Which scale do we use for fall risk assessment? A comprehensive guide

According to the Centers for Disease Control and Prevention (CDC), more than one in four older adults experiences a fall each year. For clinicians and caregivers, using the right tool is crucial for identifying risk and implementing prevention strategies, addressing the question of which scale do we use for fall risk assessment.

Quick Summary

Healthcare professionals use several validated tools for fall risk assessment, including the Morse Fall Scale (MFS) for hospitalized patients and the Timed Up and Go (TUG) Test for general mobility. The specific scale chosen depends on the care setting and patient's condition, providing a systematic way to identify and manage fall risk factors.

Key Points

• Multiple Scales Exist: No single scale is used for all fall risk assessments; the tool is chosen based on the care setting and patient needs.

• Morse Fall Scale: This is a quick and simple scale widely used in hospitals and long-term care to assess a patient's risk based on six variables.

• Timed Up and Go Test: A quick and easy performance-based test for community-dwelling seniors that assesses mobility and balance.

• Berg Balance Scale: A comprehensive 14-item test often used by physical therapists to evaluate and track balance in detail over time.

• Context is Key: Choosing the right scale depends on whether the assessment is for an inpatient, outpatient, or rehabilitation setting.

• Assess and Intervene: The assessment itself is just the first step; the results should inform tailored interventions to reduce risk, such as exercise programs and home modifications.

The Importance of Fall Risk Assessment

For older adults, a fall can have serious consequences, including injuries, loss of independence, and a diminished quality of life. For healthcare providers and senior care facilities, proactive fall risk assessment is a critical component of a patient safety program. These assessments are not just about predicting who will fall, but also about identifying specific, modifiable risk factors that can be addressed to improve a person's safety and well-being. Using a standardized scale ensures a consistent, evidence-based approach to care.

Key Fall Risk Assessment Scales in Practice

Selecting the right tool for the job is essential, as different scales are designed for different settings or populations. While there isn't one universal answer to which scale do we use for fall risk assessment, several are considered gold standards in the field.

Morse Fall Scale (MFS)

• Target Population: Inpatient acute care settings and long-term care facilities.
• Description: The MFS is one of the most widely used and straightforward scales for assessing fall risk in hospitalized patients. It evaluates six simple variables, and the total score categorizes the patient into a low, medium, or high-risk group.
• Variables Scored: History of falls, presence of a secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status.

Hendrich II Fall Risk Model (HIIFRM)

• Target Population: Acute care settings.
• Description: This model is notable for its brevity and focus on intrinsic risk factors. It also includes specific categories for medications that are known to increase fall risk, such as antiepileptics and benzodiazepines.
• Variables Scored: Confusion/disorientation/impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, gender, prescribed medications, and the "Get-up-and-Go" Test.

Timed Up and Go (TUG) Test

• Target Population: Community-dwelling older adults and in outpatient settings.
• Description: The TUG is a quick and simple performance-based test. The patient is timed as they rise from a chair, walk a short distance (usually 3 meters or 10 feet), turn around, walk back, and sit down. The time taken reveals a lot about the patient's mobility and balance.
• Interpretation: A time of 12 seconds or more generally indicates a high risk for falling.

Berg Balance Scale (BBS)

• Target Population: Primarily used by physical therapists to assess balance in older adults and those with neurological conditions.
• Description: The BBS is a more in-depth assessment tool consisting of 14 tasks. It provides a functional measure of balance performance and is excellent for tracking progress over time.
• Variables Scored: Tasks include standing unsupported, sit-to-stand transfers, retrieving an object from the floor, and standing on one leg.

Comparison of Common Fall Risk Assessment Tools

Feature	Morse Fall Scale (MFS)	Hendrich II Fall Risk Model (HIIFRM)	Timed Up and Go (TUG) Test	Berg Balance Scale (BBS)
Primary Setting	Acute care (hospital)	Acute care (hospital)	Community-dwelling, Outpatient	Rehabilitation, Clinic
Focus	Identifying physiological risk factors, clinical status	Intrinsic risk factors (including medication)	Basic functional mobility, quick screen	Comprehensive balance assessment, tracking progress
Time to Administer	Rapid (typically under 5 minutes)	Rapid (brief administration)	Very quick (under 1 minute)	Longer (10-20 minutes)
Equipment	Minimal (pen, paper)	Minimal (pen, paper, chair)	Standard armchair, stopwatch, line on floor	Stopwatch, ruler, standard seating, step/stool
Scoring Output	Low, Medium, High risk categories	Risk score, identifies specific risk factors	Time in seconds	Total score (0-56) indicating balance level
Strengths	Quick, easy for nurses, good for inpatient use	Includes medication risks, focuses on modifiable factors	Excellent screening tool, quick, low burden	Highly reliable, detailed, good for tracking change

Beyond the Scale: A Multifactorial Approach

It is important to remember that these scales are just one part of a comprehensive fall prevention strategy. Effective programs often involve a combination of interventions tailored to the individual's needs. The CDC's STEADI (Stopping Elderly Accidents, Deaths, and Injuries) toolkit is an excellent resource for providers looking to implement a complete program. For more information, healthcare professionals can consult the CDC STEADI Toolkit for Healthcare Providers.

Key components of a holistic strategy include:

• Medication Review: Assessing medications, both prescription and over-the-counter, for side effects like dizziness that increase fall risk.
• Home Safety Modifications: Clearing clutter, improving lighting, and installing grab bars can drastically reduce environmental hazards.
• Regular Exercise: Targeted programs that focus on strength, balance, and gait can significantly reduce fall risk. Tai Chi is a prime example of an effective exercise for balance.
• Vision and Hearing Checks: Regular check-ups can help manage sensory impairments that contribute to falls.

How Caregivers Can Participate

Family caregivers are often on the front line of fall prevention. They can help by:

• Observing Changes: Noting any changes in balance, gait, or behavior that might increase fall risk.
• Communicating with Healthcare Providers: Sharing observations and providing information on any falls, even minor ones, with a clinician.
• Conducting Home Safety Audits: Using checklists from resources like the CDC to identify and fix potential hazards.

Conclusion

While the answer to which scale do we use for fall risk assessment is not a single one, understanding the options is crucial for effective senior care. The Morse and Hendrich II scales are valuable for acute care, while the TUG and Berg scales are effective for community-dwelling and rehabilitation settings, respectively. Ultimately, the best practice is to use an appropriate, evidence-based tool as part of a broader, multifactorial fall prevention program that involves both professional care and active participation from caregivers and older adults themselves. By taking a proactive and informed approach, the risk of falls can be significantly reduced.

Frequently Asked Questions

Which scale do we use for fall risk assessment in a hospital setting?

For inpatient settings like hospitals, the Morse Fall Scale (MFS) is one of the most commonly used tools. It is quick, easy for nurses to administer, and effectively identifies patients at high, medium, or low risk of falling.

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

The TUG test is a simple performance-based mobility test used to assess fall risk in community-dwelling older adults. It measures the time it takes for a person to stand from a chair, walk 10 feet, turn around, walk back, and sit down.

How often should a fall risk assessment be performed?

Assessments should be conducted upon admission to a facility, regularly thereafter (e.g., quarterly), and following any significant change in a patient's condition, such as after a fall or a change in medication.

What does a high score on a fall risk scale mean?

A high score indicates that the individual has several risk factors for falling, such as a history of falls, balance issues, or cognitive impairment. This signals to healthcare providers that focused, proactive interventions are necessary to minimize the risk.

Is there a difference between the Morse Fall Scale and the Hendrich II Fall Risk Model?

While both are used in acute care, the Hendrich II model specifically incorporates a medication review and a variation of the Get-up-and-Go test, focusing more on modifiable risk factors. The Morse scale is a bit more general but still highly effective.

Can caregivers use these scales for assessment?

Formal clinical scales are best administered by trained professionals. However, caregivers can be aware of the factors assessed and use this knowledge to observe and communicate relevant changes in the senior’s health and behavior to their healthcare team.

What happens after a fall risk assessment?

The assessment results guide the creation of a personalized care plan. This can include environmental modifications, physical therapy for balance and strength, medication adjustments, and patient/family education on fall prevention strategies.