Review

Fall Risk Assessment Scales: A Systematic Literature Review

Veronica Strini 1 , Roberta Schiavolin 2 and Angela Prendin 3,*

1
Clinical Research Unit, University-Hospital of Padua, 35128 Padua, Italy; [email protected]
2
Continuity of Care Service-University-Hospital of Padua, 35128 Padua, Italy;
[email protected]
3
Independent Research, University-Hospital of Padua, 35128 Padua, Italy
* Correspondence: [email protected]

Abstract: Background: Falls are recognized globally as a major public health problem. Although the
elderly are the most affected population, it should be noted that the pediatric population is also very
susceptible to the risk of falling. The fall risk approach is the assessment tool. There are different
types of tools used in both clinical and territorial settings. Material and methods: In the month of
January 2021, a literature search was undertaken of MEDLINE, CINHAL and The Cochrane Database,
adopting as limits: last 10 years, abstract available, and English and Italian language. The search
terms used were “Accidental Falls” AND “Risk Assessment” and “Fall Risk Assessment Tool” or
“Fall Risk Assessment Tools”. Results: From the 115 selected articles, 38 different fall risk assessment
tools were identified, divided into two groups: the first with the main tools present in the literature,
and the second represented by tools of some specific areas, of lesser use and with less supporting
literature. Most of these articles are prospective cohort or cross-sectional studies. All articles focus on
presenting, creating or validating fall risk assessment tools. Conclusion: Due to the multidimensional
nature of falling risk, there is no “ideal” tool that can be used in any context or that performs a perfect
check ror
updates risk assessment. For this reason, a simultaneous application of multiple tools is recommended, and a
direct and in-depth analysis by the healthcare professional is essential.
Citation: Strini, V.; Schiavolin, R.;
Prendin, A. Fall Risk Assessment
Keywords: fall; scale; assessment tool; review
Scales: A Systematic Literature
Review. Nurs. Rep. 2021, 11, 430–443.
https://doi.org/10.3390/
nursrep11020041
1. Introduction
Academic Editor: Richard Gray
The phenomenon of falls is recognized globally as a major public health problem.
Falling down is globally the number-one health problem, and a common problem of
Received: 9 April 2021
evaluation by healthcare professionals. A fall is defined as a “sudden, not intentional, and
Accepted: 24 May 2021
unexpected movement from orthostatic position, from seat to position, or from clinical
Published: 2 June 2021
position” [1]. Falls involve elderly people for two main reasons: (1) the decrease of
functional reserves that are used to maintain the orthostatic position; (2) the following
Publisher’s Note: MDPI stays neutral
vulnerabilities or pathologies caused by factors that occur simultaneously, pathological
with regard to jurisdictional claims in
published maps and institutional affil-
processes, and adverse pharmacological incentives. People over 65 have the highest
iations.
probability of falling down: 30% of them fall down at least once per year, while the
percentages become higher, (about 50%) on people over 80 [2]. Even if elderly people run
the highest risk of falling down, it is necessary to point out that the pediatric population
runs quite a high risk of downfall as well. About three million children are victims of
wounds related to annual falls [3]. Although nearly 40% of the total daily falls worldwide
Copyright: © 2021 by the authors. occur in children, this measurement may not accurately reflect the impact of fall-related
Licensee MDPI, Basel, Switzerland. disabilities for older individuals who have more disabling outcomes and are at greater risk
This article is an open access article of institutionalization [1].
distributed under the terms and The financial costs of fall injuries are substantial. For people aged 65 and over in
conditions of the Creative Commons
Finland and Australia, it was calculated at USD 3611 and USD 1049, respectively. Evidence
Attribution (CC BY) license (https://
from Canada suggests implementing effective prevention strategies with a subsequent 20%
creativecommons.org/licenses/by/
reduction of the incidence of falls among children under 10 could create net savings of more
4.0/).

Nurs. Rep. 2021, 11, 430–443. https://doi.org/10.3390/nursrep11020041 https://www.mdpi.com/journal/nursrep

Nurs. Rep. 2021, 11 431

than USD 120 million annually [1]. The Joint Commission International for
Accreditation Standards for Hospitals specifies that hospitals should aim to reduce the
risk of injury from falls to inpatients and outpatients, including appropriate screening
or assessment of fall risk tools, a process for re-evaluation, especially if there are
changes in the patient’s condition; and implement interventions to reduce the risk of
falling [4]. For this reason, risk assessment is important. The expression of risk assessment
is based on the following: checklists drafted of different risk factors for fall and numerical
indexes to predict the risk. The checklists help the staff to identify the most common factors,
while the numerical index is used to predict the risk of an individual using a numerical
score that is proportional to the number of risk factors included [5].
However, the characteristics of the patient for a fall risk tool are varied: age, cognitive
state, state of health in general, particular comorbidities, hospital or home context. These
are just a few features. In fact, in recent studies, particular risk factors have been evaluated
such as being hospitalized, being hospitalized in neuropsychiatry, suffering from dementia
and delirium, and going to the bathroom [6].
Currently in the literature, there is no study that summarizes the tools available to
healthcare professionals according to the different contexts in which they operate. Knowing
the fall assessment tools, through the analysis of their characteristics, allows to identify
the most suitable scale for each individual patient and to prevent the risk. As described in
NICE, 2004, the patients should be cared for by personnel who have undergone appropriate
training and who know how to initiate and maintain correct and suitable preventative
measures. Staffing levels and skill mix should reflect the needs of patients [6].
This review aims to analyze different fall risk assessment tools present in the literature
with the aim of supporting healthcare professionals in choosing the tool best suited to their
operational context and the characteristics of the patients.

2. Material and Methods

A literature search was undertaken from MEDLINE, CINHAL and The Cochrane
Database in the month of January 2021.
The present review of literature followed the PRISMA guidelines [7]. The PICO
method was adopted [8] as shown below to find the correct research terms to use:
Population: individuals who are in hospital environments or who stay in the territory,
without any age limit.
Intervention: application of instruments to evaluate the risk of falling.
Comparison: none.
Outcomes: measurement of the downfall risk.
For every database, the following search terms were used: “Accidental Falls” and
“Risk Assessment”, “Fall Risk Assessment Tool” or “Fall Risk Assessment Tools”.
The limits applied to each study were: year of publication 2010–2020 (last ten years);
abstract available, Italian and English languages. Specific criteria of inclusion and exclusion
were defined as shown below:
Inclusion Criteria: Revision and research studies (experimental, observational and
descriptive studies) focused on the presentation, creation, validation, or critique of instru-
ments of fall risk evaluation.
Exclusion criteria: articles that report evaluations measuring the risk of falling with
medical parameters or criteria (ex. Laboratory data), or evaluations made through move-
ment sensors; articles without abstract or not available in Italian or English languages.
The review was not registered in any database or similar, and it was conducted by two
separate reviewers who then compared the results on the basis of the limits and eligibility
criteria chosen. The agreement was found as shown in Figure 1.
 Figure 1. PRISMA flow diagram.

3. Results
Figure 1 is an illustrative example of the selection process with the final total number
of articles included (n = 115). Most selected studies are prospective cohort studies or
transverse studies, focused on the validation of an instrument in a different environment
from the original one. In the other articles: retrospective studies, descriptive studies,
methodical studies, and systematic reviews are present. Some instruments of evaluation
have been compared to analyze their properties in relation to each other.
For the selected scales, the history and any important changes over the years have
been reconstructed. Each scale, in fact, belongs to different populations or contexts, for the
purpose of presenting the entire scenario of the tolls for assessing the risk of falling.
 Tools identified by the analysis of the articles are 38, divided into two groups.
The first group is represented by the main 21 risk assessment tools, described in
Table 1.

Table 1. Risk of falling evaluation tools.

Scale, Reference, Language—Year Time of

Country Rate of Validation Sample Administration How to Use

Hospital setting (Parkinson’s

Tinetti Performance- Score 0–28. English 1986; disease, patients with
Oriented Mobility <18–19 patient at German 2017; amyotrophic lateral sclerosis, 5 to 10 min Performance.
Assessment [9] USA. risk of falling Korean 2018. Huntington’s disease and
community-resident elderly).
English 1989;
Score 0–125. German 2006;
Morse Fall 0–20 No risk or low Hospital setting (acute patient,
Chinese 2007;
Scale [10] Canada. risk;≥25 Medium rehabilitation and nursing 2 min. Self-report.
Korean 2011
risk; ≥45, 50–55 home departments).
High risk. Portuguese and
Brazilian 2013.
Hospital setting + screening of
population (acute patients or
Timed Up and Go Risk of falling if test English 1991:
time is >13.5 s. Most community residents,
(TUG) used cut-off in the Brazilian 2012; individuals with different 1 to 3 min. Performance.
test [11] Canada. literature. Chinese 2017. health alterations such as
Parkinson’s syndrome or
mental disabilities).
Hospital setting + screening
of population (elderly living
Score 0–56. English 1992;
Berg Balance Scale in communities or suffering
<45 patient at risk of Norwegian 2007;
from chronic diseases or with 20 to 30 min. Performance.
(BBS) [12] Canada. Brazilian 2009;
falling. intellectual and visual
Arabic 2016. disabilities, neuromuscular
pathologies).
Score 0–11. English 1993;
Downton Fall Risk Hospital setting (post-stroke
Index [13] England. ≥3 patient at risk of Spanish 2015; N/a. Self-report.
German 2003. rehabilitation).
falling.
Percentage value
attributed of 0– Screening of population
100%. <50 Low English 1995;
Activities-specific Swedish 2003 (elderly living home, people
level of
Balance Confidence functionality; 50–80 Chinese 2006; with Parkinson’s Syndrome,
French 2006; 20 min or less. Self-report.
Scale (ABC Medium level of post-stroke, lower limb
Scale) [14] Canada. functionality; >80 Portuguese 2013; amputations and vestibular
High level of Arabic2016. disorders).
functionality.
Hospital setting + screening
of population (elderly
Dynamic Gait Index Total score 0–24. people, subjects suffering
<19 at risk of falling. English 1997. 15 min. Performance.
(DGI) [15] USA. from vestibular dysfunction,
multiple sclerosis and
post-stroke).
St. Thomas
Risk Score 0–5.
Assessment English 1997; Hospital setting (ICU,
Tool in Falling ≥2 patient at risk of Italian 2014; geriatric and rehabilitation 3 min. Self-report.
Elderly Inpatients falling. Spanish 2017. departments).
(STRATIFY) [16]
England. Score 0–10.
0–2 no risk; ≥2 English 1999; Hospital setting (medicine
Conley patient at risk of 2 min. Self-report.
Italian 2002. and surgery departments).
Scale [17] USA. falling; ≥8 high risk.
Performance > 47
cm = Very high risk;
Minimal Chair performance 34–47 Hospital setting + screening of
Height Standing cm = High risk; English 2002. population (heart disease N/a. Performance.
Ability Test performance < 34 or stroke).
(MCHSAT) [18] cm Low risk.
Australia.
 Table 1. Cont.

Scale, Reference, Language—Year Time of

Country of Validation Administration How to Use
Rate Sample
Aachen Falls
Prevention Scale Score 0–10. Screening of population (no
Self-report +
[19] Germany. ≤5 High risk of German 2004. specific population, home care N/a.
Performance.
falling. context).
Falls Risk for Older
Persons-
Community Setting Score 0–45.
0–5 Low risk; 6–20 English 2004. Hospital setting (subacute
Screening Tool Chinese and N/a. Self-report.
Medium risk; 21–45 patients’ departments).
(FROP Com High risk. Thai
Screen) [20] 2017.
Australia.
Five Times Sit to Hospital setting + screening of
Stand Test (5T-STS) Time taken ≥15 population (Parkinson’s
[21] USA. English 2005. N/a. Performance.
s = at risk of falling. syndrome, stroke, arthritis of
the lower limbs).

Falls Efficacy Scale English 2005;

Brazilian 2010; Screening of population (no
—International
(FES-I) [22] England. Score 16–64. Portuguese 2011; specific context, home N/a. Self-report.
Turkish 2012; care ederly).
Persian 2013.
Johns Hopkins English 2005.
Fall Risk Score 0–35.
Chinese 2016; Hospital setting + screening
Assessment Tool 0–6 Low risk; 7–13
Medium risk; 14–35 Brazilian 2016; of population (ICU, 5 min. Self-report.
(JHFRAT) Korean 2011; medicine departments).
High risk.
[23] USA. Persian 2018.
Fullerton Advanced
Balance (FAB) Scale. Score 0–40. Screening of population
English 2006;
[24] USA. (functionally 10 to 12 min. Performance.
German 2011.
independent seniors).
English 2007;
Hendrich II Score 0–16. Italian 2011; Hospital setting (adult
Fall Risk Self-report +
≥5 patient at risk of Portuguese 2013; patients at risk in acute 10 min or less.
Model Performance.
falling. Lebanese nel 2014; care hospitals).
[25] USA. Chinese 2011.
Score: 3 points for
each drug of the Hospital setting
Medication fall risk first item, 2 for each
score [26] USA. (pharmacist-coordinated falls
of the second item, 1 English 2009. N/a. Self-report.
prevention program, patients
for the drug of the with high risk drug therapy).
third one.
≥6 a Risk of falling.
Mini Balance
Evaluation Systems Hospital setting
Score 0–28. Italian 2009. 10 to 20 min. Performance.
Test (Mini-BESTest) (Parkinson’s syndrome).
[27] Italy.
Answer no to all
questions = Low
risk; at least one
answer yes to the
questions and
passing the tests
Stopping Elderly (hold the position
Accidents, Deaths, for >10 s in each Hospital setting + screening Self-report +
and Injuries phase and get up English 2013. N/a.
(STEADI) [28] of population (routine Performance.
from the chair more
USA. than 5 times in 30 s practice).
or less) = Medium
risk; failure to pass
the tests or report
numerous falls or
with hip
fracture = High risk.
Answer “Yes” to
Austin Health Falls one of the items =
Risk Screening Tool at Risk of falling.
(AHFRST) [29] Answer “No” to English 2017. Hospital setting (acute and N/a. Self-report.
Australia. each item = Not subacute patients’
at risk. departments).
 Table 2 describes the second group, with 17 additional assessment tools specific to
some areas, but of lesser use and with less supporting literature. The tools divided by
scope are the following: psychiatric field: “Baptist Health High Risk Falls Assessment
(BHHRFA)”, “Wilson-Sims Fall Risk Assessment Tool (WSFRAT)”; pediatric field: “4-item
Little Schmidy Pediatric Hospital Fall Risk Assessment Index”, “Humpty Dumpty Fall
Scale (HDS)”, “Bayındır Hospital Risk Evaluation Scale for In-hospital Falls of Newborn
Infants”; emergency department: “KINDER 1 Fall Risk Assessment Tool”, “Memorial
Emergency Department (MED-FRAT)”; rehabilitation field: “Casa Colina Fall Risk
Assess- ment Scale (CCFRAS)”, “Predict_FIRST”, “Marianjoy Fall Risk Assessment Tool
(MFRAT)”, scope of home care: “Simple clinical scale”, “Home Falls and Accidents
Screening Tool (HOME FAST)”; patients affected by stroke: “Stroke Assessment of Fall
Risk (SAFR)”, “Royal Melbourne Hospital Falls Risk Assessment Tool (RMH FRAT)”,
“Sydney Fall Risk Screening Tool”, “Outdoor Falls Questionnaire”, “Questionnaire for Fall
Risk Assessment in the Elderly”.

Table 2. Specific tools for given contests/population.

Language—Year
Scale, Reference, Country Rate Sample Time of
Administration How to Use
of Validation
Baptist Health High Risk Score items +
Falls Assessment Hospital
Nurse’s clinical
(BHHRFA) [30] USA. English 2014. setting.Psychiatric 3 min or less. Self-report.
judgment (0–10).
≥13 a Risk of falling. field.
WSFRAT (Wilson-Sims Fall
Risk Assessment Hospital
0–6 Low risk; English 2014 and
Tool) [31] USA. setting.Psychiatric N/a. Self-report.
≥7 High risk. 2016.
field.
4-item Little Schmidy
Pediatric Hospital Fall Score 0–4. Hospital
Risk Assessment ≥1 a Risk of falling English 2016. setting.Pediatric N/a. Self-report.
Index [32] USA. ≥3 High risk. field.
Humpty Dumpty Fall Scale Score 0–23. Hospital
(HDS) [33] USA. 7–11 Low risk; English 2007. setting.Pediatric N/a. Self-report.
12–23 High risk. field.
Bayındır Hospital Risk
Evaluation Scale for
In-hospital Falls of Hospital
1–3 Low risk.
Newborn Infants [34] Turkish 2010. setting.Pediatric N/a. Self-report.
≥4 High risk.
Turkey. field.

KINDER 1 Fall Risk Answer “Yes” to any Hospital

Assessment Tool [35] USA.
item = High risk English 2013. setting.Emergency N/a. Self-report.
of falling. department.
Memorial Emergency
Department Score 0–14. Hospital
1–2 Low risk;
(MED-FRAT) [36] USA. 3–4 Moderate; English 2013. setting.Emergency N/a. Self-report.
≥5 High risk. department.

Casa Colina Fall Risk Score 0–260. If you

Assessment Scale answer “Yes” to the Hospital set-
(CCFRAS) [37] USA. item English 2014. ting.Rehabilitation N/a. Self-report.
“Tetraplegia” = Low field.
risk. ≥80 High risk.
Score 0–5.
Predict_FIRST [38] Probability of falling Hospital set-
Australia. based on the score: English 2010. ting.Rehabilitation N/a. Self-report.
0 = 2%; 1 = 4%;
2 = 9%; 3 = 18%; field.
4 = 33%; 5 = 52%.
Marianjoy Fall Risk Hospital set-
Assessment Tool [39] Score 0–10
English 2005. ting.Rehabilitation N/a. Self-report.
USA. ≥4 a Risk of falling.
field.
Score 0–16. Screening of
Simple clinical scale [40] 0–4 Low risk;
France. 5–10 Moderate risk; French 2010. population. N/a. Self-report.
11–16 Other risk. Home care.
 Table 2. Cont.

Language—Year Time of
Scale, Reference, Country Rate of Validation How to Use
Administration
Sample
Home Falls and Accidents Score 0–25.
Screening Tool (HOME Screening of
A higher
FAST) [41] Australia. English 2002. population. N/a. Self-report.
score = herefore a Home care.
higher risk of falling.
The Stroke Assessment of Score 0–49 Hospital
Fall Risk (SAFR) [42] USA. 0 = Low risk; setting.Stroke
English 2011. N/a. Self-report.
49 = Higher risk. patients.
The Royal Melbourne
Hospital Falls Risk 0–4 Low risk; Hospital
Assessment Tool 5–14 Medium risk; English 1997. setting.Stroke N/a. Self-report.
(RMH FRAT) [43] Australia. ≥15 High risk. patients.
Sydney Falls Risk
Score ≥ 33 = a Risk Hospital
Screening Tool English 2018. setting.Stroke N/a. Self-report.
[44] Australia. of falling. patients.
A higher score Screening of
Outdoor Falls indicates a higher risk English 2015. population. 20 to 25 min. Self-report.
Questionnaire [45] USA.
of falling. Stroke patients.
Questionnaire for Screening of
Fall Risk Assessment in the N/a. Brazilian 2017. population. N/a. Self-report.
Elderly [46] Brazil. Stroke patients.

4. Discussion
The vast majority of the proposed tools have been developed for use in acute and
geriatric settings, in which there are numerous factors that expose individuals to this risk.
The target most subjected to the assessment is the elderly population (>65 years), followed
by people suffering from pathologies that alter walking and balance skills (e.g., Parkinson’s
disease, mental disabilities, stroke outcomes, etc.).
Falls Efficacy Scale—International (FES-I). The FES-I scale is the most used tool in
literature for the “fear of falling” evaluation, a factor closely related to the genesis of
falls [22]. This scale refers only to basic daily activities of frail elderly people or people
with disabilities. The FES-I includes 16 daily life activities, and the individual must
report the perceived degree of concern in implementing each of the activities listed. It is the
ideal tool for investigating the “fear of falling” of the elderly in normal daily activities.
The Activities-specific Balance Confidence Scale (ABC Scale) was developed to assess
the perceived degree of confidence in maintaining balance or not becoming unstable in
performing various functional tasks. It is a structured questionnaire that measures the
confidence of an individual in carrying out activities and consists in attributing a percentage
value, between “insecurity” and “complete security”, to the 16 proposed activities [ 14].
The ABC scale is simple to complete, and the time required for filling out can be as much
as 20 min, which is why a simplified version has been proposed that includes six of the
most challenging activities of the previous scale. The scale has been validated for use
with different ratings including people with Parkinson’s Syndrome, post-stroke, with lower
limb amputations and vestibular disorders; it has also been translated into several
languages besides English such as Swedish, Chinese, Canadian French and Arabic [47].
Comparing the two scales, it emerged that the FES-I scale has a greater
appropriateness of use in clinical settings than the ABC Scale, whose use is recommended
mainly in the elderly living at home [22].
The STRATIFY scale is a predictive tool for the risk of falls in hospitalized patients. The
compilation of the scale is not performed through direct observation of the patient, but the
evaluator reports the score based on information obtained from the previous observation
or from other caregivers. STRATIFY has been extensively studied in intensive care units
in Australia, Europe and Canada [48] and has also been applied in numerous geriatric
and rehabilitation departments [49]. In these contexts, it has long been considered the
“Gold standard” tool to be used at patient admission thanks to the high sensitivity value
demonstrated by numerous studies (between 73.7% and 93.0%) and the simplicity and
speed of application (3 min).
At the same time, some studies criticize its reduced specificity, or identify its scarce
usefulness if applied in different or specific contexts such as rehabilitation from traumatic
brain injury, or in patients younger than 65 years old. The Hendrich II Fall Risk Model
(HIIFRM) was designed to identify adult patients at risk of falling in acute care hospi-
tals [25]. Unlike the STRATIFY scale, the history of previous falls was not considered as
a risk factor. They are also taken into account due to drug categories that are at greater
risk for falls and side effects than other drug categories. The time required for its
compilation is approximately similar to that of the STRATIFY scale. The scale was tested
on acute phase patients with different diagnoses (diabetes mellitus, stroke, heart
failure), demonstrating that its effectiveness varies according to the patient group, the
healthcare professional’s skill level and the clinical units in which is applied.
The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) was used for the multi-
factorial assessment of the risk of falling in departments for acute patients [ 23]. The
JHFRAT scale is a tool that makes possible to implement a multi-factorial assessment of the
risk of falling in a simple way, which requires an average of 5 min for its completion and is
widely used in adult departments in the acute phase [50]. However, there are discordant
results in the literature regarding its statistical characteristics: in some studies, a high
sensitivity is reported, but a low specificity, vice versa in other studies, which consider it
weak if used in specific contexts, such as in the departments of medicine [50,51].
The Tinetti Mobility Test (TMT) or the Performance-Oriented Mobility Assessment
(POMA) consists of the combined use of the useful components drawn from both ap-
proaches [9]. The total POMA (POMA-T) consists of two sub-scales: the balance rating
scale (“balance scale” or POMA-B) and the gait rating scale (“gait scale” or POMA-G) [52].
The scale is also used in different clinical contexts: its effectiveness was analyzed on pa-
tients with Parkinson’s disease, with amyotrophic lateral sclerosis, Huntington’s disease
and community-resident elderly [52]. The time taken is 5–10 min, but it requires training
for the examiner as a prerequisite and requires some equipment (stopwatch, chair, 5-pound
object = about 2.5 kg and a space to walk 15 feet = about 5 m). It can also be burdensome for
patients. There is a “long” version of the scale consisting of a total of 40 points that assesses
the individual in more depth, but consequently requires more time for its application [6].
The Aachen Falls Prevention Scale was developed in order to allow the elderly to
perform a self-assessment of their risk of falling [19]. The Aachen Fall Prevention Scale
is an easy-to-understand tool that investigates various factors that contribute to the
genesis of falls and introduces a quick and safe test; it allows the individual to perform a
self- assessment and increase the degree of self-perception. The authors have also
created an evaluation index, the “Aachen Mobility and Balance Index” to measure the
physiological risk of falling in the elderly at home; this includes the execution of
performances character- ized by the progressive increase of difficulty in the components
of balance, mobility and grip strength required for the completion of the test. The index
demonstrated a strong correlation with the Tinetti POMA Scale and a good degree of
discrimination between individuals at risk of falling and not, but the time required to
execute the performances and the necessary equipment make it more complex.
The Fullerton Advanced Balance (FAB) Scale is a multidimensional tool for
assessing balance developed for functionally independent seniors. It aims to identify
highly active seniors who are at increased risk of suffering fall-related injuries due to
sensory impair- ments [24]. The validity of its contents is based on a theoretical analysis of
the components of the static and dynamic balance, the reception and integration of the
sensory components and the anticipatory and reactive postural control. Berg Balance Scale
(BBS) was developed for the evaluation of both static and dynamic balance capacity. It
provides a detailed bal- ance assessment and has been extensively tested in various
contexts: United States, Canada, Brazil, Australia, China, Japan, Korea and United
Kingdom. It has shown accuracy in predicting falls in different types of population
(elderly living in communities or suffering
from chronic diseases or with intellectual and visual disabilities) and a greater sensitivity
was highlighted when applied in populations affected by diseases that affect the balance
(e.g., neuromuscular pathologies) both in clinical and home settings [53]. Compared to the
FAB scale, it has a “ceiling effect” that does not allow it to be administered to physically
active elderly people [54]. It also requires a much longer application time, about 20 min.
The Balance Evaluation Systems Test (BESTest) aims to identify the disordered
systems underlying postural control responsible for poor functional balance in adults. It
is widely used to evaluate six balance control systems; however, it is difficult to apply in
clinical situations due to the long administration time (approximately 20–30 min). The
BESTest has two shorter versions: the Mini-BESTest [18], developed in 2010, allows the
evaluation of four balance control systems (compared to the six total of the original)
and has been used with different clinical populations and has shown particular
psychometric properties in individuals with Parkinson’s syndrome [55]. The test,
however, requires a moderate amount of equipment to be completed and, moreover, it
focuses on dynamic balance, without evaluating all the stability control systems; while
the Brief-BESTest, developed in 2012, is a reduced version, consisting of eight items
that allow an analysis of all six balance control systems evaluated by the BESTest;
moreover, it requires even less time and material to complete it [56]. The comparison of the
two tests shows that the Brief-BESTest is recommended as a guide for planning
interventions, while the Mini-BESTest is more appropriate as a screening tool for the
dynamic balance of patients [55].
The 5 Times-Sit to Stand Test (5T-STS) was developed and validated in America to es-
tablish the ability of individuals with balance disorders to perform transitional movements.
A simple and quick test provided an objective measurement of the level of balance and
coordination of individuals subject to various health alterations such as Sdr. Parkinson’s
disease or chronic stroke [56]. Subsequently, the restriction of use of the 5T-STS test defined
as unable to evaluate a population of individuals with different degrees of motor ability
was criticized, which is essential if a tool is to be applied within institutionalized geriatric
contexts. Similar to 5T-STS is the Dynamic Gait Index (DGI), that verifies the participant’s
ability to maintain the equilibrium of walking by responding to different requests. Some
studies demonstrated the high reliability of the assessment in elderly people, subjects
suffering from vestibular dysfunction, multiple sclerosis and post-stroke [15]. It can be
performed in both hospital and home settings, as it does not require any special equipment.
It evaluates all aspects of gait, but takes a long time to administer (15 min) [15].
The Timed Up and Go (TUG) test is simple and effective, and seeks functional mobility:
it provides a quick assessment of the individual’s strength, mobility capacity and
dynamic balance [11]. Numerous studies have attested its validity by applying it in different
contexts such as wards for acute patients or community residents [57], or to individuals
with different health alterations such as Parkinson’s syndrome [58] or mental
disabilities [59]. It is a simple test to implement, therefore applicable in clinical
situations where the time available to the healthcare professional is a fundamental
resource. Compared to the 5T-STS and the DGI, it presents multiple variables that can
alter the result of the test (such as the support foot while getting up from the chair, the
moment in which the stopwatch starts, the clear understanding of the tasks to be
performed by the individual), has also shown reduced efficacy when administered to
people with high or normal functional mobility [45]. Finally, the different cut-off values
must be considered based on the age, context and pathological condition of the
population being tested.
The Downton Fall Risk Index (DFRI) detects the risk of falling. The tool has been used
in several studies with different purposes: to evaluate the effectiveness of a program for the
elderly in post-stroke rehabilitation aimed at muscle strengthening, or to discriminate in a
population of elderly who had experienced previous episodes of falls. The Tool has been
extensively analyzed in contexts that do not include acute patients such as nursing homes,
while when applied to the hospital environment, its ability to predict falls significantly
decreases [60].
 The Conley Scale assesses the risk of falls. The scale has been inserted and used in
various Italian hospital contexts (mainly medicine and surgery). It is quick to use (about 2
min) and is easily understood; it is usually administered upon admission of the patient to
the ward. However, the inability to identify patients not at risk of falling due to the low
specificity value was contested [61]; therefore, it is recommended to use it as a preliminary
evaluation to identify subjects who need a more in-depth clinical evaluation [62].
The Minimal Chair Height Standing Ability Test (MCHSAT) involves measurements
of the minimum height of the chair from which the person is able to stand up. The tool
has been used in several studies with different purposes: to evaluate the effectiveness
of a program for the elderly in post-stroke rehabilitation aimed at muscle
strengthening, or to discriminate in a population of elderly people who had experienced
previous episodes of falls. The test showed, if administered in a standardized way, a
high sensitivity (75%), which, combined with its simplicity of execution and speed of
administration, makes it an appropriate tool for screening the risk of falling in
healthcare settings [63]. From the comparison performed between the MCHSAT test
and the 5T-STS, it emerged that both are less effective if performed by patients with
heart disease or stroke, while in patients suffering from arthritis of the lower limbs, the
5T-STS is more effective [63].
Stopping Elderly Accidents, Deaths, and Injuries (STEADI) was created to help health
professionals integrate fall risk assessment into routine practice. The tool also includes
a list of fall prevention interventions for clinical use. The STEADI algorithm provides
valid, unique information on the risk of falling, independently of traditional indicators
based on a low level of physical health [28].
Morse Fall Scale (MFS) is a quick and easy way to assess the likelihood of a patient
falling. It was developed in acute patient, rehabilitation and nursing home departments.
The scale was computer tested in a simulated population and was subsequently applied
to the populations of the previously mentioned departments. The Morse scale takes a
few minutes to complete (approximately 2 min), allows for three different risk
categories (low, medium and high) and is used in hospital settings [64]. This tool,
however, does not investigate factors relevant to the risk of falls such as sensory deficits
and the intake of certain drugs that can affect the mechanisms involved in the genesis of
falls. For this reason, some studies have implemented a more accurate stratification of the
areas investigated by the items.
A scale concerning the presence of drugs is the medication fall risk score (RxFS). It was
developed as part of the pharmacist-coordinated falls prevention program in America
to compensate for the lack of various drug therapy risk assessment tools [65]. The US
Agency for Healthcare Research and Quality (AHRQ) has approved and recommended
its use in conjunction with various nurse-administered rating scales, such as MFS and
STRATIFY. The retrospective cohort study by Yazdani and Hall evaluated the efficacy of the
association of RxFS with the MFS scale [26].
Falls Risk for Older People-Community Setting Screening Tool (FRHOP Com
Screen) was developed by a multidisciplinary team of experts and tested in the wards of
subacute patients. The Thai version of the scale has demonstrated satisfactory reliability
and validity in hospitalized elderly subjects. Sensitivity and specificity are, respectively,
57% and 68%. By applying modifications to the FRHOP, the Western Health Fall Risk
Assessment (WHeFRA) scale was developed by Walsh et al. and demonstrated efficacy
comparable to the STRATIFY scale [20]. Austin Health Falls Risk Screening Tool (AHFRST)
was developed for acute or subacute patients. This tool is administered to all patients
upon entering the ward for a preliminary identification of those at risk of falling; it is fast
and easy to use [29]. Comparison with the TNH-STRATIFY scale performed in the
original study showed that both are unable to identify individuals not at risk of falling.
Therefore, they demonstrate a low degree of “predictivity” if applied in this type of
population [29].
The main elements that distinguish the assessment tools shown in the review are:
the risk factors investigated (intrinsic and/or extrinsic), the sample subjected to analysis
(hospital population and/or resident at home) and the way the test is used (questions to be
answered and/or physical actions to be performed). Between the instruments
presented between the discussion and Table 2, eight involve the execution of one or
multiple physical actions, with the aim of evaluating the mechanisms that regulate the
maintenance of balance and coordination in the individual (“Performance”); 26
investigate different risk factors through questions directed to the patient or elements on
which the attention of the professional using the instrument is guided (“Self-report”), and
finally, three scales include both the investigation of some risk factors through
questionnaire, and the execution of one or more physical activities. The RxFS is
excluded from this distribution, as it guides the attribution of a score exclusively based
on the type of drugs taken by the individual. The risk factors investigated by the “Self-
report” tools are mainly intrinsic, which means referred to the person; among these,
there are: the identification of previous episodes of falls (present in 23 scales); the
evaluation of the cognitive state aimed at identifying confusion, disorientation,
agitation, impulsiveness or mnemonic difficulties (present in 18 scales), alterations of
organs or systems and intake of drugs linked or not to specific pathological conditions,
and other intrinsic variables such as age and gender. Regarding extrinsic factors, only 5
tools evaluate them in a specific way, paying attention to the context in which the
individual lives. Instead, the environmental factor represented by walking aid devices is
investigated by almost all the instruments presented.
Each scale, before being applied in a specific clinical context or on a population
other than that for which it was created, must be properly tested, to verify its
effectiveness and reliability [61]; in fact, the same instrument can have variable values
of sensitivity and specificity if used in different contexts or with different populations.
For example, the combined application of a test with high and stable sensitivity (e.g.,
TUG test) and one with a high and stable specificity (e.g., BBS) allows increasing the
diagnostic precision in predicting the risk of falling. The use of a scale that evaluates
the state of illness or the alterations individual (e.g., STRATIFY or HIIFRM)
simultaneously with a test that evaluates the physical ability to maintain balance (e.g.,
BBS) can permit greater accuracy in identifying those at risk, even in different contexts
[53].

5. Limitations
This revision has the following limitations: only the articles of the last 10 years were
analyzed, the entire scenario of fall risk assessment tools present in the literature, there
is not sufficient information available on the statistical characteristics of the different
instruments to compare the tools or their parameters.

6. Conclusions
This study presents the entire scenario of fall risk assessment tools present in the
literature. Between most of the tools analyzed, 23 tools target hospitalized patients, eight
are used for risk assessment in home residents, while seven are applicable to both
populations. The primary purpose of using a fall risk assessment tool is not to reduce falls,
but to identify individuals at high and low risk [53]. In this way, the subjects that need a
more in-depth analysis are identified, and the healthcare professional’s attention is
focused on the main risk factors responsible of falls. To these subjects should be offered
a multifactorial falls risk assessment [6].
According to some studies, to maximize the predictability characteristics of each
instrument, it would be recommended to use two tests in combination.
Indeed, due to the multidimensional nature of the risk of falling, there is no “ideal”
a single tool that can be used in any context or that performs a perfect risk assessment.
A simultaneous application of several instruments is recommended and a direct and
in-depth analysis by the healthcare professional is essential [6]. The results of the risk
assessment should be discussed within the multi-professional team in order to identify the
most effective interventions for preventing falls, especially among people with cognitive
disorders, where the risk of fall is very common and have different etiologies [66].
 Author Contributions: All authors contributed to the same and review of the work. Conceptualiza-
tion, V.S., R.S. and A.P.; methodology, V.S., R.S. and A.P.; software, V.S., R.S. and A.P.; validation, V.S.,
R.S. and A.P.; formal analysis, V.S., R.S. and A.P.; investigation, V.S., R.S. and A.P.; resources, V.S.,
R.S. and A.P.; data curation, V.S., R.S. and A.P.; writing—original draft preparation, V.S., R.S. and
A.P.; writing—review and editing, V.S., R.S. and A.P.; visualization, V.S., R.S. and A.P.; supervision,
V.S.,
R.S. and A.P.; project administration, V.S., R.S. and A.P.; funding acquisition, V.S., R.S. and A.P. All
authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: Thanks to Giosuè Bacchin for his precious assistance in translation.
Conflicts of Interest: The authors declare that they have no conflict of interest. The authors declare
that they have not used any source of funding.
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