JPT200104_JGPT 12/11/11 4:10 AM Page 174
Special Interest Paper
Multifactorial Screening for Fall Risk in
Community-Dwelling Older Adults in the
Primary Care Office: Development of the Fall
Risk Assessment & Screening Tool
Mindy Oxman Renfro, MS, PT, GCS, CPH1; Steven Fehrer, PhD, PT2
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ABSTRACT
Background: Unintentional falls is an increasing public health
problem as incidence of falls rises and the population ages. The
Centers for Disease Control and Prevention reports that 1 in 3
adults aged 65 years and older will experience a fall this year;
20% to 30% of those who fall will sustain a moderate to severe
injury. Physical therapists caring for older adults are usually
engaged with these patients after the first injury fall and may
have little opportunity to abate fall risk before the injuries occur.
Purpose: This article describes the content selection and devel-
opment of a simple-to-administer, multifactorial, Fall Risk
Assessment & Screening Tool (FRAST), designed specifically for
use in primary care settings to identify those older adults with
high fall risk. Fall Risk Assessment & Screening Tool incorpo-
rates previously validated measures within a new multifactorial
tool and includes targeted recommendations for intervention.
Methods: Development of the multifactorial FRAST used a
5-part process: identification of significant fall risk factors,
review of best evidence, selection of items, creation of the
scoring grid, and development of a recommended action plan.
Results: Fall Risk Assessment & Screening Tool has been devel-
oped to assess fall risk in the target population of older adults
(older than 65 years) living and ambulating independently in the
community. Many fall risk factors have been considered and
15 items selected for inclusion. Fall Risk Assessment & Screen-
ing Tool includes 4 previously validated measures to assess
balance, depression, falls efficacy, and home safety. Reliability
and validity studies of FRAST are under way.
Conclusion: Fall risk for community-dwelling older adults is an
urgent, multifactorial, public health problem. Providing pri-
mary care practitioners (PCPs) with a very simple screening
tool is imperative. Fall Risk Assessment & Screening Tool was
created to allow for safe, quick, and low-cost administration by
minimally trained office staff with interpretation and follow-up
provided by the PCP.
1Doctoral Candidate—Interdisciplinary Studies, University
of Montana, Missoula.
2School of Physical Therapy & Rehabilitation Science,
University of Montana, Missoula.
The authors declare no conflict of interest.
Address correspondence to: Mindy Oxman Renfro, MS, PT,
GCS, CPH, Program including Gerontology, Physical Therapy,
& Public Health Policy, Skaggs Bldg 110, University of
Montana, Missoula, MT 59812 (mindy.renfro@umontana.edu).
DOI: 10.1519/JPT.0b013e31820e4855
174
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Key Words: community-dwelling older adults, falls, fall risk, fall
risk assessment tool, primary care practitioner
(J Geriatr Phys Ther 2011;34:174-183.)
INTRODUCTION
One in 3 adults who are 65 years or older will fall this year;
20% to 30% of those who fall will sustain significant
injury.1 For many older adults, falls are the primary cause
for the loss of independent living, development of fear,
which may result in limitation of physical activity, and loss
of social contact and/or death.2 Many health care provider
groups have studied falls; most have identified and meas-
ured single-dimension factors as being important in assess-
ing fall risk. Physicians and physical therapists (PTs) have
created tests for balance and physical mobility, such as
the Timed Up and Go Test (TUG),3 the Performance-
Oriented Mobility Assessment (POMA),4 the Berg Balance
Scale (BBS),5 and others.6 Pharmacists have recognized
that polypharmacy significantly increases fall risk.7
Occupational therapists (OTs) have looked at hazards in
the home.8 Psychologists have studied the negative effects of
fear of falling, depression, and anxiety.9 Optometrists and
otolaryngologists are responding to the risks of poor vision,
multifocal lenses, dizziness, and hearing loss.10 Recently,
researchers have begun to recognize the value and increased
need for multifactorial fall risk assessments.11 A single 1-
dimensional tool used alone may not accurately identify all
potential fallers.12
Now that the Center for Medicare Services has announced
funding for preventative care, health care providers must begin
to screen for fall risk as part of normal preventative health care
for older adults in the primary care office. Proactive steps to
alleviate the identified risk factors must be instituted to prevent
falls. Physical therapists may play a critical role in facilitating
this change.
The primary care office needs a simple, multifactorial, fall
risk assessment tool that can be administered by minimally
trained office staff and then be interpreted by a primary care
practitioner (PCP). For the purposes of this article, “minimally
trained office staff” will include all people who are not trained
Volume 34 • Number 4 • October-December 2011
JPT200104_JGPT 12/11/11 4:10 AM Page 175
clinicians. After the administration of this tool by the minimal-
ly trained office staff, the PCP would sit down with the patient,
review the results, and determine the best individualized plan
for intervention. Recommendations for interventions within
the tool itself facilitate a well-targeted plan.
This article describes the content selection used in the
development of the Fall Risk Assessment & Screening Tool
(FRAST). Reliability and validity studies of FRAST are cur-
rently under way and will be reported in a subsequent paper.
METHODS
Development of FRAST was a 5-part process, which
included the following:
1. Review of the literature to identify key risk factors for
falls;
2. Evaluation of evidence-based tools currently used to
assess fall risk factors;
3. Assembling of a variety of measures meeting criteria for
reliability and validity and ease of administration into a
single source measure;
4. Creation of a simple scoring grid; and
5. Development of recommendations for interventions
based on responses.
Literature Review
Publications from the Centers for Disease Control and
Prevention (CDC) were first considered to focus the
authors’ literature search on fall risk factors. The CDC has
identified 4 actions older adults can take to prevent falls,
including regular exercise, medication review, vision care,
and making one’s home safer.13 Extrapolating from these
recommendations, the first 4 fall risk factors investigated
included physical inactivity, polypharmacy, vision care, and
home safety. Searches were conducted in Hooked on
Evidence, PubMed and Cochrane reviews between
December of 2009 and July of 2010 for studies written in
English and published in peer-reviewed journals. Although
more recent studies were reviewed first (published between
2005 and 2010), dates were extended to include older key
studies on the basis of citations in recent studies. Search cri-
teria included a variety of combinations of the following
key words: falls, fall risk, fall prevention, older adults, com-
munity-dwelling, age, balance, physical activity, depression,
fear of falling, medications, polypharmacy, vision, multifo-
cal glasses, epidemiology, home modification, vestibular,
dizziness, interventions, statistics, physical therapy, primary
care, physician, and rural.
Only risk factors found to be significant by the CDC
and/or found to be significant in 2 or more Cochrane
reviews for the target population were included. Overall,
more than 425 article abstracts were read. Only articles
dealing with the specific target population and published in
peer-reviewed journals were retrieved. More than 300 arti-
cles were reviewed and catalogued into 15 fall risk cate-
gories (Figure 1). The categories included age, gender, fall
Journal of GERIATRIC Physical Therapy
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Special Interest Paper
history, physical activity, medical conditions and polyphar-
macy, vision and hearing, home safety, dizziness/vestibular
issues, gait deviations and use of assistive devices, risk-tak-
ing behavior, social contact and support, mood and depres-
sion, fear of falling, balance, and multifactorial risk.
Because of the broad range of risk factors examined and
lack of homogeneity of studies, a meta-analysis was not
conducted and risk factors could not be ranked or weight-
ed.
Evaluation of Fall Risk Tools
For each identified fall risk category, existing objective
measures were sought. Only fall risk tools demonstrating
both reliability and validity for the target population in
multiple studies and described in more than 1 Cochrane
review were included. Tools requiring purchase, found to be
lengthy, or requiring a skilled and/or licensed tester were
excluded. In addition, those measures, including items that
may require immediate follow-up (ie, suicidal ideation),
were excluded.
Assembling of Measures
Levels of scores (denoting low, medium, or high fall risk)
for each measure were taken from best evidence available.
For example, the CDC WISQARS data was used to deter-
mine the age parameters related to low, medium, and/or
high fall risk.13 Multiple studies were considered in setting
the cutoff scores for TUG,14 Modified Falls Efficacy Scale
(MFES),15 and the Geriatric Depression Scale (GDS).16
Creation of Scoring Grid
Many test formats were considered for use in FRAST.
Expert opinions were gathered from members of the
National Council on Aging’s Falls Free Coalition as well as
posttest feedback from subjects. On the basis of this input,
the original form was modified to improve ease of use. The
current grid format was chosen for the facilitation of both
quick visualization of results and improved attention to rec-
ommended interventions by the PCP. A low-vision form is
available and language translations are under way. FRAST
is not intended for use by older adults experiencing cogni-
tive impairments. Weighting of the items was not possible
on the basis of current literature and will be considered
after the statistical analysis of reliability and validity stud-
ies. Scoring at this time is based on raw scores over 15
items, in which low risk ⫽ 0, medium risk ⫽ 1, and high
risk ⫽ 2, resulting in total test scores ranging from 0 to 30.
Since any score greater than 0 indicates at least medium risk
on some items, a total FRAST score greater than 5 would
result in PCP review.
Development of Interventions
Most recommended interventions were taken from the ref-
erenced articles describing the specific measure. Some input
was based on the clinical expertise of the authors. When
potential interventions fell outside of the scope of physical
therapy practice of PT, the appropriate health care profes-
sionals from the faculty at the University of Montana’s
175
JPT200104_JGPT 12/11/11 4:10 AM Page 176
Special Interest Paper
College of Health Professions and Biomedical Sciences were
consulted for input and recommendations.
RESULTS
Multiple factors have been shown to increase fall risk in
community-dwelling adults older than 65 years.17 These
factors can be broken down into demographic traits (age,
gender, etc), internal factors (health, medications, etc), and
external factors (home environment and social) on the basis
of best-available evidence; only those risk factors that were
consistently identified as important were included in
FRAST.18 Some fall risk factors, such as the condition of
community sidewalks, are difficult to assess objectively and
so were not included. On the basis of the combined clinical
experience of the authors, risk-taking behavior (Figure 1,
item 10) was felt to be an important aspect of fall risk that
had not been previously studied and was included on
FRAST for the purpose of primary data collection.
DEMOGRAPHIC FACTORS
Age
According to the CDC, in 2005, Americans aged 65 to 85
years and older, reported 3 284 671 unintentional injuries,
of which, 64.4% were falls.13 Epidemiologic research
demonstrates that 1 of 3 adults older than 65 years will fall
each year in the United States.19 Stevens et al20 described
that the risk of being seriously injured in a fall increases with
age and that the rates of fall injuries for adults aged 85 years
and older were 4 to 5 times that of adults aged 65 to 74
years. Nearly 85% of deaths from falls in 2004 were among
people aged 75 years and older,20 and people older than 75
years who fall are 4 to 5 times more likely to be admitted to
a long-term care facility for a year or longer.1 On the basis
of these statistics, FRAST will assign a medium risk for those
aged 65 to 74 years and a high risk level for those aged 75
years and older (Figure 1, item 1).
Gender
In studying unintentional, nonfatal, injury falls, it was
found that about 70% of fallers were women.21 Although
men are more likely to die from a fall, women are more like-
ly to sustain a hip fracture. On the basis of these findings,
being a woman will impart a high fall risk on FRAST and
being a man will impart a medium fall risk on FRAST
(Figure 1, item 2).
INTERNAL FACTORS
History of Falls
Literature on falls quickly reveals the high risk of falls in
people with a history of falls.22 Among the general popula-
tion of older adults, previous falls are the factor most
strongly associated with risk of falling.23 In a literature
review and meta-analysis on fall risk factors, Deandrea et
al23 found that the strongest associations were found for
history of falls for all fallers. Sai et al18 studied fall predic-
176
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
tors in the community-dwelling older adults and also con-
cluded that a significant predictor of being a faller was his-
tory of falls.18 On the basis of this evidence, fall history is
included in FRAST (Figure 1, item 3). In Shumway-Cook’s3
1997 study, a faller is defined as a person who self-reports
2 or more falls within the past 6 months and a fall is defined
as any event that led to an unplanned, unexpected contact
with a supporting surface.3 To provide consistency with the
evidence, these criteria are utilized in FRAST.
Chronic Medical Conditions
Many chronic medical conditions are known to result in
lower physical activity,24 diminished balance,25 and physical
decline, all of which can lead to a heightened risk of falls.25
Older adults with lower extremity arthritis have been found
to experience increased fear of falling, fall risk, and fall inci-
dence.26 Some medications commonly prescribed for pain,
diabetes, psychological disorders, and cardiovascular disease
have each been associated with a higher fall risk.27 Patients
with diabetes, peripheral neuropathy, and vascular disorders
may all experience diminished lower extremity sensation
and/or muscle strength, with a higher fall risk.28 Capturing a
full medical history and assigning fall risk based on that med-
ical history would be difficult on a simple screening tool;
however, the importance of this information must be remem-
bered. For the purposes of FRAST, polypharmacy will be one
indication of a complicated medical history (Figure 1, item 5).
The PCPs, including PTs, must be cognizant of the role of
medical conditions and medication use in the assessment and
treatment of their patients, especially those at risk for falls.
Physical Activity
The literature describes the protective influence of daily phys-
ical activity on health and mental well-being in older adults
as well as a direct positive impact on their fall risk.29 Kruger
et al30 conducted a detailed analysis of the Behavioral Risk
Factor Surveillance system data and concluded that regular
physical activity can reduce the risk of falling. In a 2007
Cochrane review, which included 34 studies representing
2883 participants, Howe et al31 concluded that there were
statistically significant improvements in balance with exercise
interventions. Rogers et al32 found significant improvements
in the physical functioning of older adults, which included
reduction of blood pressure, fall risk, depression, and anxiety.
Both the American College of Sports Medicine and the
American Heart Association recommend that adults older
than 65 years exercise moderately for 30 minutes per day, 5
to 7 days per week.33 On the basis of these findings, FRAST
includes a self-assessment of physical activity level (Figure 1,
item 4) and advises participation in age-appropriate, thera-
pist-prescribed, exercise programs. The physical activity risk
levels and recommendations on FRAST are based on the
guidelines of the American College of Sports Medicine’s
Current Comments on Exercise and the Older Adult.34
Vision
Grue et al10 found that patients older than 65 years with hip
fractures frequently had hearing, vision, and combined
Volume 34 • Number 4 • October-December 2011
 Directions: For each question, please check the box with the response that best represents you today. Whenever your responses are in the high or medium risk column, we strongly
encour age you to discuss the recommended actions in the last column with your health care provider. Please fill in your initials, year of birth and age on each page. Thank you.
RISK FACTOR
1. As of today, my age is ______.
2. My gender is _____ .
3. A fall is any event that led to an
unplanned, unexpected con-
tact with a supporting surface
such as the floor.
Have you fallen?
Journal of GERIATRIC Physical Therapy
4. How would you describe your
daily physical activity level?
This might be walking, an exer-
cise class, working out at the
gym, swimming or dancing.
When you are active, your
heart works harder and your
breathing gets deeper.
5. How many prescription
medicines do you take?
6. In regard to your eye care,
please choose the best answer:
7. In regard to your glasses or
contacts, please choose the
best answer
8. Do you ever get dizzy?
Figure 1. Fall Risk Assessment & Screening Tool (FRAST). (continues)
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
177
LOW RISK ⫽ 0 MEDIUM RISK ⫽ 1
Below 65 years old. Between 65 and 75 years old.
Male
No, I have not fallen. In the past six months, I have fall-
en only once and was NOT
injured.
I am engaged in exer- I am engaged in exercise or mod-
cise or moderate phys- erate physical activity at least
ical activity 30 min/ 15 min/day, 2-4 times/week.
day, 5-7 days/week.
I have not been I currently take at least one but
prescribed any not more than 4 prescription
medications. medications.
I see my eye doctor at I have seen an eye doctor once in
least once/year. the past 2 years.
I do not wear glasses I wear single-vision glasses or
or contacts. contact lenses (not bifocals or
progressive lenses).
No, I do not have any I occasionally feel dizzy if I get up
problem with dizziness. out of bed fast or when I am ill.
HIGH RISK ⫽ 2
Over 75 years old.
Female
In the past 6 months I have fallen
2 or more times,
OR
In the past 2 years, I have fallen
and been injured requiring med-
ical attention.
I am generally not active and do
not do exercise that makes my
heart rate or breathing increase.
I currently take 5 or more pre-
scription medications.
I have not seen an eye doctor in
the past 3 years.
I wear multifocal lenses or con-
tacts.
Dizziness is a problem for me.
ACTION RECOMMENDED
Attending a fall prevention program may be recommended
to lower your fall risk.
People who have had falls or have balance issues are at
greater risk for more falls. Your doctor may recommend a:
1. Full annual physical exam
2. Fall prevention program
JPT200104_JGPT 12/11/11 4:10 AM Page 177
3. PT1 evaluation for balance
4. PT or OT2 evaluation of home
5. PT or podiatrist evaluation of footwear
6. Home fall alarm system
Your doctor may feel that you should begin to
exercise, but before you do, s/he might suggest a physi-
cal therapy referral to design a safe, individualized pro-
gram that meets your needs safely.
It is recommend that:
1. Your doctor and/or pharmacist review your medica-
tions carefully
2. You use a weekly pill dispenser to avoid mistakes
3. You keep a list of your medicines
Your doctor may refer you to an eye doctor for an annual
exam and to discuss vision care options.
Your doctor may refer you to an eye doctor for an annual
exam and to discuss vision care options.
Please Note:
Multifocal lenses (bifocals, progressive lenses, etc.) may
increase fall risk.
Your doctor can check to see if your blood pressure
drops when you stand up or if there are other medical
problems. He/she may also recommend PT, audiologist
or ENT3 referral.
Special Interest Paper
 RISK FACTOR LOW RISK = 0 MEDIUM RISK = 1 HIGH RISK = 2 ACTION RECOMMENDED

178
9. In the past week, have you
used any assistive devices (AD)
to walk?
Assistive devices include canes,
quad canes, and/or walkers.
No I don’t have an
assistive device or need
one to walk safely.
My doctor has not rec-
ommended that I use
an assistive device.
I have and correctly use an assis-
tive device that was prescribed for
and fit to me. A therapist taught
me how to use it correctly.
I use an assistive device but no
one has taught me how to use it.
OR
I lean on furniture and walls as I
walk by.
If you use an assistive device (AD) or need one, your
doctor might want you to see a PT if:
1. You need to begin to use an AD.
2. Yours was not fit for you by a PT.
3. You have not been taught how to use it properly.
4. It has been a long time since a PT fit it and it may
now need updating.

10. Choose the group of state- I am careful and seldom Sometimes I do things that later I I refuse to limit myself as I age. I Remaining active is critical, but sometimes taking risks
Special Interest Paper

ments that best describes your take risks. I am not easily (or others) think may have been might climb up a ladder or learn has greater implications as we age. Discuss your
overall risk-taking behaviors: distracted. I do not hurry risky. a new risky sport. answers with your health provider and seek their
to answer the phone. advice.
JPT200104_JGPT 12/11/11 4:10 AM Page 178

11. In the past week, how socially I come and go often and I see other people I see other people less than 2 Your doctor might advise you to visit with the service
active have you been? see others 5-7 days/week 2-4 days/week. times/week. coordinator at your Area Agency on Aging and/or Senior
and/or I am married. Center to learn about programs to assist you.

12. Please carefully complete the
Home Safety Checklist on
pages 4 and 5. When you fin-
ish, count the total check
marks that you made.
I have fewer than 6 I have 6-11 checks. I have more than 11 checks. It appears that your home is not as safe as it might be.
check marks. It is important that either an OT or PT make a home
visit and help you consider modifications that would
make your home safer for you.

13. Please complete the Modified
Falls Efficacy Scale on page 6.
What is your average score?
(Add up the score on each of the
ten items and then divide the
sum by 10)
My average score is 8, My average score is between My average score is 0, 1 or 2. This score might indicate that your concern about
9 or 10. 3 and 7. falling is causing you to limit your activities. Your doctor
may recommend any or all of the following:
1. Group fall prevention program.
2. Physical therapy referral.
3. Referral to a counselor/social worker.

14. Please complete the Mood I scored between 0 and I scored 6,7 or 8. I scored 9 or above. Your doctor may want to discuss a number of options
Scale on page 7 and then 5 on the mood scale. with you to help improve your mood.
score it following the direc-
tions on the bottom

15. Please let the receptionist know My TUG score was 7 I scored between 8-13 sec. on My TUG test score was greater The TUG test is a test for balance and mobility. If your
that you are ready to take your seconds or less. my TUG test. than 13 sec. time is longer, your doctor may want to have you see a
timed-up-and-go test (TUG).© physical therapist.

TOTAL SCORE ___ out of 30

Scoring: 0-4 ⫽ low fall risk; 5 and above: recommend review with your PCP.
Test reviewed and discussed with client. The following actions have been suggested: _________________________________________________________________________________________________________________________________________________
Total Score/ Fall Risk Rating: ___ out of 30 Fall Risk: Low Risk or High Fall Risk
Printed Name/Signature/credentials/Date: __________________________________________________________________________________________________________________________________________________________________________

Your Initials: ________Year of Birth: ______________ Age Today: ______

1Physical Therapist, 2Occupational Therapist, 3Ear, Nose & Throat doctor

Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Figure 1. (Continued) Fall Risk Assessment & Screening Tool (FRAST).

Volume 34 • Number 4 • October-December 2011

JPT200104_JGPT 12/11/11 4:10 AM Page 179
impairments. Abdelhafiz and Austin35 recommended that
annual measurement of visual functions, such as acuity, con-
trast sensitivity, and depth perception, might identify older
people at risk of falls and hip fracture. They further added
that targeted intervention might have the potential of improv-
ing visual function and preventing falls in older people.35
Lord et al36 stated that impaired vision is an important and
independent risk factor for falls. Adequate depth perception
and distant-edge contrast sensitivity appear to be important
for maintaining balance and detecting and avoiding hazards
in the environment.37
Research documents show that the use of multifocal
lenses by older adults increases fall risk. Lord et al37 found
that multifocal glasses might add to fall risk because the
near-vision lenses impair distance-contrast sensitivity and
depth perception in the lower visual field. Johnson et al38
concluded that because of increased within-subject variabil-
ity in vertical toe clearance when wearing multifocal glass-
es, older adults might be at greater risk of falling when
negotiating steps and stairs. On the basis of these findings,
FRAST assigns a high fall risk for those who do not regu-
larly visit an eye professional (Figure 1, item 6) and/or those
who wear multifocal lenses (glasses and/or contact lenses)
(Figure 1, item 7). Although older adults may decide to not
give up multifocal lenses, awareness of the risk is still
important.
Dizziness
Self-reported dizziness is a lay term describing many symp-
toms (lightheadedness, vertigo, etc) with a wide variety of
etiologies (vestibular, orthostatic hypotension, etc). Ekwall
et al39 found that dizziness was associated with an increased
risk of falling. Agrawal et al40 reported that study partici-
pants with vestibular dysfunction who were clinically symp-
tomatic (ie, reported dizziness) had a 12-fold increase in the
odds of falling. Ramdas et al41 found that the main out-
come measures indicating an increased fall risk were a pos-
itive falls history and the presence of orthostatic hypoten-
sion.41 Other researchers have also reported that dizziness
and vertigo are important public health care issues.42 Given
the evidence cited indicating self-reported dizziness as a sig-
nificant fall risk factor, FRAST assigns a high fall risk rating
for a current complaint of dizziness (Figure 1, item 8).
Assistive Devices
Many older adults require assistive devices to walk safely
and independently.43 In FRAST, assistive devices will
include all forms of canes and walkers.
Older adults commonly self-prescribe assistive devices for
a variety of reasons. Brooks et al44 found that of 70 patients
interviewed, only 71% of the assistive devices being used
had been prescribed. In Sheehan and Millicheap’s45 study,
which evaluated the use of canes, 38% were used incorrect-
ly, 44% were of incorrect length, and 54% were in poor
condition. Joyce and Kirby46 concluded that prescribed
assistive devices were underutilized and needed to be fit cor-
rectly. A correctly prescribed, fit, and used assistive device
may result in a lower fall risk; however, a self-prescribed,
Journal of GERIATRIC Physical Therapy
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Special Interest Paper
misfit, or inappropriate assistive device may result in a high-
er fall risk.43 For these reasons, FRAST (Figure 1, item 9)
includes an item that imparts high fall risk both for those
who use an assistive device that was not prescribed and fit
for them and for those who cruise along furniture and walls
and may benefit from the use of an assistive device.
Balance
Many physical changes associated with aging have a nega-
tive effect on balance.47 Cognitive slowing may impact reac-
tion times48; lower extremity weakness may limit postural
stability47; and degenerative joint changes may limit motion
needed to reestablish equilibrium.26 Diminished balance is
associated with heightened fall risk49 and improved balance
after intervention is associated with a lower fall risk.50
Balance must be screened as part of FRAST, and diminished
balance requires early intervention.
Choosing the best objective instrument to assess balance
in older adults is difficult. Many tools have been developed,
studied, and updated.51 Researchers have established valid-
ity, reliability, and sensitivity for certain populations.5 The
goal of this project was to identify a validated balance test,
designed specifically for community-dwelling older adults,
which can be safely and reliably administered and scored by
personnel with minimal training. Many balance assessment
tools were considered. In a systematic review, Langley and
Mackintosh52 concluded that of 17 studied tests, the BBS
and TUG were most rigorously studied and had published
reliability and validity with community-dwelling older
adults. Although the BBS has been shown to be valid and
reliable,5 a few of the test items require the patient to
attempt difficult tasks while the tester is timing or rating the
patient. Therefore, it was concluded that this test required
the judgment and skills of a clinician to assure patient safe-
ty and was not selected for FRAST.
Shumway-Cook et al3 found TUG to be a sensitive and spe-
cific measure for identifying community-dwelling adults who
are at risk for falls. She found TUG to be quick and simple to
administer. Older adults who take longer than 14 seconds to
complete TUG were found to have a high risk for falls.3 The
addition of manual or cognitive tasks to TUG did not result in
a more sensitive test.14 Herman et al53 found that TUG also
exhibited some psychometric assessment capabilities, adding
an indirect cognitive measure. Desai et al54 compared TUG, the
BBS, gait speed, and the 6-minute walk test and concluded that
only TUG was able to differentiate between the faller and non-
faller groups. Morris et al51 concluded that combining the fac-
tors of previous falls with a prolonged time on the TUG test
resulted in the ability to predict falls with high specificity.
Considering the current best evidence, the TUG test was select-
ed as a reliable, valid, and simple-to-administer balance test for
inclusion on FRAST (Figure 1, item 15).
Polypharmacy
Many physiologic changes of aging affect both pharmaco-
kinetics and pharmacodynamics, which may increase the
inherent risks imparted by polypharmacy (defined as ⬎4
prescription medications taken simultaneously).7 In older
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Special Interest Paper
adults, fall risk increases with an increase in medication
use.55 Prescription of more than 4 medications was associ-
ated with an increase in falls,56 and central nervous system
drugs, especially psychotropics, seem to be associated with
an added risk.7 Use of over-the-counter, nonsteroidal anti-
inflammatory drugs have also been shown to increase fall
risk for older adults.57
On the basis of the findings of these studies, FRAST will
include the use of 1 to 4 prescription medications to impart
medium fall risk and the use of more than 4 medications
to impart high fall risk. Although this is an effective screen-
ing method, pharmacist-led medication reviews have been
studied and proposed as an effective adjunct to routine
health care and will be included in FRAST’s recommended
intervention for identified polypharmacy risk58 (Figure 1,
item 5).
Fear of Falling
Falls increase the fear of falling, and fear of falling increas-
es fall risk.59 In addition, fear of falling often leads to self-
imposed restriction of physical activity, which further
heightens fall risk, and fear of falling is oftentimes experi-
enced even without a fall.59 It has been found that fear of
falling was increased with advancing age, female gender,
perceived poor health, and history of falls,60 as well as lim-
itations in activity of daily living, impaired vision, chronic
morbidity, low general self-efficacy, and depression.61
Since fear of falling results in a significant increase in fall
risk, it is important that we be able to quantify this experi-
ence objectively. The 3 scales considered for inclusion on
FRAST were the Activities-Specific Balance Confidence
(ABC),62 the Falls Efficacy Scale (FES),63 and the Survey of
Activities and Fear of Falling in the Elderly (SAFE).64
Hotchkiss et al65 studied the 3 scales and concluded that the
ABC and the FES were highly correlated with each other
and to a lesser extent with SAFE. They also found that the
FES was the best predictor for those people who restricted
their activity.65 The FES also included fewer items than the
ABC, making it slightly faster to administer. The original
FES was developed and reported by Tinetti et al63 in 1990
as an instrument to measure fear of falling. Subjects who
reported avoiding activities because of fear of falling had
higher FES scores, representing lower self-efficacy or confi-
dence, than the subjects not reporting fear of falling.
However, the FES did not include community-level activi-
ties, so it was updated in 1996 as the MFES, which was
studied and validated by Hill et al66 in 1996. Since the
MFES is aimed at community-dwelling older adults in the
United States and has been shown to reliably indicate activ-
ity avoidance due to fear of falling, it has been selected for
FRAST (Figure 1, Item 13).
Depression
Depression has been shown to significantly increase fall risk
in community-dwelling older adults.67 The occurrence and
undertreatment of depression in later life is well documented.68
Geriatric depression may be misinterpreted as fatigue or
dementia or simply misattributed to normal aging. Many psy-
180
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
chosocial and physical aspects of advancing years may con-
tribute to depression, including loss of spouse and/or friends,
decreases in vision and hearing, nocturia, sleep disturbance,
pain, and lack of physical activity.69 According to the National
Institute of Mental Health, suicide rates are significantly
elevated in older adults when compared with the general
population.70
Many tools have been developed to objectively measure
depression, but only a few tools are validated for older adults.
Well-known, validated, and commonly used measures, both
the GDS71 and the short form of the GDS (GDS-short or
Mood Scale),16 are self-administered, user-friendly measures.
Because of its ease of use, short completion time, and wealth
of literature on its validity, the GDS-short is utilized to screen
for the signs of depression on FRAST (Figure 1, item 14).
Risk-Taking Behaviors
Although the fear of falling can result in a higher fall rate,
what about the opposite end of the spectrum—elevated
risk-taking behavior? In considering unintentional falls, the
authors were curious about the role of risk-taking behaviors
as a personality trait in fallers. Increased risk-taking behav-
ior is not an identified fall risk factor in older adults in the
current literature. A study has identified the increase in
human immunodeficiency virus positive older adults, which
has been tied to increased risk-taking behavior in this pop-
ulation.72 Traffic accidents are higher in adults older than
65 years, which may reflect decline in judgment, reaction
time, or an increase in risk taking.73 Although risk-taking
behavior is not identified as a fall risk factor in older adults,
it may be worthwhile to study.
Attempts to identify a validated objective test to quanti-
fy risk-taking behavior in this population were unsuccess-
ful. The psychometric Balloon Analogue Risk Task does
exist for use in adolescents and young adults but is not val-
idated for use in this population.74 Therefore, FRAST asks
each subject to self-rate their risk-taking behavior (Figure 1,
item 10). Engaging in risky behavior will be correlated with
a high fall risk and will prompt a discussion with the PCP
to ascertain whether further intervention is warranted. Item
validity will be studied.
EXTERNAL FACTORS
Home and Living Situation
About half of all falls occur in the home. Making the home
safer is listed by the CDC as 1 of the 4 most important
things older adults can do to decrease their fall risk.13
Studies demonstrate that home hazard assessments need to
be accompanied by education, facilitation of modifications,
consideration of the person and home interface, and follow-
up.8 In 2003, Nikolaus and Bach75 found that home inter-
vention based on home visits to assess the home for envi-
ronmental hazards, providing information about possible
changes, facilitating any necessary modifications, and train-
ing in the use of technical and mobility aids, was effective
in a selected group of older adults with a history of recurrent
falling. Iwarsson et al87 found that the person-environment
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JPT200104_JGPT 12/11/11 4:11 AM Page 181
fit or interface was a stronger fall predictor than number of
environmental barriers. For example, standard-height
kitchen cabinets might present a problem for a shorter per-
son but not for a taller person. These studies certainly high-
light the need for a carefully completed home hazard assess-
ment done by a therapist as part of an effective abatement
of fall risk. FRAST will use a self-assessment for screening
the CDC’s Home Fall Prevention Safety Checklist. A high
fall risk score on this item will prompt the PCP to consider
a referral for PT or OT to complete an individualized home
assessment and follow-up (Figure 1, item 12).
Sidewalks, Traffic, and Adverse Weather
A great deal of time and attention is afforded to falls with-
in the home, but we must also look at the city or county
infrastructure, as it relates to safety for pedestrians.76
Access to the community must be made possible to ensure
successful aging in place. Therapists performing home visits
should consider factors that may hinder access to and from
the home into the community. Despite the importance of
these issues, the literature regarding the characteristics of
the physical environment outdoors in relation to falls is lim-
ited, as are assessment tools, making objective comparison
of neighborhoods difficult. For these reasons, evaluation of
community access has not been included in FRAST. Lack of
social contact (Figure 1, item 11) may indicate issues of lim-
ited community access.
Social Support and Contact
Social isolation is very common for adults as they age.77
Loss of spouse, friends, employment, expendable income,
and independent driving can all lead to a sense of captivity
at home.78 This shrinking-world phenomenon may lead to
physical inactivity, cognitive decline, and heightened fall
risk.79 Stanley et al80 found that the experience of loneliness
was a pressing issue. Peel et al81 found that healthy psy-
chosocial factors (being married, living in the same home,
etc) were protective, that is, prevented older adults from
falls. It has been consistently reported that increased social
contact (more than 5-7 per week) is correlated with a lower
fall risk.82 On FRAST, subjects will self-rate their frequency
of social contact (Figure 1, item 11). On the basis of the
findings of Mossey83 and Strawbridge et al,84 a response
indicating fewer social contacts (less than 2 per week) cor-
relates to a high fall risk and triggers a recommendation for
referral to an aging services provider.
OVERALL FALL RISK
In addition to examining each fall risk individually, FRAST
is scored for overall fall risk. Scores in all columns are
added for a score of 0 to 30 out of 30. Since FRAST is only
a screening tool, there is greater risk in not identifying
heightened fall risk than in overdiagnosing high fall risk.
For this reason, a low cutoff of 5 was chosen. Scoring
ranges may be updated following reliability and validity
data analysis.
Journal of GERIATRIC Physical Therapy
Copyright © 2011 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Special Interest Paper
Actions Recommended
The interventions recommended in FRAST are based pri-
marily on the referenced literature in combination with
extensive clinical expertise of the authors. Clinical judgment
of the PCP and/or referral practitioners, geographic loca-
tion, third-party payor guidelines, and availability of staff
will affect which interventions are utilized in each situation.
DISCUSSION
FRAST has been developed as a multifactorial, simple-to-
administer, fall risk screening tool for community-dwelling
adults older than 65 years. The tool is intended for use by
minimally trained staff, with follow-up interpretation and
action by the trained PCP. Evidence regarding many of the
significant components of fall risk for community-dwelling
older adults has been presented. Reliable and validated
objective measures for these fall risks have been discussed.
Action recommendations are included for consideration by
the PCP to proactively address each aspect of heightened
fall risk based on the patient’s individual needs.
Limitations impacted this article. Most fall risk studies
deal with 1 risk factor or a limited group. Multifactorial
studies each considered a different group of factors, making
comparison between studies difficult. To maintain simplici-
ty and brevity, not all risk factors could be included in
FRAST or addressed in this article. However, some of these
factors are indirectly included by items on FRAST. For
instance, 1 study has concluded that cognition is measured
indirectly by the TUG test.53 Gait disorders, quadriceps
strength, and flexibility may all adversely affect the TUG
test performance47 (Figure 1, item 15). Research to docu-
ment the validity and reliability of FRAST is under way.
Plans for dissemination of FRAST via a number of routes
are being investigated. Future prospective longitudinal
study is planned.
The population projections for this age group create a
pressing time line for intervention. The need to add fall risk
assessment in primary care has been well documented.
Rubenstein et al85 found that community physicians appear
to underdetect falls and gait disorders. As physical therapy
evolves into a doctoring profession and we assume a greater
role as PCPs, utilization of tools like FRAST will facilitate
our comprehensive screening.
CONCLUSIONS
Early identification of heightened fall risk in community-
dwelling older adults, when combined with proactive fall pre-
vention interventions, should lead to a decrease in fall risk,
fall rate, and injury or death resulting from falls.86 Providing
the primary care office with a simple, objective, multifactori-
al screening tool, which includes targeted intervention rec-
ommendations, is imperative. Each component of FRAST
represents 1 or more of the fall risk factors that have been
demonstrated to significantly impact fall risk of community-
dwelling older adults. Risk-taking behavior has been added
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Special Interest Paper
to ascertain its significance as a fall risk factor. The interre-
lated effect of some of these risk factors has been clearly
demonstrated in the literature.2 Assessing fall risk by using
any 1 criterion may result in missing heightened fall risk in a
significant portion of the older adult population.3
Considering each risk factor individually allows the PCP to
provide targeted intervention for specific risk factors. FRAST
is intended for administration by minimally trained staff in
primary care offices and/or public health departments, with
interpretation and management by PCPs to facilitate early
identification and abatement of fall risk. Dissemination and
utilization of this tool by PTs and PCPs should serve to abate
fall risk and positively impact older adults’ ability to success-
fully age in place.
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