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 Continue normal care.
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.
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.
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. Researchers continue to investigate the most efficient and accurate screening tools. One of the most recent studies comes from the Academy of Geriatric Physical Therapy’s systematic review of the literature by Lusardi and colleagues (2017). This
comprehensive review explored the predictive ability of single questions or exams and combinations of exams to identify future fallers. They concluded that no single test or measure demonstrated strong predictive values, but they did make recommendations for clinicians performing fall risk screenings. Five history questions, two self-report measures, and five performance-based measures were considered clinically useful in assessing risk for falling (Table 6). They also determined that the most evidence-supported functional measures for predicting falls include: ● Berg Balance Scale score (≤50 points). ● TUG times (≥12 seconds). ● Five-time sit-to-stand times (≥12) seconds. Table 6: Lusardi Recommendations for Fall Risk Screening Category Test Cut point Medical history questions. Any previous falls. Yes/no Pychoactive medications. Yes/no Requiring ADL assistance. Yes/no Self-report fear of falling. Yes/no Ambulatory assistive device use. Yes/no
Self-report measures.
Geriatric Depression Scale 15. Falls Efficacy Scale International.
<6 points >24 points <50 points
Performance- based
Berg Balance Scale.
Single-limb stance eyes open. Timed Up and Go Test. Five-Time Sit-to-Stand Test.
>11 s <6.5 s >12 s
functional measures.
Self-selected walking speed. <1 m/s Note . Adapted from Lusardi, MM., Fritz, S., Middleton, A., Allison, L., Wingood, M., Phillips, E., … Chui, K. K. (2017). Determining risk of falls in community dwelling older adults: A systematic review and meta- analysis using posttest probability. J Geriatr Phys Ther, 40 , 1-36.
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Book Code: PTNY3622B
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