Falls are a leading cause of injury and death in older adults, making accurate risk assessment a priority for healthcare professionals. While online resources like Quizlet may present a list of tools, selecting the right one requires a deeper understanding of each tool's purpose, reliability, and application. The choice often depends on the clinical setting and the patient's functional level.
Popular Fall Risk Assessment Tools
Morse Fall Scale (MFS)
The Morse Fall Scale (MFS) is a widely used tool, particularly in inpatient and acute care settings. It quickly assesses risk based on several factors and generates a score that indicates a patient's risk level. The MFS helps staff implement specific interventions based on the identified risks.
Components of the MFS include:
- History of falling
- Secondary diagnoses
- Ambulatory aid use
- Intravenous therapy or heparin lock
- Gait assessment
- Mental status evaluation
Timed Up and Go (TUG) Test
The Timed Up and Go (TUG) Test is a simple and effective measure of functional mobility and balance. It is suitable for outpatient, community, and home health settings due to minimal equipment needs. The test involves standing from a chair, walking 3 meters, turning, walking back, and sitting down, with the time recorded. A time of 12 seconds or more suggests a high fall risk.
Hendrich II Fall Risk Model (HIIFRM)
The Hendrich II Fall Risk Model is designed for acute care and helps identify inpatients at risk. It often integrates with electronic health records and focuses on evidence-based risk factors to guide personalized care plans.
Key factors in the HIIFRM include:
- Fall history
- Gender
- Mental and emotional status
- Dizziness symptoms
- Use of high-risk medications
- Mobility/Gait
- Bowel and bladder control
- Secondary diagnoses
Berg Balance Scale (BBS)
The Berg Balance Scale (BBS) is a performance-based test evaluating static and dynamic balance. It takes 15-20 minutes and requires some equipment. A score below 45 is linked to increased fall risk.
Tasks in the BBS include:
- Standing unsupported
- Standing with eyes closed
- Sit-to-stand transfers
- Standing on one leg
Comparison of Fall Risk Assessment Tools
| Feature | Morse Fall Scale (MFS) | Timed Up and Go (TUG) Test | Hendrich II Fall Risk Model (HIIFRM) | Berg Balance Scale (BBS) |
|---|---|---|---|---|
| Best Setting | Acute care, inpatient hospital | Community, home health, outpatient | Acute care, skilled nursing facilities | Community, outpatient clinics, rehabilitation |
| Administration | Quick, simple questionnaire | Very quick, performance-based | Quick, includes specific risk factors | Time-consuming (15-20 min), performance-based |
| Primary Focus | General fall risk screening and intervention guidance | Functional mobility and dynamic balance | Specific, evidence-based risk factors | Static and dynamic balance performance |
| Equipment Needed | Assessment form, pen | Armchair, tape measure, stopwatch | Assessment form, pen, potentially EHR | Standard chair, ruler, step, stopwatch |
| Strength | Quick and widely used; prompts interventions | Simple, reliable, and functional | EHR integration, holistic, targets interventions | Detailed, gold standard for balance evaluation |
| Limitation | May have lower predictive value in some settings | Can have a ceiling effect for higher-functioning individuals | Predictive accuracy can vary; some factors may be less relevant in certain groups | Time-intensive; lower predictive value for future falls alone |
Multifactorial Assessment Approach
Because falls often have complex causes, a single tool may not be enough. The CDC's STEADI initiative promotes a comprehensive approach. STEADI includes screening with quick questions, a detailed assessment for those at high risk (including medical history, medications, and physical exam), and tailored interventions.
Key Factors for Choosing an Assessment Tool
When selecting a tool, healthcare providers should consider:
- Clinical setting: Acute hospitals might prefer quick tools like MFS or Hendrich II, while outpatient clinics may use TUG or BBS.
- Patient population: The patient's functional level is important; the BBS might have a ceiling effect for higher-functioning individuals.
- Purpose of assessment: The goal dictates the tool – screening vs. detailed evaluation.
- Feasibility: Time, equipment, and training needs are practical considerations.
- Combination of tools: Often, using a combination of screening and assessment tools is best practice.
Conclusion
While the Morse Fall Scale is commonly mentioned on platforms like Quizlet for hospitals, no single tool is universally superior for identifying fall risk in all older adults. MFS and Hendrich II are popular in acute care, while the TUG is effective in the community. The BBS provides detailed balance assessment but is more time-intensive. A multifactorial approach, starting with screening and followed by comprehensive assessment for high-risk individuals, as recommended by the CDC's STEADI, is the most effective strategy. Choosing the right tool depends on the setting and patient needs to create a personalized fall prevention plan.
Additional Resources
- Centers for Disease Control and Prevention (CDC) STEADI Initiative: https://www.cdc.gov/steadi/hcp/clinical-resources/index.html - Offers tools and resources for screening, assessing, and intervening to reduce fall risk.
