Older adults at low risk for falls Older adults who are considered at low risk for falls are described as such in different terms, depending on which practice guideline is being used for the fall risk screening. The most conservative approach to determining “low risk” for falls would include the following criteria: ● Lacking a fall history of recent injurious fall within the past 12 months. Complete fall risk assessment for high risk older adults Older adults who are found to be at high risk for falls should receive a more detailed evaluation beyond the STEADI tests. This assessment should be performed by experts in function and movement, such as physical and occupational therapists, and should more specifically examine function, gait, balance, strength, and endurance. These assessments can lead to a more effective intervention aimed at addressing deficits identified in the assessment that a simple screen would not fully explore. It is important to gather information on age, fall history, medical conditions, and medications. To gather more information regarding an individual’s fall history, the “SPLATT” questionnaire, which prompts the clinician to investigate the circumstances surrounding past falls, could be used (Bauman et al., 2014). SPLATT stands for the following: (S) ymptoms before and at the time of the fall(s). (P) revious falls, near falls, and/or fear of falling. (L) o cation to identify contributing environmental factors (such as poor lighting, poor footing, busy crowd). (A) ctivity the person was participating in when they fell (such as turning, changing position, transferring). (T) ime of day the falls occurred. (T) rauma resulting from the fall (injurious, noninjurious, medical attention sought). There are several validated, reliable assessments that can be performed by physical or occupational therapists that can guide the design of interventions for community-dwelling older adults. Tools also exist that are population-specific and can be investigated further at https://www.sralab.org/rehabilitation- measures, a frequently updated website that houses common outcome measures used by both occupational and physical therapists. The areas of gait and balance assessments are mentioned first as they often are factors that influence fall risk, but clinicians may begin their more detailed evaluation at the impairment level such as strength, ROM, and sensation, which are discussed later in more detail. Gait and balance There is an abundance of gait and balance exams. Therapists should consider several factors when choosing the most appropriate exam for both gait and balance. Some of the most important factors include whether normative data exists for the exam to allow comparisons, the population intended to
● Having only a single risk factor for falls during fall risk questioning. It is recommended that individuals at low risk have gait and balance screenings if they report or the clinician has observed difficulty with gait or balance, by using the STEADI physical assessments or other reliable gait and balance exams. This would include older adults who report only a single noninjurious fall in the past year. be assessed, the level of cognitive and physical challenge of the exam, the setting where the exam will be performed, the length of the exam and its effect on endurance or fatigue, and the level of health and disability assessed by the International Classification of Functioning (ICF; World Health Organization [WHO], 2016). The ICF is the WHO model of classification of health and health-related domains that allows common language among healthcare providers when measuring health and disability at both individual and population levels. The ICF model is organized in two parts and it recognizes the dynamic interaction of a person’s health conditions, environmental factors, and personal factors. One part addresses function and disability and the other section includes contextual factors that affect health. When choosing an assessment, the clinician should consider the following concepts of the ICF model: ● The body functions and structures of people, and impairments thereof (functioning at the level of the body). ● The activities of people (functioning at the level of the individual) and the activity limitations they experience. ● The participation or involvement of people in all areas of life, and the participation restrictions they experience (functioning of a person as a member of society). ● The environmental factors that affect these experiences (and whether these factors are facilitators or barriers). Different outcome assessments and exams measure different components included in this model, and it is helpful for the clinician to recognize the areas addressed by the assessments they choose. Additional considerations when choosing a gait or balance assessment could include whether the assessment requires a fee, and the assessment’s degree of challenge. The clinician should choose an assessment that challenges the older adult without total failure on the test. If an exam is too easy, then the test results may show a ceiling effect, and if the test is too difficult, then the results may indicate a floor effect. Both ceiling and floor effects should be avoided by using an exam that gives credit for some positive attributes, but leaves room for improvement. Clinicians must use their experience and expertise to determine the best gait and balance assessment for each individual. Some of the more common gait and balance tests are listed below and in Table 7, which also shows attributes and fall risk threshold scores for each measurement tool.
Table 7: Gait and Balance Outcome Measures Tests Including Gait Scoring Considerations
Advantages
Disadvantages
ICF Domain
Dynamic Gait Index (DGI; adapted from Shumway-Cook & Woollacott, 1995) Functional Gait Assessment (Wrisley, Marchetti, Kuharsky, & Whitney, 2004)
8 items. Top score: 24. Fall risk: variable, but <19 predicts falls in community elderly. 10 items. Top score: 30. 7 items from DGI. Fall risk: increased if <20; activities similar to the DGI with 3 more challenging tasks of walking with narrow base of support, backward, and with eyes closed.
Minimal time and equipment needed; able to use assistive
Requires 20 ft. of space; may be too challenging for frailer older adults.
Activity.
device; good validity and reliability; includes head turning during gait for vestibular stimulation. 10 - 15 min to perform; dynamic gait activities with head turns assists in identifying fall risk in adults with vestibular disorders; can use assistive device.
May be too challenging for more frail older adults; need 20 ft of space to test.
Activity.
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