anyone who has experienced a fall, reports a fear of falling, or feels unsteady while walking should receive a fall assessment. These screenings are often conducted annually in primary care settings.

What is the Timed Up-and-Go (TUG) test?

The TUG test is a simple screening tool where a person stands up from a chair, walks 10 feet, turns around, and returns to sit down. The time taken to complete the task indicates mobility and balance; longer times suggest a higher fall risk.

How do medications factor into a fall assessment?

A medication review is a key part of the assessment, identifying drugs (prescription and OTC) that can increase fall risk due to side effects like dizziness, sedation, or drops in blood pressure. The healthcare provider may suggest adjusting doses or changing prescriptions.

Can an occupational therapist assist with a fall assessment?

Yes, occupational therapists are often referred to perform a detailed environmental assessment of the home. They identify specific hazards and recommend practical modifications to improve safety and function.

Why is a cognitive check included in a fall assessment?

Cognitive impairment can affect judgment, spatial awareness, and the ability to react quickly, all of which increase fall risk. A brief cognitive screen helps assess this aspect of a person's health.

How does fear of falling relate to a fall assessment?

Fear of falling can cause individuals to restrict their activities, leading to muscle deconditioning and poor balance, ironically increasing their risk. A fall assessment evaluates this fear and can lead to interventions like targeted exercises or psychological support.

After an assessment, what are the next steps?

Following the assessment, a personalized intervention plan is developed. This might include beginning balance and strength exercises, adjusting medications, modifying the home environment, and addressing any underlying medical conditions contributing to the risk.