Physical therapists as experts of human movement and exercise are in a pivotal position to provide fall prevention services to at-risk populations. But how do we discover who belongs in these at risk populations? We conduct a screen to determine who receives a more in depth assessment. The American Geriatrics Society provides Clinical Practice Guidelines which recommends, in part, that “all older people should be given a short screen for fall risk, and if at risk referred on to further detailed assessment and intervention.”
But what is actually meant by a “screen”? What is the definition of “short”? What items should be in the screen? Do “all older people” get the same screen? What does “further detailed assessment and intervention” include? Who should be doing the assessment? Where does the assessment take place and how are these result measured?
These are all valid questions and the answers may actually be variable depending on the goal of the screen or assessment, the setting in which it is performed and the population on whom it is done. Unfortunately, there is no one screen, assessment or outcome measure that can be applied across all setting to accurately predict fall risk for all populations of those at risk for falls.
Meaning of “screen” and "assessment"
In the context of falls, a screen is a process that determines who is at risk for falls and who should receive a multifactorial assessment (Chen 2013). An assessment is an in-depth measure of the potential causes of falls in a particular individual in enough detail to make decisions on which factors require intervention (Ganz 2007).
What is meant by “short”?
Extensive research has been done to identify independent risk factors for falls such as age > 65, being female, living alone, taking > 4 medications, having a gait speed of < 1.0 m/s, inability to rise from a chair, presence of dementia, lower extremity muscle weakness, having a vitamin D deficiency, and demonstrating gait variability during dual tasking to name a few. The value, or clinemetric properties, of each of these factors is extremely variable. In other words, if an individual lives alone and has a Vitamin D deficiency, which one of these factors contributes more to the risk of falling? This type of information does not exist equally for all factors, screens or assessments. What is known however, is that falls are multifactorial in nature and therefore the manner in which falls are measured should also be multifactorial. Research has focused on identifying the most appropriate combination of risk factors that will be cost effective while still yielding accurate and useable result.
The fall risk screen recommended by the American Geriatrics Society consists of 3 questions:
- Has the individual had 2 or more falls in the prior 12 months?
- Does the individual present with an acute fall?
- Does the individual have a self-reported or is there an observed difficulty with walking or balance?
A “yes” answer to any one of the above screening questions categorizes the older adult into the “high risk of falls category” which warrants further multifactorial assessment. It is intended that any individual working with older adults could conduct this screen.
A “no” answer to the screening questions above, triggers the following question, “Has there been a single fall in the last 12 months?” If the answer is “no” than the recommendation is to rescreen that older adult periodically throughout the year. If the answer is “yes” than an evaluation of gait and balance occurs.* If abnormalities are found, then a multifactorial assessment is recommended which includes the following assessments:
- History of falls – frequency, symptoms, injuries
- Gait, balance, and mobility
- Visual acuity
- Other neurological impairments
- Muscle strength
- Heart rate and rhythm
- Postural Hypotension
- Feet and footwear
- Environmental hazards
*The Guideline does not specifically recommend gait and balance tests but reports that the TUG, BBS, and POMA are frequently used tests to evaluate gait and balance. It is important to note here that the BBS has been found to be an inferior assessment for fall risk in community dwelling older adults however, is a psychometrically sound test for the assessment of balance in the older adult. (Muir 2008) Other assessments that may be appropriate in a primary care setting include SLS or a measure of gait speed.
Community dwelling older adults
Community dwelling older adults are identified as at risk for falls by the US Preventative Services Task Force if:
- There is a reported history of falls.
- There is a reported history of mobility problems.
- If there is poor performance on the Timed Up and Go Test (performed in) = 10 seconds.
It is intended that this screen be completed by physicians or other medical staff at a physician office visit.
- Have you fallen during the last 3 months?
- Do you use any assistive walking devices such as a walker or a cane?
- Are you afraid of falling?
It is intended that this screen be completed by any individual employed at a senior center in the following departments: Day Center, Case Management, Home Care, Outreach to Potential Clients
The FRAST is a multifactorial tool developed for community dwelling older adults = 65 to be administered by minimally trained staff with a follow-up interpretation provided by a primary care provider. This primary care provider could be a physician or physical therapist if the therapist is practicing under direct access.
The FRAST can be used as a screen despite the use of the word “assessment” in the name because some of the actions recommended by the tool are further assessments. The tool assess fall risk factors individually for a composite score out of 30. A score of = 5/30 indicates the need for a review from the primary care provider to determine further targeted intervention strategies. A low cutoff score was chosen because there is greater harm in misclassifying a faller as a nonfaller than in classifying a nonfaller as a faller.
In a large study of over 2,700 community dwelling older adults, a group of authors from France identified 4 determinants of recurrent falls among many known risk factors for falls including age, gender, living alone, BMI, cognitive status via the MMSE, health perceptions score, alcohol consumption, medication use, use of psychotropic drugs, history of falls in the last year, Five Time Sit to Stand time, TUG time, one legged stance time, and duration since last follow-up with physician. Recurrent falls were defined as those who have experienced 2 or more falls. A risk score was subsequently developed for each of the 4 determinants so that an individual could be stratified according to fall risk:
4 determinants for recurrent falls:
- History of falls in the last 12 months = 8 points
- Living alone = 3 points
- Taking > 4 medications per day = 3 points
- Female gender = 2 points
Low risk = 0 – 4 points Moderate Risk = 5-10 points High Risk = 11 – 16 points
Recommendation: Perform an in-depth multifactorial assessment for those in the high risk category AS WELL AS for those in the moderate risk category who fail the Five Time Sit to Stand Test (>15 seconds)
The Initial Preventative Physical Examination (IPPE) is one-time benefit for a Medicare beneficiary and must occur within the first 12 months after the effective date of that individual’s 1st Medicare Part B coverage period. Included in the IPPE is a “review of the beneficiary’s functional ability and level of safety”. This includes a measure of fall risk. To be a covered service, the components of the IPPE must be performed by an MD, DO, NP, PA, or a CNS. Medicare indicates that the provider must use any appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review at a minimum the following areas:
- Hearing impairment
- Activities of Daily Living
- Falls risk
- Home Safety
Physician Quality Reporting System (PQRS)
This is Medicare’s incentive-based reporting program that becomes mandatory in January 2015. This means that non-participating providers receive a 1.5% reduction in Medicare reimbursement.
PQRS #154: asks those > 65 with a history of falls who have had a fall risk assessment in the previous year, “Have you fallen in the last 12 months?” If yes, then the number of falls and the number of injuries that have occurred as a result of the fall(s) is recorded. Then the older adult receives a multifactorial assessment that includes:
- Gait, balance and mobility assessment (i.e TUG)
- Orthostatic Hypotension (supine and standing)
- Visual Deficits (elf-report)
- Environmental Hazards in the Home (checklist)
- Medication Review (Beer’s Criteria)
If the older adult does not report a fall in the last 12 months, than the falls risk screen is considered complete.
PQRS #155: requires that older adults > 65 with a documented history of falls in the last 12 months, have a multifactorial plan of care implemented which must include:
- That balance/strength and gait training education was provided OR that referral to physical therapy or a community-based exercise program for balance, strength, and/or gait training occurred
- Documentation that Vitamin D supplementation was advised, OR that the patient was referred for Vitamin D supplementation advice.
The STEADI Toolkit was developed by the CDC to assist primary care providers to incorporate fall risk assessment and individualized interventions into their clinical practice. It was launched in 2011 to pilot in 3 states over 5 years (Oregon, New York, and Colorado). It is based on the Clinical Practice Guidelines for Fall Prevention developed by the AGS and the BGS and is presented in algorithmic format. (Add link – below)
Screen = Stay Independent Brochure a score of > 4 triggers an evaluation of gait, strength and balance.
- Timed Up & Go
- 30 Second Chair Stand
- 4 Stage Balance Test
The next step is to determine the number of falls that have occurred in the last year as well as to determine the circumstances of the fall(s). If >2 falls or a fall injury OR 1 fall in the last year, then the older adult receives a multifactorial risk assessment which includes:
- A review of the Stay Independent Brochure
- Falls history
- Physical Exam
- Postural dizziness/hypotension
- Cognitive Screening
- Medication Review
- Feet and footwear
- Use of mobility aids
- Visual acuity check
Gait speed has been dubbed “the sixth vital sign.” It is a reliable and valid measure. Self-selected walking speed can be used to help determine outcomes such as functional status, discharge location and the need for rehabilitation. Speeds less than 1.0 m/s have been associated with an increased fall risk and indicate a need for intervention to reduce falls risk.