Risk Assessments for Falls Risk

Risk Assessments for Falls Risk

One of the biggest threats to frail and infirm elderly individuals aged 65 years and older is falls. Whether at home or in a healthcare facility, a fall can easily result in a broken hip or other debilitating condition and many elderly people are incapable of recovering from these injuries. To gain some fresh insights in this area, this paper provides a reflection on the purpose and intent of the falls risk assessment followed by a discussion concerning how this assessment contributes to an individual's comprehensive health assessment. A discussion concerning three abnormal findings that can reasonably be expected when performing falls risk assessments is followed by an analysis of the actions that should be initiated for each one of the three abnormal findings. Finally, a summary of the research and important findings are presented in the conclusion.

Review and Discussion

Purpose and Intent of Falls Risk Assessments

Unlike a comprehensive health assessment that provides a holistic evaluation of an individual's status, the purpose and intent of falls risk assessments is to identify individuals at high risk of falling, either at home, in a long-term care facility or other institutional setting. These assessments are important because at least 30% of all adults over the age of 65 years who live independently in the community suffer from a fall each year (Levin & Feldman, 2006) and approximately 5 to 10% of these adults will experience a serious injury as a result (Gates, Smith, Fisher & Lamb, 2008). Moreover, the injuries that result from falls among the elderly adults are enormous expensive for these older individuals as well as the larger society in which they live (Rose, 2008). In fact, the direct medical costs associated with fall-related injuries in the United States amount to $179 million for fatal falls and $19 billion for nonfatal injuries incurred by adults aged 65 years and older in 2000 (Rose, 2008). In sum, risk assessments of older adults, then, provide clinicians with the information they need to implement fall-prevention inventions for those who are most in need (Gates et al., 2008).

How Falls Risk Assessments Contribute to Individual Comprehensive Health Assessment

The research to date indicates that a number of interventions can be effective in fall prevention, including (a) strength and balance training, (b) home hazard modification, and (c) withdrawal of psychotropic medication (Gates et al., 2008). Other interventions have been identified as well in a number of studies focused on fall risk assessment in recent years, and several factors that are predictive of future falls have emerged, with the most accurate predictors appearing to be abnormalities in gait or balance and/or a history of falls, especially within the past year (Faber, Bosscher & Van Wieringen, 2006). There are other factors that have been shown to be predictive of falls by the elderly, though, including visual impairment, medications, and impaired cognition, but these are less common compared to the two major predictors noted above (Faber et al., 2006). According to Gates and her colleagues, "Numerous clinical screening instruments for identifying older people at high risk of falling have been proposed, and these vary in complexity from a single clinical test to scales involving 10 or more assessments" (2008, p. 1106). These screening assessments can include specific questions targeted at identifying fall risk patients such as whether they have fallen at any point during the previous year (Gates et al., 2008). In addition, a number of screening instruments have been developed for use by clinicians in different settings, including hospitalized older adults, adults in residential care, and the community-dwelling elderly (Gates et al., 2008). While intervention strategies based on multifactor assessment have been demonstrated to have the most significant effect in reducing fall rates and fall-related injury rates among older adults with a history of falls, there remains a need more additional research in this area to identify optimal combinations of clinical intervention strategies as well as the degree to which each risk component contributes to the total reduction for future fall risk (Rose, 2008). In this regard, Rose (2008) emphasizes that there is no "one-size-fits-all" assessment and intervention strategy that will be appropriate for all at-risk populations. According to Rose, "Different test attributes may be needed to predict falls successfully in different populations; for example, the timescale over which a prediction is needed varies from a few days or weeks in hospitalized patients to a year or more for community-living populations. Tools developed for one population may therefore be less accurate when used in a different setting" (p. 1155). Institutional protocols for fall prevention in typically include standard precautions such as referrals to physical therapy by physicians where indicated, keeping side rails up at specific times with specific clients, and ensuring that patients know how and when to use their call button when necessary (Levin & Feldman, 2006). Home-based interventions include handrails in the bathroom, removing trip hazards from pathways and referrals for healthcare assistance where necessary (Gates et al., 2008).

Three Abnormal Findings that Can Reasonably be Expected when Performing Falls Risk Assessments and Clinical Responses

It is important to note at the outset that one of the three principles of geriatric care is that, "Abnormal findings are common but not always relevant" (Functional assessment, 2012, para. 3). Therefore, it is essential to examine abnormal findings in their context with respect to other factors that may be contributory, and these include visual impairment, slowed or impaired gait and cognitive impairment. For example, older women who are visually impaired are at twice the risk of experiencing a serious injury as a result of a fall and the risk of hip fracture is fully 40% higher for all elderly individuals with poor visual acuity (Ray & Wolf, 2008). According to Ray and Wolf, "Slowed gait velocity is significantly related to fall risk and affects an older adult's independence. Gait and balance abnormalities in older adults are also typically associated with increased fall risk and poor balance confidence" (p. 1118). Cognitive impairments may also contribute to the incidence of falls among the elderly (Gates et al., 2008).

The research to date indicates that individualized interventions may be more effective for comparable risk groups because these interventions typically cost less, require fewer lifestyle changes by the elderly and are less confusing to older adults (Rose, 2008). Depending on the risk category that is established by the screening assessment for any of these three abnormalities noted above, the interventions set forth in Table 1 below are recommended.

Table 1

Key recommendations for clinicians and practitioners planning exercise programs for older adults at various levels of fall risk

Patient Risk Level

Recommendations

Low*

Multimodal group exercise programs with or without home exercise.

Moderate-intensity walking program.

Tai chi class.

Other recreational activities with strong balance component (e.g., tennis, golf, bike riding).