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Three Part Question

In [elderly patients presenting to the emergency department after a fall] is [STRATIFY better than FRAT] at [predicting risk of future falls]?

Clinical Scenario

A 74-year-old woman presents to the emergency department following a fall. She can’t remember how she fell, but thinks she must have just tripped over. You want to perform the necessary initial investigations and predict her risk of subsequent falls before she is discharged.

Search Strategy

Medline 1946 to June Week 4 2014, and EMBASE 1980 to 2014 Week 26 using the OVID interface, and CINAHL 1937 to June Week 4 2014 via the John Rylands University Library (JRUL) interface.

[exp accidental falls OR falling] AND [exp elderly OR aged] AND [exp emergency department OR ward] AND [exp STRATIFY OR FRAT keyword] LIMIT to human and English language

Search Outcome

A total of four papers were retrieved, of which two were relevant to the clinical question and two were not in English.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wong Shee, A et al. November 2012 Ireland	Sub-acute unit for inpatient rehabilitation – 53 patients over a 6 month period	Retrospective cohort study 2b	The study looked at accuracy of two falls risk assessments – TNH-STRATIFY and BHS-FRAT	Both FRAT and STRATIFY showed a low specificity. FRAT has a specificity of 0.07 while STRATIFY had a specificity of 0.13.	Use of retrospective data can lead to bias, using previous audit data may not be representative as not all falls may have been recorded
De Costa, B.R et al. July 2012 Spain	754 elderly patients falling as inpatients in rehabilitation hospitals	Systematic review and meta-analysis 2a	STRATIFY, DOWNTON and PJC-FRAT were compared for their efficacy.	No single tool is better than another at predicting risk of subsequent falls. STRATIFY had a specificity of 74% and a sensitivity of 42% compared with DOWNTON which the highest sensitivity at 92%, while PJC-FRAT had a specificity of 75% and a sensitivity of 73%.	Review of current literature, discussions about eligibility of certain reviews to be included or not

Comment(s)

The papers described limited specificity of both screening tools, which makes it difficult to predict if a person is more likely to fall, in both patients who have fallen previously or had no history of falls. With regards to their efficacy, one screening tool hasn’t been shown to be superior to another. Other factors which were discussed included how time consuming it was to fill out each questionnaire. This is important for busy clinical staff and shorter, less complex surveys make it more likely that a patient will be risk assessed for falling.

Clinical Bottom Line

While neither STRATIFY or FRAT were perfect indicators of predicting risk of subsequent falls in the elderly, there were advantages to both and better than no risk assessment at all.

References

1. Wong Shee A, Phillips B, Hill K. Comparison of two fall risk assessment tools (FRATs) targeting falls prevention in sub-acute care. Arch Gerontol Geriatr. 2012:Nov-Dec;55(3):653-9.
2. da Costa BR, Rutjes AW, Mendy A Can Falls Risk Prediction Tools Correctly Identify Fall-Prone Elderly Rehabilitation Inpatients? A Systematic Review and Meta-Analysis PLoS One. 2012;7(7):e41061.