Lippincott Nursing Pocket Card - Updated March 2020

Assessing Fall Risk and Reducing Falls


Assessing Fall Risk and Reducing Falls


More than one in four American adults 65 years of age and older have reported falling and one in 10 reported a severe fall-related injury, including fractures and traumatic brain injuries. Falls account for over 50% of injury-related deaths in older adults annually (Haddad et al., 2018). Nurses play a vital role in reducing patients’ fall risk by implementing a risk assessment scale, early intervention strategies and education.

Risk Factors for Fall (Lee, Lee & Khang, 2013; Kiel, 2018a; Centers for Disease Control & Prevention, 2017)

Intrinsic Factors  

  • Fear of falling: a geriatric syndrome that may contribute to further functional decline and may limit ambition to participate in physical activities; can lead to weakness, muscle atrophy, decreased agility, and predisposition to falls
  • Advanced age
  • Female sex
  • Previous falls
  • Muscle weakness
  • Gait and balance impairments
  • Visual impairment
  • Postural hypotension (orthostasis)
  • Chronic conditions: arthritis, stroke, incontinence, Parkinson’s disease, dementia/cognitive impairment, diabetes

Extrinsic Factors

  • Polypharmacy and psychoactive medications
  • Lack of stair handrails and bathroom grab bars; poor stair design
  • Dim lighting, obstacles and tripping hazards
  • Slippery or uneven surfaces
  • Improper use of assistive devices (canes or walkers)

The Community Setting

Screening for Fall Risk (Lee, Lee & Khang, 2013; Kiel, 2018b)

  • At each visit, ask patient about history of falls, frequency of falls, and gait or balance disturbances.
  • For patients who report a fall or gait/balance impairment, follow up with further risk assessment.
    • Review medical history and medications
    • Physical examination
      • Cognitive evaluation, visual acuity, and functional assessment
      • Cardiovascular system, include heart rate and rhythm, postural hypotension
      • Neurological impairment
      • Muscular strength
    • History of falls
    • Feet and footwear
    • Environmental hazards/Home safety evaluation
    • Get Up and Go test
      • Ask patient to rise from chair, walk 9 feet, turn around, walk back to chair and sit back down
      • Normal time is 14 seconds or less
      • Observe postural stability, gait, stride length, sway, and leg strength

Fall Prevention (Lee, Lee  & Khang, 2013; Kiel, 2018b)

  • Exercise/physical therapy targeting balance, gait and strength (ideally three hours per week)
  • Medication modification, as appropriate (i.e. decreasing or stopping psychoactive medications)
  • Vitamin D supplementation for patients deficient or a high fall risk (800-1000 international units cholecalciferol daily)
  • Evaluation and modification of the home environment (most effective when directed by occupation therapist)
  • Patient education

For patients with comorbidities, consider the following recommendations (Kiel, 2018b):

Comorbidity Possible Interventions
Carotid sinus hypersensitivity
  • Insertion of cardiac pacemaker insertion in appropriate patients
  • Surgical correction
  • Refer for nutrition counseling
  • Nutritional supplementation
Postural hypotension
  • Fluid optimization
  • Compression stockings
  • Medications (fludrocortisone or midodrine)
Foot pain/neuropathy
  • Refer to podiatry


The Nursing Care Facility or Hospital Setting

Screening for Fall Risk (Kiel, 2018a)

  • Utilize standardized screening tools
    • Morse Fall Scale
    • Hendrich II Fall Risk Model
    • Schmid Fall Risk Assessment Tool
    • Johns Hopkins Hospital Fall Risk Assessment Tool
    • St. Thomas’ Risk Assessment Tool (STRATIFY)

Fall Prevention (Lee, Lee & Khang, 2013; Berry & Kiel, 2018) 

  • Exercise/physical therapy
  • Medication modification (i.e. decreasing or stopping psychoactive medications, if appropriate)
  • Call bell in reach
  • Patient’s hearing aids or glasses in reach
  • Hourly rounding to assess pain, positioning, toileting, and personal needs
  • Early and frequent mobilization
  • Nonslip footwear
  • Elimination of barriers to transfer and ambulation
  • Avoidance of restraints
  • Use of bed alarm, when appropriate
  • Bed in lowest position to the floor
  • Vitamin D supplementation for patients deficient or a high fall risk (800-1000 international units cholecalciferol daily)
  • Patient and family education


Berry, S., & Kiel, D. (2018). Falls: Prevention in nursing care facilities and hospital setting. UpToDate. Retrieved from
Kiel, D. (2018a). Falls in older persons: Risk factors and patient evaluation. UpToDate. Retrieved from
Kiel, D. (2018b). Falls: Prevention in community-dwelling older patients. UpToDate. Retrieved from

Haddad, Y., Bergen, G., & Luo, F. (2018). Reducing fall risk in older adult. American Journal of Nursing, 118(7), 21-22. doi: 10.1097/01.NAJ.0000541429.36218.2d

Lee, A., Lee, K-W., & Khang, P. (2013). Preventing falls in the geriatric population. The Permanente Journal, 17(4), 37-39. doi:  10.7812/TPP/12-119
Moncada, L., & Mire, L. (2017). Preventing falls in older persons. American Family Physician, 96(4), 240-247. Retrieved from  

Centers for Disease Control and Prevention. (2017). Fact sheet: Risk factors for falls. Retrieved from