What components should be included in a template for the assessment and evaluation of falls according to the United States Preventive Services Task Force (USPSTF) guidelines?

Fall Risk Assessment and Evaluation Template Based on USPSTF Guidelines

All community-dwelling adults aged 65 years and older should be asked annually about falls history, and those with a positive history, mobility problems, or concerns about falling should undergo a structured multifactorial fall risk assessment. 1

Initial Screening (Annual for All Adults ≥65 Years)

Screen ALL older adults annually with these three questions: 1

• Have you fallen in the past year?
• Do you have difficulty with walking or balance?
• Do you have concerns about falling?

Perform the Timed Get-Up-and-Go Test: 1, 2

• Adults over 60 should complete this in <10 seconds 2
• Completion time ≥10 seconds indicates increased fall risk and warrants comprehensive assessment 1

Multifactorial Fall Risk Assessment Components

If screening is positive (history of falls, mobility problems, or failed Get-Up-and-Go test), proceed with comprehensive multifactorial assessment including: 1

1. Focused Medical History

Fall-specific history: 1

• Number of falls in past 12 months
• Circumstances of each fall (location, activity, time of day)
• Injuries sustained from falls
• Fear of falling and activity restriction due to fear

Medication review (CRITICAL COMPONENT): 1

• Total number of medications (≥4 medications increases risk) 3
• Psychoactive medications (benzodiazepines, sedatives, antipsychotics, antidepressants) 1, 3
• Antihypertensives and medications causing orthostatic hypotension 1
• Polypharmacy assessment with plan for deprescribing 3

Medical conditions assessment: 1

• Cardiovascular disorders and symptomatic orthostatic hypotension 3
• Arthritis and musculoskeletal problems 4
• Depression screening 3
• Cognitive impairment 4
• Urinary incontinence or urgency
• Chronic pain affecting mobility

2. Physical Examination

Gait and balance assessment (ESSENTIAL): 1

• Observe walking pattern, stride length, symmetry
• Assess ability to rise from chair without using arms
• Tandem stance and single-leg stance testing
• Functional Reach Test (feasible for primary care) 1

Musculoskeletal examination: 1

• Lower extremity muscle strength testing (hip flexors, knee extensors, ankle dorsiflexors) 4
• Joint range of motion, particularly ankles and hips
• Foot problems and footwear assessment 1

Neurological examination: 1

• Proprioception testing (vibration sense at great toe)
• Visual acuity assessment 1
• Hearing assessment 3

Cardiovascular examination: 1, 3

• Orthostatic vital signs (measure supine, after 1 minute standing, and after 3 minutes standing)
• Document symptomatic orthostatic hypotension (≥20 mmHg systolic or ≥10 mmHg diastolic drop with symptoms)

3. Functional Assessment

Activities of daily living (ADL) evaluation: 1

• Basic ADLs (bathing, dressing, toileting, transferring)
• Instrumental ADLs (shopping, cooking, managing medications, housework)
• Use of assistive devices 4

Mobility assessment: 1, 4

• Ability to navigate stairs
• Ability to get up from floor
• Transfer ability (bed to chair, toilet, bathtub)

4. Environmental Assessment

Home hazard evaluation (for high-risk patients): 1

• Poor lighting, especially in hallways and stairs
• Loose rugs or carpets
• Clutter and obstacles in walkways
• Lack of grab bars in bathroom
• Unstable furniture
• Slippery surfaces
• Inadequate stair railings
• Pets that may cause tripping

Risk Stratification

High-risk criteria (any of the following): 1, 4

• ≥2 falls in past year
• 1 fall with injury requiring medical attention
• Gait or balance impairment on examination
• Timed Get-Up-and-Go test ≥10 seconds 2
• Use of ≥4 medications 3
• Use of psychoactive medications 3
• Age ≥80 years 4

Documentation Template Structure

Patient Demographics and Fall History

• Age, living situation
• Number of falls in past 12 months with details
• Previous fall-related injuries

Risk Factor Checklist

• □ History of falls (specify number: ___)
• □ Gait/balance impairment
• □ Muscle weakness
• □ Visual impairment
• □ Cognitive impairment
• □ Depression
• □ Orthostatic hypotension
• □ Polypharmacy (≥4 medications)
• □ Psychoactive medication use
• □ Environmental hazards
• □ Assistive device use
• □ Fear of falling
• □ Age ≥80 years

Assessment Results

• Timed Get-Up-and-Go: ___ seconds
• Orthostatic vitals: Supine /, Standing 1 min /, Standing 3 min /
• Gait assessment findings
• Balance test results
• Muscle strength findings

Risk Level: □ Low Risk □ High Risk

Management Plan Based on Assessment

For ALL patients at increased risk, implement: 1, 2

Exercise/Physical Therapy (HIGHEST PRIORITY - strongest evidence): 1, 2

• Refer to physical therapy for balance and functional exercises
• Prescribe exercises focusing on leg strength and balance training
• Target: 2-3 sessions per week for at least 12 weeks 5

Medication Management: 1, 3

• Withdraw or minimize psychoactive medications 1, 3
• Reduce total medication burden when possible 3
• Address medications causing orthostatic hypotension 1

Vitamin D Supplementation: 1

• Note: The 2018 USPSTF guideline recommends AGAINST routine vitamin D supplementation for fall prevention in community-dwelling adults without known deficiency 1
• However, the American Geriatrics Society recommends ≥800 IU daily for those with vitamin D deficiency or at increased risk 1
• Check vitamin D level if deficiency suspected; supplement only if deficient

Specific Interventions Based on Identified Risk Factors: 1

• Orthostatic hypotension: medication adjustment, compression stockings, hydration counseling 1, 3
• Foot problems: podiatry referral, appropriate footwear 1
• Vision impairment: ophthalmology referral (cataract surgery if indicated) 1, 5
• Hearing impairment: audiology referral 3
• Depression: treatment initiation 3

Environmental Modification (for high-risk patients only): 1

• Home safety assessment by occupational therapy or trained professional
• Specific modifications: install grab bars, improve lighting, remove hazards, secure rugs 1

Follow-Up Schedule

Reassessment intervals: 1

• High-risk patients: 3-month follow-up initially, then every 6 months
• Monitor adherence to exercise program
• Reassess fall frequency and circumstances
• Review medication changes
• Evaluate effectiveness of interventions

Critical Pitfalls to Avoid

The USPSTF distinguishes between "brief risk assessment" and "multifactorial risk assessment" - brief assessment identifies high-risk patients who need interventions, while comprehensive multifactorial assessment is reserved for those who screen positive 1

Do NOT perform comprehensive multifactorial assessment on all older adults - this has only small benefit and should be targeted to those at increased risk 1

Exercise/physical therapy has the strongest evidence and should NEVER be omitted from the management plan for high-risk patients 1, 2, 5

Environmental modification alone is insufficient - it must be part of a comprehensive multicomponent approach 3, 5

Vision screening alone as a single intervention is not recommended for fall prevention 1

Comprehensive management is essential - multifactorial assessment without follow-up and management of identified risks is ineffective 1