A Multidimensional Approach for Nurse Practitioners to Screen Fall Risk and Fear of Falling in Community-Dwelling Older Adults

Abstract

Nurse practitioners are essential in the care of the older adult population. Older adults are at high risk for falls; therefore, nursing assessment should include psychological and physiological measures. Fear of falling is a primary psychological contributor to fall risk. The Falls Efficacy Scale International short; Centers for Disease Control and Prevention Stopping Elderly Accidents, Deaths, and Injuries fall risk scale; and Balance Tracking System (BTrackS) balance test are reliable, efficient tools for assessment. Data obtained from these multifactoral tools may inform mobility interventions and education for the patient, further meeting a national safety goal of reducing falls in the older adult population.

Introduction

Thirty- three percent of older adults (defined by Medicare as those aged 65 or older) experience falls each year, and falls are the second leading cause of injury in those over age 65. Therefore, preventing falls and subsequent injuries is a high priority among this population.^1,2 Falls increase by 50% for those over age 80, raising concern for the large aging population worldwide.³ As of 2020, the Centers for Disease Control and Prevention (CDC) reports that approximately $50 billion is spent annually on care for nonfatal falls in older adults, which is burdensome on the health care system and has been shown to reduce quality of life and function in the older adult population.^4–7

Fear of falling has been shown to have a high association with fall risk.⁸ In simple terms, fear of falling is an anticipation of a fall occurring, which causes fear and avoidance of activities that promote that fear.^9,10 Fear of falling is more broadly defined to include decreased self-efficacy or confidence in one’s balance or ability to complete an activity.^11,12 The presence of fear of falling in older adults is estimated to occur in 20% to 39% of the population, making it a high contributor to community falls.¹⁰

Psychological factors are infrequently represented in the literature; however, the psychological factors must be considered in addition to physical factors when assessing the risk to fall.¹³ Fear of falling contributes significantly to fall risk.¹⁴ A maladaptive fall risk presents when there is a noted difference in the physiological and the perceived risk of falls.¹⁵ Therefore, promotion of a multidimensional approach to fall risk and fear of falling assessments is the goal of this article. The use of psychological and physiological tools in combination yields a higher sensitivity and specificity in fall risk assessments.² The tools selected for this review are the Falls Efficacy Scale International short version (FES-I short) for assessment of fear of falling; CDC Stopping Elderly Accidents, Deaths, and Injuries (CDC-STEADI) fall risk scale; and BTrackS balance system based on reliability and ease of use of the tools. The target population for use is the community-dwelling older adult being seen by a primary care practitioner or in other nonacute community settings to focus on primary prevention of falls and potential subsequent need for hospitalization. Community-dwelling is anyone that lives within their own private home, whether that is an apartment or house, but does not include those in long-term care residences. Although there are more than 270,000 nurse practitioners in the United States, most of them are family practice practitioners without a focus and training in geriatric care.¹⁶ These assessments can be completed by a nurse practitioner during an exam or used as a prescreening tool to teach patients and caregivers even before their exam visit with little training to get the process started. Each tool is discussed in further detail related to reliability and how to implement moving from subjective to objective assessments.

Subjective Assessments

Fear of Falling

The FES-I was developed as part of the Prevention of Falls Network project in Europe between 2003 and 2006. It can be used to measure a person’s perceived self-efficacy, fear of falling, or confidence in performing an activity without falling.¹⁷ Because there is not a consistent definition of fear from person to person, this tool offers a universal measure of activities that are identified as sources of fear to focus on during the assessment.¹⁸ The FES-I surveys 16 common activities that the older adult would do in their day, such as stairs, walking on an incline, dressing, and going out to an event.¹⁹ Each question can be answered by 1 of 4 choices; “not at all,” “somewhat concerned,” “fairly concerned,” or “very concerned,” with each question generating a score of 1 to 4.²⁰ The scoring of the tool ranges from 7 to 28 with low fear of falling being 7–8, moderate 9–13, and high 14–28. This tool has been translated and evaluated in different languages and cultures and deemed reliable for cross-culture studies.¹⁹ A study designed to review the reliability of the FES-I included 86 participants, aged 50–85 years, and produced a Cronbach’s alpha of 0.95 with an interitem correlation average of 0.55 (range 0.2–0.82).¹⁷ It was noted that this was a small sample size (n = 86), which may affect the correlation but was not cause for concern regarding reliability. The FES-I short form has been translated into 14 languages, is available online, and is free to download.¹⁹ A layperson in the community could even use this tool as a self-screening opportunity at home and then contact a practitioner for further evaluation if fear of falling is identified. The modified short form consists of only 7 questions, has been validated in comparison with the full-length version and may increase practitioner administration and participant response due to its ease of use.

Fall Risk

The CDC created the STEADI program to prevent falls in the community with assessment and early intervention.²¹ The STEADI tool is a fall risk assessment that was originally developed by the Los Angeles Veterans Affairs Geriatric Research Education Clinical Center. The validity of the tool was determined by 40 participants completing the questionnaire and then having the responses compared to a gold standard tool from the American and British Geriatrics Society which produced a strong agreement (kappa = .875, P < .0001).²² The CDC conducted its own internal validity testing to confirm the outside studies before use as a reliable predictor for future falls.¹ More recently, the tool was also adopted and validated for community-dwelling older adults with osteoporosis in Thailand. The Thai version has a Cronbach’s alpha of 0.936, suggesting it is reliable cross-culturally and within specific disease processes as well.²³ The STEADI tool consists of a 12-question, yes-or-no answer survey that determines whether someone is at risk for falls. This quick, 5-minute self-report tool produces a score of 0 to 14, where scores of 4 or higher indicate higher fall risk.²⁴ Access to the tool is free online, with an English and Spanish version, so any community member could use this self-assessment and then seek guidance from their practitioner if the results indicated. Another benefit of using this tool is that the CDC provides an algorithm for practitioners to inform next steps by providing further assessment suggestions, appropriate interventions, and materials to continue use at home for further engagement.

Objective Assessments

Balance Performance Test

Previous studies have shown a relationship between fear of falling, fall occurrence, and balance.²⁵ Some researchers have further defined fear of falling as diminished confidence in their balance.²⁶ Therefore, balance testing is needed in conjunction with fall risk and fear of falling assessments to establish a baseline understanding of the relationship and what the older adult is actually experiencing. The BTrackS balance test is a portable standing plate on which the participant stands with feet shoulder-width apart and hands on their hips. The device measures postural sway by 3 consecutive measurements of the total center of pressure that the device sends to a computer using a USB port. The test consists of three 20-second testing trials and comprises a score for the average of the 3 tests, allowing it to be a time-efficient evaluation. The BTrackS has been determined to be a valid and reliable tool for measuring balance. A sample of 49 community-dwelling older adults doing multitrials demonstrated validity using Pearson correlation (r > 0.90) and a sample of 47 doing test–retest reliability showed a correlation of 0.83.²⁷ An added benefit of this tool is that it can be administered consistently between providers without extensive training. This increases reliability compared with other balance tests, such as the Timed Up and Go. The recommended cutoff, based on normative data, for low fall risk, is those scoring <31 total center of pressure in females and <33 total center of pressure in males on a 0–100 measurement.²⁸ Those with scores >31 in females and >33 in males are considered to have a moderate to high fall risk. This tool also offers biofeedback-based balance training for participants that are determined to have difficulty with postural sway.²⁸ Thus, the transition from assessment to intervention is timely and practicable.

Implementation

Each of the tools described here provides data essential to planning and provision of primary care among the older adult population. Training is available for each tool so that nurse practitioners can fully understand how to incorporate these assessments and evaluate for outcomes proficiently. However, the FES-I and STEADI are simple enough that a layperson could use them within the community on themselves or for a family member with minimal time requirement. This could help a nurse practitioner identify whether fall risk is present in the self-screenings or be added as a prescreening tool when an appointment with the practitioner is approaching. These assessments could be incorporated in senior activity centers for identification of risk even without a health care appointment or access to health care because they are free and readily available online for download. This would allow outreach to more vulnerable members of the older adult population who may not be regularly followed by health care professionals. Early detection of falls risk factors allows for intervention that may reduce injury and preserve mobility and independence among older adults.

Primary care is the most used health care provider among adults, and as our population ages, these providers need a framework to use in a consistent way to assess and manage falls.²⁹ Various formats are available to administer these tools. With most health care providers using electronic medical record (EMR) systems, these tools may be added to current flow sheets for easier use within the health care visit, and the CDC has been working with EMR companies to integrate STEADI.²⁹ FES-I and STEADI can also be done in advance of the visit depending on the patient’s need, access to the Internet, and abilities. The BTrackS is small enough to be placed in an office cabinet and can be completed in office during an annual visit and then used during future, ongoing appointments to track progress or regression in balance abilities. Use of fall risk assessment tools has been qualified through the Medicare system for reimbursement, further justifying their use in routine primary care.¹⁴ Data obtained from these tools may inform mobility interventions and education for the patient, thus meeting a national safety goal of reducing falls in the older adult population.

Conclusion

Incidence of falls continues to rise among the older adult population; therefore, prioritization of falls prevention is imperative. Nurse practitioners are essential in the care and education of the older adult population as this population continues to grow and health care worker shortages climb. Inadequate screening and fall risk identification is a gap in the care of the older adult population.¹⁶ Nurse practitioners can be used to fill gaps in what is already a population with complex health care needs.³⁰ The use of FES-I, STEADI, and BTrackS can provide ongoing assessment and intervention for the community-dwelling older adult. Older adults need to be informed of the available resources to screen at home using the FES-I and STEADI so that they can recognize risks to discuss at their next appointment with their nurse practitioner. Using a multidimensional assessment approach, nurse practitioners can discern a comprehensive understanding of the contributing factors related to fall risk and are better equipped to deliver personalized plans of care to prevent falls from occurring among older adults, thus improving their quality of life and ability to remain in the community setting.