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Subjective Assessment The subjective assessment can give a general overview of nonobjective and nonmedical factors that can play a part in causing a fall. Subjective measurements include reviewing the patient’s recent history of falls, current and recent changes in medications, and their medical history related to risk factors.
Patterns related to repeated falls Interview of patient or care giver –Circumstances of falls –Surroundings during falls –Medication changes before falls –Conditions prior to falls
When digging a little deeper into the patient’s history to determine if they have had episodes of falling, healthcare workers should look for patterns related to falls. Repeated falls should be closely evaluated to identify those areas and activities that are particularly risk-prone. If falls have occurred, patients should be questioned as to where the fall occurred, the type of surface they were on, what type of lighting did the room have, what time of day was it, what were they wearing on their feet, what tasks being performed at the time of fall, and what any other information that might be helpful when considering the general surroundings. Repeated falls can be very similar in circumstance; for example, a person may fall only when getting out of bed in a darkened room, or only in a crowded setting, or only on uneven surfaces. This information can then be compared to the findings from the objective assessment. The patient’s medication history should be reviewed, paying particular attention to medications that affect blood pressure, cardiac function, cognition, or that cause dizziness or lightheadedness. If possible, it should be noted when medications changed to see if the fall could have been related to a recent medication change. The patient’s medical history should focus on diseases and disorders that can lead to weakness or loss of feeling such as peripheral neuropathy, vascular disorders, and visual deficits.
Mobility and Gait There are several good evaluation tools for testing functional mobility and gait. The purpose of testing these is to determine how a person performs functional tasks that depend on postural control. (Shumway-Cook & Woollacott, 2001). It is important to get a baseline evaluation in persons suspected of having a balance deficit. Functional tests can be divided into two categories: functional mobility tests and functional gait tests. A functional mobility test quantifies mobility skills: sit to stand, reaching, turning, climbing stairs and retrieving an item from the floor. Functional mobility tests are good at identifying problem areas and generally predicting the risk of falls, but cannot fully identify the underlying cause of the deficit. There are a few tests that are given to patients suspected of having an impairment that limits their mobility. Some, like the Berg Balance Test, are designed to objectively measure a patient’s ability to safely perform several common activities of daily living and to assess their risk of a fall while doing so. These include such tasks as standing still with eyes closed, transferring from a bed to a chair, looking over their shoulder while standing, turning 360 degrees, and the functional reach test. This series of tests is good for providing a baseline for measuring improvement.
Functional mobility tests
–Sit
to stand, reaching,
turning, climbing
stairs, retrieving item
from
the floor
Functional gait tests
–Activities
of daily living
tasks?
–Time
and distance
tests?
–Walking
speed with
balance tasks
Another test useful in determining a patient’s ability to maintain balance during a functional task is the Functional Reach Test. This test measures the ability to reach forward beyond an arm’s length, while standing with feet fixed in the same position on the floor. And another test of mobility is the Get Up and Go Test. This test measures a patient’s ability to rise from a chair, walk 10 feet, turn, then return to the chair. The patient is graded accordingly. A variation on this is the timed Up and Go Test (TUG Test), which times the individual during the same task. The assessment of functional gait is compounded by a general lack of agreement among clinicians as to how to measure it. Should the measurement be based on activities of daily living—walking to the bathroom, climbing the stairs to get to the bedroom? Or should it reflect a certain distance walked in a set amount of time? Or should there be some obstacles involved, just like there are in the real world? Things like stepping up curbs or turning the head while walking. And tougher questions arise from this criteria, such as, are these tests profound enough to warrant a longer hospital stay until a goal can be met? Or for the home patient, should more therapy visits be authorized until the patient is able to meet the goal. And what is the goal? Should it change with the patient’s age, medical history, or specific life situation? Or is one goal for all people sufficient? There have been a number of studies on ambulation, namely the relationship between walking speed and walking impairment. In 1999, Bernardi looked at the physiologic cost of walking.[9] They measured cardiac and ventilatory output, and energy output. Since then it has been determined that walking speed is the single best measure of impairment. Not only is it an easier measure to use, but it is easy to adjust based on age and other fall risk factors. Researchers Shumway-Cook and Woollacott have suggested that for an individual to be considered ambulatory and on their own in the community they need to be able to walk 1,000 feet, have the ability to walk at a predetermined rate of speed for a set distance that equates to walking across a street with a green light, step up and down a city curb, and turn their head while walking without losing their balance.[10] There are other tests as well, and all are similar in that they test the patient’s mobility along with some degree of balance assessment.
[10] Brauer SG, Woollacott M, Shumway-Cook A. The interacting effects of cognitive demand and recovery of postural stability in balance-impaired elderly persons. J Gerontol A Biol Sci Med Sci. 2001 Aug;56(8):M489-96.
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