Enhanced Practice Fall Risk Assessment

19050(2015-01)

Enhanced Practice Fall Risk Assessment Purpose: Assessment tool used for identification of enhanced falls risk and subsequent management.

Date of Assessment (yyyy-Mon-dd) Referral Source

Client / Guardian consents to assessment Yes No Family Member Name

Medical History / Diagnosis Specify: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Netcare Review Yes No Clinibase Review Yes No

Medications Fall Risk Drug Identification Review Yes No Device Dosette Blister Pack Bottles Managed By: Client Other: ___________________________________

Nutrition / Hydration / Bone Health Multivitamins Calcium ____________ mg/day Vitamin D ____________ iu/day How many servings of milk and alternative do you drink per day? ____________ How many cups of fluid do you drink in a day? ____________ cups Number of Full meals eaten per day ________________ Current height (cm) _______ Historical height (cm) ________ Current weight (kg) ________ Historical Weight (kg) ________ Has your weight changed in the past 6 months? __________ gained __________ lost __________ no Appetite: Good Fair Poor How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times/month 2 to 3 times/week 4 or more times/week How many drinks containing alcohol do you have on a typical day when you are drinking? Never 1 or 2 3 or 4 5 to 6 7, 8 or 9 10 or more

Comments: ______________________________________________________________________________________________ ________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________

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Page 1 (Side A) of 7

Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment Guidelines Consent - Record that informed consent was received to proceed with assessment by ticking the box, if it was the client or guardian who gave consent. Informed consent requires that the client / guardian understand the nature, purpose, benefits, risks, alternatives and consequences associated with the assessment. In order for informed consent to be valid, the following criteria need to be met: consent needs to be informed, specific to a particular treatment or assessment, provided voluntarily, explained in a language that is understood, and provided by an individual with capacity. Medical History / Diagnosis - Document client’s pertinent medical conditions / diagnosis related to or impacting assessment. Of particular relevance; history of fractures, plus any other corroborative evidence leaning towards osteoporosis, postural hypotension, neurological problems, severe musculoskeletal problems, syncope, cognitive impairment, depression, visual problems such as cataracts, glaucoma and macular degeneration (and ask when eyes were last checked and by whom), etc. Netcare/Clinibase Review - Review information from Netcare/Clinibase. Medications – Review medications for any that may increase risk of falls. Device - Check which form of medication distribution client is currently using. Nutrition / Hydration / Bone Health – Ask the various questions concerning nutrition, hydration and bone health. If there is no reason client is avoiding milk (allergy, intolerance, etc.) just ask question about servings of milk per day. If client has known problem, and can’t drink milk, use guide on calcium rich food to estimate current calcium intake.

Page 1 (Side B) of 7

Sample

19050(2015-01)


Fall Events Number of falls in past 3 months: ____________ Number of Emergency Department Visits related to Falls _______________ Number of injury falls in past 3 months: ____________ Number of near falls in the past 3 months: ______ Daily ______ Weekly ______ Occasionally _____ None

Circumstances of Fall Location (Indoor/Outdoor)

* list from most recent fall to most remote

Date/Time Of Day

Injuries & ED Visit

Changes related to

Fall

Shoes Worn

Yes/No

Walking Aid

Yes/No

Falls History Dizziness Yes No Pre-syncope Yes No Sense of imbalance Yes No Comments: ____________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _____________________________________________________________________________________________________








Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment Guidelines

Fall Events - Document total number of falls, emergency department visits, injury falls and near falls reported within previous 3 months. Be very specific in description of falls. Under circumstances of fall, include direction client fell, whether they think they lost consciousness, especially if hit head, if they’re dizzy when they’re first up, etc. For post-fall interventions, include any medical interventions sought after fall, results of investigations, etc. Circumstances of Fall - Complete as reported (i.e. up at night going to the bathroom with no lights on). Location - Indicate the location where the fall occurred. Date/Time of Day - Complete for each fall reported. Complete date and time under each reported incidence of a fall (i.e. fall #1, 2014-Mar-15 @ 13:00). Injuries & Emergency Department Visit (ED) - Complete as reported re: any injuries sustained as a result of the fall (i.e. laceration, bruising, soft tissue injury, fracture). Complete as reported re: need to go to ER / Urgent Care (UC) as a result of the fall. Shoes Worn – Indicate with a yes or no whether shoes were worn at the time of fall. Walking Aid – Indicate whether a walking aid was being used at the time of fall. Falls History – Check if client has suffered from dizziness, pre-syncope or sense of imbalance, note any details. Dizziness – Is a disorientated sensation such as faintness, light-headedness, or unsteadiness. Pre-syncope - Is a sense of impending loss of consciousness. Terms that might be used by patients would include “light-headed”, “unsteadiness”, “dizzy”, “faint” and “disoriented”. Typically it doesn’t progress to a loss of consciousness – if it does the sensation is a prodrome for syncope (this is a transient loss of consciousness with spontaneous recovery; terms that might be used by patients include “blackout”, “faint”, “spell” and collapse”). Sense of Imbalance - Unsteadiness, or what some people refer to as a loss of sure-footedness.


Sample

19050(2015-01)


Fear of Falling Are you afraid of falling? Yes No Are you afraid you might fall when you are…

Question Yes No Comments

Taking a bath or shower?

Reaching into cupboards?

Preparing a meal (excluding carrying heavy or hot objects)?

Walking around the house?

Getting in and out of bed?

Answering the door or telephone?

Getting in and out of a chair?

Getting dressed or undressed?

Doing light housekeeping?

Doing simple shopping?

Post-Fall Behaviors: ____________________ _________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Emergency Response System Yes No








Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment Guidelines Fear of Falling – Ask regarding client’s fear of falling and when they become afraid. Post Fall Behaviors – Document post fall behavior. Example: caution, anxiety, use of walk aid.

Emergency Response System – Check if client has an emergency response system.


Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment Purpose: Assessment tool used for identification of enhanced falls risk and subsequent management. Pain On Medications Yes No Describe_______________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Front Back

Continence Concerns _____________________________________ No Concerns Identified ___________________________ History of Urinary Tract Infection (UTI) _______________ Incontinent: Bladder or Bowel______________________ Urgency Bladder or Bowel ________________________ Nocturia: Number of times _______________________ Frequency Bladder or Bowel ______________________ Incontinence Supplies ___________________________ Describe _______________________________________________________________________________________________ ______________________________________________________________________________________________________

Sleep

On Medication Yes No Time of last Food Intake ______________________ am/pm Describe _______________________________________________________________________________________________ _______________________________________________________________________________________________________

Vision Do you have any concerns with your vision? Yes No _________________________________________ Last visit to Optometrist (yyyy-Mon-dd) Glasses Yes No Bi / Tri-focal / Progressive / Contacts Yes No Low Contrast – Lea Numbers / Light Contrast Sensitivity _______________ The client recognizes numbers to the ____________ level Interpretation __________________________________________ ______________________________________________________________________________________________________ Colour Vision: _____________ / 3 Comments on Vision _____________________________________________________ _______________________________________________________________________________________________________








Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment Guidelines Pain - Ask client if they have any complaints of pain, complete as appropriate & use pain scale. Using the 0 – 10 pain scale and mark in the body above the score(s) they would give their pain.

Continence Issue - Document if there are any continence concerns and note any concerns pertaining to falls risk safety. - History of Urinary Tract Infections (UTI’s) – Check if there is a history of UTI’s - and comment. Symptoms may include frequency, urgency, confusion / change in behavior. - Urgency Bladder or Bowel: Check if there is a concern and comment on safety issues as pertaining to falls risk. - Frequency Bladder or Bowel: Check if there is a concern pertaining to falls risk safety. - Nocturia: Check if there is a concern and note number of episodes per night. - Incontinent Bladder or Bowel: Check if there is a concern and comment on safety issues as pertaining to falls risk. - Catheter Concerns: Check if catheter used & if there are any concerns pertaining to falls risk. - Incontinent Supplies: Check if supplies used & comment on safety issues pertaining to falls risk. - No Concerns Identified: No bowel or bladder functional concerns related to (or that pose a) falls risk.

Sleep - Describe sleep and document any altered sleep patterns.

Vision - Concerns with vision may be elicited if the client has difficulty safely functioning in the environment (i.e. reading pill bottle, maneuvering in home). Concerns may also relate to visual correction aids such as wearing bifocals / trifocals / progressives where vision may be distorted. Add any comments to recent visual changes (i.e. in visual acuity, change in eyewear or prescription, use of eye drops.)

Last visit to Optometrist - Note date of last visit to Optometrist.

Low Contrast-Lea Numbers / Light Contrast Sensitivity - - The client does not see any of the numbers. Contrast sensitivity function is extremely limited and enhancement of contrast is needed for the client to function. The client may require assistance to ambulate safely in environments.

- The client recognizes numbers only at the 25% level. Enhancement of contrast is needed for the client to function safely and independently. The client may require assistance to ambulate safely in environments.

- The client recognizes numbers to the 10% level. The client likely will have difficulty detecting subtle changes in the support surface, reading materials printed in low contrast formats, seeing black and white photographs, facial features, water, and other low contrast materials. Magnification and increased illumination may assist the client to recognize low contrast features.

- The client recognizes numbers to the 5-2.5% level. The client likely will have difficulty seeing facial expressions and recognizing friends across the street. He or she may have difficulty detecting curbs and other low contrast drop offs. Increased illumination may assist the client to recognize low contrast features and modification of the environment to increase the contrast of important environmental features is recommended.

*Taken from the test manual for the Brain Injury Visual Assessment Battery for Adults Colour Vision (Scored out of 3)

Card 1 – Normal vision then see ‘128, See only ‘2’ then green blindness possibility, See ‘18’ then blue blindness possibility Card 2 – Normal vision see a ‘3’, see nothing then red blindness possibility Card 3 – Normal vision see “HC’, if see ‘13’ then green blindness possibility


Sample

19050(2015-01)


Vestibular-Ocular Vertigo Yes No (Assess by 5 neck rotations) Vestibular Ocular Reflex Present Yes No (Five neck rotations focused ahead on target) Comments ____________________________________________________________________________________________ ______________________________________________________________________________________________________

Cognition / Behaviour

Mini Mental Status Exam Score (MMSE) Refused ___________ (up to 3 months ago)

Montreal Cognitive Assessment (MOCA) ___________ Clock Drawing Normal Abnormal Cognitive Performance Scale (CPS) _______________ (up to 3 months ago)

Depression: Are you depressed? Yes No Geriatric Depression Scale (GDS) _______________ /15 Comments ___________________________________________________________________________________________ _____________________________________________________________________________________________________

Gait / Balance / Strength Do you have a current regular exercise program? Yes No Frequency _____________ Specify ______________________________________________________________________ Do you have a specific exercise program for balance, gait and/or falls prevention? Yes No Frequency: ______________ Specify _____________________________________________________________________

Timed Up and Go Unable to do __________ With Walking Aid ___________ Without Walking Aid Observations of Gait Ambulation and Balance No significant deviation observed Guardedness / Caution Widened base support Trunk lateral lean Weaving Bending

Forward trunk flexion Staggering / Stumbling Gait initiation

Hip hiking Ataxic gait pattern Turning balance

Hip circumduction Antalgic gait pattern Rhythm

Scissoring Festinating Symmetry

Trendelenberg Shuffling Lower Extremity Movement

Knee hyperextension Decreased gait speed Other:

Foot drop Comments ____________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Chair Stand Test _________________________ within 30 seconds Berg Balance Score _______________/56 Walking Aid Used Yes No “Classic Romberg” Eyes Open: _________________ / 30 Eyes Closed ________________ /30








Sample

19050(2015-01)


Vestibular-Ocular – Note if the reflex eye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement is present. Vertigo - The sensation of movement. Classically the person has a feeling of spinning or rotation. A sensation that the external world is revolving around an individual is sometimes called objective vertigo while subjective vertigo is if the individual feels they are revolving in space. Vestibular Ocular Reflex Present - Document any comments as related to Vestibular-Ocular. Mini Mental Status Exam Score (MMSE) - A brief, quantitative measure of cognitive status in adults. A score of 24 or less may be indicative of mild cognitive impairment. If completed enter the score. Montreal Cognitive Assessment (MOCA) - A cognitive screening test designed to assist in detection of mild cognitive impairment. A score of 25 or less may be indicative of mild cognitive impairment. If completed enter the score. Cognitive Performance Scale (CPS) - A RAI-Home Care outcome measure used to rate the cognitive status of clients. CPS scores of two (2) or greater indicate cognitive impairment.

Depression - Check if client reports feeling of sadness, dejection, or appears to have low affect. Geriatric Depression Scale - Fifteen item questionnaire in which clients are asked to respond yes or no in reference to how they felt over the past week. If completed, enter the score (0 – 5 Low Risk) (6 – 10 Moderate Risk) (11 – 15 High Risk). Gait / Balance / Strength - Ask if client exercises regularly, and provide details. Balance / Gait - Ask if client has a specific exercise program related to balance, gait and / or falls prevention and provide specifics. Timed Up and Go (TUG Test) - A test performed from a typical chair with arms; the client rises, walks 3 meters (with typical gait aid) and returns to the original sitting position. Clients with scores of more than 15 seconds are considered high risk for falls. Comment on performance of the test (e.g. gait aid used, mobility concerns). Observations of Gait Ambulation - Check all that apply. Chair Stand Test - Measure the total number of sit-to-stands that can be completed by an individual in 30 seconds. The objective is to stand up fully from a standard straight-backed firm chair with no arm rests (approximate seat height of 46 cm), return the buttocks to the chair, and repeat for as many times possible in 30 seconds Berg Balance Scale - Assessment scale for balance while performing various functional movements and activities. Indicate comments on performance of the test. Score: • 0 – 20 Wheel Chair Use Only • 21 – 40 needs an assistive device • 21 – 26.5 Standard Walker • 26.6 – 35.6 Walker 2- Wheeled • 32.6 – 40 4-wheeled walker • 41 – 56 Walks independently • No aid required for mobility • May use a cane. Classic Romberg - This test is to detect poor balance. Ask the client to start by standing normally. Then demonstrate Romberg (standing with feet together). Ask them to get into this position, and, if possible, hold it for 10 seconds. If unable to do for 10 seconds, record how long they can hold the position. Note the ability to maintain a standing posture with eyes opened and then repeat the test with eyes closed.

CPS Score Description CPS Score Description 0 Intact 4 Moderate / Severe Impairment 1 Borderline Intact 5 Severely Impaired 2 Mild Impairment 6 Very Severely Impaired 3 Moderate Impairment


Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment

Purpose: Assessment tool used for identification of enhanced falls risk and subsequent management.

Gait/Balance/Strength continued

Four-Test Balance Scale Feet together Stand: ______________ (seconds) Semi-tandem: ___________________ (seconds) Tandem Stance: __________________ (seconds) One-leg: ________________________ (seconds) Scale: ___________________________ / 4 Observations of Balance ___________________________________________________________________________________ _________________________________________________________________________________________________________

Gait / Balance Risk Standing Yes No Walking Yes No Turning Yes No Tremor Yes No Specify whether intention, postural, and / or at rest __________________________________________________________________________________________________________________________________________________ Abnormal Tone Yes No Describe _______________________________________________________________ __________________________________________________________________________________________________________ Appropriate use of walking aids / braces Yes No Specify _______________________________________________Assess Transfers Bed _____________________________________________________________________________ Chair _____________________________________________________________________________ Toilet _____________________________________________________________________________ Bath _____________________________________________________________________________

Assistive Device/Brace Indoors Outdoors Orthotics / Shoes Cane Wheeled Walker Standard Walker Brace Wheel Chair Electric Wheel Chair/Scooter Prosthesis “Cruising” Furniture

Comments ____________________________________________________________________________________________ _______________________________________________________________________________________________________ Lower Extremity Assessment Feet Problems Yes No Describe ______________________________________________________ Professional Foot Care Yes No Describe ______________________________________________________

Foot Wear Indoor Appropriate Inappropriate Outdoor Appropriate Inappropriate Semmes-Weinstein Sensory Testing Monofilament for Loss of Protective Sensation L = ___________ R = _________ Comments ______________________________________________________________________________________________ _______________________________________________________________________________________________________








Sample

19050(2015-01)


Four – Test Balance Scale

Feet Together Stand - Hold for 10 seconds. Semi-Tandem Stand - The person chooses which foot to place in front. Hold for 10 seconds. Tandem Stand - The person chooses which foot to place in front. Hold for 10 seconds. One Legged Stand - Person chooses which foot to stand on, time starts as soon as the person raises one foot off the ground, and we chose to extend the maximum length of time of one legged stand test from 10 seconds to 30 seconds to lessen the ceiling effects of this test. Scale - Number of stances client is able to perform and hold for 10 seconds.

Observations of Balance - Note speed of gait initiation. Particularly important to note if there is a significant delay between when you ask them to start and when they are able (“freezing” may indicate movement disorder such as Parkinson’s disease, or normal pressure hydrocephalus).

Gait / Balance Risk - Check appropriate answer. Tremor - Intention tremor is noted when the client goes to move affected body part, postural tremor occurs during maintenance of a position against gravity (you can look for it by asking the client to hold their arms out in front of their body), and at rest is simply noted when client is sitting quietly. Note whether tremor is in arm, head, trunk, or leg (most commonly seen in arms). Abnormal Tone - Muscle rigidity is an alteration of muscle tone where the muscles are in an involuntary state of continual tension. Neurological damage or a side effect of certain medications can cause rigidity Appropriate use of walking aids/braces - Comment on whether aid fits client properly, whether client is using safely to the best of your knowledge, whether aid appears sufficient to meet balance impairment etc. Assess Transfers - Observe ability to transfer on and off each area as listed, and specify any other transfers assessed. May describe transfer style and intensity or other notes related to falls risk. Measure heights of seating surfaces. Assistive Device/Brace - List any devices, braces, etc. used to assist mobility. Comment on level of independence with application, appropriateness and safety of use. Lower Extremity Assessment - Observe if client has any foot problems and describe, note type of footwear and comment on any foot issues. Appropriate footwear usually means it has no more than 1 ½ inch heel, non-slip sole, lace-up or buckle up, relatively straight medial (inside) edge. Inappropriate means these conditions haven’t been met. May also mean inadequate room in toe box if client has deformities such as claw toes, or if obvious pressure areas are present on feet, may mean that shoes are too old or don’t fit properly, etc.

Feet Together Stand Semi-Tandem Stand Tandem Stand One Legged Stand


Sample

19050(2015-01)


Lower Extremity Range Of Motion Left Right Hip Flexion Knee Extension Ankle Dorsiflexion / Plantar Flexion

Lower Extremity Strength Left Right Hip Flexion Knee Extension Ankle Dorsiflexion / Plantar Flexion

Lower Extremity Abnormality Yes No Specify ________________________________________ Postural Hypotension BP Lying (after 10 minutes of lying) Pulse Lying Rhythm BP Standing (after 1 minute of standing) Pulse Standing Rhythm BP Standing (after 3 minutes of standing) Pulse Standing Rhythm (A decrease of 20 mm pressure or more is a concern)

Symptomatic Hypotension Yes No Specify ________________________________________________ Comments ___________________________________________________________________________________________

_______________________________________________________________________________________________________________

Environment Assessment and Safety Risk Noted Using the Home Fast Tool Home Fast Tool Completed? Yes No Environmental Risks Yes No Comments __________________________________________________________________________________________

Fall Risks Identified

___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Recommendations

Referral to Senior Health Yes No Refer to Pharmacist

Referral to Day Hospital Yes No Refer to NP

Others ___________________________________ Refer to OT

Please see assessment summary report Yes No Refer to Geriatrician Refer to FP Refer to Dietician

Assessor’s Signature Assessor’s Designation Date (yyyy-Mon-dd)

Assessor’s Signature Assessor’s Designation Date (yyyy-Mon-dd)

RLS








Sample

19050(2015-01)

Enhanced Practice Fall Risk Assessment Guidelines Lower Extremity Range of Motion - Assess for functional limitations in relevant muscle groups for gait and balance. Describe any abnormalities such as low swing through leg, scuffing, differences in stride length between legs, Trendelenberg (weakness of hip abductors which results in dropping of the pelvis when leg is lifted to step forward), etc. Lower Extremity Strength - Again done in sitting position. If they have known pain in either knee or ankle, start with less resistance, and build up if they are able to tolerate it. If they have pain during movement, ask where it is (in the joint being tested, where your hand is pushing, etc.). Assess for functional limitations in relevant muscle groups for gait and balance. Lower Extremity Abnormality - Note any obvious limitations, usually due to musculoskeletal problems, such as impairment following fractured hip, severe osteoarthritis, joint instability, etc. Postural Hypotension - Specify client’s problems / concerns with blood pressure. Check if client reports dizziness/feeling of light-headed (i.e. like they’re going to faint or black out) when changing positions (i.e. lying to standing) and detail in notes section. Environment Assessment and Safety - Record number of yes responses, plus whether or not client has an Emergency Response system. Assessor’s Signature - If there are two assessors, both sign. RLS - Indicate here that a report has been submitted. Routing - Completed assessment filed in the Main Chart under the Assessment tab.


Sample

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Enhanced Practice Fall Risk Assessment