preventing falls in your communityRisk Factor Assessment Tools
Falls are due to many factors, and a holistic approach to the individual and environment is necessary. A number of assessment tools are readily available to identify adults’ fall risk factors. Several tools can be used with confidence as part of a comprehensive falls prevention program.
Use the tool that works best for your adult.
Gait and Balance Assessment
Fear of Falling Assessment
Cognitive Assessment
Depression Assessment
Environmental Assessment Checklist
Assessment of the Hospitalized Patient
Research on Assessment Tools
Gait and Balance Assessment
Back to the topTimed Up and Go (TUG)
A simple office based test used to identify persons at risk of falling due to balance or gait problems. Individuals should be instructed to rise from a straight backed chair without using their arms. Individual uses his or her cane, walker or gait device and wears shoes. Observe this person walking 10 feet, turning, and returning to their chair. This event should be timed. It has been found that adults without balance problems can perform this test in under 10 seconds. Alternatively, samples of adults with mobility difficulty or ADL dependence require more than 30 seconds.Normal TUG TUG 1 (wmv) TUG 1 (fla) |
Abnormal TUG TUG 2 (wmv) TUG 2 (fla) |
Normal timed Sit to Stand TUG 3 (wmv) TUG 3 (fla) |
Available:
http://www.saskatoonhealthregion.ca/pdf/03_Timed%20Up%20and%20Go%20procedure.pdf
http://foxrehab.org/uploads/pdf/2008_AssitedLivingConsult_TUGTest.pdf
Get Up and Go Test
Assesses risk of falling and identifies those with balance deficits. Measures dynamic balance, gait speed, and functional capacity for household and community mobility. Requires 5 minutes to administer. Training is required to administer this test.
Available:
http://www.aan.com/practice/guideline/uploads/273.pdf
Berg Balance Scale (BBS)
Rates the ability of an individual to maintain balance while performing Activities of Daily Living related tasks. Components include balance, lower and upper extremity strength. 14-item scale designed to measure balance of an adult in a clinical setting. Requires 15 to 20 minutes to administer. Training is required to administer this test.
Available:http://www.strokecenter.org/trials/scales/berg.pdf
http://web.missouri.edu/~proste/tool/Berg-Balance-Scale.rtf
Dynamic Gait Index
Assesses the likelihood of falling in adults. Used to rate the ability of an individual to modify gait in response to changing task demands. Designed to test eight facets of gait. Requires 15 minutes to administer. Training is required to administer this test.
Available:
http://web.missouri.edu/~proste/tool/Dynamic-Gait-Index.rtf
Tinetti Performance Oriented Mobility Assessment (POMA)
Tinetti Performance Oriented Mobility Assessment (POMA)
Easily administered task-oriented test that measures an adult’s gait and balance abilities. Rates the ability of an individual to maintain balance while performing Activities of Daily Living related tasks. Components include balance, lower and upper extremity strength. Requires 10 to 15 minutes to administer. Training is required to administer this test.
Available:
http://web.missouri.edu/~proste/tool/Tinetti-Balance-Gait--POMA.rtf
Fear of Falling
Activities-specific Balance Confidence (ABC) Scale
The ABC is a 16-item scale. Adults are asked to rate their confidence that they will lose their balance or become unsteady in the course of daily activities. The ABC can be self-administered or administered via personal or telephone interview. Regardless of method of administration, each respondent should be queried concerning their understanding of instructions, and probed regarding difficulty answering specific items.
Available:
http://web.missouri.edu/~proste/tool/
Activities-specific-Balance-Confidence-Scale.rtf
Falls Efficacy Scale (FES)
FES is a 10-item rating scale to assess confidence in performing daily activities without falling.Available:
http://www.fallpreventiontaskforce.org/pdf/FallsEfficacyScale.pdf
http://www.injuryresearch.bc.ca/publications/repository/falls%20efficacy%20scale.pdf
Cognitive Assessment
Mini Mental State Examination (MMSE)
Widely used, well-validated screening tool for cognitive impairment. Briefly measures orientation to time and plan, immediate recall, short-term verbal memory, calculation, language, and construct ability.
Montreal Cognitive Assessment (MoCA)
Available at:
http://www.mocatest.org/
St. Louis University Mental Status (SLUMS)
Available at:
http://aging.slu.edu/index.php?page=screening-tools
Depression Assessment
Geriatric Depression Scale
Developed as a basic screening measure for depression in adults.
Available:
http://www.stanford.edu/~yesavage/GDS.html
PHQ-9
Available:
http://www.phqscreeners.com/
Environmental Assessment Checklists
Assessment of the Hospitalized Patient
Morse Fall Scale
National Center for Patient Safety recommended risk assessment tool for inpatients. The Morse Fall Scale (MFS) is used widely in acute care settings, both in hospital and long-term care inpatient settings. The MFS requires systematic, reliable assessment of a client’s fall risk factors upon admission, after a fall, with a change in status, and at discharge or transfer to a new setting. It is a reliable and valid measure of fall risk.
Available:
http://www.patientsafety.gov/SafetyTopics/fallstoolkit/
Hendrich Fall Risk Assessment
National Center for Patient Safety recommended risk assessment tool for inpatients. Used in some long-term care settings. This assessment is not as researched as the Morse Fall Risk Assessment.
Available:
http://www.nursingcenter.com/prodev/ce_article.asp?tid=751712
St. Thomas Risk Assessment Tool (STRATIFY)
Well supported tool that identifies risk factors and creates a risk profile score. Used to identify clinical fall risk factors in the elderly and to predict chance of falling.Available:
http://www.injuryresearch.bc.ca/Publications/Repository/STRATIFY.pdf