Balance, Postural Control, and Falls in Older AdultsPage 7 of 11

5. Assessing Fall Risk

In 2005 the Joint Commission added the goal of “reducing the risk of patient harm resulting from falls” to its 2005 JCAHO National Patient Safety Goals (NPSG), which were recently renewed. The goals state that Joint Commission-accredited healthcare organizations must:

  • Assess all patients for fall risk
  • Implement interventions to reduce the risk of falls based upon the resident’s assessed risk
  • Educate staff in the prevention of falls
  • Evaluate the effectiveness of fall reduction activities (Joint Commission, 2012)

A number of professional organizations have also recommended that older adults be assessed for fall risk. The American Geriatrics Society (AGS) encourages healthcare providers to ask all older adult clients about falls at least once a year. If an older adult patient has fallen within the last year, a gait and balance assessment is recommended. Those who cannot perform or who perform poorly on a standardized gait and balance test should be given a multifactorial fall risk assessment. The multifactorial fall risk assessment should include a focused medical history, physical examination, functional assessments, and an environmental assessment (Moyer, 2012).

The Prevention of Falls in the Elderly Trial (PROFET) found that a structured interdisciplinary assessment for older adults presenting to a hospital emergency department in the United Kingdom after a fall reduced subsequent falls and hospitalizations. The intervention involved a detailed medical assessment by a geriatrician with appropriate referral, as well as home-based occupational therapy review assessing for environmental hazards with education and advice (Elley, 2007).

The National Institute for Clinical Excellence (NICE) also recommends that healthcare providers routinely assess their older adult clients for fall risk. Those reporting falls should be observed for balance and gait deficits and considered for interventions to improve strength and balance. Older adults appearing to be at high risk for falls should be offered an individualized, multifactorial intervention including strength and balance training, home hazard assessment and intervention, vision assessment and referral, and medication review and modification (Michael, 2010).

The Joint Commission has launched a Long Term Care Accreditation Program, expected to take effect by July 2013. When this voluntary program is fully implemented, accredited nursing homes will be required to comply with Joint Commission safety standards, including those related to prevention of falls.


Screening is a method for detecting dysfunction before an individual would normally seek medical care. Screening tests are usually administered to individuals without current symptoms but who may be at high risk for certain adverse outcomes. The purpose of screening is early diagnosis and treatment. Screening tools that address fall risk have been developed for use in various populations, including hospitalized older adults, adults in residential care, and community-dwelling older people.

Screening is an effective tool for quickly identifying patients at high risk for falling. But just as there is confusion about how to define a fall, finding an agreed-upon definition for “screening” is also fraught with problems. For example, some clinicians consider a check box on a form to be an adequate screen.

As an example of how the requirement to screen patients for specific behaviors or risks can create confusion, Medicare recently instituted a requirement that patients be screened for smoking. There are no parameters for how long, when, or what “smoking” means in this screen. The reason for the smoking screen is to provide education and, if warranted, to expand the examination based on the patient’s answer to the question.

The same problem occurs when screening for fall risk—if a patient is asked “Have you fallen in the last year?” and the answer is no, the screen leads nowhere, even in the case of an older adult patient who has real risk factors for falls. So it is important to observe the patient and have a screening tool that is quick and easy but also provides guidance about fall risk.

In fall intervention studies, age and history of falls are the two risk factors most commonly used to define high risk. Also considered are gender, impaired balance and gait, visual impairment, and use of multiple medications. A number of studies have indicated that a history of falls, use of certain medications, and gait and balance impairment are important indicators of the likelihood of future falls in older adults (Moyer, 2012).

A practical approach for screening high-risk persons is to ask and assess: ask about history of falls, frequency and circumstances of falls, and mobility problems, then assess performance using a quick test such as a Timed Up and Go (TUG) test. The TUG test is performed by observing the time it takes a person to rise from an armchair, walk 10 feet, turn, walk back, and sit down again. The average healthy adult older than 60 years can perform this task in less than 10 seconds (Moyer, 2012).

Recently a registered nurse received a comprehensive physical exam at a local clinic. Although she is 68 years old and is in the age category for fall risk, she was not asked about falls. There was a checkbox on the intake form asking “Have you fallen over the past year?” The patient answered no, even though she has fallen twice in the last year. Although she was examined by a doctor and a nurse practitioner, neither asked about falls. In this case, the checkbox on the intake form stopped the doctor from inquiring further even though the patient is in the age category for high risk and has two other risk factors: cataracts and stiff knees. When a clinician considers a checkbox on a form to be an adequate screen for fall risk a gap is created. In this case it failed to lead to some sort of action—patient education, a referral, or further assessment.

Brief Fall Risk Assessment

The Morse Fall Scale (MFS) is a brief fall risk assessment tool used widely in acute care settings. The MFS (Table 1) assesses a patient’s fall risk upon admission, following a change in status, and at discharge or transfer to a new setting. Prevention interventions are based on the Morse Fall Scale score (Table 2) (USDVA, 2009).

Source: USDVA, 2009.

Table 1. Morse Fall Scale

  1. History of falling; immediate or within 3 months

No = 0

Yes = 25

  1. Secondary diagnosis

No = 0

Yes = 15

  1. Ambulatory aid

None, bed rest, wheel chair, nurse = 0

Crutches, cane, walker = 15

Furniture = 30

  1. IV/heparin lock

No = 0

Yes = 20

  1. Gait/transferring

Normal, bed rest, immobile = 0

Weak = 10

Impaired = 20

  1. Mental status

Oriented to own ability = 0

Forgets limitations = 15

Source: USDVA, 2009.

Table 2. Recommendations Based on Morse Fall Scale

Risk factor

MFS score


No risk



Low risk


Initiate standard fall prevention interventions

High risk


Initiate high risk fall prevention interventions

Multifactorial Assessment

The multifactorial assessment is an additional assessment tool that offers a more comprehensive look at fall risk. If, during a quick screening, an older adult has difficulty with balance or has unsteady gait, a multifactorial fall risk assessment should be completed. The multifactorial fall risk assessment should include a focused medical history, physical examination, functional assessments, and an environmental assessment. The AGS recommends the following interventions for falls prevention:

  • Adaptation or modification of home environment
  • Withdrawal or minimization of psychoactive or other medications
  • Management of postural hypotension
  • Management of foot problems and footwear
  • Exercise (particularly balance), strength, and gait training
  • Vitamin D supplementation of at least 800 IU per day for people who have vitamin D deficiency or are at increased risk for falls (USPSTF, 2012)

Mary Tinetti refers to the multifactorial assessment as an intervention that flows out of a fall risk screening. It is meant to put parameters around the issue of fall risk and is part of a continuum going back to the simple check box.

According to AGS/BGS guidelines, any older adult reporting a single fall within the last year should be referred to a specialist for a comprehensive gait and balance assessment. If, after reporting a single fall, an older adult performs well on the gait and balance assessment, a multifactorial fall risk assessment is not recommended (AGS/BGS, 2009).

Medicare OASIS-C Fall Risk Assessment

For over a decade, the Centers for Medicare and Medicaid Services (CMS) has required Medicare-certified home health agencies to collect and transmit Outcome and Assessment Information Set (OASIS) data for all adult home health patients 18 and older receiving skilled services, whose care is reimbursed by Medicare and Medicaid, with the exception of patients receiving pre- or postnatal services only (CMS, 2010).

The OASIS directs home health agencies to assess fall risk in all patients over the age of 65. The multifactorial assessment includes items such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, and environmental hazards (CMS, 2010).

During the multifactor fall risk assessment, the agency:

  • Can use the single standardized, validated comprehensive multifactor falls risk assessment tool
  • May incorporate several tools so long as one of them is standardized and validated

The purpose is to promote falls risk assessment across disciples and across healthcare settings.

Fall Risk Assessment in Nursing Homes

About 1,800 older adults living in nursing homes die each year from fall-related injuries and those who survive falls frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life (CDC, 2012b).

In nursing homes, nurses assess residents for fall risk upon admission to the facility and on a regular basis after admission. To assess fall risk, nurses can choose from a variety of fall risk assessment tools, which are generally not standardized or regulated. Most assessment tools contain a scoring system that evaluates the cumulative effect of risk factors for the purpose of identifying those at greatest risk of falling or sustaining a fall-related injury (Wagner, 2011).

A Canadian study involving 137 nursing homes in the province of Ontario asked about what fall risk assessment tools were being used and tried to identify commonalities across the assessment tools (Wagner, 2011). The most commonly used fall risk assessment tools were the Morse Fall Scale and the Performance-Oriented Mobility Scale. Across all facilities the common domains assessed included:

  • Intrinsic factors
  • Treatment-related or extrinsic factors
  • Mobility status
  • Cognitive status
  • Sensory status
  • History of falls
  • Behaviors and attitudes (Wagner, 2011)

In this study, the researchers noted the need for an evidence-based tool for the assessment of fall risk similar to the universally excepted Braden Scale for predicting pressure ulcer risk. They point out that poorly designed assessment tools hinder the development of a fall-risk reduction program and fail to address the needs of individual patients (Wagner, 2011).

A particular barrier for quality improvement programs is that many do not fully address the ways in which staff duties overlap when attempting to address fall risk among their patients. Complex syndromes such as fall risk result from multiple risk factors and require multifactorial, interdisciplinary interventions to improve outcomes. Reducing multiple risk factors may be difficult because it requires many staff members to have strong connections that permit effective information flow and problem solving from varied perspectives; thus, an intervention is needed to help staff establish a working relationship and improved communication to support the new practices introduced by fall-reduction programs (Anderson et al., 2012).

Fall Classification Using a Mobile Phone

A novel way of documenting patient falls is through the use of mobile phones; most smart phones are equipped with accelerometers that can be used to detect when patients fall with exceptionally high accuracy. Falls are generally high-impact events, making detection simpler than identifying other daily activities. Automatically detecting falls can allow rapid response to potential emergencies; in addition, knowing the cause or manner of a fall can be beneficial for prevention studies or a more tailored emergency response.

A Rehabilitation Institute of Chicago study sought to demonstrate techniques that not only reliably detect a fall but also automatically classify the type. Fifteen subjects simulated four different types of falls—left and right lateral, forward trips, and backward slips—while wearing mobile phones and accelerometers. Nine subjects also wore the devices for ten days, to provide data for comparison with the simulated falls. Researchers were able to identify a fall with 98% accuracy and classify the type of fall with 99% accuracy (Albert, 2012).

Types of Falls Measured and Axes of Measurement

Four different types of simulated falls, positioned according to direction of the fall.
Using a smart phone with an accelerometer to measure the direction of a fall.
axes of the accelerometer

(A) Four different types of simulated falls, positioned according to direction of the fall. (B) The G1 android mobile phone that was used for recording, and the placement of the phone on the back of subjects. (C) The axes of the accelerometer. The phone was placed on the back of the subject so that the three axes pointed up, left, and to the back of the subject. Source: Albert, 2012. Used with permission.

This work demonstrates how current machine-learning approaches can simplify data collection as well as improve rapid response to potential injuries due to falls (Albert, 2012).

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