The goal of both falls risks screenings and assessments should include the identification of specific targets for interventions and referral to community and/or health care providers who may assist the older adult with managing their falls risks.
There do not appear to be any standardized approaches to screening for demographics and medical and health history. However, on the basis of the extant literature that indicates these are risk factors for falls, the authors recommend that, at a minimum, the items listed in Table 3 should be collected.
There are several instruments for screening and assessing somatosensory function that may be useful for predicting falls in community-dwelling older adults (Table 4).
There are many instruments for assessing physical function. Some include assessment of sensory function but have been included here because they describe function at the level of the individual, rather than a particular body system or structure. Table 5 identifies only those instruments that are objective and have been evaluated for their potential to inform the tester about falls risks. This list is not necessarily exhaustive, but is representative of commonly used instruments for physical function screening and assessment as related to falls.
Fear of falling, falls efficacy, and balance confidence are constructs that have been explored as to their utility in predicting falls in older adults. The Falls Efficacy Scale163 and all of its versions164,165 appear to provide investigators with a valid avenue for assessing falls efficacy, while the 16- and 6-item Activity-Specific Balance Confidence scales166,167 have emerged as useful measures for assessing perceived mobility problems in older adults (Table 6). For more comprehensive lists of psychological instruments related to falls among older adults, please see the studies of Moore and Ellis.174
A number of instruments are available for home safety as it relates to fall risk, but there is little evidence available to support the use of these instruments. Table 7 includes information about the Home Falls and Accident Screening Tool168 and the Westmead Home Safety Assessment170 as these 2 instruments appear to have undergone at least some assessment of psychometric properties, with both providing evidence of acceptable content validity and interrater reliability.168–171 Of the 2 instruments, the 72-item Westmead survey appears to be the most comprehensive, as it explores a greater number of potential risks including outdoor falls hazards.
Most of the falls risk screening instruments found in the literature to date tend to focus on a single or a few related risk factors. While many clinicians and investigators use various tests to evaluate risks across several domains, there is little information available in terms of a comprehensive falls risk screening instrument that would allow investigators to simultaneously assess multiple risk factors, examine the interrelations among risk factors, and derive a comprehensive falls risk score or odds ratio. Recently, however, 2 multidimensional instruments have appeared in the literature. The Falls Risk for Older People in the Community (FROP-com)172 and the Thai-FRAT173 incorporate information from multiple domains into a single falls risk score (Table 8). For example, the Thai FRAT incorporates 6 factors including history of falls, female gender, impaired balance, use of medications, visual deficits, and style of house into an overall risk score that is predictive of future falls and mortality. The instrument appears to predict falls with good sensitivity and specificity (92% and 83%, respectively), but at present the instrument is generalizable only to older adults with a previous history of falls. The FROP-com is perhaps the most comprehensive instrument, as it purports to assess 13 risk factors via a 28-item survey. While this instrument appears to be reliable and predictive of falls, the items rely on self-report and/or subjective appraisal of the tester. This may explain the no greater than moderate predictive validity of the instrument. Nonetheless, encouraging results from the validation of these instruments should bolster continued efforts at the development of comprehensive falls-risk screenings and assessments.
Assessing falls risks is becoming a greater concern from a variety of perspectives. From the public health perspective, falls in older adults presents the number 1 cause of injurious death, a threat to independence and quality of life for the older adult, and a financial drain on the patient, the family, and the community. In addition, health care providers must strive to meet the needs of their patients, and provide a safe environment in which they care for their patients. For these reasons, increased emphasis has been placed on falls-risk management. The literature reveals that falls risks exist in several domains, and that there are numerous instruments from which the clinician might choose to screen and/or assess falls risks. Thus, it is important that the clinician decide what instrument(s) are most appropriate given the history of the patient, the resources available, and the setting in which they are working. Some of the tools mentioned are indeed indicated as positive predictors of falls in older adults and can potentially identify an older adult at risk for falls. However, few research studies attempt to envelop multiple domains of risk. The quick screening tools that have been revealed may not identify the actual falls risk factor or cause of fall. In addition, those tools that are comprehensive in nature cannot be easily delivered by lay leaders in community-based settings. Thus, development and use of comprehensive falls risk screening tools that identify and weight falls risk factors is encouraged among researchers and clinicians and should be a focal point of falls prevention research, as comprehensive screening algorithms may lower the rates of false negatives associated with using very specific instruments that screen or assess in only 1 domain. Programs can then be implemented specific to the falls risk factors identified, and those older adults that are identified can receive referrals for additional medical services as deemed medically necessary. Furthermore, clinicians can use comprehensive falls risk screening tool outcomes to aid in identifying those older adults at risk for falling and those with falls history, so that programs can be initiated for falls prevention, falls risk reduction, and intervention strategies.
This review article is part of a literature review for dissertation preparation of Jennifer M Fabre, PT, PhD, while a student at Louisiana State University. The overall project, development and validation of the Comprehensive Falls Risk Screening Instrument, was supported by a grant from the Faculty Research Grant Program that was sponsored by the Office of Research & Economic Development at the Louisiana State University (PI = Ellis) and an AAHPERD Research Consortium Graduate Student Grant (PI = Moore). At the time the project was funded, Drs Rebecca Ellis and Robert H. Wood were affiliated with the Department of Kinesiology at Louisiana State University. The authors thank all of the community leaders for their participation, as well as the numerous undergraduate students in the Department of Kinesiology at Louisiana State University who volunteered to assist with the falls risk screenings.
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assessment; comprehensive; falls risk; screening