Repatriation General
Hospital
Falls Assessment Clinic
Falls Assessment Clinic
The RGH Falls Assessment Clinic provides specialised
multidisciplinary assessments for older clients with more
complex needs around falls prevention.
The program is for older adults living in the community who have
more complex issues around falls and frailty who would benefit
from a comprehensive assessment and coordination of falls
prevention services.
What does the service offer?
The service offers a specialised, comprehensive, Geriatrician led
multidisciplinary assessment:
• To identify falls risk factors
• Offer services/interventions to address these risk factors
• Access to a specialised Day Rehabilitation Service (FIT
Program)
• To link in with other community services as required
• Follow up with geriatrician as required
What is the criteria for referral?
•
•
•
•
•
•
•
•
Need for more detailed specialist medical assessment
Uncertain diagnosis
Unexplained falls/gait disturbances
Untreated osteoporosis
Declining function with mod-severe disability
Unexplained syncope or collapse
Complex medication issues
Cognitive issues affecting mobility
Falls Clinic Decision Making Support Protocol
This flow chart provides
information on the most
appropriate service to meet the
patient’s needs, depending on
their presentation.
Assessments used
• The following assessments will be used in the clinic to assess the patient:
• Subjective assessment
• Mini Mental State Examination (MMSE)
• Mini Nutritional Assessment (MNA)
• Modified Falls Efficacy Scale (MFES)
• Timed Up and Go (TUG)
• OT / Continence screen
• Lying and standing BP
Then:
Goal Setting
Case Conference Discussion
Subjective Assessment
Falls Clinic FIT Screening
Falls History
Number of falls:
Have you had near misses?
Yes
How often?
Have you sustained any injuries from falls?
No
Pattern and History of Falls:
Mobility
What walking aids do you use?
Indoors:
Outdoors:
Are you able to get up off the floor on your own?
Yes
No
Do you have any pain, stiffness, weakness or lack of sensation in your legs or feet?
(check footwear)
Yes
No
Do you have difficulty with or avoid walking in the community? (eg steps, slopes, uneven ground, shopping centres, catching
your toes on obstacles)
Yes
No
Do you participate in any regular exercise or activity programs or have you in the past? What are your goals?
Gait/Other balance:
Yes
No
Falls Clinic FIT Screening
TUG :
BP:
Lying Standing-
During assessment, did the patient show any signs of cognitive deficit?
MMSE score:
Referral To OT indicated:
Yes/No
MNA score:
Referral to Dietitian indicated:
Yes/No
Other comments:
Appropriate for FIT
Yes/No
Plan:
Signed:
Date:
Mini Mental State Examination
(MMSE)
• The Mini Mental State Examination (MMSE) is a valid and reliable
instrument used to screen for cognitive impairment in older adults..
• The MMSE provides a global score of cognitive ability that correlates with
function in activities of daily living
• The MMSE measures various domains of cognitive function including
orientation to time and place; registration; concentration; short-term recall;
naming familiar items; repeating a common expression; and the ability to
read and follow written instructions, write a sentence, construct a diagram,
and follow a three-step verbal command.
• The MMSE takes approximately 10 minutes to administer, provides a
baseline score of cognitive function, and pinpoints specific deficits that can
aid in forming a diagnosis
• Click on the following website for more
information on administering the
MMSE.
• http://www.unc.edu/~vreddy/index_fil
es/Medical%20Resources/Clinical%20To
pics//Geriatrics/MMSE%20MANUAL.pdf
Mini Nutritional Assessment
(MNA)
• The Mini-Nutritional Assessment Short-Form (MNA®-SF) is a screening tool used
to identify older adults (> 65 years) who are malnourished or at risk of
malnutrition.
• The MNA®-SF is based on the full MNA®, the original 18-item questionnaire
published in 1994 by Guigoz, et al.
• The MNA®-SF consists of 6 questions on food intake, weight loss, mobility,
psychological stress or acute disease, presence of dementia or depression, and
body mass index (BMI). When height and/or weight cannot be assessed, then an
alternate scoring for BMI includes the measurement of calf circumference.
• Scoring:
• Scores of 12-14 are considered normal nutritional status;
• 8-11 indicate at risk of malnutrition;
• 0-7 indicate malnutrition.
http://consultgerirn.org/uploads
/File/trythis/try_this_9.pdf
Modified Falls Efficacy Scale
(MFES)
• The Modified Falls Efficacy Scale (MFES) is a 14 item
questionnaire, asking participants to rate their level of
confidence on how they are able to undertake each activity
without falling, on a scale of 0 (not confident at all) to 10
(completely confident).
• Higher scores reflect more confidence and less fear of falling
• Lower scores reflect less confidence and more fear of falling
• An overall score is calculated by averaging the scores for all items
which were rated (ie – score out of 10).
• The test takes approximately 5 minutes to administer
Timed Up and Go (TUG)
• The Timed Up and Go test (TUG) is a simple test used to
assess a person's mobility, requiring both static and dynamic
balance.
• The TUG measures the time that a person takes to rise from a
chair, walk three metres, turn around, walk back to the chair,
and sit down. During the test, the person is expected to wear
their regular footwear and use any mobility aids that they
would normally use.
• The TUG is used frequently in the elderly population, as it is
easy to administer and can generally be completed by most
older adults.
Timed Up and Go (TUG)
Instructions:
The person may wear their usual footwear and can use any assistive device they normally
use.
1.
Have the person sit in the chair with their back to the chair and their arms resting on
the arm rests.
2.
Ask the person to stand up from a standard chair and walk a distance of 10 ft. (3m).
3.
Have the person turn around, walk back to the chair and sit down again.
Timing begins when the person starts to rise from the chair and ends when he or she
returns to the chair and sits down. The score is written in seconds.
Predictive Results
Seconds Rating
• <10 Freely mobile
• <20 Mostly independent
• 20-29 Variable mobility
• >20 Impaired mobility
Podsiadlo, D., Richardson, S. The timed ‘Up and Go’ Test: a Test of Basic Functional Mobility for
Frail Elderly Persons.
Journal of American Geriatric Society. 1991; 39:142-148
OT / Continence Screen
• Information on home environment, activity limitations, current supports,
previous falls and ability to seek help, as well as continence issues, need to
be obtained in order to determine if further advice or intervention is
required. The following checklist provides a framework for identifying these
issues.
Measuring BP
• A lying and standing BP needs to be measured on each
patient.
Goal Setting
Following the assessment process, goal setting needs to be undertaken with
each patient.
• What does the patient feel is their main concern? What are their goals?
• Are these goals realistic?
• What is the best service to meet these goals?
Case Conference
Using the Falls Clinic Decision Making Support Protocol, provide a brief plan of
action for the patient(s) you have assessed. For example,
• Mrs X needs to be referred to a community therapy service because she has
had 2 falls in the past year however she is currently independent at home
with no significant decline in function. She would benefit from an ongoing
community exercise program to maintain strength and balance.
• Mr M has had 2 falls in his bathroom and 1 in the garden the past 6 months.
He has no equipment in place, his toilet is off the back veranda, he has urge
incontinence, poor vision and is malnourished. He would benefit from a FIT
referral for multidisciplinary team input.