Falls are expensive, can result in significant disability, and can make life less enjoyable. In this article, we will be considering some fall risk assessment tools.
Caretakers could reduce the number of falls by identifying individuals who are at risk of falling by making use of standardized assessment tools.
Fall Risk Assessment Tools
Some of the most widely used assessment tools/methods for assessing the risk of falling are listed below.
- The 30-Second Chair Stand Test: the 30-Second Chair Stand Test measures endurance and leg strength. A stopwatch, a chair with a straight back and no armrests, and a 17-inch high chair are all necessary for this test. The patient sits in the chair with his feet flat on the floor for this test. Throughout the course of the examination, he holds both hands on the opposite shoulder and crosses his arms at the wrist. The patient comes to a full standing position and sits back down as many times as he can in 30 seconds without using his hands when the tester says “Go” and starts the stopwatch. The patient’s ability to stand is counted during the test. The tester should consider the patient’s halfway-standing position to be a full stand. By age and gender, the Centers for Disease Control and Prevention (CDC) lists scores that are below average. For instance, a man between the ages of 60 and 64 can stand up 14 or more times in 30 seconds, whereas the woman can stand up 12 times.
- The Timed Up and Go (TUG) Test: The TUG Test measures mobility. A tape measure, a stopwatch, and a method for drawing a temporary line on the floor approximately 10 feet away from a standard armchair are all important for the tester. If necessary, the patient should walk with a walking aid and wear normal footwear. In the chair, the patient is seated; the patient gets up, walks at her normal pace to the floor line, turns, walks back to the chair, and sits down again when the tester says “go” and starts the stopwatch. The time taken by the patient to complete the task is recorded by the tester. According to the Oncology Nursing Society, a patient who takes more than 12 seconds to complete the TUG test runs a high risk of falling.
3. The 4-Stage Balance Test: The 4-Stage Balance Test aids caregivers in determining a patient’s static balance—the capacity to maintain equilibrium while stationary. There are four positions on the 4-Stage Balance Test that are progressively more difficult. A stopwatch is needed by the tester. During the tests, patients should keep their eyes open and not use a cane, walker, or any other assistive device. Each position should be described and demonstrated to the patient by the tester. The tester should stand next to the patient or resident as he tries the position, hold the subject’s arm, and help him get his feet in the right position. The tester should let go when the patient feels stable, but they should still be ready to catch the patient or resident if he falls over. The resident or patient holding the position should be timed by the tester. The tester can stop that part of the test and move on to the next position if the patient or resident can hold the position for at least 10 seconds without requiring support or moving his feet. If the patient or resident loses his or her balance, the tester should stop the test.
- Orthostatic Hypotension, or blood pressure that drops suddenly when the patient stands up, is the goal of an orthostatic blood pressure test. Falls and dizziness can occur when blood pressure drops significantly. According to the Mayo Clinic, falling is a frequent complication in individuals with orthostatic hypotension. A bed or hospital cart, a blood pressure cuff, and, if necessary, a stethoscope are all required to perform an orthostatic blood pressure.
The patient or resident should be instructed to lie down for five minutes before the orthostatic blood pressure test can be performed. After that, the tester should take the patient’s or resident’s pulse and blood pressure while they remain in a comfortable position. If the patient begins to experience dizziness, the tester should instruct the patient to stand and remain close by. After standing for one minute and walking for three minutes, the tester should take the patient’s or resident’s pulse and blood pressure again.
According to the CDC, an abnormal result is a drop in blood pressure of at least 20 millimeters of mercury or a drop in diastolic blood pressure of at least 10 millimeters of mercury. It is also abnormal to experience lightheadedness or dizziness, which indicates an increased risk of falling.
- The Allen Cognitive Screen, also known as the leather lacing tool, is a cognitive assessment tool that aids in determining the chances of falling due to functional cognition issues. This screening, also known as the leather lacing tool, measures a person’s ability to perform, learn, and process information globally.
A kit for the Allen Cognitive Screen includes lace, a large needle, and a piece of leather with holes already punched in it. The patient stitches three more difficult stitches through the leather’s holes with a needle. The patient’s results are evaluated by testers using the Allen Cognitive Levels, Modes of Performance, and Level of Care.
Many cognition screening tools are available, and cognitive screening is common when screening for falls risk. An app called icon-FES, which uses pictures to assess an individual’s fear of falling, has been developed by Neuroscience Research Australia (NeuRA) if you are concerned about an individual’s fear of falling rather than their overall cognitive capacity.
By administering these tests, caregivers can identify residents or patients at high risk for falling and take preventive measures.
- Dynamic Gait Index: This is used to assess the eight facets of gait. It rates each of 8 stages as: (3) Normal, (2) Mild Impairment, (1) Moderate Impairment, (0) Severe Impairment
- Gait on level surface
- Gait with speed changes
- Horizontal head turns
- Vertical head turns
- Gait and pivot turn
- Step over obstacle
- Step around obstacles
- Tinetti Performance Oriented Mobility Assessment (POMA): This is designed to measure balance and the strength of the lower and upper body. Administration time is 10 to 15 minutes.
- Mini Mental State Examination (MMSE): This is the most popular screening tool for cognitive impairment. It is recommended for measures orientation, immediate recall, short-term verbal memory, calculation, language, and construct ability.
Apart from fall risk assessment on admission for every patient as the standard of care, when to reassess the patient’s risk for fall injury is less consistent. There is support for reassessment after the following events.
- When a fall occurs
- When a significant change in patient condition or medication occurs
- When a patient is transferred to a new area
In addition, very high-risk patients should be assessed each day or even at every change of shift.
There are other assessment tools for older adults. Falls Risk for Older Adults in the Community (FROP-Com) screening tool evaluates 13 risk factors for falling. The tool can help determine a person’s overall risk of falling and the specific risk factors to target. A shorter version of the FROP-Com, the FROP-Com screen looks at three common risk factors for falling.
It is intended for use by health professionals. This is still a valid and dependable tool, but it saves more time and is simpler to use. It is used to identify individuals at risk of falling and as a guide for referral and can be carried out by a health professional as well as support staff.
The following are Screening and Assessment Tools for Community-Dwelling Older Adults:
- Timed Up and Go (TUG) Test: the TUG Test measures a person’s function and shows whether they are in dynamic balance. It is recommended for use by a medical professional and does not necessitate any special equipment. The test measures how long it takes a person to get up from a chair, walk three meters, and then sit down and go back to the chair. The validity and reliability of the TUG Test have been extensively studied, and it is frequently used in research studies.
- The 4-Stage Balance Test measures a person’s static balance by requiring them to attempt four standing positions that become increasingly challenging to maintain. The individual is instructed to remain in the correct position (with assistance if necessary) for ten seconds before moving on to the more difficult position. If these positions cannot be maintained, this test indicates the risk of falling.
- Thomas Risk Assessment Tool (STRATIFY): This is mostly used to predict fall risk factors in the elderly. According to a report by Castellini, the True Positive Rate was 35.6% while the False Negative Rate was 64.4% of fallers.
Practical and validated tool to assess falls risk in the primary care setting: a systematic review
Using Fall Risk Assessment Tools in Care Planning
Tools for assessing fall risk in the elderly: a systematic review and meta-analysis