Risk Factor Yes/No Suggested Interventions Actions/Comments Balance, Transfers and Walking YES: Provide appropriate Has difficulty moving from bed to chair? NO: equipment/check condition Unsteady on their feet, shuffles or takes Home or group exercise uneven steps? programme to improve strength and balance Footwear/Foot care YES: Advise on suitable footwear NO: Check foot condition Difficulty with foot care affecting Advise on foot care mobility? Inappropriate footwear? Continence YES: Provide advice and Experiences urgency, frequency, NO: education nocturia, frequent UTI’s and/or Encourage regular fluid incontinence? intake Urinalysis and temperature check to exclude infection Provide aids/equipment Agitation / Confusion YES: Complete Abbreviated term memory or comprehension NO: Mental Test Score (AMTS) difficulties which have a significant Investigate cause of acute impact on their daily life? confusion Has a diagnosis of dementia? Provide advice and education Nutrition and Hydration YES: Advise on diet and hydration Unintentional weight loss? NO: Record dietary/fluid intake Poor food/fluid intake? MUST score of 1 or more? Alcohol YES: Explain reduced tolerance to More than one unit of alcohol per day? NO: alcohol with age and Alcohol intake links with falls risk medications Signpost to support services Vision YES: Advise caution with Unable to recognise a key/pen held a NO: bi/varifocal glasses bed length away (with glasses if worn)? Signpost to optician Unable to see print clearly (with glasses Discuss environmental if worn)? hazards Wears bifocals/varifocals? YES: Check any hearing aid is NO: worn correctly and working Difficulty hearing conversational speech Check ears for wax (with hearing aid if worn)? Signpost for hearing assessment Confidence/ Coping YES: Discuss coping strategies NO: including how to get up off Strategies the floor and calling for help Fear of further falls, have they changed Advice and education their lifestyle due to falls? Rehabilitation to increase Unable to get up off the confidence Unable to summon help? Risk Factor Yes/No Suggested Interventions Actions/Comments
Risk Factor Yes/No Suggested Interventions Actions/Comments Balance, Transfers and Walking Has difficulty moving from bed to chair? Unsteady on their feet, shuffles or takes uneven steps? YES: NO: Provide appropriate equipment/check condition Home or group exercise programme to improve strength and balance Footwear/Foot care Difficulty with foot care affecting mobility? Inappropriate footwear? YES: NO: Advise on suitable footwear Check foot condition Advise on foot care Continence Experiences urgency, frequency, nocturia, frequent UTI’s and/or incontinence? YES: NO: Provide advice and education Encourage regular fluid intake Urinalysis and temperature check to exclude infection Provide aids/equipment Agitation / Confusion term memory or comprehension difficulties which have a significant impact on their daily life? Has a diagnosis of dementia? YES: NO: Complete Abbreviated Mental Test Score (AMTS) Investigate cause of acute confusion Provide advice and education Nutrition and Hydration Unintentional weight loss? Poor food/fluid intake? MUST score of 1 or more? YES: NO: Advise on diet and hydration Record dietary/fluid intake Alcohol More than one unit of alcohol per day? Alcohol intake links with falls risk YES: NO: Explain reduced tolerance to alcohol with age and medications Signpost to support services Vision Unable to recognise a key/pen held a bed length away (with glasses if worn)? Unable to see print clearly (with glasses if worn)? Wears bifocals/varifocals? YES: NO: Advise caution with bi/varifocal glasses Signpost to optician Discuss environmental hazards Difficulty hearing conversational speech (with hearing aid if worn)? YES: NO: Check any hearing aid is worn correctly and working Check ears for wax Signpost for hearing assessment Confidence/ Coping Strategies Fear of further falls, have they changed their lifestyle due to falls? Unable to get up off the Unable to summon help? YES: NO: Discuss coping strategies including how to get up off the floor and calling for help Advice and education Rehabilitation to increase confidence Risk Factor Yes/No Suggested Interventions Actions/Comments
Community-Falls-Assessment-Tool-stage-1-3-version-4-finalSTEES.docx