Nakanishi et al reported a decision tree for assessing fall risk for inpatients in Japan. The authors are from Kumamoto Universit and Sojo University in Japan.
Patient selection: inpatient, ages from 54 to 980 years
Algorithm: decision tree
Number of end-nodes: 12
Extra-high fall risk (2-5%):
(1) delirium AND uses walking aid
(2) no delirium AND fall history AND stagger AND impaired judgment/comprehension
High fall risk (1-2%):
(1) history of delirium AND does not use walking aid
(2) no history of delirium AND fall history AND stagger AND no impaired judgment/comprehension AND night urination
(3) no delirium AND fall history AND does not stagger AND muscle weakness in the lower extremities AND uses sleeping drug
(4) no delirium AND fall history AND impaired judgment/comprehension
Moderate fall risk (0.2-1%):
(1) no delirium AND fall history AND stagger AND no impaired judgment/comprehension AND no night urination
(2) no delirium AND fall history AND does not stagger AND muscle weakness in the lower extremities AND does not use sleeping drug
(3) no delirium AND fall history AND does not stagger AND no muscle weakness in the lower extremities AND presence of infusion route/tube
(4) no delirium AND fall history AND no impaired judgment/comprehension AND muscle weakness in legs
Low fall risk:
(1) no delirium AND fall history AND does not stagger AND no muscle weakness in lower extremities AND no infusion route/tube
(2) no delirium AND fall history AND no impaired judgment/comprehension AND no muscle weakness in lower extremities
