Evaluation of Fall Risk Tools
For each identified fall risk category, existing objective measures were sought. Only fall risk tools demonstrating both reliability and validity for the target population in multiple studies and described in more than 1 Cochrane review were included. Tools requiring purchase, found to be lengthy, or requiring a skilled and/or licensed tester were excluded. In addition, those measures, including items that may require immediate follow-up (ie, suicidal ideation), were excluded.
Assembling of Measures
Levels of scores (denoting low, medium, or high fall risk) for each measure were taken from best evidence available. For example, the CDC WISQARS data was used to determine the age parameters related to low, medium, and/or high fall risk.13 Multiple studies were considered in setting the cutoff scores for TUG,14 Modified Falls Efficacy Scale (MFES),15 and the Geriatric Depression Scale (GDS).16
Creation of Scoring Grid
Many test formats were considered for use in FRAST. Expert opinions were gathered from members of the National Council on Aging's Falls Free Coalition as well as posttest feedback from subjects. On the basis of this input, the original form was modified to improve ease of use. The current grid format was chosen for the facilitation of both quick visualization of results and improved attention to recommended interventions by the PCP. A low-vision form is available and language translations are under way. FRAST is not intended for use by older adults experiencing cognitive impairments. Weighting of the items was not possible on the basis of current literature and will be considered after the statistical analysis of reliability and validity studies. Scoring at this time is based on raw scores over 15 items, in which low risk = 0, medium risk = 1, and high risk = 2, resulting in total test scores ranging from 0 to 30. Since any score greater than 0 indicates at least medium risk on some items, a total FRAST score greater than 5 would result in PCP review.
Development of Interventions
Most recommended interventions were taken from the referenced articles describing the specific measure. Some input was based on the clinical expertise of the authors. When potential interventions fell outside of the scope of physical therapy practice of PT, the appropriate health care professionals from the faculty at the University of Montana's College of Health Professions and Biomedical Sciences were consulted for input and recommendations.
Multiple factors have been shown to increase fall risk in community-dwelling adults older than 65 years.17 These factors can be broken down into demographic traits (age, gender, etc), internal factors (health, medications, etc), and external factors (home environment and social) on the basis of best-available evidence; only those risk factors that were consistently identified as important were included in FRAST.18 Some fall risk factors, such as the condition of community sidewalks, are difficult to assess objectively and so were not included. On the basis of the combined clinical experience of the authors, risk-taking behavior (Figure 1, item 10) was felt to be an important aspect of fall risk that had not been previously studied and was included on FRAST for the purpose of primary data collection.
According to the CDC, in 2005, Americans aged 65 to 85 years and older, reported 3 284 671 unintentional injuries, of which, 64.4% were falls.13 Epidemiologic research demonstrates that 1 of 3 adults older than 65 years will fall each year in the United States.19 Stevens et al20 described that the risk of being seriously injured in a fall increases with age and that the rates of fall injuries for adults aged 85 years and older were 4 to 5 times that of adults aged 65 to 74 years. Nearly 85% of deaths from falls in 2004 were among people aged 75 years and older,20 and people older than 75 years who fall are 4 to 5 times more likely to be admitted to a long-term care facility for a year or longer.1 On the basis of these statistics, FRAST will assign a medium risk for those aged 65 to 74 years and a high risk level for those aged 75 years and older (Figure 1, item 1).
In studying unintentional, nonfatal, injury falls, it was found that about 70% of fallers were women.21 Although men are more likely to die from a fall, women are more likely to sustain a hip fracture. On the basis of these findings, being a woman will impart a high fall risk on FRAST and being a man will impart a medium fall risk on FRAST (Figure 1, item 2).
History of Falls
Literature on falls quickly reveals the high risk of falls in people with a history of falls.22 Among the general population of older adults, previous falls are the factor most strongly associated with risk of falling.23 In a literature review and meta-analysis on fall risk factors, Deandrea et al23 found that the strongest associations were found for history of falls for all fallers. Sai et al18 studied fall predictors in the community-dwelling older adults and also concluded that a significant predictor of being a faller was history of falls.18 On the basis of this evidence, fall history is included in FRAST (Figure 1, item 3). In Shumway-Cook's3 1997 study, a faller is defined as a person who self-reports 2 or more falls within the past 6 months and a fall is defined as any event that led to an unplanned, unexpected contact with a supporting surface.3 To provide consistency with the evidence, these criteria are utilized in FRAST.
Chronic Medical Conditions
Many chronic medical conditions are known to result in lower physical activity,24 diminished balance,25 and physical decline, all of which can lead to a heightened risk of falls.25 Older adults with lower extremity arthritis have been found to experience increased fear of falling, fall risk, and fall incidence.26 Some medications commonly prescribed for pain, diabetes, psychological disorders, and cardiovascular disease have each been associated with a higher fall risk.27 Patients with diabetes, peripheral neuropathy, and vascular disorders may all experience diminished lower extremity sensation and/or muscle strength, with a higher fall risk.28 Capturing a full medical history and assigning fall risk based on that medical history would be difficult on a simple screening tool; however, the importance of this information must be remembered. For the purposes of FRAST, polypharmacy will be one indication of a complicated medical history (Figure 1, item 5). The PCPs, including PTs, must be cognizant of the role of medical conditions and medication use in the assessment and treatment of their patients, especially those at risk for falls.
The literature describes the protective influence of daily physical activity on health and mental well-being in older adults as well as a direct positive impact on their fall risk.29 Kruger et al30 conducted a detailed analysis of the Behavioral Risk Factor Surveillance system data and concluded that regular physical activity can reduce the risk of falling. In a 2007 Cochrane review, which included 34 studies representing 2883 participants, Howe et al31 concluded that there were statistically significant improvements in balance with exercise interventions. Rogers et al32 found significant improvements in the physical functioning of older adults, which included reduction of blood pressure, fall risk, depression, and anxiety. Both the American College of Sports Medicine and the American Heart Association recommend that adults older than 65 years exercise moderately for 30 minutes per day, 5 to 7 days per week.33 On the basis of these findings, FRAST includes a self-assessment of physical activity level (Figure 1, item 4) and advises participation in age-appropriate, therapist-prescribed, exercise programs. The physical activity risk levels and recommendations on FRAST are based on the guidelines of the American College of Sports Medicine's Current Comments on Exercise and the Older Adult.34
Grue et al10 found that patients older than 65 years with hip fractures frequently had hearing, vision, and combined impairments. Abdelhafiz and Austin35 recommended that annual measurement of visual functions, such as acuity, contrast sensitivity, and depth perception, might identify older people at risk of falls and hip fracture. They further added that targeted intervention might have the potential of improving visual function and preventing falls in older people.35 Lord et al36 stated that impaired vision is an important and independent risk factor for falls. Adequate depth perception and distant-edge contrast sensitivity appear to be important for maintaining balance and detecting and avoiding hazards in the environment.37
Research documents show that the use of multifocal lenses by older adults increases fall risk. Lord et al37 found that multifocal glasses might add to fall risk because the near-vision lenses impair distance-contrast sensitivity and depth perception in the lower visual field. Johnson et al38 concluded that because of increased within-subject variability in vertical toe clearance when wearing multifocal glasses, older adults might be at greater risk of falling when negotiating steps and stairs. On the basis of these findings, FRAST assigns a high fall risk for those who do not regularly visit an eye professional (Figure 1, item 6) and/or those who wear multifocal lenses (glasses and/or contact lenses) (Figure 1, item 7). Although older adults may decide to not give up multifocal lenses, awareness of the risk is still important.
Self-reported dizziness is a lay term describing many symptoms (lightheadedness, vertigo, etc) with a wide variety of etiologies (vestibular, orthostatic hypotension, etc). Ekwall et al39 found that dizziness was associated with an increased risk of falling. Agrawal et al40 reported that study participants with vestibular dysfunction who were clinically symptomatic (ie, reported dizziness) had a 12-fold increase in the odds of falling. Ramdas et al41 found that the main outcome measures indicating an increased fall risk were a positive falls history and the presence of orthostatic hypotension.41 Other researchers have also reported that dizziness and vertigo are important public health care issues.42 Given the evidence cited indicating self-reported dizziness as a significant fall risk factor, FRAST assigns a high fall risk rating for a current complaint of dizziness (Figure 1, item 8).
Many older adults require assistive devices to walk safely and independently.43 In FRAST, assistive devices will include all forms of canes and walkers.
Older adults commonly self-prescribe assistive devices for a variety of reasons. Brooks et al44 found that of 70 patients interviewed, only 71% of the assistive devices being used had been prescribed. In Sheehan and Millicheap's45 study, which evaluated the use of canes, 38% were used incorrectly, 44% were of incorrect length, and 54% were in poor condition. Joyce and Kirby46 concluded that prescribed assistive devices were underutilized and needed to be fit correctly. A correctly prescribed, fit, and used assistive device may result in a lower fall risk; however, a self-prescribed, misfit, or inappropriate assistive device may result in a higher fall risk.43 For these reasons, FRAST (Figure 1, item 9) includes an item that imparts high fall risk both for those who use an assistive device that was not prescribed and fit for them and for those who cruise along furniture and walls and may benefit from the use of an assistive device.
Many physical changes associated with aging have a negative effect on balance.47 Cognitive slowing may impact reaction times48; lower extremity weakness may limit postural stability47; and degenerative joint changes may limit motion needed to reestablish equilibrium.26 Diminished balance is associated with heightened fall risk49 and improved balance after intervention is associated with a lower fall risk.50 Balance must be screened as part of FRAST, and diminished balance requires early intervention.
Choosing the best objective instrument to assess balance in older adults is difficult. Many tools have been developed, studied, and updated.51 Researchers have established validity, reliability, and sensitivity for certain populations.5 The goal of this project was to identify a validated balance test, designed specifically for community-dwelling older adults, which can be safely and reliably administered and scored by personnel with minimal training. Many balance assessment tools were considered. In a systematic review, Langley and Mackintosh52 concluded that of 17 studied tests, the BBS and TUG were most rigorously studied and had published reliability and validity with community-dwelling older adults. Although the BBS has been shown to be valid and reliable,5 a few of the test items require the patient to attempt difficult tasks while the tester is timing or rating the patient. Therefore, it was concluded that this test required the judgment and skills of a clinician to assure patient safety and was not selected for FRAST.
Shumway-Cook et al3 found TUG to be a sensitive and specific measure for identifying community-dwelling adults who are at risk for falls. She found TUG to be quick and simple to administer. Older adults who take longer than 14 seconds to complete TUG were found to have a high risk for falls.3 The addition of manual or cognitive tasks to TUG did not result in a more sensitive test.14 Herman et al53 found that TUG also exhibited some psychometric assessment capabilities, adding an indirect cognitive measure. Desai et al54 compared TUG, the BBS, gait speed, and the 6-minute walk test and concluded that only TUG was able to differentiate between the faller and nonfaller groups. Morris et al51 concluded that combining the factors of previous falls with a prolonged time on the TUG test resulted in the ability to predict falls with high specificity. Considering the current best evidence, the TUG test was selected as a reliable, valid, and simple-to-administer balance test for inclusion on FRAST (Figure 1, item 15).
Many physiologic changes of aging affect both pharmacokinetics and pharmacodynamics, which may increase the inherent risks imparted by polypharmacy (defined as >4 prescription medications taken simultaneously).7 In older adults, fall risk increases with an increase in medication use.55 Prescription of more than 4 medications was associated with an increase in falls,56 and central nervous system drugs, especially psychotropics, seem to be associated with an added risk.7 Use of over-the-counter, nonsteroidal anti-inflammatory drugs have also been shown to increase fall risk for older adults.57
On the basis of the findings of these studies, FRAST will include the use of 1 to 4 prescription medications to impart medium fall risk and the use of more than 4 medications to impart high fall risk. Although this is an effective screening method, pharmacist-led medication reviews have been studied and proposed as an effective adjunct to routine health care and will be included in FRAST's recommended intervention for identified polypharmacy risk58 (Figure 1, item 5).
Fear of Falling
Falls increase the fear of falling, and fear of falling increases fall risk.59 In addition, fear of falling often leads to self-imposed restriction of physical activity, which further heightens fall risk, and fear of falling is oftentimes experienced even without a fall.59 It has been found that fear of falling was increased with advancing age, female gender, perceived poor health, and history of falls,60 as well as limitations in activity of daily living, impaired vision, chronic morbidity, low general self-efficacy, and depression.61
Since fear of falling results in a significant increase in fall risk, it is important that we be able to quantify this experience objectively. The 3 scales considered for inclusion on FRAST were the Activities-Specific Balance Confidence (ABC),62 the Falls Efficacy Scale (FES),63 and the Survey of Activities and Fear of Falling in the Elderly (SAFE).64 Hotchkiss et al65 studied the 3 scales and concluded that the ABC and the FES were highly correlated with each other and to a lesser extent with SAFE. They also found that the FES was the best predictor for those people who restricted their activity.65 The FES also included fewer items than the ABC, making it slightly faster to administer. The original FES was developed and reported by Tinetti et al63 in 1990 as an instrument to measure fear of falling. Subjects who reported avoiding activities because of fear of falling had higher FES scores, representing lower self-efficacy or confidence, than the subjects not reporting fear of falling. However, the FES did not include community-level activities, so it was updated in 1996 as the MFES, which was studied and validated by Hill et al66 in 1996. Since the MFES is aimed at community-dwelling older adults in the United States and has been shown to reliably indicate activity avoidance due to fear of falling, it has been selected for FRAST (Figure 1, Item 13).
Depression has been shown to significantly increase fall risk in community-dwelling older adults.67 The occurrence and undertreatment of depression in later life is well documented.68 Geriatric depression may be misinterpreted as fatigue or dementia or simply misattributed to normal aging. Many psychosocial and physical aspects of advancing years may contribute to depression, including loss of spouse and/or friends, decreases in vision and hearing, nocturia, sleep disturbance, pain, and lack of physical activity.69 According to the National Institute of Mental Health, suicide rates are significantly elevated in older adults when compared with the general population.70
Many tools have been developed to objectively measure depression, but only a few tools are validated for older adults. Well-known, validated, and commonly used measures, both the GDS71 and the short form of the GDS (GDS-short or Mood Scale),16 are self-administered, user-friendly measures. Because of its ease of use, short completion time, and wealth of literature on its validity, the GDS-short is utilized to screen for the signs of depression on FRAST (Figure 1, item 14).
Although the fear of falling can result in a higher fall rate, what about the opposite end of the spectrum—elevated risk-taking behavior? In considering unintentional falls, the authors were curious about the role of risk-taking behaviors as a personality trait in fallers. Increased risk-taking behavior is not an identified fall risk factor in older adults in the current literature. A study has identified the increase in human immunodeficiency virus positive older adults, which has been tied to increased risk-taking behavior in this population.72 Traffic accidents are higher in adults older than 65 years, which may reflect decline in judgment, reaction time, or an increase in risk taking.73 Although risk-taking behavior is not identified as a fall risk factor in older adults, it may be worthwhile to study.
Attempts to identify a validated objective test to quantify risk-taking behavior in this population were unsuccessful. The psychometric Balloon Analogue Risk Task does exist for use in adolescents and young adults but is not validated for use in this population.74 Therefore, FRAST asks each subject to self-rate their risk-taking behavior (Figure 1, item 10). Engaging in risky behavior will be correlated with a high fall risk and will prompt a discussion with the PCP to ascertain whether further intervention is warranted. Item validity will be studied.
Home and Living Situation
About half of all falls occur in the home. Making the home safer is listed by the CDC as 1 of the 4 most important things older adults can do to decrease their fall risk.13 Studies demonstrate that home hazard assessments need to be accompanied by education, facilitation of modifications, consideration of the person and home interface, and follow-up.8 In 2003, Nikolaus and Bach75 found that home intervention based on home visits to assess the home for environmental hazards, providing information about possible changes, facilitating any necessary modifications, and training in the use of technical and mobility aids, was effective in a selected group of older adults with a history of recurrent falling. Iwarsson et al87 found that the person-environment fit or interface was a stronger fall predictor than number of environmental barriers. For example, standard-height kitchen cabinets might present a problem for a shorter person but not for a taller person. These studies certainly highlight the need for a carefully completed home hazard assessment done by a therapist as part of an effective abatement of fall risk. FRAST will use a self-assessment for screening the CDC's Home Fall Prevention Safety Checklist. A high fall risk score on this item will prompt the PCP to consider a referral for PT or OT to complete an individualized home assessment and follow-up (Figure 1, item 12).
Sidewalks, Traffic, and Adverse Weather
A great deal of time and attention is afforded to falls within the home, but we must also look at the city or county infrastructure, as it relates to safety for pedestrians.76 Access to the community must be made possible to ensure successful aging in place. Therapists performing home visits should consider factors that may hinder access to and from the home into the community. Despite the importance of these issues, the literature regarding the characteristics of the physical environment outdoors in relation to falls is limited, as are assessment tools, making objective comparison of neighborhoods difficult. For these reasons, evaluation of community access has not been included in FRAST. Lack of social contact (Figure 1, item 11) may indicate issues of limited community access.
Social Support and Contact
Social isolation is very common for adults as they age.77 Loss of spouse, friends, employment, expendable income, and independent driving can all lead to a sense of captivity at home.78 This shrinking-world phenomenon may lead to physical inactivity, cognitive decline, and heightened fall risk.79 Stanley et al80 found that the experience of loneliness was a pressing issue. Peel et al81 found that healthy psychosocial factors (being married, living in the same home, etc) were protective, that is, prevented older adults from falls. It has been consistently reported that increased social contact (more than 5–7 per week) is correlated with a lower fall risk.82 On FRAST, subjects will self-rate their frequency of social contact (Figure 1, item 11). On the basis of the findings of Mossey83 and Strawbridge et al,84 a response indicating fewer social contacts (less than 2 per week) correlates to a high fall risk and triggers a recommendation for referral to an aging services provider.
OVERALL FALL RISK
In addition to examining each fall risk individually, FRAST is scored for overall fall risk. Scores in all columns are added for a score of 0 to 30 out of 30. Since FRAST is only a screening tool, there is greater risk in not identifying heightened fall risk than in overdiagnosing high fall risk. For this reason, a low cutoff of 5 was chosen. Scoring ranges may be updated following reliability and validity data analysis.
The interventions recommended in FRAST are based primarily on the referenced literature in combination with extensive clinical expertise of the authors. Clinical judgment of the PCP and/or referral practitioners, geographic location, third-party payor guidelines, and availability of staff will affect which interventions are utilized in each situation.
FRAST has been developed as a multifactorial, simple-to-administer, fall risk screening tool for community-dwelling adults older than 65 years. The tool is intended for use by minimally trained staff, with follow-up interpretation and action by the trained PCP. Evidence regarding many of the significant components of fall risk for community-dwelling older adults has been presented. Reliable and validated objective measures for these fall risks have been discussed. Action recommendations are included for consideration by the PCP to proactively address each aspect of heightened fall risk based on the patient's individual needs.
Limitations impacted this article. Most fall risk studies deal with 1 risk factor or a limited group. Multifactorial studies each considered a different group of factors, making comparison between studies difficult. To maintain simplicity and brevity, not all risk factors could be included in FRAST or addressed in this article. However, some of these factors are indirectly included by items on FRAST. For instance, 1 study has concluded that cognition is measured indirectly by the TUG test.53 Gait disorders, quadriceps strength, and flexibility may all adversely affect the TUG test performance47 (Figure 1, item 15). Research to document the validity and reliability of FRAST is under way. Plans for dissemination of FRAST via a number of routes are being investigated. Future prospective longitudinal study is planned.
The population projections for this age group create a pressing time line for intervention. The need to add fall risk assessment in primary care has been well documented. Rubenstein et al85 found that community physicians appear to underdetect falls and gait disorders. As physical therapy evolves into a doctoring profession and we assume a greater role as PCPs, utilization of tools like FRAST will facilitate our comprehensive screening.
Early identification of heightened fall risk in community-dwelling older adults, when combined with proactive fall prevention interventions, should lead to a decrease in fall risk, fall rate, and injury or death resulting from falls.86 Providing the primary care office with a simple, objective, multifactorial screening tool, which includes targeted intervention recommendations, is imperative. Each component of FRAST represents 1 or more of the fall risk factors that have been demonstrated to significantly impact fall risk of community-dwelling older adults. Risk-taking behavior has been added to ascertain its significance as a fall risk factor. The interrelated effect of some of these risk factors has been clearly demonstrated in the literature.2 Assessing fall risk by using any 1 criterion may result in missing heightened fall risk in a significant portion of the older adult population.3 Considering each risk factor individually allows the PCP to provide targeted intervention for specific risk factors. FRAST is intended for administration by minimally trained staff in primary care offices and/or public health departments, with interpretation and management by PCPs to facilitate early identification and abatement of fall risk. Dissemination and utilization of this tool by PTs and PCPs should serve to abate fall risk and positively impact older adults' ability to successfully age in place.
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Keywords:Copyright © 2011 the Section on Geriatrics of the American Physical Therapy Association
community-dwelling older adults; falls; fall risk; fall risk assessment tool; primary care practitioner