What Should You Use to Identify Patients at Risk for Falling?

According to the CDC, over one in four adults aged 65 and older fall each year, with more than 3 million treated in emergency departments for fall injuries. Healthcare professionals need reliable, evidence-based methods to identify patients at risk for falling, and thankfully, several validated assessment tools exist for this crucial task.

Quick Summary

Several validated tools, including the Morse Fall Scale, Hendrich II Fall Risk Model, Timed Up & Go Test, and Berg Balance Scale, help healthcare providers evaluate a patient's likelihood of falling. The selection of the best tool depends on the patient's specific risk factors and the clinical setting. These assessments inform the development of targeted prevention strategies to enhance patient safety.

Key Points

• Use a validated assessment tool: Standardized tools like the Morse Fall Scale, Hendrich II Fall Risk Model, and Berg Balance Scale are essential for objectively identifying at-risk patients.

• Conduct functional mobility tests: Performance-based tests, such as the Timed Up & Go (TUG) Test, assess a patient's balance and gait, with longer completion times indicating a higher fall risk.

• Review intrinsic and extrinsic risk factors: A comprehensive assessment must consider the patient's physiological conditions (intrinsic) and environmental hazards (extrinsic) to gain a full picture of their risk.

• Focus on multiple variables: Effective tools incorporate a range of factors, including a patient's history of falls, current medications, cognitive status, and mobility needs.

• Implement a multifactorial strategy: A holistic approach, guided by frameworks like the CDC's STEADI initiative, involves screening, detailed assessment, and targeted interventions to manage fall risks effectively.

• Regularly reassess patient status: A patient's risk level can change due to new medications or a change in health status, so regular reassessments are crucial to maintaining effective prevention strategies.

The Importance of Fall Risk Assessment

Falls are a significant safety concern in all healthcare settings, from hospitals to long-term care facilities and home care. Beyond physical injury, falls can lead to fear of falling, reduced quality of life, and increased healthcare costs. A standardized fall risk assessment is the foundation of any effective prevention program. By systematically evaluating patients for risk factors, clinicians can implement proactive, individualized interventions to mitigate hazards and improve outcomes.

Comprehensive Assessment for Patient Safety

Identifying patients at risk involves evaluating both intrinsic and extrinsic factors. Intrinsic factors are physiological conditions of the patient, such as gait and balance impairments, visual or hearing deficits, and cognitive status. Extrinsic factors relate to the patient's environment, such as poor lighting, clutter, or the improper use of assistive devices. The most effective assessments use a multifactorial approach that considers all relevant risks to provide a holistic view of the patient's vulnerability.

Common Fall Risk Assessment Tools

Healthcare professionals can choose from several validated tools to identify patients at risk for falling. The best tool often depends on the patient's specific needs and the clinical setting.

• Morse Fall Scale (MFS): A widely used scale, particularly in acute care settings, that assesses six variables to determine a patient's fall risk. The categories include a history of falling, secondary diagnoses, ambulatory aids, IV therapy, gait, and mental status. Higher scores indicate a greater risk of falling.

• Hendrich II Fall Risk Model: Designed for use in acute care, this model is quick to administer and focuses on eight independent risk factors, including mental status, medications, dizziness, and performance on the "Get Up and Go" test.

• Timed Up and Go (TUG) Test: A mobility and balance test where a patient is timed as they stand from a chair, walk 3 meters (10 feet), turn, walk back, and sit down again. A time of 12 seconds or more suggests an increased risk of falling. The qualitative observation of the patient's gait is also a key component.

• Berg Balance Scale (BBS): An objective assessment tool that uses a 14-item list to measure a patient's ability to safely balance during a series of predetermined tasks. Tasks range from standing unsupported to more complex movements. Lower scores correlate with higher fall risk.

• Johns Hopkins Fall Risk Assessment Tool: A comprehensive, hospital-based tool that considers multiple variables, including age, medication use, mobility, and a history of falls, to provide a holistic risk picture.

How to Choose the Right Tool

Choosing the best fall risk assessment tool involves matching the tool to the patient and clinical context. For instance, a quick screen like the TUG test might be appropriate for a routine check-up, while a multifactorial assessment is necessary for patients with complex health issues. Considering the setting is also crucial; the Hendrich II model is optimized for acute care, whereas the Berg Balance Scale is valuable in rehabilitation settings. Many facilities combine tools or integrate them into electronic health records (EHRs) for seamless workflow and consistent application.

Integrating Assessment with Intervention

An assessment is only the first step. The results should guide the development of an individualized care plan with targeted interventions. The Centers for Disease Control and Prevention (CDC) offers a coordinated approach through its STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative, which includes three core elements: Screen, Assess, and Intervene. Interventions can include:

• Modifying the environment to reduce hazards.
• Adjusting medications that may cause dizziness or imbalance.
• Implementing exercise programs to improve strength, balance, and gait.
• Providing proper assistive devices and ensuring their correct use.
• Using bed or chair alarms for high-risk patients.
• Educating patients and their families on fall prevention strategies.

Reassessment is vital, especially after a change in the patient's condition or upon transfer to a new setting. This continuous loop of assessment and intervention ensures that fall prevention remains proactive rather than reactive.

Comparison of Fall Risk Assessment Tools

Feature	Morse Fall Scale (MFS)	Hendrich II Fall Risk Model	Timed Up and Go (TUG) Test	Berg Balance Scale (BBS)
Primary Use Case	Acute care settings (hospitals)	Acute care settings	General mobility screening	Rehabilitation; assessing functional balance
Focus	History of falls, secondary diagnoses, aids, IV, gait, mental status	Mental status, medications, dizziness, “Get Up and Go” test	Functional mobility, walking ability, gait	Static and dynamic balance abilities
Administered By	Nurses	Nurses	Physical therapists, healthcare providers	Physical/occupational therapists
Time to Complete	Quick, usually under 3 minutes	Quick	Very quick, under 30 seconds	Takes longer, around 15–20 minutes
Predicts Gait?	Yes (categorized as part of the assessment)	Yes (via the Get Up and Go test)	Yes (primary focus)	Minimal focus on gait
Scoring Range	0 to 125 (higher score = higher risk)	Variable points system (score ≥5 = high risk)	Time in seconds (≥12 seconds = high risk)	0 to 56 (lower score = higher risk)

Conclusion

To identify patients at risk for falling, healthcare professionals should employ validated assessment tools and a multifactorial evaluation approach. Standardized scales like the Morse Fall Scale and Hendrich II Fall Risk Model are valuable in acute care settings, while functional mobility tests such as the Timed Up and Go (TUG) test and Berg Balance Scale are essential for evaluating balance and gait. By combining these assessment methods with a thorough review of medical history, medications, and the patient's environment, clinicians can create comprehensive, tailored prevention plans. Regular reassessment ensures that interventions remain effective as the patient's condition evolves. A systematic, evidence-based approach is key to reducing fall incidents, improving patient safety, and enhancing overall quality of care.

Center for Disease Control and Prevention - STEADI

Frequently Asked Questions

What are the most common fall risk assessment tools used in hospitals?

The most common fall risk assessment tools used in hospitals are the Morse Fall Scale (MFS) and the Hendrich II Fall Risk Model. The MFS is widely used in acute care to score a patient's risk based on six factors, while the Hendrich II model assesses eight specific risk factors, including the 'Get Up and Go' test.

How is the Timed Up and Go (TUG) test performed?

The TUG test is performed by timing a patient as they rise from a standard armchair, walk 3 meters (10 feet), turn around, walk back, and sit down again. A completion time of 12 seconds or longer is generally considered an increased risk for falling.

What is the Berg Balance Scale used for?

The Berg Balance Scale is a 14-item assessment used to objectively measure a patient's ability to balance through a series of predetermined tasks. It is particularly useful for assessing functional and static balance in rehabilitation settings.

What are some of the key risk factors assessed by the Morse Fall Scale?

The Morse Fall Scale assesses key risk factors, including a history of recent falls, the presence of secondary diagnoses, the use of ambulatory aids (like a cane or walker), intravenous therapy, gait, and the patient's mental status.

How often should a patient's fall risk be assessed?

A patient's fall risk should be assessed upon admission, with any significant change in their condition, upon transfer to a new setting, and at regular intervals during their stay. Continuous monitoring and reassessment are vital for maintaining patient safety.

Besides formal tools, what other factors should be considered in a fall risk assessment?

In addition to formal assessment tools, healthcare providers should consider a patient’s medications, vision and hearing impairment, history of dizziness, muscle weakness, and environmental hazards like clutter or poor lighting.

What is the CDC's approach to fall prevention?

The CDC's approach to fall prevention, known as STEADI (Stopping Elderly Accidents, Deaths & Injuries), involves three core elements: Screen patients for fall risk, Assess for modifiable risk factors, and Intervene with targeted strategies to reduce risk.