Fall is a season to enjoy the changing of the leaves on trees, pumpkin spice flavors and football, not a time for slips and trips. That is why it is a timely reminder to be aware of the risks of falling as we age. A fall risk assessment is an examination done on every patient throughout their hospital stay to determine their risk of falls based on different variables. The initial fall risk screening will include asking if the patient has a history of falls, difficulty walking, and or concerns about falling. Patients should be assessed any time there is a change in their status while at the hospital. This could be the removal of a urinary catheter (so now they have to get up to go to the bathroom), after surgery, changing medications, or a new diagnosis. It is important to continually reassess because any change in the patient’s care could change their fall risk
What is Fall Risk Assessment?
The purpose of the ongoing fall risk assessment is to assess for risk and changes in status, as well as to put interventions into place to prevent falls. The assessment’s main purpose is to identify risks and prevent patient falls.
Patient falls are very common, especially for patients older than 65. There are times when a patient will have a low risk that could quickly change to a higher risk for reasons such as surgery or medications. They could also be at risk once a first fall occurs. Assessing a patient frequently will allow for proper interventions to be put in place for fall prevention.
Fall Risk Classifications
1. Anticipated Physiological Falls
Anticipated physiological falls are caused by expected physiological factors, including:
- Unstable gait
- History of falling
- Altered mental status
- Frequent toileting needs
- Certain medications
2. Unanticipated Physiological Falls
Unanticipated physiological falls are caused by unexpected physiological factors, including:
- Seizures
- Syncopal episodes
- Delirium
3. Accidental Falls
Accidental falls are caused by slipping, tripping, and other extrinsic factors.
Fall Risk Factors: Intrinsic and Extrinsic
Intrinsic Fall Risks
Intrinsic fall risks originate within the patient, such as low blood pressure, impaired mobility, impaired vision, or foot pain/paresthesia.
Extrinsic Fall Risks
Extrinsic fall risks originate outside the patient, such as slippery floors, poor lighting, or an uneven threshold.
What fall risks are typically considered during a fall risk assessment?
Age
Older patients are typically at a higher risk for falls. Some fall risk assessments assign increasing point values if the patient is over 60, over 70, and over 80.
Previous Fall History
If a patient has fallen in the past six to twelve months, they are at a higher risk to fall again. If they have fallen multiple times, they may be considered a high fall risk.
Gait Instability
Difficulty walking due to impaired mobility or lower limb weakness, often due to illness, inactivity, age-related challenges, or conditions that affect gait and balance, like Parkinson’s disease, can increase a patient’s fall risk. Patients are also at a higher risk for falls if they use a mobility device.
Urinary Incontinence, Frequency, or Need for Assistance
Medications and I.V.s can increase urinary urgency and frequency. Some patients may get up quickly or walk without assistance to avoid urinary incontinence, which can lead to falls.
Medication
Medications and their side effects may put patients at a higher risk for falls. Sedatives, diuretics, opioids, anticonvulsants, psychotropics, and other medications may cause dizziness, unsteadiness, postural hypotension, and other effects that increase fall risks. If a patient is on multiple medications, the medication interactions may also increase your patient’s fall risk.
Patient Care Equipment
Patients tethered to I.V.s, chest tubes, catheters, etc. are at a higher risk for trips and falls.
Altered Mental Status
Patients who are agitated, confused, or lack understanding of their physical and mental limitations may get out of bed without assistance (when it’s needed) and are at a higher risk of falling out of bed.
High Risk of Injury, Evaluated Using ABCS
- Age: If your patient is over 85 years old, increases in frailty increase their risk of injury.
- Bones: Osteoporosis or a history of fractures increases your patient’s risk of a broken bone after a fall.
- Coagulation: Anticoagulation medications, low platelet counts, and other conditions can put patients at a high risk of bleeding after a fall.
- Surgery: Recent surgery, including lower limb amputation and abdominal or thoracic surgery, also increases a patient’s risk of injury after a fall.
If you notice new things that may increase the risk of a fall, like stumbling or dizziness, be sure to document them and inform your physician.
Additional Information: Older Adult Fall Prevention – Centers for Disease Control and Prevention (CDC)
Autumn Is The Time For Fall Prevention – Nebraska DHHS
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