Falls are the leading cause of preventable injury in older adults. Around one-third of adults over the age of 65 fall each year, with falls being the most common cause of injuries like fractures and traumatic brain injuries in this population. As the older adult population grows, the healthcare system will see more fall-related injuries if the risk of falling is not addressed proactively.
Healthcare providers aim to identify patients at risk for falls and intervene to reduce this risk. Fall risk assessment tools are important for identifying patients who may benefit from preventive strategies. There are several key components that comprise evidence-based fall risk assessments.
Risk Factors
A fall risk assessment evaluates a variety of risk factors that make a patient more likely to experience a fall. Some important risk factors included in standard assessment tools are:
- Age – Advanced age, especially over 80 years old, increases fall risk.
- History of falls – Previous falls indicate greater risk of future falls.
- Mobility problems – Difficulty with walking, transfering, and balance increases fall risk.
- Use of assistive devices – Dependence on walkers, canes or wheelchairs for mobility indicates instability.
- Musculoskeletal issues – Arthritis, muscle weakness, osteoporosis, and impaired vision contribute to risk.
- Neurological problems – Conditions like dementia, Parkinson’s disease, and epilepsy affect balance and coordination.
- Incontinence – Needing to rush to the bathroom urgently increases risk of falling.
- Medications – Psychoactive drugs, antidepressants, and polypharmacy impact alertness, orientation, and balance.
- Environmental hazards – Clutter, inadequate lighting, loose rugs or lack of bathroom safety equipment increase risk at home.
Identifying which of these common risk factors are present allows providers to estimate an individual patient’s probability of falling.
Physical Assessments
In addition to asking about risk factors, many fall assessment tools incorporate physical assessments of balance, mobility, vision, leg strength, foot problems, and heart rate/blood pressure.
Some examples of physical screens in fall risk assessments include:
- Timed Up and Go Test – The patient rises from a chair, walks 10 feet, turns around, and returns to sitting. Taking over 10-12 seconds on this indicates fall risk.
- 30-second Chair Stand – The patient rises to a full standing position from a chair repeatedly in 30 seconds. Being unable to perform this at least 10 times indicates poor leg strength.
- Balance assessments – The health provider evaluates the patient’s ability to stand with feet together, stand on one leg, and maintain stability while being gently pushed from different directions.
- Vision checks – Screens for visual acuity and depth perception identify vision issues linked to falls.
- Vital sign measurement – Orthostatic hypotension, an excessive drop in blood pressure upon standing, increases fall risk.
By directly examining physical function and abilities, providers obtain objective data on instability and frailty.
Medication Review
Fall risk tends to increase with greater numbers of medications, so a thorough medication review is an important component of multidimensional fall risk assessments. High-risk medications that can cause dizziness or low blood pressure, like sedatives and hypnotics, diuretics, anticonvulsants, antipsychotics, and antidepressants, are noted.
The Beers criteria, STOPP guidelines, and other tools identify problematic medications for older adults. Reviewing for drug interactions and total number of medications helps determine whether polypharmacy contributes to the patient’s fall risk profile.
Questionnaires
In a clinical setting, providers often incorporate validated questionnaires into a comprehensive fall risk assessment. These questionnaires use patient self-report data to quantify risk.
Some commonly used fall risk questionnaires in older adults include:
- CDC STEADI Algorithm
- Tinetti Falls Efficacy Scale
- Berg Balance Scale
- Morse Falls Scale
- STRATIFY Fall Risk Assessment Tool
Questionnaires allow for standardized scoring of fall risk and can be compared over time to assess changes. Some tools like STEADI simplify results into low, moderate or high risk categorization to guide management.
Diagnostic Assessments
If initial fall screening indicates an elevated risk for falls, a physician may order additional diagnostic assessments to identify specific causes that can be treated. These can include:
- Neurological exam to assess cognitive status, muscle strength, reflexes, sensation.
- Gait and balance analysis using advanced techniques, such as computerized dynamic posturography.
- Cardiovascular examination for blood pressure abnormalities or arrhythmias.
- Orthopedic evaluation of joints, spine, and bones.
- Podiatry exam for foot problems contributing to instability.
- Physical therapy assessment of mobility safety and assistive device needs.
- Ophthalmology tests for glaucoma, cataracts, depth perception, visual field defects.
Diagnostic information allows providers to identify appropriate interventions to reduce falls by addressing the patient’s specific impairments and needs.
Home Environment Evaluation
The home environment plays a significant role in fall risk. Hazards like clutter, poor lighting, lack of grab bars in bathrooms, and slippery floors often contribute to falls in older adults.
Visiting nurses, occupational therapists, physical therapists, and other providers often perform home evaluations as part of comprehensive fall prevention programs, especially following a hospitalization or injury. They assess for environmental risks and recommend modifications like:
- Improving lighting, reducing tripping hazards by removing loose cords and rugs.
- Installing grab bars, shower chairs, raised toilet seats and other bathroom safety equipment.
- Adding stair railings and handles throughout the home for support.
- Encouraging patient to wear shoes instead of socks at home.
- Adjusting furniture placement for clear paths.
Home evaluation identifies opportunities to create a safer environment and prevent future falls in high risk individuals.
Sample Fall Risk Assessment Form
A sample fall risk assessment form that incorporates many of these key assessment components may look like:
| Patient Name | Date |
| Assessment Components | Results |
| Age | __ years old |
| 2 or more falls in last year? | Yes/No |
| Ambulation status/use of assistive device | Normal gait/Cane/Walker/Wheelchair |
| Timed Up and Go test | __ seconds |
| 30-second chair stand test | __ stands |
| Balance testing | Able to stand on one foot for >5 seconds? Yes/No |
| Orthostatic hypotension | Drop in systolic BP > 20 mm Hg? Yes/No |
| Medications | High fall risk drugs: __ |
| Vision check | Visual acuity: __/20 |
| Cognitive assessment | MMSE score: __/30 |
| Fall Risk Questionnaire | STRATIFY score: __ |
| Home safety evaluation | Changes recommended: __ |
This sample incorporates both risk factor assessment, physical function tests, vision check, medication review, questionnaires and home safety evaluation into a comprehensive analysis.
Scoring Fall Risk Level
After assessing fall risk factors, most evidence-based tools classify patients into mild, moderate and high risk categories. Some examples of risk level categorization include:
| Assessment Tool | Low Risk | Moderate Risk | High Risk |
|---|---|---|---|
| STEADI Algorithm | 0-24 points | 25-44 points | >45 points |
| Johns Hopkins Fall Risk Assessment Tool | 0-9 points | 10-15 points | >16 points |
| Morse Fall Risk Scale | 0-24 points | 25-50 points | >51 points |
Higher risk categories prompt more intensive fall prevention interventions, like physical therapy, vision treatment, medication changes, or admission to a skilled nursing facility with close supervision. Accurately stratifying fall risk ensures appropriate management.
Monotonous Assessment
Fall risk should be periodically re-assessed, such as annually for low-risk patients and quarterly for high-risk patients. Changes over time are detected to adjust interventions accordingly. Values like gait speed, balance testing, Timed Up and Go performance, and orthostatic blood pressure response can be compared over subsequent assessments. Questionnaires can also demonstrate improved or worsening fall efficacy and fear.
For hospitalized patients, fall risk assessment should be conducted both on admission and discharge. Outpatient fall assessments may occur at annual wellness visits for community-dwelling seniors. Any significant change in condition, like an infection, surgery, or new medication, should also prompt reevaluation.
Ongoing monitoring provides opportunities to modify care as a patient’s abilities evolve.
Ideas for Assessment Questions
Patient questions are an important part of gathering subjective data during fall risk assessments. Some examples of questions that may be asked include:
- How many times have you fallen in the past year and what were the circumstances?
- Do you feel unsteady when standing or walking?
- Do you struggle getting up from a chair?
- Are you worried about falling when doing certain activities? Which ones?
- Do you ever feel dizzy or have sudden drops in blood pressure with position changes?
- What medications are you currently taking?
- Have you had any recent changes in your vision or hearing?
- What type of physical activity do you engage in and has this changed recently?
- Have you modified your home environment to prevent falls and are there other changes needed?
Listening carefully to patients’ responses supplements objective findings, giving a fuller picture of modifiable and non-modifiable contributors to fall risk.
Conclusion
Fall prevention is an essential component of health care for older adults. A multidimensional fall risk assessment identifies patients who can benefit from interventions across disciplines including physical therapy, pharmacy, optometry, cardiology, geriatric medicine and nursing.
Key components comprise screening for intrinsic risk factors, quantitative physical function assessment, medication reconciliation, administering validated fall risk questionnaires, diagnostic workup and home safety evaluation.
Periodic reassessment monitors changes over time to guide appropriate modification of the patient’s care plan. Multifactorial assessment facilitates evidence-based management to reduce preventable injury and maintain seniors’ independence, function and quality of life.
