Falls Risk Assessment Skill

Support clinicians and clinic staff with structured fall risk screening, risk-factor assessment, and prevention planning. This skill follows the CDC STEADI "screen, assess, intervene" approach and incorporates NICE-style safeguards against using prediction tools as a substitute for clinical assessment.

Clinical Scope

Use this skill for:

• Adults 65 years and older during annual checks, routine visits, post-fall follow-up, or care transitions.
• Adults 50 to 64 with elevated risk factors such as frailty, neurologic disease, diabetes complications, arthritis, dizziness, visual impairment, sedating medications, alcohol misuse, or mobility impairment.
• Patients in clinic, community, hospital, or residential-care contexts who need individualized fall prevention planning.
• Staff triage after a reported fall, near fall, fear of falling, unsteady walking, or repeated calls about balance or dizziness.

This skill does not replace emergency evaluation, clinician examination, physical therapy assessment, occupational therapy home assessment, pharmacy medication review, or local inpatient fall protocols.

Immediate Escalation Triggers

Before routine fall-risk work, screen for urgent harm. Recommend emergency care or immediate clinician escalation for any of the following:

• Fall with head strike while taking anticoagulants or antiplatelet therapy.
• Loss of consciousness, suspected syncope, seizure, new severe dizziness, chest pain, palpitations, or shortness of breath around the fall.
• New weakness, facial droop, slurred speech, vision loss, severe headache, confusion, or other stroke-like symptom.
• Severe pain, deformity, inability to bear weight, suspected hip fracture, spinal pain, or major bleeding.
• Repeated falls over hours to days, acute delirium, fever, dehydration, hypoglycemia, overdose, intoxication, or medication error.
• Patient is alone and cannot get up safely, cannot access help, or lacks safe supervision.
• Any fall in pregnancy, pediatric patient, or postoperative patient where local protocol requires urgent review.

When an escalation trigger is present:

1. State the urgency plainly.
2. Recommend emergency services or immediate clinician review according to local protocol.
3. Avoid home exercise, medication changes, or reassurance as the primary action.
4. Collect only essential safety details if doing so does not delay escalation.

Screening Workflow

Step 1: Establish Setting and Goal

Ask or infer:

• Care setting: community/clinic, hospital inpatient, residential care, home health, telehealth.
• Reason: routine screen, first fall, repeated falls, fear of falling, unsteady gait, post-discharge follow-up.
• Patient age and relevant risk context.
• Whether a local protocol or fall scale must be used.

Step 2: Ask STEADI-Style Screen Questions

For older adults, screen at least yearly and any time they present after a fall:

1. Have you fallen in the past year?
2. Do you feel unsteady when standing or walking?
3. Are you worried about falling?

If the patient fell, ask:

• How many times?
• Were you injured or did you need medical care?
• Did you lose consciousness or feel faint?
• Where and when did it happen?
• What were you doing just before the fall?
• Were you using a walking aid, footwear, alcohol, or a new medication?

Step 3: Determine Assessment Path

Use clinical judgment and local policy. Do not present a prediction score as a definitive probability of falling.

Screened not at risk

• No fall in past year.
• No unsteadiness.
• No concern about falling.
• No obvious high-risk medication, frailty, dizziness, or mobility issue.

Recommended output: prevention education, activity guidance, vitamin D/nutrition discussion per local policy, and yearly rescreening.

Needs fall-risk assessment

• Yes to any screening question.
• Single fall without major injury but with gait, balance, medication, vision, orthostatic, or home hazard concerns.
• Patient or caregiver reports fear of falling, restricted activity, or near falls.

Recommended output: structured risk-factor assessment and individualized prevention plan.

Needs comprehensive falls assessment or urgent referral

• Two or more falls in the past year.
• Fall with injury needing medical treatment.
• Loss of consciousness related to fall.
• Unable to get up independently after fall.
• Frailty, cognitive impairment, recurrent dizziness/syncope, high-risk medications, or unsafe home environment.

Recommended output: clinician review, PT/OT/pharmacy referrals as appropriate, and follow-up plan.

Risk-Factor Assessment

Collect and organize modifiable factors. If details are missing, ask only the highest-yield follow-up questions.

Falls History

• Number, timing, location, activity, footwear, lighting, surface, assistive device use.
• Injury, medical treatment, head strike, loss of consciousness, inability to get up.
• Pattern: night bathroom trips, standing from chair, stairs, shower, transfers, outdoor uneven surface.

Gait, Balance, Mobility, and Strength

• Observed unsteadiness, shuffling, difficulty rising from chair, furniture walking, transfer difficulty.
• Walking aid type, fit, use consistency, and training.
• Functional tests when clinically appropriate and feasible:
  • Timed Up and Go.
  • 30-Second Chair Stand.
  • 4-Stage Balance Test.
• Refer to PT or trained clinician for formal testing when remote context is insufficient.

Medication and Substance Review

Flag medications associated with sedation, dizziness, orthostatic hypotension, blurred vision, confusion, or hypoglycemia, especially:

• Benzodiazepines, sedative-hypnotics, opioids, antipsychotics, antidepressants, anticholinergics.
• Antihypertensives, diuretics, alpha blockers, nitrates.
• Insulin and sulfonylureas when hypoglycemia is possible.
• Polypharmacy, recent starts, dose increases, duplications, or missed doses.
• Alcohol or recreational substances.

Never instruct the patient to stop a medication abruptly. Recommend clinician/pharmacist review.

Cardiovascular and Orthostatic Factors

• Dizziness on standing, fainting, palpitations, chest pain.
• Hydration, recent illness, diarrhea/vomiting, low intake.
• Lying and standing blood pressure if trained staff can measure it.
• Escalate syncope, chest pain, or neurologic symptoms.

Vision, Hearing, Feet, and Footwear

• Recent vision change, cataracts, bifocals/multifocals, poor lighting.
• Hearing impairment affecting environmental awareness.
• Foot pain, neuropathy, ulcers, poor sensation, inappropriate footwear.
• Refer to optometry/ophthalmology, podiatry, or diabetic foot care as appropriate.

Home and Environmental Hazards

• Throw rugs, clutter, cords, loose mats, slippery bathroom surfaces, poor lighting, stairs, pets underfoot.
• Missing grab bars, unstable furniture, lack of railings, frequently used items stored too high/low.
• For high-risk patients, recommend OT or trained home-safety assessment.

Cognition, Mood, Continence, and Comorbidities

• Cognitive impairment, delirium, depression, anxiety, fear of falling.
• Urgency/incontinence, nocturia, rushing to bathroom.
• Parkinson's disease, stroke, neuropathy, arthritis, osteoporosis, diabetes, vestibular disorders.
• Diet, fluid intake, weight loss, frailty, and exercise level.

Inpatient and Residential-Care Notes

Follow the local institution's fall protocol. If a local tool such as Morse Fall Scale or STRATIFY is required:

• Use the validated local version and cut points.
• Treat the score as one input, not a standalone prediction.
• Map each positive item to a care-plan action.
• Reassess when status changes: transfer, new medication, delirium, procedure, toileting change, mobility change, or post-fall.

Do not copy a score from the chart without checking current mental status, gait, mobility, and medication changes.

Output Format

Use this structure unless the user asks for a different format:

1. Urgency

   • Emergency / urgent clinician review / routine prevention.
   • One-sentence rationale.

2. Screening Summary

   • Falls in past year, unsteadiness, fear of falling.
   • Any injury, loss of consciousness, head strike, inability to get up.

3. Key Risk Factors

   • Group by gait/balance, medications, orthostasis/cardiac, vision/feet, home hazards, cognition/mood, continence, comorbidities.

4. Recommended Actions

   • Immediate safety actions.
   • Referrals: clinician, PT, OT/home safety, pharmacist, optometry, podiatry, neurology/cardiology when indicated.
   • Medication review targets without making unsupervised medication changes.
   • Exercise/fall prevention program suggestions tailored to ability.
   • Home hazard changes.

5. Patient Education

   • Plain-language steps.
   • Include caregiver involvement when appropriate.
   • Include what to do if another fall occurs.

6. Follow-Up

   • Recheck timeframe.
   • What to monitor and when to escalate.

Example: Community Clinic

Input: "Mrs. Rao is 78. She fell twice this year, once while hurrying to the bathroom at night. She takes lorazepam at bedtime and amlodipine. She says she is afraid to walk outside."

Output pattern:

• Urgency: urgent clinician review, not emergency unless injury/head strike/syncope symptoms are present.
• Screen: at risk because of recurrent falls and fear of falling.
• Key risk factors: nocturia/rushing, sedative medication, possible orthostatic symptoms, reduced confidence/activity restriction.
• Actions: clinician review, medication review with prescriber/pharmacist, gait/balance assessment, PT fall-prevention exercises, bathroom/night lighting and clear path, toileting plan, caregiver education, follow-up in 30-90 days or sooner if another fall occurs.

Example: Post-Fall Triage

Input: "My father fell and hit his head this morning. He is on apixaban. He says he feels okay but has a bump."

Output pattern:

• Urgency: emergency evaluation now because head strike while taking an anticoagulant can cause serious bleeding even if symptoms are mild.
• Action: call emergency services or follow local emergency pathway; do not drive himself; monitor for confusion, worsening headache, vomiting, weakness, slurred speech while help is arranged.
• Do not: provide routine home prevention advice as the primary response before emergency evaluation.

Safety Rules

• Do not claim to predict exactly whether a patient will fall.
• Do not use falls prediction tools as a substitute for comprehensive assessment.
• Do not advise abrupt medication discontinuation.
• Do not recommend unsupervised exercise for patients with acute injury, severe dizziness, syncope, new neurologic symptoms, or unsafe mobility.
• Do not minimize head injury, anticoagulant use, loss of consciousness, or inability to bear weight.
• Always preserve clinician authority and local protocol.

References

• CDC STEADI Clinical Resources: https://www.cdc.gov/steadi/hcp/clinical-resources/index.html
• CDC STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention: https://www.cdc.gov/steadi/media/pdfs/STEADI-Algorithm-508.pdf
• NICE NG249 Falls: assessment and prevention in older people and in people 50 and over at higher risk: https://www.nice.org.uk/guidance/ng249
• AHRQ Preventing Falls in Hospitals Toolkit: https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html