How is high risk for falls or low risk for falls determined in Medicare patients?

Fall Risk Assessment in Medicare Patients

Fall risk in Medicare patients is primarily determined by evaluating key risk factors including history of falls, medication use (especially psychoactive medications), and gait/balance impairment, with specific screening tools like the timed Get-Up-and-Go test and Functional Reach Test being most feasible for primary care settings. 1

Key Risk Factors for Fall Assessment

• Age and fall history: These are the two most commonly used factors to define high risk in fall intervention studies 1
• Medication use: Particularly psychoactive medications, which provide independent prognostic value for fall risk 1
• Gait and balance impairment: A critical factor that shows independent prognostic value across most studies 1
• Additional risk factors: Female sex, visual impairment, and certain medical conditions also contribute to fall risk assessment 1

Validated Assessment Tools

Primary Care-Feasible Tools

• Timed Get-Up-and-Go test: Patient rises from a chair, walks 3 meters, turns around, walks back, and sits down; time >12 seconds indicates increased fall risk 1, 2
• Functional Reach Test: Measures how far a patient can reach forward while maintaining a fixed base of support 1

Other Common Assessment Tools (Less Feasible for Primary Care)

• Falls Risk Assessment Tool (FRAT) 1
• Performance Oriented Mobility Assessment 1
• Falls Risk Assessment Score for the Elderly 1
• Berg Balance Scale 1

Standardized Screening Approaches

• Three Key Questions: A positive screen is answering "yes" to any of these questions 1:

  1. Have you fallen in the past year?
  2. Do you feel unsteady when standing or walking?
  3. Are you worried about falling?

• The Stay Independent questionnaire: Evaluates multiple domains with a score of 4 (out of 12) indicating increased fall risk 1

• The 4-Stage Balance Test: Patient stands in 4 increasingly challenging positions for 10 seconds each; inability to hold tandem stand for 10 seconds indicates increased fall risk 1

Risk Stratification Framework

Medicare patients are typically categorized as high-risk for falls when they have:

1. History of falls in the previous year 1
2. Gait or balance problems identified through standardized testing 1
3. Use of high-risk medications including:
   • Anticonvulsants (hydantoins, benzodiazepines) 3
   • Antipsychotics (e.g., haloperidol) 3
   • Tricyclic antidepressants 3
   • Insulin 3
4. Multiple risk factors using the P-SCHEME mnemonic 1:
   • Pain (axial or lower extremity)
   • Shoes (suboptimal footwear)
   • Cognitive impairment
   • Hypotension (orthostatic or iatrogenic)
   • Eyesight (vision impairment)
   • Medications (centrally acting)
   • Environmental factors

Implementation Considerations

• Annual screening is recommended for all adults aged 65 and older 2
• Patients who screen positive should undergo more comprehensive assessment 1, 2
• Electronic health records can enhance fall risk prediction by incorporating multiple data points beyond traditional assessment tools 4

Common Pitfalls in Fall Risk Assessment

• Overclassification: Categorizing too many patients as high-risk may lead to decreased mobility and potentially worse outcomes 5
• Lack of reassessment: Fall risk is dynamic and should be reassessed periodically, as single assessments may lose accuracy over time 6
• Inconsistent implementation: Even when evidence-based practices are taught, there can be significant variation in how clinicians implement fall risk assessments 7

Evidence Quality Considerations

The U.S. Preventive Services Task Force notes that none of the fall risk assessment tools has been widely validated, which creates challenges in standardizing approaches across healthcare settings 1. However, the evidence most strongly supports using history of falls, medication review, and gait/balance assessment as the core components of any fall risk evaluation 1, 2.