Individual falls risk screening - Stay On Your Feet
Specific screening tools and tests have been developed to identify an individual's risk of falling. Falls risk screening tools should:
- be supported by research which shows that the tool can predict risk with a degree of certainty
- be quick and easy to use 56
- be readily available 56
- not be too costly 56
- not cause discomfort for the older person 56
- be consistent with what other organisations are using so information can be compared 56.
The following falls risk screening tools and tests are recommended by systematic reviews and/or the Queensland Stay On Your Feet® Community Good Practice Guidelines. Tools that predict a person's health risk need to be tested to show that they can accurately determine that there is a health risk present or not. For a tool to be considered valid, they need to meet the gold standard criteria for quality risk assessment tools.
Once risk factors have been identified, a health care professional should complete a comprehensive falls risk assessment and ensure that relevant interventions are arranged with the older person, their family and/or carer.
| Screening tool/test | Description | Available from |
| 6 - Metre Walk | Measures a person's gait speed over a distance of six metres at their normal walking speed. | Stay On Your Feet Community Good Practice Guidelines (page 62) |
| Alternative Step Test | Measures time taken to complete eight steps onto a stair, alternating the feet. | Stay On Your Feet Community Good Practice Guidelines (page 62) |
| Elderly Fall Screening Test (EFST) | A five item test which divides people into low and high risk, based on falls history and observations of walking speed and gait style. | Saskatoon Health Region, Canada |
| Falls Efficacy Scale - International (FES-I) | Assesses an individual's fear of falling during normal activities of daily living. | Available free by registering with the ProFaNE website |
| Falls Risk for Older People in the Community Screen (FROP-Com Screen) | A three item tool to help determine those who are at greatest risk of future falls and need a more comprehensive falls risk assessment. Abbreviated version of the Falls Risk for Older People in the Community (FROP-Com) tool, which is quicker to complete and is therefore suitable for busy settings eg. emergency departments. | This risk screening tool and guidelines are available for use from the National Ageing Research Institute. |
| Functional Reach | Measures balance by assessing the difference between a person's arm length and maximum forward reach. | Stay On Your Feet Community Good Practice Guidelines (page 63) |
| Geriatric Depression Scale (GDS) | Use this scale to assess depression. Short and long versions available. This tool has been tested extensively with older people. | Free to use (no copyright). Stanford University has an online Geriatric Depression Scale allowing you to load responses and generate downloadable results. |
| Geriatric Postal Screening Survey (GPSS) | Use this 10 item screening tool to screen for specific geriatric conditions including falls and balance problems, urinary incontinence, depression, memory loss, mobility issues, weight loss, polypharmacy, and pain. | Geriatric Postal Screening Survey (permission granted by Geriatric Research, Education and Clinical Centre, Veterans Affairs, Greater Los Angeles Healthcare System). |
| Physiological Profile Assessment (PPA)/FallScreen© | To find out more, read this article. | Neuroscience Research Australia Falls and Balance Research Group |
| Queensland Stay On Your Feet® checklist: Will I stay active and independent? | Health professionals can guide older people through these easy to use resources. The short checklist helps older people quickly identify falls risk factors. The comprehensive checklist provides more information about ways to stay safe, active and independent. | |
| Sit to Stand Test (STS) | Measures lower limb strength and time taken to stand five times from a seated position on a chair. | Stay On Your Feet Community Good Practice Guidelines (page 62) |
| Timed Up and Go (TUG) | Measures the time taken for a person to rise from a chair, walk three metres at their normal pace and turn, return to their chair and sit down (using any normal assistive devices). | Stay On Your Feet Community Good Practice Guidelines (page 64) |
