Fall Risk Assessment
Fall-risk assessment, or the health assessment of the older adult patient “at risk”, is an essential component to a comprehensive fall reduction and prevention program. The purpose of fall-risk assessment is to identify a patient’s risk for falling in advance in order to correct problems and ultimately prevent falls from occurring. Fall-risk assessment can take the form of a simple screening of all older adults admitted to a medical facility. Or, for those at high risk for falls or who have recently fallen, a more comprehensive multidimensional fall-risk assessment is more appropriate. Ideally, fall risk assessment should be completed on admission, when transferred to a new unit, or when level of care changes, if a change in condition occurs, and after a fall (Gray-Miceli, 2008).
Fall risk assessments should incorporate the following risk factors (ConsulGeriRN.org):
- Advancing age, especially if older than 75
- History of a recent fall
- Specific co-morbidities: dementia, hip fracture, Type II diabetes, Parkinson's disease, arthritis, and depression
- Functional disability: use of assistive device
- Alteration in level of consciousness or cognitive impairment
- Gait, balance, or visual impairment
- Use of high-risk medications
- Urge urinary incontinence
- Physical restraint use
- Bare feet or inappropriate footwear
- Identify risks for significant injury due to current use of anticoagulants such as Coumadin, Plavix, or aspirin and/or those with osteoporosis or risks for osteoporosis
There are many assessment tools available for fall risk assessment. Assessment instruments for use in the acute care setting have been summarized by Perell and colleagues (2001). Only tools that have been empirically tested for reliability and validity should be used. Tools should not replace, but complement the judgment of the nurse performing fall assessments.
Commonly used risk assessment tools include:
Hendrich II Fall Risk Model
Morse Fall Scale
- Morse, J. M., Morse, R. M., & Tylko, S. J. (1989). Development of a scale to identify the fall-prone patient, Canadian Journal on Aging, 8, 366-377.
- Morse, J. M. (1996). Preventing patient falls. Thousand Oaks, CA: Sage.
St. Thomas’ Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY)
- Oliver, D., Britton, M., Seed, P., Martin, F.C., & Hopper, A.H. (1997). Development and evaluation of evidence based risk assessment tool (STRATIFY). British Medical Journal, 315(7115), 1049-1053.
Note: NICHE Encyclopedia provides links to third-party web sites, however, NICHE & the Hartford Institute for Geriatric Nursing does not recommend and does not endorse any products or any of the content on any third-party websites.
- American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention. (2001). Guidelines for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49, 664-672.
- Donaldson, M. G., Khan, K. M., Davis, J. C., Salter, A. E., Buchanan, J., McKnight, D., Janssen, P. A., Bell, M., & McKay, H. A. (2005). Emergency department fall-related presentations do not trigger fall risk assessment: A gap in care of high-risk outpatient fallers. Archives of Gerontology & Geriatrics, 41(3), 311-317.
- French, D. D., Werner, D. C., Campbell, R. R., Powell-Cope, G. M., Nelson, A. L., Rubenstein, L. Z., Bulat, T., & Spehar, A. M. (2007). A multivariate fall risk assessment model for VHA nursing homes using the minimum data set. Journal of the American Medical Directors Association, 8(2), 115-22.
- Gates, S., Fisher, J. D., Cooke, M. W., Carter, Y. H., & Lamb, S. E. (2008). Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. British Medical Journal, 19, 336(7636), 130-133.
- Haines, T., Hill, K., Walsh,W., & Osborne,R. (2007). Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis. The Journal of Gerontology, 62A, 6.
- Hendrich, P. Bender, & Nyhui, A. (February 2003). Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients. Applied Nursing Research, 16(1), 9-21.
- Kim, E. A., Mordiffi, S. Z., Bee, W. H., Devi, K., & Evans, D. (2007). Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing, 60(4), 427-435.
- Moylan, K. C., & Binder, E. F. (2007). Falls in older adults: risk assessment, management and prevention. American Journal of Medicine, 120(6), 493-496.
- Myers, H. (2003). Hospital fall risk assessment tools: a critique of the literature. International Journal of Nursing Practice, 9(4), 223-235.
- Myers, H., & Nikoletti, S. (2003). Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls. Journal of Nursing Practice, 9(3), 158-165.
- O'Connell, B., & Myers, H. (2002). The sensitivity and specificity of the Morse Fall Scale in an acute care setting. Journal of Clinical Nursing, 11(1), 134-136.
- Perrel, K. L., Nelson, A., et al. (2001). Fall risk assessment measures: an analytic review. Journals of Gerontology Series A – Biological Sciences & Medical Sciences, 2001, 56(12), M761-766.
- Podsiadlo, D., & Richardson, S. (1991). The timed "up & go": A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.
- Poe, S. S., Cvach, M., Dawson, P. B., Straus, H., & Hill, E. E. (2007). The Johns Hopkins Fall Risk Assessment Tool: post-implementation evaluation. Journal of Nursing Care Quality, 22(4), 293-298.
- Poe, S. S., Cvach, M. M., Gartrelu, D. G., Radzik, B. R., & Joy, T. L. (2005). An evidence-based approach to fall risk assessment, prevention, and management: lessons learned. Journal of Nursing Care Quality, 20(2), 107-116.
- Robey-Williams, C., Rush, K. L., Bendyk, H., Patton, L. M., Chamberlain, D., & Sparks, T. (2007). Spartanburg Fall Risk Assessment Tool: a simple three-step process. Applied Nursing Research, 20(2), 86-93.
- Schwendimann, R., De Geest, S., & Milisen, K. (2006). Evaluation of the Morse Fall Scale in hospitalised patients. Age & Ageing, 35(3), 311-313.
- Shumway-Cook, A., Brauer, S., & Woollacott, M. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Physical Therapy, 80(9), 896-903.
- Tinetti, M. E., Williams, T. S., & Mayewski, R. (1986). Fall risk index for elderly patients based on number of chronic disabilities. American Journal of Medicine, 80(3), 429-434.
- Vassallo, M., Poynter, L., Sharma, J. C., Kwan, J., & Allen, S. C. (2008). Fall risk-assessment tools compared with clinical judgment: an evaluation in a rehabilitation ward. Age & Ageing, 37(3), 277-281.
- Vassallo, M., Stockdale, R., Sharma, J. C., Briggs, R., & Allen, S. (2005). A comparative study of the use of four fall risk assessment tools on acute medical wards. Journal of the American Geriatrics Society, 53(6), 1034-1038.
For more information on falls and a more comprehensive reference list, see:
- Gray-Miceli, D. (2008). Preventing falls in acute care. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (3rd ed.). New York: Springer Publishing Company, Inc. (pp 161-198).