Bruyère

Reports
Issue No. 5. August 2016

Evidence-based screening tools

and fall risk assessment in con-
tinuing care
A Bruyère Rapid Review

REPORT AUTHORS

Vivian Welch
Elizabeth Ghogomu
Beverley Shea

ISSN 2368-8688
2
Contents

Key messages 3

Executive summary 4

Background: context and risk factors for falls 5

Evidence review 6

Synthesis of findings 7

Gap analysis at SLR in 2011 by RNAO prevention coordinator 8

Discussion of evidence review: strengths and limitations 8

Inferences and next steps for SLR 9

References 10

Key messages
Falls prevention has been identified as a high priority at Bruyère Continuing Care. Many falls occur as a
result of interactions of multiple risk factors at the individual and setting level.
Based on our assessment of the evidence, we recommend three strategies to reduce fall rates in Bruyère
Continuing Care settings:
 Implement a comprehensive risk assessment tool, tailored for the clinical setting, for use at admission
to design individualized, multifactorial falls prevention plans
 Implement post-fall huddles to foster ongoing team learning and continuously improve the compre-
hensive risk assessment process.
 Engage staff and clients in implementing falls prevention, fostering a culture of ongoing learning and
continuous monitoring and improvement of individual falls prevention plans.

Tools for implementing falls prevention strategies and a review of risk assessment tools is covered in the
companion Bruyère Evidence Review.

3
 Executive summary

The objective of this review was to assess the effective- than control/usual care (RR = 0.69, 95% CI 0.49 to
ness of fall risk screening tools and fall risk assessment 0.96)
tools as a basis for falls prevention intervention in four
All four clinical practice guidelines recommend that
settings in continuing care: the choice of screening tools and fall risk assessment
1) palliative care; tools should be guided by the patient’s needs, clinical
utility, feasibility for staff, acceptability to patients and
2) rehabilitation (geriatric and stroke);
similarity of the patient population with the population
3) long term care; and in which the instrument was developed or assessed.
No single falls risk assessment tool was recommended
4) short and long term medical care (subacute).
for these settings because of the need to tradeoff
We searched MEDLINE for guidelines and systematic strengths and limitations that is setting-specific. The
reviews assessing the predictive validity and effective- six systematic reviews identified 18 risk screening tools
ness of risk screening and risk assessment tools in and four risk assessment tools that have met the crite-
these continuing care settings. We found 4 high quali- ria of >70% sensitivity and specificity. These tools are
ty guidelines addressing this question, and 6 systemat- publicly available. The MDS_RAI was described as a
ic reviews of varying quality. tool for multifactorial risk assessment that may be easy
In the four relevant clinical practice guidelines, the util- to incorporate into practice systems because it is al-
ity of using a screening tool for falls risk at admission ready required in long term care.
to classify people as high risk of falling is controversial. All clinical practice guidelines recommended that staff
The UK NICE 2013 guidelines recommend against us- education and continuing review is important to pro-
ing a screening tool because they are no more effec- mote individualized falls risk assessments (updated
tive than clinical judgment and take up staff time. Sim- when needed), to identify modifiable risk factors and
ilarly, the Australian Commission on Safety and Quality implement targeted interventions that are compatible
in Health Care (2009) recommend that since most pa- with the client’s risk factors, needs, values, and prefer-
tients in subacute care (including geriatric and rehabil- ences. Importantly, falls prevention is sensitive for cli-
itation settings) are at high risk of falling, falls risk ents and patients because they are associated with
screening may be of limited value, and a full falls risk loss of independence. Similarly, falls prevention is a
assessment is more beneficial. In contrast, the Regis- sensitive issue for staff because there may be fear of
tered Nursing Association of Ontario (RNAO) 2011 repercussions or blame. Staff and client education can
updated guidelines recommend falls risk screening be used to address these barriers to change, and focus
with accepted tools such as the Morse or STRATIFY
on the positive aspects of falls prevention.
tools followed by a risk assessment to identify modifia-
ble risk factors. Similarly, the American Geriatrics Soci- Conclusion: Given the diversity of tools and domains
ety (2010) guidelines recommend falls risk screening assessed and the diversity of patients and clients in the
with 3 questions followed by comprehensive multifac- different settings, it may not be possible to select a
single tool for all Bruyère settings. We recommend
torial risk assessment.
that local implementation teams with clinical expertise
All four clinical practice guidelines recommended a and knowledge of each setting are best placed to se-
comprehensive multifactorial risk assessment to identi- lect the most appropriate tool for their setting, and
fy modifiable risk factors for anyone at risk of falling, method of implementing it using a combination of
accompanied by the implementation of interventions staff and client awareness and education to promote
tailored to the individual’s identified risk factors (e.g. the positive aspects of falls prevention and a culture of
strengthening exercises, medication review, client and
continuous learning.
staff education and environmental modifications). In a
companion BBERG report on effectiveness of falls pre-
vention strategies, multifactorial interventions based
on risk assessment prevent 7 out of 1000 more falls

4
Background: context and risk
factors
Context living in long-term residential care (59%) than in the
community (32%)(2).The direct health care costs for
The Senior Quality Committee of Bruyère Continuing
fall-related injuries in Canada are estimated at $2 bil-
Care requested a review of evidence regarding screen-
lion annually(1).
ing tools for falls risk in:
1) rehabilitation;
2) palliative care; Risk factors for falls
Falling is associated with a variety of risk factors in-
3) subacute care; and
cluding biological, behavioural, environmental and
4) long term care. socioeconomic risk factors(2, 4) which are intrinsic
Preventing falls was identified by a recent Accredita- (relating to a person’s behavior or condition) or extrin-
tion Canada report as a high priority(1). The Senior sic (relate to a person’s environment or their interac-
Quality Committee asked that this review of tools con- tion with the environment). Many falls occur as a result
sider the context of each of these different settings of interactions of multiple individual and extrinsic risk
with a focus on feasibility, relevance to the setting and factors(1, 2). The most powerful predictor of a fall is a
history of falling(1). Falls can occur in the home or in
validity/reliability.
various hospital settings including continuing care
Falls are a major public health problem and the lead- (subacute care) and acute care. Continuing care in-
ing cause of injury-related hospitalizations among volves two types of care – residential-based care and
seniors (aged 65 and older) in Canada; 20 to 30% will hospital-based care(1). According to CIHI Continuing
experience a fall each year(2) and 85% of all fall- Care Reporting System 2013-2014 data 9% of assessed
related hospitalizations are due to falls in seniors(1). residents in residential care are at high risk of falling
Half of adults aged 85 and older will fall each year and and 6% of patients in hospital-based continuing care
12% to 42% who fall will have a fall-related injury(3). are at high risk of falling in Ontario(1) (see Figures 1
There are more fall-related hospitalizations associated
and 2).
with serious injuries such as hip fractures in seniors

Figure 1: Percentage of Residential-Based Long-Term Care Residents at Risk of Falls

Notes:
Results for Ontario, British Co-
lumbia, Alberta, and Yukon in-
clude all publicly funded facilities
in that province/territory. Results
for the remaining provinces/
territories are based on partial
coverage [i.e., only facilities sub-
mitting data to the Continuing
Care Reporting System (CCRS)].
Source:
Continuing Care Reporting Sys-
tem, 2013–2014, Canadian Insti-
tute for Health Information.

5
Figure 2: Percentage of Hospital-based Continuing Care Residents at Risk of Falls

Notes:
Manitoba data includes only facilities in the Winnipeg Regional Health Authority. Hospitals with continuing
care beds are commonly known as extended, auxiliary, chronic or complex care beds.
Source:
Continuing Care Reporting System, 2013–2014, Canadian Institute for Health Information

may need to be assessed separately(2). See Table 1

Defining the types of tools
for risk factors to consider in falls risk assessment.
Risk screening tools estimate a person’s likelihood of
falling(5). They consider a variety of clinical factors or In this review we considered the evidence of the effec-
domains associated with falling that are relevant to the tiveness of risk screening tools and fall risk assessment
target population and the setting such as balance and tools in residential-based and hospital-based continu-
mobility, functional status, continence, cognitive sta- ing care.
tus, history of falls, medications. These tools have a
scoring mechanism that can predict the individual’s
level of risk at low, medium or high risk of falling.
Falls risk assessment is a systematic, comprehensive,
iterative process to identify an individual patient/
resident’s modifiable risk factors for falling(5). They
differ in the number of risk factors they include, and
how each risk factor is assessed. Also, most do not
assess environmental factors therefore these factors

6
Table 1: Risk Factors to consider in falls risk assessment

Risk factor Long term care Hospitalized Rehabilitation Subacute Palliative

patients
Previous fall history OR 3.41 OR 2.76 OR 3 OR 4
Gender Male (OR 1.14) Female (OR
1.54)
Ambulatory aids Cane/walker: OR 2.84 OR 3
OR 1.44
Vision impairment OR 1.6 OR 2.46 OR 2
Cognitive impairment OR 1.84 OR 2.62-6.33 OR 3-6 OR 1.2-1.5
(wandering)
Psychotropic drug use OR 2 OR 1.93-7.95 OR 2-7 OR 2.9

Balance Transfer inde-

pendence (OR
1.49)
Gait deficit OR 2
Polypharmacy 4+ medications

Benzodiazepines RR 1.44
Diuretics OR 7.2
Vasodilators OR 3.0
Restraint use OR 10.2
Hypotension systolic OR 2.0 Insufficient
data
Depression OR 2.2

RR= risk ratio; OR= odds ratio

7
Search process and methods
We searched for relevant systematic reviews and tematic reviews and clinical guidelines if they focused
guidelines published between January 2007 and June on fracture risk assessment tools or if the population
2015 in Medline, the Cochrane Library (DARE and was community-dwelling or the hospital setting fo-
HTA) and Trip Database (Appendix 1). cused on acute care.
We included systematic reviews and guidelines if they The search results and potentially eligible articles were
assessed the effectiveness of risk screening tools and screened and reviewed in duplicate. The quality of
fall risk assessment tools in predicting falls/identifying guidelines and systematic reviews were assessed us-
falls risk factors in residential-based and hospital- ing the AGREE score and AMSTAR checklist respec-
based continuing care populations. We excluded sys- tively (Appendix 2).

Guidelines on risk screening and

risk assessment
We identified 4 guidelines that met our inclusion cri- in Health Care (ACSQH) guidelines(2) and the Ameri-
teria: the Canadian Registered Nurses' Association of can Geriatrics Society (AGS) guidelines(8) with evi-
Ontario (RNAO) guidelines(6), the UK National Insti- dence on screening tools and falls risk assessment.
tute for Health and Care Excellence (NICE) guidelines The guidelines were of high quality scoring 160 -
(7), the Australian Commission on Safety and Quality 168/168 on AGREE II.

Summary findings: Guidelines on risk screening and risk assessment

NICE RNAO ACSQH AGS
Risk screening Not recom- Recommended Recommended Recommended [level
mended [level III [level Ib evidence] [level of evidence?] of evidence?]
evidence]
on admission to On admission, when there is Risk screening with
since time inten- identify modifiable a change in the health and three questions: 1) His-
sive and no more risk factors to sup- functional status of the indi- tory of fall in 12
effective than port the decision vidual or when the patient’s months; 2) presenting
clinical judg- making process for environment changes. with an acute fall; or 3)
ment. Also all the care plan. difficulty with walking
If an individual is at high risk
patients have a or balance.
on admission (e.g. with a
high risk of fall-
history of previous fall or
ing because of
medical condition) consider
their medical
using multifactorial risk

8
 NICE RNAO ACSQH AGS

Risk screening their medical assessment instead to iden- Recommended [level

continued condition, a tify modifiable risk factors. of evidence?]
change in their
Some examples of validated Risk screening with
environment and
tools for the hospital setting three questions: 1) His-
their age (65
are STRATIFY, Downton in- tory of fall in 12
years or older)
dex and Morse scale. months; 2) presenting
with an acute fall; or 3)
Suggested tools: Should be done by a staff
difficulty with walking
Morse fall scale, member who understands
or balance.
STRATIFY and Hen- the process and can admin-
drich Fall Risk ister the tool, interpret the
Model results and make referrals
where indicated.

Using validated screening

choose tool appro-
tools as part of routine clini-
priate for setting
cal management can inform
and population
care and future assessment
of patients/residents.

Comprehen- Recommended Further assessment Recommend [Grade?] Recommend for those

sive risk as- only if linked to is performed by with history of falls or
sessment multifactorial clinicians with the gait/balance problems
intervention to appropriate *choose tool based on set- [Grade?]
reduce risk of knowledge, skills, ting and population
No tool recommended,
falls based on and training if the
*multidisciplinary team rec- multiple domains sug-
risk assessment initial screening ommended with one coor-
gested
[level III evi- indicates fall risk dinator
dence] factors.

*Choose tools **choose tool ap-

and domains propriate for set-
based on setting ting and popula-
and population tion

9
 NICE RNAO ACSQH AGS
Domains de- cognitive impairment; a focused histo- Some tools were history of falls, medi-
scribed in risk continence problems; ry, physical ex- listed: cations and risk factor;
assessment falls history including amination, medi- physical exam
Care plan assessment
causes and consequenc- cation review, (assessment of gait,
items for the acute
es (such as injury and cognitive, func- cognition, cardiovas-
setting; Peninsula
fear of falling); footwear tional and envi- cular status, vision,
Health Falls Risk As-
that is unsuitable or ronmental as- feet and footwear);
sessment Tool
missing; health problems sessment functional assessment
(FRAT), Falls Risk for
that may increase their (ADL); and environ-
A Falls Risk As- Hospitalised Older
risk of falling; medica- mental assessment.
sessment Tool People (FRHOP) and
tion; postural instability,
(FRAT) should be Peter James Centre
mobility problems and/
validated for the Fall Risk Assessment
or balance problems;
population. Tool (PJC-FRAT) for
syncope syndrome; visu-
the subacute or reha-
al impairment; and envi-
bilitation setting.
ronmental hazards.

NICE: National Institute for Health and Care Excellence, UK

RNAO: Registered Nurses’ Association of Ontario, Canada
ACSQH: Australian Commission on Safety and Quality in Health Care
AGS: American Society of Geriatrics

Guidelines on multifactorial risk

The 5 tools identified as having evidence of benefit in
All four guidelines recommend some type of multifac-
prospective studies as part of a falls prevention pro-
torial risk assessment linked to a tailored, individual
plan for falls prevention which could address modifia- gram are:
ble risk factors (e.g. deprescribing medications,
strengthening exercises, environmental modifications,  Care plan assessment items for the acute setting

etc based on the assessment).  FRAT for the subacute and rehabilitation setting
 PJC FRAT for the subacute and rehabilitation set-
There is no agreement on which risk assessment tools ting
are best for particular settings. All guidelines suggest-  Falls risk for hospitalized older people (FRHOP)
ed that tools and/or domains need to be chosen based tool for the subacute and rehabilitation setting
on the setting and patient population.  MDS-RAI for long term care.

10
These tools vary in the number of risk factors they in-  Palliative – FRASE tool but did not meet the 70%
clude and how each factor is assessed. A multidiscipli- predictive accuracy criteria.
nary team should do the assessment where possible or
a skilled staff person. Some tools consist of sub-domains to assess specific
risk factors and these may involve the use of additional
Regarding subacute, rehab, long term care, palliative, validated tools and measures such as the Timed Up
we found that specific tools have been developed in and Go Test or the Functional independence measure
these settings: (FIM) for assessing balance/gait problems.
 Subacute/rehab – FRAT, PJC-FRAT, FRHOP,
 Long term care – MDS-RAI

Evidence review: systematic reviews on

screening tools and falls risk assess-
ment
We identified 6 systematic reviews(5, 9-13). The quality
of the systematic reviews varied. One review each had
an AMSTAR score of 7/11(9), 6/11(11), 5/11(12), 3/11
(10); and two scored 2/11(5, 13).

In these 6 systematic reviews, 23 screening tools and

10 falls risk assessment tools for both residential-
based and hospital-based continuing care were as-
sessed for prediction of falls. Only one review assessed
the time to administer the tool and if training was re-
quired to administer the tool. (Appendix 3). Only 18
falls screening tools and four risk assessment tools met
the criteria of >70% for specificity and sensitivity pro-
posed by NICE (13-15). (See Table 2).

Four tools could be used for both screening and falls

risk assessment: the Fall assessment questionnaire,
Falls Risk Assessment Tool (FRAT), the Peter James
Centre Fall Risk Assessment Tool (PJC-FRAT) and the
Resident Assessment instrument (MDS-RAI).

11
Table 2: Synthesis of evidence: screening tools and fall risk assessment tools with high predictive accuracy

Tool Long Rehabilit- Subacute Palliative Mixed Time to Training re-

term ation setting administer quired to
care tool administer
tool
Risk assessment tools
Falls assessment P P no
questionnaire
Fall risk assess- P
ment in Geriatric-
Psychiatric Inpa-
tients to lower
events (FRAGILE)
tool
Falls risk assess- P no
ment tool (FRAT)
PJC-FRAT P no
MDS-RAI P 80 minutes yes
Screening tools
Barthel index P
Berg balance P 14 minutes yes
scale
Clinical and func- P
tional perfor-
mance tool
Clinical assess- P
ment and sensory
measurement
data
Clinical judgment P
evaluation scale

Clinical risk fac- P

tors

Dynamic gait in- P 15 minutes no

dex

Elderly fall P 17 minutes yes

screening test

12
 Tool Long Rehabilit- Subacute Palliative Mixed Time to Training
term care ation setting adminis- required to
ter tool administer
tool
Fall assessment P P no
questionnaire
Falls risk assess- P P P no
ment tool (FRAT)
Hendrich fall risk P P <1 minute no
model
Morse fall scale P P P P <1 minute yes
MDS-Risk as- P 80 yes
sessment instru- minutes
ment
Observation of P P
wandering be-
havior
PJC-FRAT P P no
STRATIFY P P P P no
The Ontario P P P P no
modified STRAT-
IFY
Timed up an go <1 minute yes
(TUG) test
Tinetti perfor- P 20 yes
mance oriented minutes

PJC-FRAT = Peter James Center Falls risk Assessment Tool

STRATIFY = St Thomas Risk Assessment Tool in Falling Elderly In-patients

One review also considered the time it took to admin-

Falls risk screening tools ister the different tools and if training is required to
administer the tool (Table 3).
All the systematic reviews assessed the predictive ac-
curacy of different tools and four screening tools met
the high predictive accuracy criteria and were assessed
in 3 or more systematic reviews: the St Thomas Risk
Assessment Tool in Falling Elderly In-patients
(STRATIFY), Morse Fall scale, Hendrich II Fall Risk mod-
el and clinical judgment. These have been recom-
mended for use on admission or after a fall in the
RNAO guidelines to identify people at high risk of fall-
ing.

13
Table 3: Falls risk screening tools

Subacute Geriatric/rehab Palliative Long Time to ad- Training required

term minister to administer tool
care tool
Morse P P P <1 minute yes
Hendrich P P <1 minute no
STRATIFY P P P 1 minute no
Clinical judg- P P P <1 minute no
ment
MDS-RAI P 80 minutes yes

Falls risk assessment 2) the Fall assessment questionnaire

3) Fall risk assessment in Geriatric-Psychiatric inpa-
Four falls risk assessment tools met these criteria of
70% for sensitivity and specificity and were assessed in tients to lower events (FRAGILE) tool) and
2 or more systematic reviews: 4) the MDS risk assessment instrument (MDS-RAI).
1) the Falls risk assessment tool (FRAT); See Table 4.

Table 4: Falls risk assessment tools

FRAT FRAT PJC FRAGILE MDS-RAI

Setting devel- Subacute care Subacute care Geriatric psychiatric care Long term care
oped
Setting used Subacute, rehab Subacute, rehab Geriatric psychiatric care Long term care

Domains cov- Recent falls, medi- Medical (history of Conley scale (nurses’ assess- Identification and
ered cations, psychologi- falls, health condi- ment: history of falls, im- evaluation of po-
cal, cognitive status; tion); Nursing paired judgment, impaired tential problems;
vision, mobility, (toileting); physio- gait, dizziness); medical di- identification of
transfers, behavior, therapy (gait and agnosis (Alzheimer’s disease, requirements for
ADL, environment, balance); occupa- Delusions, Delirium, Depres- rehabilitation;
nutrition, conti- tional therapy sion); Medications – Sedative maintenance of
nence, other (activities of daily or antipsychotic (acute, client strengths
(osteoporosis, his- living e.g. dressing, chronic); incontinence con- and prevention of
tory of fracture/s) bathing); modified trol (females); nursing care decline; and pro-
FIM measure; (Does the patient need total motion of compre-
changes in status assistance with bathing?) hensive well-

14
 FRAT FRAT PJC FRAGILE MDS-RAI

Training re- no no no yes

quired to ad-
minister tool
(i.e. does it
need skilled
person)

Discussion of evidence review: strengths

and limitations

palliative care, thus requiring tailored risk assessment

Strengths of this review are a systematic search for the
evidence, assessment of relevance to specific settings and intervention.
and assessment of quality using validated tools The MDS risk assessment instrument is widely recom-
mended for use in long term care. Although it contains
Limitations of this review are that the underlying evi-
risk factors for falling, there is no clear pathway to spe-
dence base is low quality, dispersed, and there is dis-
parity among guideline panels about whether to use a cifically identify patients at risk.
falls risk screening tool, and about the content of a
multifactorial risk assessment tool.

There is disparity around what factors to include in the

risk assessment process. A brief assessment could be
done for a specific risk factor or for those at low risk
(e.g. balance and mobility could be assessed using the
TUG test in the outpatient setting); a more compre-
hensive assessment for high risk patients may require
referral to a geriatrician.

There is scarcity of evidence regarding the use of falls

risk assessment tools across different settings. For ex-
ample, only one tool, the Falls Risk Assessment Scale
for the Elderly (FRASE), was assessed in palliative care
but did not meet the predictive accuracy cutoff point
of 70%. A systematic review of palliative care settings
suggested that different risk factors are prevalent in

15
Implementation
The choice of screening tools and risk assessment tools five tools were intended for impaired balance and mo-
should be guided by the patient’s needs, clinical utility, bility: Berg Balance test, Timed up and go (TUG) test,
feasibility for staff, acceptability to patients and similar- Tinetti performance oriented mobility scale, Elderly fall
ity of the patient population with the population in screening test, Dynamic gait index.
which the instrument was developed or assessed, the
predictive accuracy of the tool(2, 5, 6, 10, 13, 16).
Healthcare organization leaders should also consider
training of staff to use the tool, potential staff ac-
ceptance and adherence(5, 6) which could be influ-
enced by the length of time for completing the assess-
ment. The length of time for completing the assess-
ment varied from less than one minute (for the TUG
test, Hendrich fall risk model and Morse fall scale) to
80 minutes (for Resident assessment instrument in
long-term residential care). See Appendix 3.
There is no consensus on which falls risk factors should
be included in falls screening and risk assessment
tools. Some tools are more specific for some risk fac-
tors. For example, of the high predictive accuracy tools,

Recommendations

compatible with the client’s risk factors, needs,

From our review, we suggest the following recommen-
values, and preferences.
dations.

 Tools should be tailored to the needs of the pa-

tient population. The choice should be guided by
clinical utility, feasibility for staff, acceptability to
patients/clients and similarity of the patient/client
population with the population in which the in-
strument was developed or assessed.

 Bruyère Continuing Care should develop an organ-

izational policy to conduct a comprehensive falls
risk assessment for anyone considered at risk of
falling, tailored to the client population and setting
and implement multifactorial interventions that are

16
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Appendices

Appendix 1: Methods
Eligibility criteria
We included systematic reviews and clinical guidelines if they met the following inclusion criteria.

Criteria Description

Population patients seen in any of the following hospital-based continuing settings:

palliative care, rehabilitation care (including geriatrics and stroke), and
short and long-term medical care (including out-patient care, and sub-

Intervention fall risk assessment or screening tool

Comparison not applicable

Outcomes falls

We excluded systematic reviews and clinical guidelines if they focused on fracture risk assessment tools or if the
population was community-dwelling or the setting focused on acute care

18
Search methods base on June 17 2015. Two reviewers screened the
articles and identified six systematic reviews and three
We searched for articles published between January
guidelines that met the inclusion criteria.
2007 and June 2015 in Medline, the Cochrane Library
(DARE and HTA). We used the following search strate-
gy in Medline and adapted it for the Cochrane Library.
Appendix 2: Quality assessment
1 Accidental Falls/
We assessed quality using AMSTAR score for system-
2 fall.tw. atic reviews and AGREE score for guidelines.
3 falls.tw. The AMSTAR instrument uses the following assess-
4 faller$.tw. ment criteria:

5 fallen.tw. 1. Was an a priori design provided?

6 falling.tw. 2. Was there duplicate study selection and data extrac-

tion?
7 fall-related.tw.
3. Was a comprehensive literature search performed?
8 near-fall$.tw.
4. Was the status of publication (i.e. grey literature)
9 or/1-8
used as an inclusion criterion?
10 exp Adult/ 5. Was a list of studies (included and excluded) provid-
11 randomized controlled trial.pt. ed?

12 randomized.mp. 6. Were the characteristics of the included studies pro-

vided?
13 placebo.mp.
7. Was the scientific quality of the included studies
14 or/11-13
assessed and documented?
15 9 and 10 and 14 8. Was the scientific quality of the included studies
16 exp Animals/ not (Humans/ and exp Animals/) used appropriately in formulating conclusions?
17 15 not 16 9. Were the methods used to combine the findings of
We also searched the Trip Database using the follow- studies appropriate?
ing PICO search terms: 10. Was the likelihood of publication bias assessed?
P – patients in hospital-based continuing care settings 11. Was the conflict of interest stated?
I – falls risk assessment tool
C – control The AGREE II consists of 23 key items organized within
6 domains followed by 2 global rating items (“Overall
O - falls
Assessment”). Each domain captures a unique dimen-
We also examined reference lists of relevant articles sion of guideline quality.
and consulted experts at the Bruyère Research Insti-
Domain 1. Scope and Purpose is concerned with the
tute.
overall aim of the guideline, the specific health ques-
tions, and the target population (items 1-3).
We identified 2620 articles from Medline and the Domain 2. Stakeholder Involvement focuses on the
Cochrane Library and 1808 articles (including 127 sys- extent to which the guideline was developed by the
tematic reviews and 1247 guidelines) from Trip Data- appropriate stakeholders and represents the views of

19
 prove uptake, and resource implications of applying
its intended users (items 4-6).
the guideline (items 18-21).
Domain 3. Rigour of Development relates to the pro-
Domain 6. Editorial Independence is concerned with
cess used to gather and synthesize the evidence, the
the formulation of recommendations not being unduly
methods to formulate the recommendations, and to
biased with competing interests (items 22-23).
update them (items 7-14).
Overall assessment includes the rating of the overall
Domain 4. Clarity of Presentation deals with the lan-
quality of the guideline and whether the guideline
guage, structure, and format of the guideline (items 15
would be recommended for use in practice.
-17).

Domain 5. Applicability pertains to the likely barriers

and facilitators to implementation, strategies to im-

Appendix 3: Falls risk screening and assessment tools

Fall risk screening tools Setting Number of Time to adminis-
items ter tool
Barthel index Hospital (Mixed)

Berg balance scale Subacute, Outpatient 14 15 minutes

Clinical and functional performance tool Hospital (Mixed)

Clinical assessment and sensory meas- Hospital (Mixed)

urement data
Clinical judgment evaluation scale Hospital (Mixed)

Clinical risk factors Hospital (Mixed)

Downton fall risk index Stroke rehabilitation

Dynamic gait index Hospital (Mixed) 8 15 minutes

Elderly fall screening test Hospital (Mixed) 6 17 minutes

Fall assessment questionnaire Hospital (Mixed) 5

Falls efficacy scale Hospital (Mixed)

Fall risk assessment in Geriatric- Subacute

Psychiatric Inpatients to lower events
(FRAGILE) tool
Fall risk assessment scale for the elderly Palliative care, Acute
(FRASE) care
Falls risk assessment tool (FRAT) Subacute 8

Hendrich fall risk model Subacute 7 <1 minute

Morse fall scale Hospital (Mixed) 6 <1 minute

Observation of wandering behavior Subacute

20
Fall risk screening tools Setting Number of Time to adminis-
items ter tool
Peter James Centre Fall Risk Assessment Subacute 8
Tool (PJC-FRAT)
Royal Melbourne hospital risk assess- Stroke rehabilitation 9
ment tool
St Thomas Risk Assessment Tool in Fall- Subacute 9
ing Elderly In-patients (STRATIFY)
The Ontario modified STRATIFY Subacute
Timed up and go (TUG) test Outpatient, Acute 1 <1 minute
Tinetti performance oriented mobility Hospital (mixed) 9 20 minutes
scale tool
Fall risk assessment tools
Assessment for high risk to fall Hospital (Mixed) 13 17 minutes
Fall assessment questionnaire Hospital (Mixed) 10
Fife fall risk tool Hospital (Mixed) 7
Falls risk assessment tool (FRAT) Subacute 8
Falls Risk for Hospitalised Older People Subacute
(FRHOP)
Fall prediction index Stroke 8
Resident Assessment instrument Residential long-term 99 80 minutes
care
Patient fall questionnaire Hospital (Mixed) 5
Post-fall index Residential long-term
care
Peter James Centre Fall Risk Assessment Subacute 8
Tool (PJC-FRAT)

21
STRATIFY Risk Assessment Tool(2)

STRATIFY risk screen

Did the patient present to hospital with a fall or has he or she fallen on the Yes = 1
ward since admission? No = 0
Do you think the patient (Questions 2-5):
2 Is agitated? Yes = 1
No = 0
3 Is visually impaired to the extent that everyday function is affected? Yes = 1
No = 0
4 Is in need of especially frequent toileting? Yes = 1
5 Has a transfer and mobility score of 3 of 6? Yes = 1
No = 0
Transfer Mobility
0 = unable - no sitting balance, mechanical lift 0 = Immobile

1 = major help (one strong, skilled helper or two normal 1 = wheelchair independent, in-
people; physical), can sit cluding corners, etc

2 = minor help (one person easily or needs supervision 2 = walks with help of one person
for safety) (verbal or physical)

3 = independent (use of aids to be independent is al- 3 = independent (but may use any
lowed) aid, eg cane)

Total score /5

22
Ontario modified STRATIFY Risk Assessment Tool(2, 4)

Ontario Modified STRATIFY risk screen

Falls 1. Did the patient present to hospital with a fall or has he or she Yes = 1
history fallen in the ward since admission? No = 0
If not, has the patient fallen within the past 2 months?
Mental 2. a. Is the patient confused (ie unable to make purposeful deci- Yes = 1
status sions, disorganised thinking, and memory impairment)? No = 0
b. Is the patient disorientated (ie lacking awareness, being mis- (on at least
taken about time, place or person)? one ques-
c. Is the patient agitated (ie fearful affect, frequent movements, tion)
and anxious)?
Vision 3. a. Does the patient require eyeglasses continuously? Yes = 1
b. Does the patient report blurred vision? No = 0
c. Does the patient have glaucoma, cataracts or macular degen- (on at least
eration? one ques-
tion)
Toilet- 4. Are there any alterations in urination (ie frequency, urgency, Yes = 1
ing incontinence, nocturia)? No = 0
Transfer 5. Transfer and mobility score of 3 of 6? Yes = 1
and mo- No = 0
bility
Transfer Mobility
0 = unable - no sitting balance, mechanical lift 0 = Immobile

1 = major help (one strong, skilled helper or two nor- 1 = wheelchair independent, in-
mal people; physical), can sit cluding corners, etc

2 = minor help (one person easily or needs supervi- 2 = walks with help of one per-
sion for safety) son
(verbal or physical)
3 = independent (use of aids to be independent is al- 3 = independent (but may use
lowed) any aid, eg cane)

Total score /5

For each item, 0 (no risk) or 1 (risk) is substituted in the equation:

R = 6 (falls history) + 14 (mental status) + 1 (vision) + 2 (toileting) + 7 (transfer and mobility)

23
Morse Fall Scale(17, 18)

Item Item Score Patient Score

1. History of falling No 0
(immediate or previous) Yes 25 ______
2. Secondary diagnosis (≥ 2 No 0
medical diagnoses in chart) Yes 15 ______
3. Ambulatory aid
None/bedrest/nurse assist 0
Crutches/cane/walker
Furniture 15
30 ______
4. Intravenous therapy/ No 0
heparin lock Yes 20 ______
5. Gait
Normal/bedrest/wheelchair 0
Weak* 10
Impaired† 20 ______
6. Mental status
Oriented to own ability 0
Overestimates/forgets limi-
tations 15 ______
Total Score‡: Tally the patient score and
record.
<25: Low risk
25-45: Moderate risk
>45: High risk ______

* Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furni-
ture while walking, but with light touch (for reassurance).
† Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired
balance, requiring furniture, support person, or walking aid to walk.
‡ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone
patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse herself said that the appropriate cut-points to
distinguish risk should be determined by each institution based on the risk profile of its patients. For details, see
Morse JM, , Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8;366-
7.

24
Hendrich II Fall Risk Model(19)

Confusion Disorienta- 4
tion Impulsivity
Symptomatic Depres- 2
sion
Altered 1
Elimination
Dizziness 1
Vertigo
Male 1
Gender
Any 2
Administered
Antiepileptics
Any 1
Administered
Benzodiazepines
Get Up & Go Test
Able to rise in a single movement – No loss of balance with steps 0
Pushes up, successful in one attempt 1
Multiple attempts, but successful 3
Unable to rise without assistance during test 4
(OR if a medical order states the same and/or complete bed rest is ordered)
* If unable to assess, document this on the patient chart with the date and
time
A Score of 5 or Greater = High Risk Total
Score
©2007 AHI of Indiana Inc. All Rights Reserved. US Patent (US20050182305) has been allowed.
Reproduction and use prohibited except by written permission from AHI of Indiana Inc.

25
Peter James Centre Fall Risk Assessment Tool (PJC-FRAT):
risk assessment tool for the subacute rehabilitation setting(2)
The Peter James Centre Fall Risk Assessment Tool (PJC-FRAT) is a multidisciplinary falls risk assessment tool. It was
used as the basis for developing intervention programs in a randomised controlled trial in the subacute hospital
setting that successfully reduced patient/resident falls. Permission to reproduce this tool was granted by Peter
James Centre and BMJ Publishing Group.
Acknowledgment is required if the tool is used by your organisation. Contact details for further information:
Peter James Centre
Mahoney’s Road
Burwood East VIC 3151
Phone: 03 9881 1888
Fax: 03 9881 1801

Peter James Centre Fall Risk Assessment Tool (PJC-FRAT): Falls risk Assessment Tool

(To be completed on admission) Name:

UR/MR number:
Ward/Unit:
Date of birth: Gender:
Admission Date:
Tick box or add number as appropriate Place UR sticker here or add patient details:
Medical

Does the patient suffer from frequent falls with no * à Refer for hip protector.
diagnosed cause?
Is the patient suffering from an established medical * à Refer for hip protector.
condition that is currently unable to be adequately
managed, that may cause a fall
during their Inpatient stay (e.g. drop attacks due to
vertebro-basilar artery insufficiency?
Is the patient taking any medications/medication * à Refer for hip protector.
amounts/medication combinations that you antici-
pate may directly contribute to a fall (e.g. seda-
tives)?
Signature: Date:
Nursing

Toileting (day) F.I.M. * à Document level of assistance required in pa-

tient/resident record/file.
Toileting (night) F.I.M. * àDocument level of assistance required in pa-
tient/resident record/file.
Would this patient benefit from a Falls Risk Alert * àRefer for a Falls Risk Alert Card and a Falls
Card and a Falls Prevention Information Brochure? Prevention Information Brochure
Signature: Date:

26
Peter James Centre Fall Risk Assessment Tool (PJC-FRAT): Falls risk Assessment Tool
Physiotherapy
Gait F.I.M. (Gait aid + distance) * à (__________/__________ )
Transfer (bed <—> chair F.I.M) *
Would this patient benefit from attending a Bal- * àRefer for Balance Exercise Class.
ance Exercise Class?
Signature: Date:
Falls Risk Assessment Tool
Occupational Therapy
Bathing F.I.M
Dressing F.I.M.
Would this patient benefit from attending a Falls
Prevention Education Program?

All disciplines
Has the patient demonstrated non-compliance or * à Refer for hip protector.
do you strongly anticipate non-compliance with
the above prescribed level of aids/ assistance/
supervision such that the patient becomes unsafe? Signature: Date:
The Modified Functional Independence Measure (F.I.M.)
(7) Independent with nil aids. (3) Moderate assistance required
(6) Independent with aids. (patient performs between 50% and 75% of the
(5) Supervision/prompting task).
(4) Minimal assistance required (2) Maximal assistance required
(patient greater than 75% of the task). (Patient performs between 25% and 50% of the
task).
(1) Fully dependent (patient performs less than
25% of the task).
Falls Risk Assessment Tool — Amendment sheet
Name:
UR/MR number:
Ward/Unit:
Date of birth: Gender:
Admission Date:
Place UR sticker here or add patient details:
This amendment section of the Falls Risk Assessment Tool is to be used when a patient’s condition
changes such that the employment of interventions is now indicated or now no longer indicated. For ex-
ample, if a patient’s confusion due to a UTI is now resolved, they may no longer require a hip protector.

27
 Peter James Centre Fall Risk Assessment Tool (PJC-FRAT): Falls risk Assessment Tool

Has the patient’s condition changed such that the patient:

• Does now require a hip protector: * à Refer for hip protector.
• Does no longer require a hip protector: * à Note in record and make appropriate
change
• Would now benefit from balance exercise * à Refer for balance exercise.
class:
• Would now benefit from a falls prevention * à Refer for falls prevention education.
education class:
• Would now benefit from a falls risk alert * à Refer for falls alert card.
card and information brochure:
Signature: Date:
Has the patient’s condition changed such that the patient:
• Does now require a hip protector: * à Refer for hip protector.
• Does no longer require a hip protector: * à Note in record and make appropriate
change
• Would now benefit from balance exercise * à Refer for balance exercise.
class:
• Would now benefit from a falls prevention * à Refer for falls prevention education.
education class:
• Would now benefit from a falls risk alert * à Refer for falls alert card.
card and information brochure:
Signature: Date:

Appendix 4: Glossary What is a Near Fall?

A near-fall is a slip, trip, stumble or loss of balance
Definitions (RNAO Reducing falls and injuries from
such that the individual starts to fall but is either able
falls Getting Started Kit) www.saferhealthcarenow.ca to recover (witnessed or unwitnessed) and remains
upright because their balance recovery mechanisms
were activated and/or caught by staff/other persons,
What is a Fall?
or they were eased to the ground or floor or other
A fall is defined as: an event that results in a person lower level, by staff/other persons (e.g. could not stop
coming to rest inadvertently on the ground or floor or or prevent falling to the ground, floor or lower sur-
other lower level, with or without injury. face).
This would include:
 Unwitnessed fall - where the client is able/unable What is a Fall Injury?
to explain the events and there is evidence to sup- A fall injury is defined as an injury that results from a
port that a fall has occurred. fall, which may or may not require treatment. The inju-
ry can be temporary or permanent and vary in the se-
verity of harm.

28
Other definitions  how to stay motivated if referred for falls preven-
A multifactorial intervention tion strategies that include exercise or strength
An intervention with multiple components that aims to and balancing components
address the risk factors for falling that are identified in  the preventable nature of some falls
a person's multifactorial assessment.
 the physical and psychological benefits of modify-
A multifactorial assessment may include: ing falls risk
 cognitive impairment  where they can seek further advice and assistance
 continence problems  how to cope if they have a fall, including how to
 falls history, including causes and consequences summon help and how to avoid a long lie.
(such as injury, older person’s perceived functional
ability and fear of falling, home hazards)
Staff education
 footwear that is unsuitable or missing To improve workflow and enhance the development of
 health problems that may increase their risk of routine practices related to fall prevention:
falling (such as osteoporosis)  Conduct educational sessions during staff orienta-
 Medication tion at regular intervals on:
 postural instability, mobility problems and/or bal- – The prevention of falls and fall injuries
ance problems – Safe mobility, risk assessment, risk manage-
 syncope syndrome ment, post fall follow up, alternatives to re-
straints, etc.
 visual impairment
– Promoting safe mobility risk assessment, risk
 neurological examination.
management, including post fall follow up
alternatives to restraints, sensory impairment,
Client education continence education, etc.
Education on identified risk factors and risk-reduction  Include falls injury prevention strategies (i.e., lifting
strategies: a resident after a fall or safe transfer)
 what measures they can take to prevent further  Identifying resources for falls prevention and regu-
falls latory requirements.

Acknowledgements

We acknowledge Manosila Yoganathan, Magnus Novell, and Sasha Masabanda who helped in the review develop-
ment process.

29
Copyright Bruyère Research Institute 2016. This work is licensed under the Creative Commons Attribution-
NonCommercial 4.0 International License. To view a copy of this license, visit http://creativecommons.org/
licenses/by-nc/4.0/.

Suggested citation: Welch V, Ghogomu E, Shea B. Evidence-based screening tools and fall risk assessment
in continuing care. A Bruyère rapid review. Bruyère Reports No. 6, August 2016.

30