ASSESSING A PATIENT’S FALL RISK

Identifying specific fall risks and the most appropriate strategies for intervention can be a complex task and may involve multiple members of a healthcare team. Physicians and other primary care providers, nurses, physical therapists, occupational therapists, social workers, caregivers/family members, and the patient/client all hold key areas of expertise that may help build a complete picture of the multiple factors that may put someone at risk for falling.

Every person’s situation is unique, with a distinct combination of physical/functional status, cognitive ability, living situation, family/caregiver supports, and other resources. Most falls are multifactorial in nature and unique to an individual’s specific situation; therefore, there is no one correct means to accurately predict fall risk. Instead, it is recommended that clinicians rely upon a more holistic assessment. The information gathered from multiple information sources may identify multifactorial issues, which are then addressed by various appropriate interventions (Mishra et al., 2022).

Intrinsic and Extrinsic Fall Risk Factors

Most falls occur as a result of multiple factors, and having a greater number of risk factors makes it increasingly likely that a person will suffer a fall. The risk level may be due in part to physical, sensory, and cognitive changes associated with aging in combination with environments that are not adapted for an aging population (Physiopedia, 2023b).

Some risk factors cannot be altered, while others may be lessened or even eliminated. Fall risk factors are either intrinsic (inherent to an individual) or extrinsic (pertaining to situational and/or environmental factors outside an individual).

INTRINSIC FALL RISK FACTORS

• Advanced age (>60 years)
• Young age (due to childhood developmental stages, innate curiosity, and risk-taking behavior)
• Gender (older females more likely to sustain severe injury from falls, males have higher rates of injury and death across lifespan)
• Previous falls
• Muscle weakness
• Gait disorders
• Balance disorders
• Foot and/or ankle disorders
• Poor or insufficiently corrected vision
• Postural hypotension
• Chronic conditions (arthritis, cerebrovascular accident, incontinence, diabetes, neurologic conditions, etc.)
• Impaired cognition
• Fear of falling
  (Physiopedia, 2023b; Lee et al., 2022)

EXTRINSIC RISK FACTORS

• Lack of stair handrails
• Poor stair design
• Lack of bathroom grab bars
• Dim lighting or glare
• Obstacles and tripping hazards
• Slippery or uneven surfaces
• Psychoactive medications
• Taking more than one medication (polypharmacy)
• Improper use of an assistive device
• Occupations at elevated heights or other hazardous working conditions
• Alcohol or substance use
• Socioeconomic factors (poverty, overcrowded housing, sole parenthood, young maternal age)
  (Physiopedia, 2023b; Lee et al., 2022)

Multifactorial Risk Assessment and Patient History

Falls-related clinical guidelines include recommendations from the World Falls Task Force (see box below), the American Geriatric Society, the British Geriatric Society, and the American Academy of Orthopedic Surgeons. While there are many areas of overlap between various guidelines, a recent systematic review by the Journal of the American Medical Association found that there are also considerable variations in consistency between recommendations in some areas (Montero-Odasso et al., 2021).

The components of the risk assessment described below have been drawn from numerous existing guidelines. They include a careful and comprehensive patient history in order to gain valuable information regarding an individual’s intrinsic and extrinsic risk factors for falling, which can, in turn, help to appropriately guide any needed interventions and/or preventive strategies (Physiopedia, 2023b).

SCREENING FOR FALL RISK

Numerous guidelines recommend that all older adults receive a basic fall screening on an annual basis. This may help determine specific risk levels and thus guide an individually tailored, multifactorial prevention and/or management strategy. Risk stratification may be completed as part of regular annual clinical exam, during a hospitalization, and/or after any fall-related event. Patients may be asked about:

• Falls within the past 12 months
• Severity of any recent falls
• Dizziness or altered consciousness
• Feeling of unsteadiness or difficulty walking
• Fear of falling (particularly if severe enough to limit activities)

Based upon the information gathered from such screening questions, clinicians may be able to categorize patients according to risk categories and provide associated recommendations (see table below) (Physiopedia, 2023b; Montero-Odasso et al., 202; Task Force, 2022).

FALL RISK CATEGORIZATION

Category	Description	Recommendation
(Task Force, 2022)
Low risk	No fall in last 12 months or nonsevere fall without gait or balance impairment	General fall prevention education and exercise/fitness recommendations
Intermediate risk	Nonsevere fall with gait or balance impairment	Physical therapy referral and/or specific balance and strengthening exercise recommendations in addition to general fall prevention education
High risk	Severe fall with gait and balance impairment	Highly individualized management, including a comprehensive/multifaceted fall risk assessment

FALL RISK ASSESSMENT

Fall risk assessment should be performed by a healthcare professional with appropriate skills and experience and may include:

• Identification of fall history (particularly within the past year)
• Assessment for impaired mobility (gait, balance, strength, assistive device use, foot conditions/footwear, etc.)
• Assessment of dizziness, hearing, and/or vestibular issues
• Assessment of heart rate, rhythm, and blood pressure
• Assessment of ADLs (activities of daily living)
• Assessment of osteoporosis risk
• Assessment of the person’s perceived functional ability and fear related to falling
• Assessment of visual impairment
• Assessment of cognitive impairment, mental status, and neurological examination
• Assessment of urinary continence
• Assessment of home hazards
• Cardiovascular examination
• Review of overall medication history, polypharmacy, etc.
• Assessment of vitamin D levels (as locally indicated)
• Assessment for history or presence of orthostatic hypotension
• Assessment for current medications specifically associated with falls (e.g., sedative-hypnotics, blood pressure drugs)
  (NICE, 2023; Task Force, 2022; Physiopedia, 2023b)

Medical Tests

For individuals with a history of falling, their primary care provider may order certain tests to rule out specific conditions and/or injuries, as well as complete a review of the patient’s most current list of medications. Some common, relevant medical tests may include (but not be limited to):

• Complete blood count (to detect leukocytosis or anemia)
• Blood glucose measurement
• Electrolyte measurement to test for dehydration
• Electrocardiogram (ECG), ambulatory cardiac monitoring, and/or echocardiography if cardiac pathology is suspected
• Carotid massage (with cardiac monitoring and IV access) to help determine whether a pacemaker may be indicated
• Magnetic resonance imaging (MRI), computerized tomography (CT), and/or spinal x-rays (if new neurological abnormalities are present)
  (Merck & Co., 2022a)

Functional Assessment

There are a wide variety of functional assessment tools available for helping to determine an individual’s risk of falling. Some tools are self-assessments that may be used by individuals and/or their caregivers; others require specialized training to administer and should only be carried out by clinicians with appropriate levels of training. It is important to consider an individual’s physical capabilities, previously known risk factors, home and living environment, and level of family/caregiver support when selecting an appropriate assessment tool.

FALL RISK FUNCTIONAL ASSESSMENT TOOLS

Some commonly used tools in clinical and community settings are:

• 2-Minute Walk Test (2MWT): Assesses walking distance over a timed period of two minutes to determine walking endurance.
• Activities-Specific Balance Confidence Scale (ABC): Self-administered or conducted in person or via telephone; participants indicate level of self-confidence that they will not lose balance or become unsteady during 11 various activities.
• Ankle range of motion: Measured using goniometer, inclinometer, or knee-to-wall ratio (using tape measure), ideally by a rehabilitation professional skilled in joint measurement with kinesiology background; lower-than-average ankle dorsiflexion linked to increased risk of balance-related falls in some populations as one factor contributing to variance in gait and balance performance.
• Berg Balance Scale (with adaptations for special patient populations): 14-item scale measuring balance of an adult in a clinical setting (does not assess gait); requires 15 to 20 minutes to administer; training required to administer.
• Dizziness Handicap Inventory (DHI) for Benign Paroxysmal Positional Vertigo (BPPV): Subjective 25-item patient self-assessment that measures functional limitation due to vestibular-related vertigo.
• Dynamic Gait Index: Assesses eight facets of gait in order to predict fall risk in community-dwelling older adults.
• Elderly Mobility Scale (EMS): 20-point validated scale that assesses functional mobility of frail older adult subjects in hospital settings.
• Falls Efficacy Scale-International (FES-I): 16-item self-assessment that assesses fear of falling in community-dwelling older adult populations.
• Falls Risk Assessment Tool (FRAT): Assesses fall risk via brief, clinician-administered questions; offers general guidance on any identified areas of fall risk.
• Four Step Square Test: Assesses an individual’s dynamic balance when stepping over objects forward, backward, and sideways.
• Functional Independence Measure (FIM): 18-item assessment of physical, psychological, and social function for individuals with any motor impairment that addresses feeding, grooming, bathing, upper-body dressing, lower-body dressing, and toileting.
• Functional Reach: Assesses a patient’s/client’s ability to reach outside a fixed based of support while maintaining balance; may be modified to perform in sitting posture if needed.
• Head-Shaking Nystagmus Test (pHSN): Tests for peripheral vestibular disorders by observing for presence of nystagmus during specific abrupt head movements; training and specialized equipment highly recommended for administration.
• STEADI Falls Screening Tool: Used for screening and fall risk assessment; includes patient questionnaire, fall history, and balance performance tests (Timed-Up-and-Go [TUG], static balance testing, and 30-second sit-to-stand).
• Timed-Up-and-Go (TUG), with optional cognitive (TUG-COG) and/or manual (TUGman) variations: Assesses dynamic mobility for determining fall risk by observing the patient/client rising from a chair, walking a predetermined distance, and returning to sitting; may be modified by adding cognitive and/or manual task components.
• Tinetti Performance-Oriented Mobility Assessment (POMA): Assesses gait and balance; rates ability to maintain balance while performing ADL-related tasks; training recommended to administer.
  (Prost, 2021; CDC, 2023b; Physiopedia, 2023c, 2023d; Shirley Ryan Abilitylab, 2020a–i; Smiling Senior, 2023; University of Scranton, 2020; Healthy Aging Resource Group, 2023).

Comprehensive Balance Evaluation

While not all falls are the result of specific balance impairments, problems with balance do comprise a significant subset of risk factors for falling. If an initial patient screening shows any potential red flags for specific balance impairments, a referral to a physical therapist may be indicated. A physical therapist may perform a comprehensive balance evaluation to determine specific causes of impairment and to design an appropriate intervention strategy.

When conducting a balance assessment, the following questions may be helpful in obtaining detailed and relevant patient information:

• How often do you experience problems with your balance?
• What are you doing when you experience balance problems?
• Is your balance worse at nighttime or in dark rooms?
• Does the room spin, or do you feel off balance?
• How many times have you fallen in the past year?
• Have you suffered injuries from falling?
• Have you changed or limited your daily activities because of your balance problems?
• What medications do you take?
• Have you had a vision or ear checkup recently?
• Do you have difficulty with any daily activities?
• How much and what kind of daily exercise do you get?
• Do you have any other medical conditions or problems?
• Are you under the care of a physician?
• What are your goals?
  (APTA, 2021)

Home Safety Assessment

A home safety assessment by a healthcare professional is particularly valuable when there are questions or concerns regarding a patient’s/client’s ability to safely navigate their home environment physically and/or cognitively, with sufficient safety awareness to minimize risk of injury. Observing an individual operating within their home environment provides a more holistic picture of their functional abilities than can be gleaned solely from a more controlled clinical setting.

A comprehensive home safety assessment provides an in-depth evaluation of potential structural and/or environmental hazards or concerns that may put an individual at greater risk for a fall. Home safety assessments may be performed by occupational therapists, physical therapists, medical social workers, specially trained nurses, or other appropriately trained professionals. A referral from a primary care provider or home health services may be needed for a patient to receive a professional home safety assessment.

(Recommendations for addressing specific safety deficits or potential hazards are discussed later in this course.)

CLINICIAN HOME SAFETY ASSESSMENT TOOLS

• Safe at Home Checklist: Created in partnership by the Administration on Aging and the American Occupational Therapy Association (AOTA), this checklist is used by clinicians to identify home safety, fall hazards, and accessibility issues for homeowners, patients/clients, and/or family members. It includes modifiable checklists of suggestions for addressing specific identified safety concerns.
• I-HOPE: This tool identifies performance struggles faced by individuals in their homes, with the clinician observing for barriers during problematic activities. Each barrier carries a score to determine severity level. Designed for individuals with higher functional levels, it is not appropriate for pediatric clients or for those with dementia.
• SAFER-HOME: A task performance observation and an interview are combined to assess safety concerns and functional performance. This tool addresses mobility, household, and bathroom safety. It does not fully address issues such as food preparation and personal care.
  (AOTA, 2019)

When conducting a home safety assessment, it is important for clinicians to remember that what may seem like clutter or a hazard to them may mean something entirely different to the individual and/or their family. Mementos, keepsakes, old furniture, and other seemingly replaceable items may hold great sentimental value for their owners. Clinicians should be mindful of potential emotional attachments and be respectful of an individual’s available resources and values when identifying potential environmental modifications.

PATIENT HOME SAFETY SELF-ASSESSMENT

There are a number of home safety checklists available for use by a patient and their family to examine their own living environment for potential hazards that may increase risk of a fall at home. Two examples include:

• Check for Safety: A Home Fall Prevention Checklist for Older Adults: Created by the CDC, this brief checklist helps assess a home for common environmental fall risks (such as clutter, loose rugs, improper lighting) and provides suggestions for addressing these risks.
• Home Safety Self-Assessment Tool (HSSAT): Created by the University of Buffalo’s Occupational Therapy Geriatric Group, this extensive tool includes a screening checklist for identifying environmental hazards in the home as well as written and video resources with suggestions and instructions for specific home safety improvements.

(See also “Resources” at the end of this course.)