# Falls among Older Adults: Screening, Identification, Rehabilitation, and Management
## 5 Evaluation for Patients with Increased Fall Risk
### Physical Examination and Tests  
During the physical examination, a physician evaluates alterations in muscle function, such as weakness in the lower extremities. Many tests can assess physical performance; one of the most widely used is the Short Physical Performance Battery (SPPB). SPPB is a tool that has been used to predict subsequent disability and worsening of mobility associated with injurious falls. It has recently been proposed as a screening tool for falls. This outpatient test has three rating scales (balance test, gait speed test, and chair stand test), each of which assigns a score from 0 to 4. The SPPB can assess several functional abilities, including balance, and can predict falls [39] and disability [40; 41]. The presence of an SPPB score of <10 is independently associated with a history of falls [42; 43; 44] in community-dwelling older adults, with a sensitivity of 71% and a specificity of 78% [10; 45]. Another frequently used test is the Timed Up & Go [46]. It consists of assessing the patient's ability to get up from a chair, remain balanced, travel a fixed distance (e.g., 3 m), and return while sitting in the chair. The ability to perform each command may already allow identification of a difficulty. The time taken by the patient to complete the test is compared with the average time of subjects with the same age range (e.g., 70-79). A recent study identified how, with a cut-off point of 13.9, the test's sensitivity is 92% and specificity 64% to discriminate between fallers and non-fallers [42] in community-dwelling older adults. A combination of SPPB and TUG tests would have a good predictive potential for falls. However, a recent meta-analysis indicates sensitivity of 70% and specificity of 49% [47]. The Performance-Oriented Mobility Assessment Tool (POMA) assesses walking and balance with 16 items. The tool allows assessment of autonomy in walking and the ability to maintain balance despite the intrusion of external stimuli (e.g., the subject is pushed). A POMA scale total score of <21 is associated with falls [1; 48]. A cut-off point of 19 has a sensitivity of 68% and specificity of 88% to predict whether an individual will have two or more falls [49]. However, reliable cut-offs for predicting falls have not been identified [47]. However, the characteristics of these predictive tools are derived primarily from studies of specific cohorts and not from meta-analyses. Although these instruments taken individually do not accurately screen for falls risk [47; 50], a combination of at least two tests could be an effective screening strategy. One study found a correlation between patients with difficulty in divided attention and falls. Those who had a poor score on the walking while talking (WWT) test fell more frequently [51]. Physical examination of the lower limbs also includes assessment of physical alterations, such as joint deformities, calluses, amputations, and neurological alterations, such as decreased sensitivity or propriception. A thorough general physical examination is crucial to rule out other causes of the fall. Sensory alterations in hearing or visual acuity may contribute to the fall. Visual and hearing tests are recommended. These alterations may be treated with hearing implants or lenses. Assessing blood pressure and heart rate is important, especially for the evaluation of orthostatic hypotension (OH). These vital parameters should be measured supine and at the implant after at least one to three minutes. Studies have investigated the possibility of delayed orthostatic hypotension, even several minutes after positioning in upright statics. This is because OH is positively correlated with the risk of falls [52]. For this reason, more thorough evaluations can measure pressure even at longer time intervals. The presence of a heart murmur may induce suspicion of valvulopathies, such as aortic stenosis, which is associated with syncope and falls. A suggestive finding is an indication to perform an echocardiogram.