Examples of Valid and Reliable Fall Risk Assessment Tools
The selection of a fall risk assessment tool is crucial for implementing effective fall prevention protocols. The ideal tool is both valid, meaning it measures what it is intended to, and reliable, meaning it produces consistent results. Several widely-used tools have demonstrated strong psychometric properties and are recommended for use in various clinical settings. The most appropriate choice often depends on the patient's specific characteristics, such as their mobility level, cognitive status, and the care environment.
Morse Fall Scale (MFS)
The Morse Fall Scale is a quick and simple method for assessing a patient's likelihood of falling, particularly in acute care and long-term inpatient settings. The scale evaluates six key variables, with a higher total score indicating a greater risk of falling.
- History of falling: The assessment considers recent falls within the last three months.
- Secondary diagnosis: Patients with more than one medical diagnosis are at a higher risk.
- Ambulatory aid: The type of assistance a patient needs to walk, from none to reliance on furniture.
- Intravenous (IV) therapy: Having an IV or heparin lock can increase risk.
- Gait: Evaluates whether a patient's gait is normal, weak, or impaired.
- Mental status: Assesses the patient's awareness of their limitations.
Hendrich II Fall Risk Model
The Hendrich II Fall Risk Model (HFRM II) is another well-established tool, particularly valued for its focus on specific risk factors to guide interventions. This model is commonly used in acute care and hospital settings. Unlike the MFS, it also incorporates medication use as a primary risk factor.
- Confusion/disorientation/impulsivity: Assesses mental and behavioral status.
- Symptomatic depression: Identifies depression as a contributing factor.
- Altered elimination: Addresses issues with continence.
- Dizziness/vertigo: Includes subjective reports of instability.
- Male sex: The model assigns a point for male gender, reflecting historical data trends.
- Administered medications: Includes specific points for antiepileptics and benzodiazepines.
- Timed Get-Up-and-Go (TUG) test: Measures a patient's ability to rise from a chair.
Timed Up and Go (TUG) Test
The Timed Up and Go (TUG) test is a performance-based assessment that measures a person's mobility, balance, and gait speed. It is a highly recommended screening tool, especially for older adults living in the community. A score of 12 seconds or more is often used as a cutoff point to indicate an increased fall risk. The test simply measures the time it takes for a person to:
- Rise from a standard armchair.
- Walk three meters (about 10 feet) at their normal pace.
- Turn around.
- Walk back to the chair.
- Sit down again.
Berg Balance Scale (BBS)
The Berg Balance Scale (BBS) is a 14-item performance-based assessment used to objectively measure static and dynamic balance abilities. With a scoring range from 0 to 56, it is commonly used in geriatric and neurological populations, such as those with Parkinson's disease or stroke. A higher score indicates better balance, and lower scores have been associated with increased fall risk.
Comparison of Major 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 Setting | Acute care, long-term care | Acute care, hospitals | Community-dwelling adults | Geriatric, neurological rehabilitation |
| Assessment Type | Checklist, scoring system | Checklist, scoring system, performance test | Performance-based timed test | Performance-based observation |
| Key Factors | Fall history, ambulatory aids, gait, mental status, secondary diagnosis, IV therapy | Confusion, depression, elimination, dizziness, sex, medications, TUG test | Time to complete a functional task | 14 items testing static & dynamic balance |
| Strengths | Quick and easy to use, high reliability, effective for targeted interventions | Focuses on specific risk areas for intervention, includes medication risk | Simple to administer, requires minimal equipment, excellent reliability | High intra- and inter-rater reliability, excellent for tracking balance improvements |
| Limitations | Lower predictive validity in some studies, focuses heavily on in-hospital factors | Some studies show lower predictive ability, particularly with certain cutoff scores | Measures only a specific functional task, may not capture all fall risk factors | High ceiling effect in healthier individuals, may not strongly predict falls in all populations |
The Role of Comprehensive Assessment
While single tools like the MFS or TUG are valid and reliable, a comprehensive fall risk assessment is often the most effective approach. This strategy, endorsed by the Centers for Disease Control and Prevention's (CDC) STEADI initiative, involves a multi-pronged approach. In addition to using a specific tool, it includes assessing the patient's full medical history, medications, environmental hazards, and performing clinical physical examinations.
The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) is a prime example of a valid and reliable multi-faceted approach used in hospitals. It incorporates a screen for known risk factors and, if the risk remains unknown, proceeds with a more detailed assessment covering age, fall history, specific medications, equipment, mobility, and cognition. Studies show the JHFRAT is reliable with high sensitivity, although specificity can vary.
Conclusion
Many valid and reliable fall risk assessment tools are available, each with specific strengths tailored to different patient populations and care settings. The Morse Fall Scale is highly reliable and quick for hospital use, while the TUG test is an excellent, simple tool for screening community-dwelling elders. For a more comprehensive evaluation, multi-faceted approaches like the CDC's STEADI framework and the Johns Hopkins Fall Risk Assessment Tool integrate multiple risk factors. Selecting the best tool or combination of tools requires careful consideration of the patient's needs and the clinical context, ensuring accurate risk identification and targeted prevention strategies for improved patient safety. For further information, the CDC's STEADI website offers a wealth of resources on fall prevention and assessment.
