Clinical Practice Guidelines
Fall Risk Screening
Fall risk screening identifies older adults at increased risk of falls who may need a more detailed multifactorial fall risk assessment and intervention, which can in turn help to prevent falls and fall-related injury.
Falls screening tools are sensitive, brief, and easy to complete assessments that attempt to identify individuals at a higher than average risk for falling who would likely benefit from a more in-depth evaluation.
Results can be numerical with a cut-off score or categorical where those tested are ranked as being at LOW, MEDIUM, and HIGH RISK.
Screening for fall risk
Patient scores ≥4 on the Staying Independent brochure
Patient answers YES to any of the 3 key questions:
1. Fell in the past year?
-If YES ask, How many times? Were you injured?
2. Feels unsteady when standing or walking?
3. Worries about falling?
While screening tools have been used to predict a general level of risk for falling, they do not accurately predict which people will actually fall or give much information about what can be done to decrease the risk of falling.
Certain screening tools such as the Staying Independent Checklist provide the ability for seniors to self-assess their risk for falls. Keep in mind that these validated tools can also be used as a means to encourage a discussion around falls.
If the patient score ≥ 4 on the Staying Independent brochure or if the patient answers YES to any of the key questions, proceed with Evaluating Gait, Strength and Balance.
If the patient score < 4 on the Staying Independent brochure or if patient answers NO to all key questions,
provide individualized interventions for an older patient at LOW RISK for falls.
- Algorithm for Fall Risk Screening, Assessment and Intervention
Staying Independent - Self Screening Tool