Table 4: CGS 2015 Fall Screening Guidelines Action or Question Posed to Patient
If Response or Finding is Affirmative Conduct screening for mobility and balance. Conduct screening for mobility and balance. Conduct multifactorial fall risk assessment. Provide treatment for identified risk factors within scope of PT practice.
If Response or Finding is Negative
Notes
An anomaly in balance or mobility is observed. Ask patient if they have fallen in the last year, or have difficulty walking and/or with their balance. Conduct screening for mobility and balance. Conduct multifactorial fall risk assessment.
Continue normal care.
Continue normal care.
Continue normal care.
Multifactorial fall risk assessment includes: • Medication Review : Psychoactive drugs, polypharmacy. • Medical History : New or ignored osteoporosis, depression, urinary incontinence, and cardiac signs & symptoms. • Assessment : Of strength, balance, mobility, gait, ADL, footwear, environmental hazards, cognition, neurologic and cardiac function, and vision. Treatment Includes: Training to improve strength, balance, and/or gait; Correction of foot impairments and/or footwear; Education; Correction of Environmental Hazards.
Refer to appropriate health care provider for identified risks outside scope of PT practice.
Provide treatment for identified risk factors within scope of PT practice.
N/A
N/A
Note . From Western Schools, 2019.
the four support positions, the tester refrains from assistance and gives a start command for the 10-second timing. Timing stops if the older adult moves their feet or requires assistance to maintain their balance. The four positions start with feet together, then progress to semi-tandem, tandem, and finally single-leg stance. Testing stops when the person does not successfully complete any position for 10 seconds. Eyes are open throughout testing. An older adult who fails to stand in tandem stance for at least 10 seconds is at increased risk for falling. 30-second chair rise This test, usually performed after the others due to potential fatigue, assesses functional leg strength and endurance. The person sits on a 17-inch high chair with arms crossed across their chest. On the command “go,” the person attempts to stand fully erect and then return to sitting as many times as possible in 30 seconds. Feet must stay flat on the floor and hands must not be used. If the person is more than halfway to full standing when timing stops, the standing attempt is counted. A person with a below-average score for age- and sex-matched norms is considered at high risk for falls. Chair-Stand Normative Scores from STEADI are shown in Table 5. Table 5: Chair Stand Normative Scores Age Men Women 60-64 < 14 < 12 65-69 < 12 < 11 70-74 < 12 < 10 75-79 < 11 < 10 80-84 < 10 < 9 85-89 < 8 < 8 90-94 < 7 < 4 Note : From Western Schools, 2019.
Screening recommendations for fall risk are generally agreed upon by most clinical guidelines and should identify adults in need of a more in-depth evaluation. The Academy of Geriatric Physical Therapy developed a CGS for community-dwelling older adults, examined multiple existing practice guides, and suggested screening recommendations (Avin et al., 2015). Table 4 summarizes these recommendations. General recommendations include yearly checks/screens that include asking first these two basic questions: If the client answers “yes” to either of these questions, or if the clinician observes gait or mobility impairments, the clinician should perform a balance and mobility screen, such as those in the STEADI toolkit. The general screening tools included in the STEADI toolkit can be used by medical personnel as well as minimally trained staff. Although these physical tests do not identify etiology of falls, they can trigger the need for a more in- depth evaluation by trained healthcare providers (Renfro et al., 2016). All three tests should be performed on anyone answering “yes” to either of the screening questions on fall risk or with observed gait and/or balance difficulty. STEADI also provides instructions on the performance of these three physical fall risk screening tools, which include the TUG, the 4-Stage Balance Test, and the 30-Second Chair Stand Test, described in more detail below. Timed up and go test To perform the TUG test, the person starts by sitting back in a standard arm chair, then upon the command to “go,” they rise from the chair, walk 10 feet at their normal pace (with or without an assistive device), turn around and return to a seated position in the chair. Timing starts at the “go” command and stops when the individual returns to the seated position. An older adult who takes more than 12 seconds to complete the TUG is at high risk for falls. Four-stage balance test 1. Have you fallen in the last year? 2. Do you have difficulty walking? This test of static balance requires the person to stand for at least 10 seconds in four progressively more challenging positions without the use of an assistive device. After demonstration of
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