Journal of Geriatric Physical Therapy:
Falls Risk Factors and a Compendium of Falls Risk Screening Instruments
Fabre, Jennifer M. PT, CSCS, PhD1; Ellis, Rebecca PhD2; Kosma, Maria PhD3; Wood, Robert H. PhD4
1School of Allied Health Professions, Louisiana State University Health Sciences Center—Shreveport, Louisiana.
2Department of Kinesiology and Health, Georgia State University, Atlanta.
3Department of Kinesiology, Louisiana State University, Shreveport.
4Department of Human Performance, Dance, and Recreation, New Mexico State University, Las Cruces.
Address correspondence to: Jennifer M Fabre, PT, PhD, CSCS, Department of Physical Therapy, School of Allied Health Professions, LSUHSC-S, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932 (firstname.lastname@example.org).
Clinical Problem: Falls are the leading cause of nonfatal injuries and injurious death among older adults; the aftermath of a fall stresses the health care system and places financial and psychological burdens on the patient and family. Because of this, fall prevention/risk reduction is a primary focus of numerous health care agendas. Over the last 2 decades, clinical research has provided clinicians with a variety of screening tools to quantify risk factors for falls. The majority of these measures focus on single domain intraindividual (eg, balance, strength, vision) or extraindividual (eg, home safety) falls risk factors. Some of these single domain instruments are easily introduced and administered by community lay leaders. When a more comprehensive assessment across multiple domains is required, the assessment cannot easily be administered by community program leaders. A physical therapist must determine which instrument, or combination of instruments, best targets risk of falling for a given older adult.
Purpose: This integrative review of the literature will provide clinicians and researchers a concise examination of falls risks factors and a compendium of falls risk screening and assessment instruments. Methods: Searchable databases, such as Medline and CINAHL were used to identify articles about strategies used for fall risk assessment. Information about measurement properties and characteristics were extracted and are presented in table format.
Conclusion: Comparison of recently developed multidimensional and comprehensive screening algorithms for falls risk identification may aid in lowering the rates of false negatives associated with using very specific instruments that screen or assess in only 1 falls risk factor domain.
A fall can be defined as an event resulting in the person or a body part of the person unintentionally coming to rest on the ground or other surface lower than the body.1 Falls are the leading cause of nonfatal injuries and injurious death among older adults.2 It is estimated that 1 in 3 persons older than 65 years will fall each year.3 Between 20% and 30% of those who fall suffer moderate to severe injuries including fractures and head trauma, which can lead to mortality, significant disability, decreased independence, and early admission to nursing homes.4 In 2005, 15,800 people 65 and older died from injuries related to falls; about 1.8 million people 65 and older were treated in emergency departments for nonfatal injuries from falls, and more than 433,000 of these patients were hospitalized.2
Fall events contribute to significant financial burden. In 2000, the total cost of treating fall-related injuries for adults 65 and older in the United States exceeded $19 billion5 and by 2020 is expected to reach nearly $55 billion (in today's dollars).6 Long-term care is particularly costly insofar as 40% of nursing home admissions are precipitated by falling or instability6 and as many as 25% of older adults who lived independently prior to a fall resulting in a hip fracture reside in a nursing home for at least 1 year.7
The psychological impact of falls is equally disconcerting. The prevalence of postfall anxiety syndrome and function-impairing fear of falling affects 73% of those who have fallen within the last year.8 Even among individuals who do not report a recent fall, postfall anxiety syndrome and fear of falling can be as high as 46%.8 In turn, a decrease in activity due to an impending fear of falling can lead to further reduced mobility and independence in performing daily activities.9
As a consequence of the serious public health problems associated with falls that challenge the physical and psychological well-being of older adults and the stability of our health care system, falls and falls risk reduction have become a focal point of public health care agendas. Over the last 2 decades, there has been an emergence of data regarding the identification of falls risk factors, as well as the development and introduction of a number of falls risk screening and assessment instruments. Unfortunately, most instruments tend to focus on certain risk factors such as intraindividual (eg, balance, strength, vision) or extraindividual (eg, home safety), but not both. Moreover, while there are advantages to having access to a wide array of tools for quantifying falls risks, one of the disadvantages is that comparisons across studies are problematic. The purpose of this review is to provide scientists and practitioners with a concise examination of falls risks factors and a compendium of falls risk screening and assessment instruments.
RISK FACTORS FOR FALLS
Falls risk factors are frequently classified as intrinsic or extrinsic (Table 1). Intrinsic factors reflect health history and biological factors such as age, gender, acute or chronic, physical and/or psychological illness, mobility or sensory deficits, falls history, and incontinence.12 Extrinsic factors include medication effects and home hazards.12
Guidelines for the prevention of falls in older persons compiled by the Panel on Falls Prevention of the American and British Geriatrics Society have been developed using evidence found in systematic reviews, randomized and controlled pre- and posttrials, meta-analyses, and cohort studies.10 The Guidelines identify and rank key risk factors for falls, and present odds ratios (OR), with values ranging from 1.7 to 4.4.10 These risk factors include muscle weakness, history of falls, gait or balance deficits, assistive device usage, visual deficits, arthritis, impaired activities of daily living, depression, cognitive impairment, and age more than 80 years. Moreover, there is potential for interaction among risk factors insofar as the relative risk of falling increases from 8% with no risk factors to 78% with 4 or more risk factors.13,14
Intrinsic Risk Factors
Included among the intrinsic risk factors are the nonmodifiable factors of age, race, and gender. Table 2 reveals statistics drawn from the 2006 US Census data for falls-related injuries according to race and gender/sex. While not subject to change, clinicians and scientists certainly should include an assessment of these in an overall risk profile. In addition, there are several modifiable risk factors that are primarily related to physiological phenomenon and associated with health and health behaviors. These factors are, therefore, subject to change and are frequently targeted in falls prevention interventions.
Age is directly associated with number and severity of falls.15 Age-related physiological and biological changes can affect overall mobility resulting in a decline of overall physical fitness, increasing falls risk.12,15 One in 3 community-dwelling, older adults 65 or more falls at least once a year. Strikingly however, the epidemic increases with age such that those 85 and older have 4 to 5 times the risk of falling as compared with younger adults.15
Female older adults are 67% more likely to sustain a nonfatal fall than males.2 The higher rate among females may be attributed to generally lower muscle strength and lower levels of physical activity.17 However, the age-adjusted fatality rate due to falls is 49% higher for males than for females, perhaps due to the cause or severity of the fall2 as males tend to fall from greater heights and/or may be in poorer health at the time they fall.
Race or ethnicity is associated with falls risk. The 2006 US census retrospective data suggest that White, non-Hispanic older adults fall and sustain more fall-related injuries than Black, Hispanic, and other non-Hispanic older adults.16,18,19,20 Similarly, White women demonstrate significantly higher rates of fall-related hip fractures than women of other races.20 In spite of these findings, evidence of sociodemographic factors as related to falls and falls risk is scant and equivocal and, in particular, remains unsubstantiated by prospective data. For example, while Hanlon et al.19 observed a 23% lower rate of reporting a fall (within the previous year) among African Americans than that among White older adults, they did not find race to be a significant predictor of multiple falls in a 10-year longitudinal study.19 Furthermore, data from 2 independent laboratories21,22 reveal similar rates of reported falls in Whites and African Americans. Thus, the relationship between race and falls represents a current gap in the literature that should be addressed as we examine health disparities and identify target audiences for falls prevention programs.
While data regarding other potential sociodemographic risk factors are scant, there is some evidence indicating that education level and income are inversely associated with falls risk.19,23 These data suggest that relationships between ethnicity and falls risk may be influenced more by a social determinant than by a biological determinant. While there are some data describing relationships between these factors and “falls risks,” a direct relationship between falls and sociodemographic factors has not been established. Rather, poor (below poverty level) or near poor adults are believed to be disadvantaged in terms of health status, health care utilization, and health behaviors, and that poorer overall health or access to health care or community resources may be contributing factors to falls among older adults with lower income or lower educational levels. In the absence of direct compelling evidence, however, the relationships between sociodemographic variables and falls, as with race, also represent a current gap in the literature.
Older adults who have experienced 1 or more falls have 3 times the risk of falling again within the following year compared to participants with no history of falls.24 Furthermore, older adults who have sustained a fall decrease their overall level of physical activity possibly inducing a gradual decline in mobility that further interferes with the potential to obtain a full recovery and return to prior functional status. Consequently, an older adult is more likely to suffer one or more additional falls.25
Acute and chronic health disturbances such as influenza and infections, bowel and bladder incontinence, osteoarthritis,26 Parkinson disease,26 cerebrovascular accidents,26 and conditions associated with cardiovascular disease27,28 can also have significant detrimental effects on fall rates among older adults. Among the most common chronic diseases in older adults is osteoarthritis (OA), a progressively incapacitating disease with clinical manifestations that negatively affect the older adult's ability to perform daily activities.29 Osteoarthritis is subsequently associated with a decrease in physical activity and affects more than 50% of people aged 65, and 70% of people older than 75 years.29,30 The RR of falling among older adults with OA is 2.4,10 and in particular, those with OA have an increased chance of tripping over an obstacle and a decreased standing balance test score as compared to controls.31
Other comorbidities such as cardiovascular disease and blood pressure irregularities increase in prevalence with age.27 In an aged, weakened, or pathological system, the heart and vasculature are less effective in meeting homeostatic demands during physical activity, and functional limitations are more evident with worsening heart function. Moreover, hypertension worsens cardiac performance, renal function, and cerebral blood flow. This places the older adult at risk for abnormal blood pressure regulation and cerebral perfusion, leading to postural and postprandial hypotension, carotid sinus hypersensitivity, cardiac arrhythmias, or other syncopal events27,28 and thereby increases incidence of falls.
The somatosensory, vestibular, and visual systems are responsible for receiving and transmitting sensory information via afferent nerves to the central nervous system and are therefore important in maintaining balance and defending against falls. Age is associated with impairments in somatosensory32,33 and mechanical receptor responsiveness34,35 as well as problems with integration of external stimuli.36,37 These deficits are associated with an increase in postural sway,38 a strong indicator of standing balance. Therefore, function of the somatosensory system is important to evaluate when determining falls risk insofar as these deficits may negatively impact the older adult's safety, body position awareness, and/or muscle reaction to a perturbation while in a balanced position39 during functional activities.
The vestibular system provides information about position in space and head movement with respect to gravity and inertial forces. Age affects the vestibular system such that there is an increase in lipofuscin content, a 40% reduction in hair cells for those older than 70 years, a progressive loss of nerve fibers in the peripheral vestibular system,40,41 and an overall decline in vestibular system function, which contribute to unsteadiness, dizziness, and lightheadedness.42 The incidence of falls for those aged 65 to 74 years with bilateral vestibular dysfunction is 26.1% greater than age-matched community-dwelling older adults with normal vestibular function.43
Age-related visual system problems include poor lens elasticity, lack of lens transparency, decreased peripheral field view,44 reduced acuity in near vision, decreased contrast sensitivity,45 and decreased accommodation during lighting changes. Other age-related pathologies known to affect visual function include cataracts, macular degeneration, and glaucoma, and other factors related to visual functioning associated with falls include using bifocal and multifocal lenses, wearing ill-fitting glasses, or relying on an out-of-date lens prescription.46 Not surprisingly, older adults with visual deficits are 2.5 times more likely to sustain a fall than those without visual deficits.10 An increase in sway during standing when visual input is altered or removed may account for this increased risk.47 Contrast sensitivity48 (deficits often seen in older adults with cataracts)49 and visual acuity (worse than 20/30)48 are each associated with 2 or more falls.
Physical fitness, defined as a set of physical attributes that contribute to one's ability to perform physical activities, includes components such as cardiorespiratory function, muscular strength and endurance, balance and coordination, flexibility, and body composition.50 Specific age-related changes in physical fitness that are associated with falls include loss of muscle strength and endurance, loss of range of motion or flexibility, and deterioration of balance and coordination.51,52
Aging and the reduced physical activity levels that often accompany aging, are associated with a deterioration of muscular strength53 accompanied by signs of sarcopenia and atrophy. It is estimated that 20% to 40% of maximal strength is lost by the age of 65 in a sedentary adult.54 Strikingly, older adults with muscular weakness14,56 have a RR = 4.4 of sustaining a fall.10 In general, decreased ankle dorsiflexion power,56 hip strength,57 and knee extension strength56 are associated with falls history in older adults. In addition, nerve impulse conduction to and from muscular tissue is prolonged in older adults, affecting coordination and sensory integration during activities, which limits balance reactions to an impending fall.58
Age-related changes in cardiorespiratory fitness may have an indirect impact on fall frequency in older adults. Advancing age is associated with reduced lung volumes and capacities, decreased cardiac output at rest and response to stress, and increased systolic blood pressure and peripheral vascular resistance. Among the critical functions of the cardiovascular and cardiorespiratory systems is their role in recovery following a physical activity restriction. Recovery is often prolonged in older adults because of multisystem impairments59 and a tendency toward a greater relative work rate during physical activities. These factors may lead to an increased reliance on anaerobic metabolism, as well as slower heat elimination. However, data establishing a direct link between age-related changes in cardiorespiratory fitness and falls or falls risk are not presently available and represent a gap in the literature regarding fitness and falls risk.
Another important element of physical fitness is flexibility. Most of the age-related decline in flexibility is related to changes in the viscoelastic properties of muscle including a decrease in elastin and an increase in collagen of the muscle tissue.60 Similar to cardiovascular fitness, the link between flexibility and falls is at best hypothetical insofar as no evidence exists directly relating flexibility to falls in older adults.61 Nonetheless, age-related changes in bone and connective tissue structure and function surrounding the joint in older adults can affect movements, limiting the ability to execute daily tasks and other areas of physical function. While research regarding the relationship between certain fitness measures and falls is scant, the available data in general indicate an inverse relationship between physical fitness and falls.
Functional outcomes that are of particular relevance in the falls literature include competency with basic and instrumental activities of daily living (BADL and IADL, respectively). Difficulty with BADLs (such as feeding oneself, dressing, bathing, getting out of bed, toileting, walking, and climbing steps and stairs)62,63 is associated with an increased falls risk. Difficulty with IADLs (such as grocery shopping, performing housework, gardening, preparing meals, or using a telephone)62,63 is associated with a loss of balance.64
Poor mobility or other physical disabilities such as gait abnormalities and poor postural control correlate with functional balance.65 Postural sway has a higher velocity in older adults than in younger individuals,66 and sway during static stand in the anteroposterior direction is greater in older adults with history of falls than in those with no history of falls67 indicating less postural control and greater postural instability in older adults with history of falls. In addition, common gait deficits observed in older adults such as an increased stride width, a reduced walking speed,68 and stride-to-stride variability are independent predictors of falling.14,69 Balance deficits such as postural sway and gait deficits can impose up to 3 times the risk (RR = 2.9) of falling.10
In general, the use of assistive devices is indicative of a high risk for falls (RR = 2.6),10 and not surprisingly, time to complete a functional mobility test by community-dwelling older adults with a history of falls was highly correlated (r = .95) with the type of assistive device used for ambulation.70 The extent to which the use of assistive devices contributes to falls risk is not entirely clear; however, walking without a mobility aid when one is prescribed, and/or an otherwise inappropriate use of such a device can be harmful.71 Used correctly and appropriately, however, assistive devices such as walkers, canes, scooters, and wheelchairs may reduce the risk of falling by allowing safe mobility while increasing independence and activity levels. Thus, there is a present gap in the literature regarding the nature of the relationship between the use of assistive devices and increased falls risk.
Hazardous behaviors cause approximately 5% of all falls.13 Behaviors that increase an older adult's risk for falling include frequent changing of shoe styles or wearing inappropriate footwear,45 alcohol consumption,72 and attempting to perform activities or chores beyond one's physical ability.73,74 Many falls occur while climbing ladders, trimming trees, or performing overhead activities while standing on a stool.73 Inattention to one's surroundings also increases the chance of falling particularly in a new environment or transition area such as a doorway entrance or an elevation change.73,74
Psychological factors may independently or in concert with environmental demands contribute to a reduction in physical activity and consequent deterioration in strength, balance, and coordination.13 Psychological states common in older adults, such as depression (RR of 2.2), dementia, delirium, anxiety, and Alzheimer's disease,75 may also diminish alertness or cognitive functioning. A decline in cognitive function (RR = 1.8) can thereby increase the risk of falls.10
Self-rated health status and experience of previous falls are significantly associated with fear of falling.76 As a reaction to a previous fall, the fear of falling again can lead to avoidance of performing chores or participating in various forms of physical activity.77–79 The consequential degeneration of postural control80 then places the older adult at an increased risk of future falls. Furthermore, fear of falling is an independent risk factor for decreased mobility and loss of quality of life that may affect social interaction76 and possibly health-related quality of life. The marked deficits in strength and health status81 observed among independent community-dwelling older adults who report a fear of falling underscore the importance of fear as a falls risk factor.
Extrinsic Risk Factors
Older adults use an average of 4.5 prescription medications and 2.0 over-the-counter medicines per person on a daily basis, and take roughly 26 different prescription drugs annually.82 The use of 3 or more medications, including prescriptive or over-the-counter medications, increases the risk of initial or recurrent falls,83,84 and the risk of falling increases with the number of prescription and over-the-counter medications taken concurrently. Few studies have assessed whether and to what extent various combinations of medications are associated with this risk, although there is evidence to suggest that concurrent use of nonsteroidal antiinflammatory agents, cardiac, and psychotropic drugs places patients at a high risk for falls.83
Certain classes of medications are associated with falls, including antidepressants, antipsychotics, long and short acting benzodiazepines and other anticonvulsants, antihypertensives, cardiac medications, analgesics, antihistamines, and gastrointestinal-histamine antagonists.85 Some of the more common side effects of medications include blurred or impaired vision, sedation or decreased alertness, confusion and impaired judgment, delirium, compromised neuromuscular function, anxiety, or hypotension leading to dizziness and lightheadedness.
Over 20% of community-dwelling older adults are at increased risk for falls from taking 1 or more psychoactive medications,86 some of which are believed to increase the risk of falling by 66%.84 Antidepressants seem to be among the most common culprits, and serotonin reuptake inhibitors appear to be particularly linked to risk of falls.87 Antianxiety medications are also associated with falls risk. Benzodiazepines are prescribed for up to 15% of older adults to treat anxiety, insomnia, and seizure disorders88 and are associated with up to 48% greater risk for falls and fractures in older adults84 with an even greater risk for falling within 15 days of a new prescription.89
Medications prescribed for the treatment of certain cardiac conditions such as Class I antiarrhythmics (ie, sodium channel blockers) have adverse effects90 and are associated with an elevated risk of 1 or more falls.84 Clinically, there may also be episodes of increased arrhythmias or changes in the nature of arrhythmias resulting in cardiotoxic drug effects accompanied by dizziness and fainting.91 Among antihypertensive medications, diuretics are the only type that appear to independently increase the risk of falling.85 However, persons taking more than 1 type of antihypertensive drug have an increased risk of falling compared with those taking just one.92
Other medications commonly taken by older adults such as some narcotic pain relievers, as well as nonsteroidal antiinflammatory agents may not directly cause an increased risk for falls. However, indication for taking a certain medication (such as a diagnosis of arthritis; RR = 2.4) can consequently yield the medication as an indirect influence on falls risk.88 Also, the use of topical eye medications, not including miotics, is associated with a greater than 5-fold increase in falls risk because of pupil constriction.85 In addition, medications with anticholinergic properties, such as those used for nausea and gastrointestinal disorders, dizziness, Parkinson disease, antihistamines, and muscle relaxants may cause blurred vision, drowsiness, tachycardia, confusion, dizziness, agitation or anxiety, weakness, and/or delirium contributing to falls.85
Environmental hazards at home and in the community create opportunities for falls among community-dwelling older adults who may already have multiple intrinsic falls risk factors.74 A majority (55%) of injuries that occurred from falls take place inside of the home,93 and over 20% of additional fall-related injuries occurred outside, but near the home. The highest risk for falling in the home was among community-dwelling older adults who were mobile, but unsteady on their feet.94 The most common cause of falls was tripping or slipping while forward walking followed by falling during transfers from one position (chair to bed) to another or while negotiating stairs or steps.95,96 Thus, falls can occur while performing routine activities in the home like dressing, bathing, toileting, or walking along a familiar route.
It is estimated that 80% of homes have at least 1 hazard and that nearly 40% have 5 or more hazards that are associated with falls97 such as excessive clutter, electrical cords in walkways, throw rugs and loose carpets,97,98 inadequate lighting, floor surface transitions or slippery surfaces, lack of stair handrails, inappropriate chair or cabinet heights, and pets and pet-related objects.98–101 In addition, many homes present obstacles or barriers for safely executing activities of daily living such as negotiating outside steps or indoor stairs and using unsafe bathrooms. With respect to community hazards, poor sidewalk and pavement maintenance such as pavement cracks, tree roots, inadequate street markings, slippery footing, and obstacles in walkways (bike racks, flower boxes, and garbage cans)102 are other common causes of falls for older adults.
RISK SCREENING AND ASSESSMENT INSTRUMENTS
The initial step in virtually all falls prevention intervention programs is identification of persons at risk for falling. In selecting an effective screening tool, one must consider its validity with respect to aging adults. This goes beyond basic properties of construct validity, test-retest and interrater reliabilities, sensitivity, and specificity; it also must include understanding of the limitations of the instrument. It is important to consider the populations for whom the instrument has been validated; the availability and applicability of standardized written procedures that explicitly outline the appropriate use of the tool; the time, space, and equipment constraints imposed by the methodology; and the meaningfulness of the findings; that is, whether there exist established thresholds of “risk” that aptly indicate the need for intervention.103
Certainly, approaches to screening for falls vary across, and even within, disciplines. At a minimum, however, older adults should be screened for history of falls and use of certain medications at least once a year10 as these are among the strongest predictors of risk.104 But, regardless of the screening instrument, persons who screen positive for falls risks should be prompted for further detailed assessments. Detailed falls risk assessments are believed to be beneficial for older adults who have had one or more falls, have identifiable abnormalities of gait and/or balance, who report recurrent falls,10 or who are found to have a high falls risk as determined from a screening. An extensive assessment should be performed by a clinician with appropriate skills and expertise (as indicated by the specific outcome measure standards), which may then necessitate referral to a specialist.
Because of the wide array of conditions and circumstances that may lead to a fall in an older adult, a detailed assessment may include examination of history of fall circumstances, medications, acute/chronic medical problems, mobility levels, vision, gait and balance, functional mobility, basic neurological function, mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal, and cerebellar function, and basic cardiovascular status (heart rate and rhythm, postural pulse, blood pressure).10 In most cases, identification of specific risk factors in an individual can often be revealed with a thorough assessment.
Lists of falls risk screening and assessment tools and other tests are provided in Tables 3 to 8. Each table classifies the test/measure as useful for screening or more in depth assessment. This recommendation is based to some extent on the complexity of the test, including the time of administration, the training required of the tester, the cost of the equipment, and the population for whom the test is designed. Those items that are indicated as being appropriate for screenings typically require little time and little specialized training, are inexpensive, and are valid for use in general populations of older adults. On the other hand, those items designated as appropriate for assessments require more time as well as some specialized training, may be somewhat expensive, and/or may be limited to specific populations of older adults, such as those with specific diagnoses.
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.
Table 5-b. Physical ...Image Tools
SCREENING FOR DEMOGRAPHICS AND MEDICAL AND HEALTH HISTORY
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.
Somatosensory Screening Instruments
There are several instruments for screening and assessing somatosensory function that may be useful for predicting falls in community-dwelling older adults (Table 4).
Physical Function Instruments
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.
Table 5-a. Physical ...Image Tools
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
Home Safety Assessments
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.
SUMMARY AND CONCLUSIONS
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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