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How do I assess for falls?

When a client has been identified as being at risk of falls or has a history of falls, an assessment needs to be carried out. Any member of staff can carry out an assessment, the type and complexity of which differs from staff member to staff member depending on their profession.

The test that should be used as a screening tool by all members of staff is the ‘Timed Up and Go’ (TUAG) test. This test is to be used as a guide to determine whether further assessment is required.

Details of how to perform the TUAG test and which assessment forms staff should use are detailed below.

Timed up and go test

The “Timed up and go” (TUAG) test is a simple and quick measure of general mobility. This test can and should be used by all, including health and social care professionals and non health care professionals such as carer(s) and family members, to guide falls management. The TUAG test is incorporated in the basic and general assessment forms.

Performing the TUAG test will allow those with impaired mobility to be referred for a specialist assessment to determine the cause(s) of their postural instability.

A TUAG taking 15 seconds or over is indicative of increased falls risk. Clients with a TUAG of 15 seconds or over should be referred for a specialist physiotherapy assessment.

How to perform timed up and go test

Instructions to client:

Stand up from chair, using the arms if necessary, walk to the line at your usual speed, turn at the line, return to the chair and sit down. Use your usual walking aid.

The tester should:

Demonstrate the TUAG procedure to ensure the client is aware of what to do.Using a stopwatch measure the time taken, starting when the client transfers their weight off the seat of the chair to when they return to sitting on the chair.

Outcomes for the timed up and go test

Outcome Action
<15 seconds No further action required (unless client is obviously at risk of falls, in which case complete the general assessment form, refer to appropriate healthcare professional as guided by form, and refer for physiotherapy assessment)
≥15 seconds Complete the general assessment form, refer to appropriate healthcare professional as guided by form, and refer for physiotherapy specialist assessment

However, please be mindful that the 15 second cut off is to be used as a guide. There needs to be a degree of clinical reasoning for clients with a TUAG of less than 15 seconds as some may also require a physiotherapy assessment if they demonstrate obvious signs of unsteadiness and/or are at risk of falls but are able to complete the test in less than 15 seconds by rushing through it.

What assessment form should I use to assess?

Please use the following table to guide the assessment process.

Person completing assessment form Form to use Assessment to be carried out Outcome (guided by assessment form)
  • Client
  • Carer(s)
  • Family members
  • Social care and voluntary sector staff
Basic assessment form Timed Up and Go test Refer to appropriate service for further assessment/intervention:
  • falls clinic
  • GP
  • community therapy
  • optician
  • All healthcare professionals
  • Falls clinic staff
General assessment form Timed Up and Go test
Plus additional multifactorial measures as guided by assessment form (each healthcare professional to complete as much of form as possible)
Refer to appropriate service:
  • falls clinic
  • community therapy
  • any other healthcare professional as required
Physiotherapist Full specialist physiotherapy assessment form

Mini specialist physiotherapy assessment form
OR
PPA assessment form (Falls clinic and community therapy staff)
** Please note that the General assessment form should be completed by the physiotherapist (unless already performed by another healthcare professional) prior to the specialist PT assessment to identify any other needs
Timed Up and Go test
plus
TUSS, Berg balance, 180 degree turn
OR
PPA or PPA QuickScreen© (Falls Clinic and community therapy staff)
Use segmentation matrix (see ‘Exercise to reduce the risk of falls’ section of website) to refer to appropriate form of exercise intervention:
  • community exercise class
  • home otago programme
  • one to one physiotherapy
  • strength and balance class at Day Hospital
  • general advice about exercise and leisure services

Each SLIPS assessment form has been designed to guide the referral pathway. If you have any questions please contact:

Southwark:

Adult Therapy Rehab Team
Phone: 020 3049 8960

Lambeth:

Lambeth Community Therapies
Phone: 020 3049 4004

Assessment

Following NICE guidelines, an individualised multifactorial risk assessment should be offered to all older people with recurrent falls or those at increased risk of falling. The general assessment should be carried to identify any multifactorial needs. This may include any of the following which may require further investigation by the appropriate healthcare professional:

  • Identification of falls history
  • Assessment of gait, balance and mobility, and muscle weakness
  • Assessment of osteoporosis risk
  • Assessment of client’s perceived functional ability and fear relating to falling
  • Assessment of visual impairment
  • Assessment of cognitive impairment and neurological examination
  • Assessment of urinary incontinence
  • Assessment of home hazards
  • Cardiovascular examination and medication review

(NICE Clinical Guidelines 2.1, November 2004)

Intervention

Once an assessment has been carried out to identify the cause of falls, appropriate individualised treatment can be initiated. This could involve any of the following interventions:

  • Strength and balance exercises
  • Review of medications including modification/withdrawal if required
  • Osteoporosis treatment
  • Vision assessment and referral
  • Home hazard assessment and intervention
  • Advice and information

(NICE Clinical Guidelines 2.1, November 2004)

Whilst the interventions listed above may be beneficial in meeting the needs of the client, it is acknowledged that some clients may have non-modifiable risk factors for falling and may continue to have falls despite intervention. Management would therefore be aimed at maximizing independence and providing coping strategies to reduce the risk and impact of falls.

Exercise to improve strength and balance and manage falls

Strength and balance training is one of a number of interventions that has been proven to reduce the risk of falls. SLIPS has a comprehensive range of evidence based exercise programmes designed to cater to the varying needs of all clients. Please refer to the exercise to reduce the risk of falls section of this website.