One in three Americans over the age of 65 falls each year, according to the National Council on Aging, which makes falls the leading cause of non-fatal and fatal injuries in older adults in the nation. Falls are costly, can cause significant disability, and can decrease quality of life.
Identifying patients and residents at high risk for falling can help caregivers reduce falls in and out of hospitals, long-term care facilities, and other healthcare institutions. Using standardized assessment tools helps care providers identify those at risk for falling. Here are five of the most widely used assessment tools to determine the risk of falls.
Five Standardized Assessment Tools
1. The 30-Second Chair Stand Test
The 30-Second Chair Stand Test assesses legs strength and endurance. Equipment needed to perform this test includes a stopwatch and a chair that measures 17” high, has a straight back and no armrests.
To perform this test, the patient sits on the chair with his feet flat on the floor. He places each hand on the opposite shoulder, crossing his arms at the wrist, and holds them there throughout the duration of the test. When the tester says “Go” and starts the stopwatch, the patient comes to a full standing position and sits back down as many times as he can in 30 seconds without using his hands. The test counts the number of times the patient can stand up. If the patient comes halfway to a standing position, the tester should count it as a full stand.
A below average score indicates a high risk for standing. The Centers for Disease Control and Prevention (CDC) lists below average scores by age and gender. The average man aged 60 to 64 can stand up 14 or more times in 30 seconds, for example, while the typical woman can stand up 12 times.
2. The Timed Up and Go (TUG) Test
The Timed Up and Go (TUG) Test assesses mobility. The tester needs a stopwatch, a tape measure, and a way to create a temporary line on the floor about 10 feet away from a standard armchair.
The patient should wear regular footwear and use a walking aid, if needed. The patient sits in the chair; when the tester says “go” and starts the stopwatch, the patient stands up and walks at her normal pace to the line on the floor, turns, walks back to the chair and sits down again. The tester times how long it takes for the patient to complete the task. A patient that takes longer than 12 seconds to complete the TUG test is at high risk of falling, according to the Oncology Nursing Society.
3. The 4-Stage Balance Test
The 4-Stage Balance Test helps caregivers assess static balance, which is the ability to remain balanced when stationary. The 4-Stage Balance Test features four progressively challenging positions. The tester needs a stopwatch. Patients should not use a cane, walker or other assistive devices, and they should keep their eyes open throughout the tests.
The tester should describe then demonstrate each position to the patient or resident. As the patient or resident tries the position, the tester should stand next to him, hold the subject’s arm and help him assume the correct foot position. When the patient feels steady, the tester should let go but remain ready to catch the patient or resident in the event he should lose his balance.
The tester should time the resident or patient holding the position. If the patient or resident can hold the position for at least 10 seconds without needing support or moving his feet, the tester may stop that portion of the test and move on to the next position. The tester should stop the test if the patient or resident loses his balance.
The four positions include standing with feet side by side, standing with the big toe of one foot touching the instep of the other foot, standing with the heel of one foot touching the toe of the other foot, and standing on one foot. The CDC says that patients or residents who cannot hold the final position, known as the tandem stance, for longer than 10 seconds is at higher risk of falling.
4. Orthostatic Blood Pressure
An orthostatic blood pressure test looks for orthostatic hypotension, which is blood pressure that drops suddenly when the patient stands up. A drastic drop in blood pressure can cause dizziness and falls. In fact, Mayo Clinic says that falling is a common complication in people with orthostatic hypotension.
Equipment to perform an orthostatic blood pressure includes a bed or hospital cart, blood pressure cuff, and stethoscope if needed.
To perform an orthostatic blood pressure test, the tester should ask the patient or resident to lie down for five minutes. The tester should then measure blood pressure and pulse while the patient or resident continues to lie comfortably. Next, the tester should ask the patient to stand and remain in close proximity in case the patient begins to feel dizzy. The tester should take the patient or resident’s blood pressure and pulse again after one minute of standing and after three minutes.
The CDC says that a decrease in blood pressure equal to or greater than 20 mm Hg, or a decline in diastolic blood pressure equal to or greater than 10 mm Hg is an abnormal result. Experiencing lightheadedness or dizziness is also abnormal and indicates an increased risk for falling.
5. Allen Cognitive Screen
The Allen Cognitive Screen, also known as the leather lacing tool, is a cognitive assessment tool that helps evaluate risk of falls due to problems related to functional cognition. Also known as the leather lacing tool, this screening measures an individual’s global cognitive processing capabilities, learning potential, and performance abilities.
Equipment for the Allen Cognitive Screen includes a kit containing a piece of leather with pre-punched holes, lace, and a large needle. The patient uses the needle to stitch three increasingly difficult stitches through the holes in the leather. Testers use the Allen Cognitive Levels and Modes of Performance and Level of Care to assess the patient’s results.
Administering these tests can help caregivers identify patients or residents at high risk for falls then take action to prevent these accidents.
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