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Falls risk assessment and prevention in older people in healthcare facilities

03 April 2025
Volume 34 · Issue 7
Nurse helping the elderly

Abstract

Falls among older adults in healthcare facilities are a significant cause of injury and morbidity, with serious implications for patient health and healthcare costs. This article provides an in-depth review of falls risk assessment tools and prevention strategies, emphasising the multifactorial nature of falls, which include intrinsic factors such as medical conditions and extrinsic factors such as environmental hazards. The article discusses widely used risk assessment tools in the UK, including the Morse fall scale, Stratify, and the timed up and go test, and highlights the importance of a comprehensive, multidisciplinary approach to fall prevention. Evidence-based strategies such as environmental modifications, exercise programmes, medication reviews, and patient education are explored. The article concludes that ongoing assessment, staff training and the integration of technology are vital in reducing falls and improving patient safety in healthcare settings.

Falls are a significant cause of injury and morbidity among older adults, particularly those residing in healthcare facilities such as hospitals, nursing homes and long-term care institutions. Globally, one-third of individuals aged 65 and older experience a fall annually (National Institute for Health and Care Excellence (NICE), 2013; Ganz and Latham, 2020). Approximately half of these individuals will suffer recurrent falls (World Health Organization (WHO), 2021). Salari et al (2022) indicated the prevalence of falls in older people in the world to be 26.5%.

Falls often lead to adverse outcomes, including fractures, head injuries, decreased functional independence and, in some cases, death (Seppala and van der Velde, 2023; Sturnieks et al, 2024). Total deaths and disability-adjusted life years (DALYs) due to falls have increased gradually since 1990 in Europe (Haagsma et al, 2020), with 38 million DALYs lost each year globally (WHO, 2021). The financial burden of falls to the NHS was estimated to be more than £2.3 billion per year (NICE, 2013). Therefore, prevention of falls is a critical concern in older person care, and healthcare systems have prioritised reducing fall-related injuries among the elderly (Cameron et al, 2024; Camp et al, 2024).

Falls risk assessment and prevention strategies are essential components of high-quality care in healthcare facilities. These assessments help to identify individuals at high risk of falling and enable health professionals to implement targeted interventions to mitigate that risk.

In recent years, numerous studies have emphasised the importance of a multidisciplinary approach that combines environmental modifications (Lewis and Griffin, 2023), pharmacological reviews (Heng et al, 2022), physical therapy (Taylor et al, 2023), and patient education to prevent falls (Äijö et al, 2023; Montero-Odasso et al, 2023; Aline et al, 2024; Camp et al, 2024).

This article provides an overview of fall risk-assessment methods and evidence-based prevention strategies for older adults in healthcare facilities. It highlights the importance of early identification of at-risk individuals and discusses best practice to reduce fall incidents, drawing on recent research to inform practical recommendations.

Falls risk factors in older people

Understanding the risk factors associated with falls in older adults is the first step toward effective fall prevention. Falls in this population are typically multifactorial, influenced by intrinsic factors (eg medical condition, medication, balance impairment) and extrinsic factors (eg environmental hazards, inappropriate footwear).

Intrinsic risk factors

Intrinsic risk factors are often related to the physiological changes associated with ageing. For instance, reduced muscle strength, balance impairment and declining visual acuity contribute significantly to fall risk (Harper, 2024). Additionally, chronic medical conditions such as Parkinson's disease, arthritis, diabetes and cardiovascular diseases increase the likelihood of falls. Cognitive impairments, including dementia and delirium, also heighten the risk of falling due to impaired judgement and orientation (Allan et al, 2009; Hamdan et al, 2024).

The use of certain medications, particularly sedatives, antipsychotics, and antihypertensive agents, significantly increases the risk of falls in older adults by causing dizziness, orthostatic hypotension, and sedation (Érszegi et al, 2024). This risk is compounded by polypharmacy, where multiple medications are prescribed, but taking only one medication can lead to the occurrence of falls (Yoshida et al, 2024).

Extrinsic risk factors

Extrinsic factors, primarily related to the environment, also play a significant role in falls among older adults in healthcare settings. Environmental hazards such as poor lighting, slippery floors and uneven surfaces are common contributors to falls in healthcare facilities (Alqrishah et al, 2024). The design of healthcare settings, including cluttered hallways and inappropriate bed heights, can create additional risks. Inadequate footwear or the use of ill-fitting walking aids further increases the likelihood of falls. Healthcare facilities should pay attention to the physical environment, ensuring that it is conducive to the mobility needs of older adults. Staff should also be trained to promptly recognise and address these environmental hazards (Elf et al, 2024).

Falls risk assessment in healthcare facilities

Falls risk assessment is a systematic process used to identify individuals who are at high risk of falling and to guide the implementation of preventive measures. A range of tools and methods is available for this purpose, and the selection of an appropriate assessment tool depends on the healthcare setting and the characteristics of the patient population.

Commonly used falls risk-assessment tools

Several validated fall risk-assessment tools are widely used in clinical practice. These tools typically evaluate a combination of intrinsic and extrinsic factors to determine a patient's falls risk.

Morse fall scale

The Morse fall scale (MFS) is one of the most commonly used tools for assessing fall risk in hospitalised patients. It assesses six variables: history of falling; secondary diagnosis; ambulatory aid; intravenous therapy; gait; and mental status. MFS was developed by Morse et al (1989), and re-evaluated for validity by Mao et al (2024). The MFS assigns a score based on these factors, with higher scores indicating a greater risk of falls.

Timed up and go test

The timed up and go (TUG) test is a simple assessment of mobility and balance. It measures the time taken for an individual to rise from a chair, walk three metres, turn around, walk back, and sit down. A time greater than 12 seconds indicates increased fall risk (Abdullah et al, 2022; Ibeneme et al, 2022). The TUG test was validated by Reis et al (2024) for monitoring risk of falls in community-dwelling older adults.

Hendrich II fall risk model

The Hendrich II model assesses fall risk based on factors such as confusion, depression, altered elimination, dizziness, male gender, use of antiepileptics, and use of benzodiazepines (Hendrich et al, 2020). Like the MFS, it assigns a score that indicates the patient's level of fall risk.

Stratify tool

The Stratify tool evaluates five risk factors: history of falls; agitation; visual impairment; frequent toileting; and transfer ability. It was developed specifically for use in acute care settings and is easy to administer (Oliver et al, 2004).

Falls risk assessment tool

The falls risk assessment tool (FRAT) is widely used in UK community care settings and general practice. It comprises three sections: risk factor checklist; risk management plan; and follow-up. FRAT is used to provide a comprehensive assessment of fall risk, particularly in community and outpatient settings (Department of Health Victoria, 2015; Peninsula Health Prevention Service, 2023). Morris et al (2021), however, found that the replacement of FRAT with a clinical reasoning approach did not lead to inferior fall outcomes in the short term.

Elderly fall screening test

The elderly fall screening test (EFST) is used in primary care settings to assess fall risk in older adults. It is a five-item test that divides people into low and high risk, based on gait and balance, history of falls and observation of walking speed (Queensland Health, 2021; Wickins et al, 2024). This tool helps GPs and community nurses identify older adults who may need further assessment or preventive interventions.

Multifactorial falls risk assessment

NICE (2017) recommends a multifactorial fall risk assessment (MFRA) for older adults who have fallen or are at risk of falling. This assessment covers: fall history; gait; balance; mobility problems; muscle strength; visual impairment; cognitive impairment; medications; polypharmacy; and environmental hazards (eg home safety). The multifactorial approach allows for a comprehensive evaluation and targeted intervention. It is used across multiple settings, including hospitals, care homes and community services.

FRAX tool

Although not a fall risk tool per se, the fracture risk-assessment tool (FRAX) is used to estimate the 10-year probability of fractures in older adults. Since fractures are a common consequence of falls, especially among those with osteoporosis, this tool is integrated into fall risk assessments in healthcare settings. FRAX calculates the fracture risk based on several factors, including age, gender, previous fractures, family history of osteoporosis, and lifestyle factors such as smoking and alcohol use. It helps identify patients who might benefit from bone-strengthening treatments and fall-prevention strategies (Cherian et al, 2019).

Falls efficacy scale—international

The falls efficacy scale–international (FES–I) is a psychological tool to assess the fear of falling, which is often associated with higher fall risks. It evaluates a person's confidence in performing daily activities without falling (Yardley et al, 2005; McGarrigle et al, 2023). This scale is used in both clinical and community settings to address the fear of falling and to help tailor interventions that can improve confidence and reduce actual fall risk.

Comprehensive geriatric assessment

In addition to using standardised tools, a comprehensive geriatric assessment (CGA) is often performed for older adults in healthcare settings. The CGA is a multidimensional diagnostic process that evaluates medical, psychological and functional capacities. It provides a more holistic understanding of a patient's risk of falls, and guides the development of a personalised care plan (Basş and Cankurtaran, 2023; Kim, 2022). The CGA typically includes an assessment of mobility, balance, muscle strength, cognitive function, nutritional status, vision, and medication use. It also evaluates environmental factors such as the patient's living conditions and available support systems.

Screening versus in-depth assessment

Falls risk assessments in healthcare settings may be conducted in two stages: screening and in-depth assessment. Screening is a quick process used to identify individuals who may be at risk of falling, while in-depth assessment involves a more thorough examination of the patient's risk factors. Screening tools such as the medication appropriateness index (MAI) or TUG test can be administered regularly to all older patients (Abdullah et al, 2022). The most used in the UK are the malnutrition universal screening tool (MUST) and mini frailty scale (MFA) (Lewis et al, 2021). If a patient is identified as being at high risk, an in-depth assessment using a tool such as the CGA may be conducted to develop a tailored falls-prevention plan (Basş and Cankurtaran, 2023).

Falls-prevention strategies

Preventing falls and fall-related injuries in older people is a crucial focus in geriatric care, with healthcare systems prioritising interventions such as exercise programmes and medication management to reduce risks effectively (Cameron et al, 2024). Preventing falls in older adults requires a multifaceted approach that combines patient education, environmental modifications, exercise programmes, medication management, and staff training. Effective fall-prevention programmes are individualised to meet the specific needs of each patient and should be regularly reassessed to ensure they remain appropriate (Camp et al, 2024).

Environmental modifications

One of the most effective methods of preventing falls in healthcare facilities is addressing environmental hazards. Ensuring that floors are dry and free from clutter, improving lighting, installing handrails and grab bars, and adjusting bed heights can significantly reduce the risk of falls (Alqrishah et al, 2024; Elf et al, 2024).

In addition, healthcare facilities should routinely assess the safety of patient rooms and common areas, making necessary adjustments to minimise hazards. Assistive devices such as walkers or walking sticks should be readily available and properly maintained.

Exercise and physical therapy

Exercise is a key component of fall prevention, as it helps to improve strength, balance and co-ordination in older adults. Studies have shown that balance training, strength exercises and flexibility exercises are particularly effective in reducing falls (Sherrington et al, 2020). Group-based exercise programmes or individualised physical therapy can be implemented depending on the patient's functional status.

Tai chi, a gentle form of exercise that emphasises balance and co-ordination, has gained popularity as a fall-prevention intervention. A randomised controlled trial found that older adults participating in tai chi classes exhibit a significantly reduced risk of falls compared to control groups (Chen et al, 2023). This conclusion is supported by various studies highlighting the effectiveness of tai chi in enhancing balance, strength and overall mobility among the elderly (Lin et al, 2024; Miles and Mulkey, 2024; Mao et al, 2024).

Medication review

Given that certain medications increase the risk of falls, regular medication reviews are essential in healthcare facilities. Deprescribing or adjusting the dosages of medications that contribute to dizziness, sedation, or orthostatic hypotension can reduce fall risk (Akin et al, 2024; Yoshida et al, 2024). Multidisciplinary teams, including pharmacists, should be involved in medication management to ensure that older adults are not taking unnecessary or harmful medications. Polypharmacy, in particular, should be minimised as much as possible.

Staff education and training

Healthcare staff play a vital role in falls prevention. Regular training programmes should be implemented to ensure that staff are knowledgeable about the risk factors for falls, the use of risk-assessment tools, and the application of fall-prevention strategies (Cameron et al, 2024; Camp et al, 2024). Staff should also be trained to respond promptly and effectively in the event of a fall, ensuring that the patient receives appropriate care and follow-up assessment.

Patient and family education

Educating older adults and their families about fall risk is essential for prevention. Patients should be encouraged to participate in their care to promote individualised and patient-centred care (Ajibade, 2021; Sonobe, 2024) by adhering to exercise programmes, using assistive devices, and making necessary lifestyle changes to reduce their risk of falling (Juarez et al, 2024; Zlatičanin et al, 2024). Family members can support these efforts by ensuring that home environments are safe, and assisting when needed. Patient education can be delivered through written materials, video presentations, or one-on-one counselling sessions. It is important to tailor education to the cognitive and physical abilities of the patient, to maximise understanding and compliance.

Technology and falls prevention

Emerging technologies are playing an increasingly important role in falls prevention. Sensor-based systems that monitor gait and detect falls in real-time are being used in some healthcare facilities to provide early warnings of potential falls. These systems can alert staff to intervene before a fall occurs and potentially prevent injuries (Basu et al, 2023). Wearable devices that track physical activity, balance and posture are also becoming popular as tools for identifying individuals at risk of falling. These devices can provide valuable data that health professionals can use to tailor interventions and monitor patient progress over time.

Multidisciplinary fall-prevention programmes

Multidisciplinary fall-prevention programmes that integrate several interventions, including exercise, medication management, environmental modifications and education, have been shown to be highly effective in reducing falls in older adults (Lewis and Griffin, 2023). These programmes involve collaboration among health professionals from various disciplines, including nurses, physicians, physiotherapists, occupational therapists, and pharmacists.

A systematic review and meta-analysis of fall-prevention interventions found that multifactorial interventions were associated with a significant reduction in falls among older adults in healthcare facilities (Cameron et al, 2018). The success of these programmes depends on the active involvement of the patient and the co-ordinated efforts of the healthcare team.

Challenges in falls prevention

Despite the availability of evidence-based interventions, there are several challenges to implementing effective fall-prevention strategies in healthcare facilities. These challenges include limited resources, staff shortages and variability in adherence to protocols (Shuman et al, 2016; Heng et al, 2020). In addition, patients may be resistant to some interventions, particularly if they involve restrictions on mobility or changes to long-standing routines.

Another challenge is the need for continuous monitoring and reassessment of fall risk. Falls prevention is not a one-time intervention, but requires ongoing efforts to ensure that patients remain safe as their health status changes (Camp et al, 2024). Healthcare facilities must invest in regular training for staff, updating of protocols and the integration of new technologies to keep pace with advances in fall-prevention research.

Conclusion

Falls are a major concern in healthcare facilities, particularly for older adults who are at increased risk due to a variety of intrinsic and extrinsic factors. Effective fall prevention requires a multifaceted approach that includes thorough risk assessment, environmental modifications, exercise programmes, medication management, staff education and patient engagement. By implementing evidence-based interventions and fostering a culture of safety, healthcare facilities can significantly reduce the incidence of falls and improve the quality of life for older adults.

Continued research and innovation in fall prevention will be essential to addressing the growing burden of fall-related injuries in the ageing population. As healthcare systems evolve to meet the needs of older adults, fall prevention must remain a priority, with focus on interdisciplinary collaboration and the adoption of new technologies that enhance patient safety.

KEY POINTS

  • Falls in older adults are multifactorial in nature. Intrinsic and extrinsic risk factors contribute to falls among older individuals in healthcare facilities
  • A number of fall risk assessment tools exist, such as the Morse fall scale, Stratify, and the timed up and go test. Research has assessed their effectiveness in different healthcare settings
  • Fall-prevention strategies to mitigate falls in older adults include environmental modification, medication review, exercise programmes and patient education
  • Interdisciplinary collaboration is important in fall prevention and multidisciplinary teams, including nurses, physiotherapists and pharmacists, contribute to effective fall-prevention programmes
  • CPD reflective questions

  • What are the most significant intrinsic and extrinsic factors contributing to falls in older adults, and how can they be mitigated in healthcare settings?
  • How do different fall risk assessment tools compare in terms of accuracy, applicability and ease of use in clinical practice?
  • What are the key challenges in implementing fall-prevention strategies, and how can health professionals overcome them?
  • In what ways can healthcare facilities integrate technology and multidisciplinary approaches to enhance fall-prevention programmes?