Falls risk assessment

FALLS RISK ASSESSMENT

[+] yes, [-] no
Risk factors (history):
[-] fall in the last 12 months. 
[-] history of osteoporosis or minimal trauma fracture. 
[-] muscle weakness. 
[-] balance problems  / dizziness / vertigo. 
[-] gait problems (unsteady). 
[-] parkinson disease. 
[-] problems with transfers or adl. 
[-] sensory impairment (peripheral sensation, proprioception). 
[-] vision impairment. 
[-] hearing impairment. 
[-] cognitive impairment / confusion / delirium. 
[-] incontinence or urgency. 
[-] arthritis. 
[-] diabetes. 
[-] history of stroke. 
[-] orthostatic hypotension. 
[-] anaemia. 
[-] antihypertensive / diuretic medication. 
[-] sedative / antidepressant / benzodiazepine / hypnotic medication. 
[-] alcohol use. 
[-] environmental hazards.

Examination findings:
  BP sitting: 
  BP standing (1 min): 
  BP standing (3 min): 
    [-] Significant postural drop (SBP 20+ mmHg, DBP 10+ mmHg)
  [-] Significant arthritis/arthropathy
  [-] Impaired proprioception
  [-] Impaired peripheral sensation
  [-] Impaired visual acuity/fields
  [-] Impaired hearing (eg whisper test)

Gait/balance assessment:

When walking and turning, does the person appear unsteady or at risk of losing their balance?
Observe the person standing, walking a few metres, turning and sitting. If the person uses an aid, observe the person with the aid. Do not base on self-report.
If the level fluctuates, tick the most unsteady rating. If the person is unable to walk due to injury, score as 3.

0 : No unsteadiness observed
1 : Minimally unsteady
2 : Moderately unsteady [-] needs supervision
3 : Consistently and severely unsteady [-] needs constant hands on assistance

Score:

Sit-to-stand test:

Use a straight-backed chair (~43 cm high) with no armrests.
Place the chair with a wall behind it for safety.
Instruct the person to stand up and sit down as quickly as possible five times, with their arms folded.
Use a stopwatch to record, in seconds, the time taken to do it five times.
Allow a maximum of two minutes to complete the test.
Fail if > 12 seconds.

Score (pass/fail):

Romberg test:

Ask patient to stand with feet comfortably close together.
With standby supervision and reassurance, ask patient to close eyes for 30 seconds.
If patient loses balance they are deemed at risk.

Score(pass/fail):

ASSESSMENT
Overall fall risk estimate (low/medium/high):

[Plan]

Fall prevention interventions:
[-] Patient / family safety and options discussion. 
[-] Education and information. 
[-] Minimise/alter medications. 
[-] Manage postural hypotension. 
[-] Manage heart rate and rhythm abnormalities. 
[-] Osteoporosis management: supplement calcium / vitamin D, exercise, anti-resorptive therapy.  
[-] Continence: Assessment/ aids
[-] Opthalmology / optometry referral: vision, including cataracts. 
[-] Geriatric assessment of cognitive function. 
[-] Physiotherapy/exercise physiology referral: exercise program. 
[-] Physiotherapy referral: gait and balance assessment for assistive devices. 
[-] Podiatry referral: manage foot and footwear problems. 
[-] Occupational therapy referral: home modification and safety ASSESSMENT
Comments:

References
1. The Prevention of Falls in Older Persons: Clinical Practice Guideline (http://www.medcats.com/FALLS/frameset.htm) from the American Geriatrics Society.

Falls risk assessment

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