Key messages
- All patients should be screened for falls risk when they are admitted to hospital and whenever the patient is transferred to another setting.
- All patients over 65 years old should be considered at risk of falling.
Screening can determine whether a person has a low or high risk of falls and assessment of risk can inform the development of prevention strategies.
Currently the National Standards require that all patients have a documented falls risk screen on admission to hospital and on transfer between settings.
Examples of screening tools currently in use in Victorian hospitals include:
- Falls Risk Assessment Tool: FRAT1
- STRATIFY2,3
Experts emphasise that drawing on our clinical judgement can be equivalent if not superior to using these types of tools. Given this we should consider the following patients as having a higher risk of falling:
- aged 65 and over
- aged between 50 and 64 who are at higher risk of falling (according to clinical judgement) due to an underlying condition4, for example Parkinson’s disease, stroke, early onset dementia
- all inpatients admitted following a fall.
For all these patients, we should undertake falls assessment and provide one to one patient education.
Assessment of falls risk and falls risk factors
Early identification of falls risk factors enables us to tailor care and respond to each patient's individual needs. Whilst the evidence for multifactorial intervention based on risk assessments is weak in the hospital setting, identifying, exploring and addressing these issues will be of benefit to the older person.
Assessment of risk factors should include assessment for individual risk factors such as:
- past history of falls
- cognitive impairment
- delirium
- incontinence, indwelling catheters
- extended period of medical illness
- foot problems and footwear
- visual impairment
- poor balance
- problems with walking and self-care
- health conditions that may increase the risk of falling, such as stroke, Parkinson’s disease, peripheral neuropathy and postural hypotension
- medication, including number and types of medication associated with falls, particularly sedatives, analgesics (opioids and antineuropathic pain medications) and antipsychotics
- musculoskeletal conditions, such as osteoarthritis of the knee and hip
- frailty
- significant weight loss and under nutrition leading to loss of muscle mass and strength
- prolonged bed rest.
Assessment for injury risk
Assessment for the risk of injury (for example, fracture, head injury) also needs to be undertaken and we should consider:
- conditions such as osteoporosis
- long term steroid use
- previous fractures
- conditions such as metastatic bone disease
- use of anticoagulants such as warfarin.
Assessment of the environment
Assessment of the environment is also vital. Scan the ward environment for hazards such as:
- clutter
- poor lighting
- slippery surfaces
- equipment in need of repair
- equipment or gait aids without brakes locked appropriately.
References
1. Stapleton, C., et al., Four-item fall risk screening tool for subacute and residential aged care: The first step in fall prevention. Australasian Journal on Ageing, 2009. 28(3): p. 139-143.
2. Barker A, Kamar J, Graco M, Lawlor V, Hill K. Adding value to the STRATIFY falls risk assessment in acute hospitals. Journal of Advanced Nursing. 2011;67:450-7.
3. Oliver, D., et al., Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ. British medical journal, 1997. 315(7115): p. 1049-53.
4. National Institute for Health and Care Excellence, NICE Clinical Guideline 161. Falls: Assessment and prevention of falls in older people, 2013: National Institute for Health and Care Excellence.
Reviewed 28 December 2023