Falls Risk Assessment Tool (FRAT): An Overview to Assist Understanding and Conduction
- 1 Introduction
- 2 How Does Medication Affect Falls?
- 3 Psychological Status
- 4 Cognitive Status
- 5 Critique of FRAT
- 6 References
Falls are problematic within the elderly population. Approximately 28.7% of older adults reported falling at least once in the preceding 12 months, resulting in an estimated 29 million falls and 7 million fall injuries in the United States. A study specifies that 44% of falls cause minor injuries such as bruises, abrasions and sprains and 4-5% of falls cause major injuries such as wrist and hip fractures. Within the NHS in 2003 the cost per 10,000 population was £300,000 in the 60–64 age group, increasing to £1,500,000 in the >75 age group. These falls cost the UK government £981 million, of which the NHS incurred 59.2%. According to the NHS long term plan (2019) they aim to increase funding for primary and community care by at least £4.5 billion and reducing falls related costs could go some way to achieving this.
The strongest single predictor of future falls is a history of previous falls. This is probably because an individual's reason for falling the first time is likely to recur. Assessment of physical functioning is the next strongest predictor and so its inclusion is likely to increase a tool's predictive ability. According to NICE (2013) assessment and prevention of falls guidelines, older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year.
Understandably therefore in elderly physiotherapy assessment there is a lot of focus around a patients falls history and often use tools like the Falls Risk Assessment Tool (FRAT). Student and newly qualified physiotherapists however don’t often understand why the factors included in falls risk assessments contribute to falls. This document aims to increase understanding of the impact of risk factors for falls in the elderly population.
FRAT is a 4-item falls-risk screening tool for sub-acute and residential care. The FRAT has three sections: Part 1 - falls risk status; Part 2 – risk factor checklist; and Part 3 – action plan. Within the UK there does not appear to be a standardised falls risk assessment. Policies regarding this tend to be trust specific. The NHS website (2018) does provide a self-assessment based on the FRAT, however from personal experience, the conduction of the FRAT and similar falls-related tools requires clarity and understanding.
A full copy of the FRAT tool can be accessed via the following link: 
How Does Medication Affect Falls?
Medication has long been known to have side effects that can increase the risk of falling. There are many different medications all with different methods of action and side-effects. It’s also important to consider the combinations of different medications that can affect falls. Different classes of drugs can influence falls risks by different mechanisms and thus when combined can majorly increase falls risk. Polypharmacy can typically be defined as a patient using more than 3 or 4 medications at one time and this is important as a study by Dhalwani et al., (2017) found that nearly one-third of the total population taking 5 or more drugs had significantly increased falls rate of 21% in a 2-year period.
The CDC produced a resource called “Stopping Elderly Accidents, Deaths & Injuries” (STEADI) to provide material to help offer effective interventions to reduce falls risk. They characterise medicines using a 3 point system which can be seen below.
Understanding Medication Fall Mechanisms
Any medication acting on the brain (psychotropics) or affecting function of the cardiovascular system can increase fall risk. Psychotropics including anxiolytics/sedative-hypnotics, antipsychotics, antidepressants, anticonvulsants, and narcotic pain medications typically increase risk due to their effects on cognitive function, resulting in sedation, slower reaction times, and impaired balance
Cardiovascular medications often either lower blood pressure with subsequent hypotension or affect heart rate, resulting in bradycardia, tachycardia, or periods of asystole . Maintaining consciousness and an upright posture requires adequate blood flow to the brain and so drugs affecting this do carry a risk of potential falls, if blood pressure is not kept in the optimal parameters.
Recent systematic reviews with meta-analyses have confirmed the effects of medications on increased falls, however, there are still some uncertainties regarding whether all drugs in certain sub-groups have the same effect as others and so further work is needed to address this. A systematic review by De Vries et al., (2018) found that loop diuretics were significantly associated with increased falls risk, beta-blockers significant decrease in falls risk. Specific drug properties and method of interaction have an effect. Another recent systematic review by Seppala et al., (2018) found antipsychotics, anti-depressants, benzodiazepines have a significant increase in falls risk.
How Does Psychological State Increase Falls Risk Status?
Impact of Cognitive Status on Falls
- The motor and sensory systems are linked by higher order neurological processes and cognition.
- Previous research has demonstrated cognition has a key role in the regulation of gait and balance in older adults.
- Increased levels of cognition are required for movement planning and adapting to environmental changes.
- Therefore, impairments in cognition increase risk of falling.
- A study (“Gait, Cognition & Decline”) on 2700 older adults with and without dementia showed that adults with dementia fall more than when compared to healthy counterparts.
- Mini Mental State Examination (MMSE) score ≤ 24 equates to increased falls risk.
- Specifically, subjects scoring < 28 on the MMSE demonstrated a nearly three-fold increased risk for falls compared to control subjects whose MMSE was 30/30.
- The cognitive test included in the FRAT is the Hodkinson Abbreviated Mental Test Score (ABTS). This test is used to assess for the possibility of dementia, and is now sometimes used for other cognitive impairments. Scores indicate the level of impairment, however more rigorous cognitive testing is required to confirm this.
Critique of FRAT
- Risk Factor Checklist (Part 2) fails to appreciate balance specifically. If this was a self-reported concern of the patient, areas of proprioception and the vestibular system could be objectively looked at in more depth within specialist physiotherapy assessment.
- Lacks context – eludes to being objective however fails to provide any guidance on questioning to obtain further information. Area for development – extended box to record subjective and objective measures.
- NICE guidelines state the FRAT does not assess all the risk variables highlighted in their guidelines for falls prevention. Furthermore, NICE state it should not be relied solely on to assess risk of falls and requires further investigation. If high falls risk is identified, more extensive assessment is required – e.g. Elderly Mobility Scale to provide objective measures that guide physiotherapy treatment.
- Nowhere to record a collateral history. Having an area to collect information would allow for exploration into issues and areas highlighted in Part 2.
- ‘History of Falls’ section lacks ability to record detailed mechanics of fall. Tick boxes can be supported by a descriptive component. (See ‘Potential Modifications to the FRAT’).
- Cognitive test included is rather outdated and cannot be relied on to confirm cognitive impairment.
- Recommendation: carry out with several members of MDT present to incorporate areas of expertise.
Potential Modifications to the FRAT
During the process of evaluating the FRAT, there is a perceived lack of depth pertaining to the falls section. It is proposed that some amendments could be made to this in order to improve clarity and increase information and reliability.
Current ‘History of Falls’ Section:
- Cuevas-Trisan R. Balance problems and fall risks in the elderly. Physical Medicine and Rehabilitation Clinics. 2017 Nov 1;28(4):727-37.
- Hart A. Falls in the Older Adult Population: Risk Factors, Risk Identification Instruments and Fall Prevention Programs (Doctoral dissertation, Stern College for Women). 2015
- Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. Journal of Epidemiology & Community Health. 2003 Sep 1;57(9):740-4.
- England NH. The NHS long term plan. London: NHS England. 2019.
- Sherrington C, Tiedemann A. Physiotherapy in the prevention of falls in older people. Journal of physiotherapy. 2015 Apr 1;61(2):54-60.
- Centre for Clinical Practice at NICE (UK. Falls: Assessment and prevention of falls in older people. 2013
- Stapleton C, Hough P, Oldmeadow L, Bull K, Hill K, Greenwood K. Four‐item fall risk screening tool for subacute and residential aged care: The first step in fall prevention. Australasian Journal on Ageing. 2009 Sep;28(3):139-43.
- Matarese M, Ivziku D. Falls risk assessment in older patients in hospital. Nursing Standard. 2016 Jul 27;30(48).
- Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ open. 2017 Oct 1;7(10):e016358.
- Centers for Disease Control and Prevention. STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool kit for health care providers. National Institute of Health and Human Services, Atlanta. 2013.
- De Jong MR, Van der Elst M, Hartholt KA. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Therapeutic advances in drug safety. 2013 Aug;4(4):147-54.
- Johnell K, Jonasdottir Bergman G, Fastbom J, Danielsson B, Borg N, Salmi P. Psychotropic drugs and the risk of fall injuries, hospitalisations and mortality among older adults. International journal of geriatric psychiatry. 2017 Apr;32(4):414-20.
- Seitz D, Iaboni A, Kirkham J. Psychotropic Drugs and Falls in Older Adults: an Update for the Geriatric Psychiatrist. The American Journal of Geriatric Psychiatry. 2017 Mar 1;25(3):S21.
- Darowski A, Whiting R. Cardiovascular medication and falls. Reviews in Clinical Gerontology. 2011 May;21(2):170-9.
- de Vries M, Seppala LJ, Daams JG, van de Glind EM, Masud T, van der Velde N, Blain H, Bousquet J, Bucht G, Caballero-Mora MA, van der Cammen T. Fall-risk-Increasing drugs: a systematic review and meta-analysis: I. cardiovascular drugs. Journal of the American Medical Directors Association. 2018 Apr 1;19(4):371-e1.
- Seppala LJ, Wermelink AM, de Vries M, Ploegmakers KJ, van de Glind EM, Daams JG, van der Velde N, Blain H, Bousquet J, Bucht G, Caballero-Mora MA. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. Journal of the American Medical Directors Association. 2018 Apr 1;19(4):371-e11.
- Purves D, Cabeza R, Huettel SA, LaBar KS, Platt ML, Woldorff MG, Brannon EM. Cognitive neuroscience. Sunderland: Sinauer Associates, Inc; 2008.
- Herman T, Mirelman A, Giladi N, Schweiger A, Hausdorff JM. Executive control deficits as a prodrome to falls in healthy older adults: a prospective study linking thinking, walking, and falling. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences. 2010 May 19;65(10):1086-92.
- Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age and ageing. 2012 Feb 27;41(3):299-308.
- Gleason CE, Gangnon RE, Fischer BL, Mahoney JE. Increased risk for falling associated with subtle cognitive impairment: secondary analysis of a randomized clinical trial. Dementia and geriatric cognitive disorders. 2009;27(6):557-63.
- Allali G, Launay CP, Blumen HM, Callisaya ML, De Cock AM, Kressig RW, Srikanth V, Steinmetz JP, Verghese J, Beauchet O, Biomathics Consortium. Falls, cognitive impairment, and gait performance: results from the GOOD initiative. Journal of the American Medical Directors Association. 2017 Apr 1;18(4):335-40.
- Anstey KJ, Von Sanden C, Luszcz MA. An 8‐year prospective study of the relationship between cognitive performance and falling in very old adults. Journal of the American Geriatrics Society. 2006 Aug;54(8):1169-76.
- Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S, Schwalbe A. Kenosha County Falls Prevention Study: A Randomized, Controlled Trial of an Intermediate‐Intensity, Community‐Based Multifactorial Falls Intervention. Journal of the American Geriatrics Society. 2007 Apr;55(4):489-98.
- Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and ageing. 1972 Nov 1;1(4):233-8.