FESI-Analytic Summary

I. Introduction

The Falls Efficacy Scale-International (FESI-I) is a brief geriatric diagnostic tool that is designed to measure a patient’s fear of falling during physical or social activities, inside or outside of the home, regardless if the activity is actually carried out or not. The tool is a 16-question survey, presenting situations that the older adult may develop a fear of falling in attempting to complete. The patient responds on a Likert scale of 1-4 (1 being the least concerned about falling and 4 being the most concerned about falling.) The FES-I is self administered by the patient, after the Registered Nurse (RN) explains to answer each question with their concerns about falling whether or not they carry out the activity, and
what the significance of each number on the Likert score signifies. It is administered to older adults in long term or acute care settings who have or have not had a previous fear of falling. The exact time the test takes to complete is not specified, but it is notable for its brevity. Summing the responses for each question scores the test. A low concern for falling will score between a 16 and 19, a moderate concern for falling will score between 20 and 27, while a high concern for falling will score between 28 and 64. A higher score indicates a greater fear of falling in the adult.

II. Clinical Problem

One in three older adults fall, and after an older adult falls once, their chances of falling doubles. A history of past falls may cause the older adult to limit their activity whether they sustained serious injuries or not, because they are concerned with falling again. Furthermore, a fear of falling causes a decline in their mobility and overall engagement in physical activities. A reduction in the physical activity of older adults causes a decrease in muscle strength and tone, as well as a psychological deterioration in confidence related to initiating certain activities, both of which increase the risk of falls. In certain cases, this decrease in confidence can lead to a feeling of loneliness and isolation, and prevent the individual from enjoying life to its full potential. Falls among older adults may cause bone fractures (95% of hip fractures), traumatic head injuries, in which falls are the most common cause, be a predictor of future falls, decrease Activities of Daily Living (ADL), and cost $94 billion dollars annually (Centers for Disease Control and Prevention [CDC], 2015). Falls not only consume massive amount of health care dollars, but they can cause a severe weakening in the wellbeing and quality of life for the individual, regardless if whether the patient actually falls or just anticipates falling. Fortunately, there are simple, effective, inexpensive tools available to aid in preventing falls that need to be recognized and implemented. Proper assessment tools are needed to recognize the individuals at greatest risk of falling, bring their needs to the forefront, and develop specialized plans of care. This is necessary for not only the safety of patients, but for their freedom, wellness, functionality, and overall quality of life. The FES-I tool is designed to assess concern for falling in simple and advanced social and physical activities, and helps determine which patients are at risk for these potentially damaging falls. This tool is important because it allows us to recognize which patients are at risk, and plan and implement specialized care plans for expected positive outcomes.

III. The Science

Article 1

In 2014 Brendon Stubbs, Laura H.P. Eggermont, Sandhi Patchay, and Pat A. Schofield conducted a multisite observational study to explore whether interference from pain has a significant role in the psychological fear of falling. The study consisted of 295 older adults with the mean age of 77.5, whom all completed brief assessment tool surveys such as the Brief Pain Inventory (BPI) interference subscale, Short Falls Efficacy Scale–International (FES-I), Activities-specific Balance Confidence Scale (ABC), mod- ified version of the Survey of Activities and Fear of Falling in Elderly Scale (mSAFFE), and Consequences of Falling Scale (CoF).

Article 2 (FESI Article 2)

In a 2010 Cohort Study conducted by Delbaere, Close, Mikolaizak, Sachdev, Brodaty, and Lord, the reliability of the 16 item and 7 item FES-I were further validated based on previously accepted psychometric properties. These properties were assessed using the item response theory, which has frequently been recognized as the best approach for developing questionnaires and scales (Delbaere et al, 2010). In this comprehensive longitudinal validation study, 500 community dwelling people aged 70-90 who lived in Sydney were assessed using the FES-I at baseline and one year later, in conjunction with demographic, physiological and neurophysiological measures. Data was collected regarding falls every month, and fear of falling was reassessed every three months.

It was concluded that both the 16 item and 7 item FESI scale present with strong reliability for previous falls or future fear of falling among older adults and should be incorporated in clinical and research purposes (Delbaere et al, 2010). Both scales had good validity as demonstrated by the strong increase in FESI scores for individuals who suffered multiple falls in a 3-month window.

This study was the first to establish cut off points for low, moderate, and high levels of fearfulness for falling, and should be preceded with caution if applying these cutoffs to the clinical setting until further research is conducted. Although this study was conducted in Australia, a similar health care delivery systems exists there, therefore allowing us to correlate data to the traditional Westernized theories of medicine utilized in America. The level of evidence pertaining to this article is a Case Control Study (Level 4).

Clinical Guideline In 2013, a clinical guideline entitled Clinical Guideline Fall prevention.
In: Evidence-based geriatric nursing protocols for best practice, was updated by Boltz M, Capezuti E, Fulmer T, Zwicker D, after originally being published on July 30, 2003. This guideline reviewed published Meta-Analyses and systematic reviews to draw information from the most valid and highly evidenced information to develop quality standardized practices. This guideline focuses on assessing intrinsic and extrinsic factors that contribute to falls and how to recognize and improve conditions to decrease falls in hospitalized older adults. Intrinsic factors include the inherent properties that involves the older adult, that increase risk of falls such as increased age, deterioration of consciousness and mental status, comorbidities such as Parkinson’s, arthritis, or hip fractures, and gait, balance, or visual impairments. Extrinsic factors that are in the patient’s direct environment include slippery floors, proper lighting, inappropriate clothing or hospital gowns that may cause tripping, or IV poles that are not secure. This guideline also recommends implementing a Post Fall Assessment (PFA), which includes documentation of all aspects of the fall, as well as physical condition of the patient after the fall. In order to instill successful fall preventions, the guideline recommends that nursing care strategies implement standardized fall risk assessment tools that have been empirically tested for validity. The FES-I has been developed, validated, and is recommended for the older adult population, therefore incorporating this tool would be an appropriate resource to pinpoint who is at risk for falling and enable the multidisciplinary team to construct a plan of action to prevent falls in that particular patient. The FES-I would contribute to decreasing falls in the older adult populations by providing a feasible way to identify patient’s fear of falling by providing identification, and
therefore intervention and post-intervention utilizing a low cost and efficient tool. Factors associated with older adults such as increased use of medications, decreased physical function, activity restrictions, and fractures are all important considerations in which fear of falling applies to (Dewin and Macdermid, 2014).