EVALUATION OF FALL RISK FACTORS PRESENT DURING INSTITUTIONALIZATION OF ELDERLY PEOPLE

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Original Article
Texto & Contexto Enfermagem 2021, v. 30:e20200331
ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2020-0331
HOW CITED: Baixinho CRSL, Dixe MACR. Evaluation of fall risk factors present during institutionalization of
elderly people. Texto Contexto Enferm [Internet]. 2021 [cited YEAR MONTH DAY]; 30:e20200331. Available from:
https://doi.org/10.1590/1980-265X-TCE-2020-0331
EVALUATION OF FALL RISK
FACTORS PRESENT DURING
INSTITUTIONALIZATION OF
ELDERLY PEOPLE
Cristina Rosa Soares Lavareda Baixinho1,2 
Maria dos Anjos Coelho Rodrigues Dixe2 
1Escola Superior de Enfermagem de Lisboa. Centro de Investigação, Inovação e Desenvolvimento em
Enfermagem de Lisboa. Lisboa, Portugal.
2Escola Superior de Saúde do Instituto Politécnico de Leiria, Centro de Inovação em Tecnologias e
Cuidados de Saúde. Leiria, Portugal.
ABSTRACT
Objectives: to describe the development and validation of the Scale of Practices of Evaluation of Fall Risk
Factors during Institutionalization of Elderly People and to describe the practices of evaluation of communication
of fall risks to institutionalized elderly people.
Methods: methodological study, which allowed construction and determination of the psychometric properties
of the Scale of Practices of Evaluation of Fall Risk Factors during Institutionalization of Elderly People, which
was carried out in six long-term care institutions for elderly people, in 2018.
Results: the scale showed satisfactory internal consistency, with a Cronbach’s alpha of 0.949. It was designed
to have three dimensions: practices of evaluation of biophysiological risk factors; practices of communication
and training; and practices of evaluation of risks related to elderly people’s putting on clothing and footwear.
Conclusions: the risk factors that had their value recognized were related to mobility. There is not proper
recognition of the importance of information about fall risk factors and communication between elderly people
and health teams during institutionalization.
DESCRIPTORS: Accidental falls. Aged. Risk. Caregivers. Homes for the aged. Institutionalization.

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AVALIAÇÃO DOS FATORES DE RISCO DE QUEDA DURANTE A
INSTITUCIONALIZAÇÃO DO IDOSO
RESUMO
Objetivos: descrever a construção e validação da escala de práticas de avaliação dos fatores de risco de
queda durante a institucionalização do idoso e descrever as práticas de avaliação e comunicação do risco de
queda aos idosos institucionalizados.
Método: estudo metodológico, que possibilitou a construção e determinação das propriedades psicométricas
da Escala de Práticas de Avaliação do Risco de Queda durante a Institucionalização da pessoa idosa, que
decorreu em seis instituições de longa permanência para idosos, em 2018.
Resultados: a escala apresenta uma consistência interna de α=0,949 e 3 dimensões: práticas de avaliação
dos fatores de risco bio siológicos; práticas de comunicação e formação; práticas de avaliação do risco
relacionados com o calçar e vestir do idoso.
Conclusões: os fatores de risco valorizados estão associados à mobilidade. Há uma desvalorização da
informação sobre os fatores de risco de queda, ao longo da institucionalização, e da comunicação dos
mesmos nas equipes de trabalho.
DESCRITORES: Acidentes por quedas. Idosos. Risco. Cuidadores. Instituições de longa permanência para
idosos. Institucionalização.
EVALUACIÓN DE FACTORES DE RIESGO DE CAÍDAS DURANTE LA
INSTITUCIONALIZACIÓN DEL ANCIANO
RESUMEN
Objetivos: describir la construcción y validación de la escala de prácticas de evaluación de factores de riesgo
de caídas durante la institucionalización del anciano, y describir las prácticas de evaluación y comunicación
de riesgo de caídas al anciano institucionalizado.
Método: estudio metodológico que permitió construir y determinar las propiedades psicométricas de las
Escala de Prácticas de Evaluación de Riesgo de Caídas durante la institucionalización del anciano, realizado
en seis hogares para ancianos, en 2018
Resultados: la escala muestra una consistencia interna de α=0,949 y 3 dimensiones: prácticas de evaluación
de factores de riesgo biosiológicos; prácticas de comunicación y formación; prácticas de evaluación de
riesgos relativos a calzado y vestimenta del anciano.
Conclusiones: los factores de riesgo evaluados están asociados a la movilidad. Está infravalorada la
información sobre factores de riesgo de caída durante la institucionalización, y la comunicación de los mismos
en los equipos de trabajo.
DESCRIPTORES: Accidentes por caídas. Anciano. Riesgo. Cuidadores. Hogares para ancianos.
Institucionalización.

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INTRODUCTION
The relationship between falls and institutionalized elderly people is complex because of the
cause-consequence e󰀨ect itself. That is, falls are one of the main factors leading to decisions to opt
for long-term care institutions (LTCIs), or greatly contribute to such decisions. But falls can also be a
consequence of institutionalization, since their incidence is higher and their consequences are more
serious when they occur in these environments than in the community1–4.
Falls are the main reason cited by relatives for looking for LTCIs. Their recurrence and e󰀨ects
can lead to institutionalization and will impact the independence of residents1,5, given that they are
inserted in a space where the prevalence of this problem is markedly higher than that recorded for
the community1,3.
An explanation o󰀨ered by researchers of the increase in fall risk, fall prevalence, and severity
of associated injuries in LTCI is that the population that lives in these places is less independent
and more frequently a󰀨ected by chronic diseases in comparison to elderly people who live in the
community1,5–9. They have also emphasized that the characteristics of the physical spaces, and even
the presence of sta󰀨 and other elderly people, make these environments di󰀨erent from homes and
can themselves be an additional risk factor5, increasing fear of possible new fall episodes.6
The problem begins from the moment elderly people are admitted to LTCIs. One out of ve
newly admitted residents fall during the rst few days after institutionalization10–11, and 56.2% of
the residents fall at least once a year8. Some elderly people are institutionalized when they are still
independent or show low levels of dependence, but losing their daily routine and not having the
obligation of doing a series of everyday activities, combined with losing condence in their ability to
carry out these activities after a fall episode, contribute to inactivity, reduction in physical tness, and,
consequently, increase in fall risk, morbidity, and mortality1,7–11.
Authors have recommended that evaluation of fall risk factors in institutionalized elderly people
follow a special approach and utilize fall risk assessment instruments that have been validated for
this specic context1,8,10, since identifying elderly people who are exposed to fall risks is the rst step
toward introducing preventive measures
1
. Despite this recommendation, the reality observed in LTCIs
is di󰀨erent. A study of teams in an LTCI concluded that professionals were familiar with instruments
for geriatric evaluation, but considered that, from the perspective of preventive care, using these
tools did not suit the residents’ reality11. This underestimation of the potential of these instruments to
prevent falls can contribute to nonuse or inadequate use of the tools1.
A study carried out in the community with caregivers showed that risks and mild secondary
injuries that follow falls were not always recognized as important by relatives, and that concern about
this type of accident manifested after it occurred12. Many elderly people and their caretakers ignore
fall risk factors and actions that can prevent fall episodes11–12.
Estimates regarding increased average life expectancy lead to prediction of an increase in
the number of elderly people who will live in LTCIs, and, consequently, in the number of falls and
associated costs4–5,8. This raises the question of whether the approach used in LTCIs is not su󰀩ciently
specic regarding individualization of fall risk factors and their association with tailored interventions
once risks are identied.
In face of the above scenario and of the fact that risk assessment is a deciding factor in the
control of this public health issue, the objectives of the present study were: a) describing the development
and validation of the Scale of Practices of Evaluation of Fall Risk Factors during Institutionalization of
Elderly People (SPERFI); and b) describing the practices of evaluation of communication of fall risks
to institutionalized elderly people.

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METHODS
This was a methodological study13–14.
A literature review was carried out to identify instruments used to evaluate fall risks in the
institutionalized elderly population1, rather than to measure the variable under discussion (practices
of caretakers in identication of fall risks present during the institutionalization period).
This latent variable is complex, which hinders its direct observation without involving mistakes.
Therefore, it was turned into an observable and mensurable measure13.
Given the lack of an instrument that measured the variable of interest, the present study resorted
to a predened protocol with the following steps: dening what should be evaluated; collecting data
in databases; observing the context; interviewing nurses and professionals in LTCIs; selecting the
material to dene the dimensions and items that would make up the scale; designing it; pretesting it;
reformulating it; applying it; and validating it13–14.
Consulting nurses who developed their professional activities in LTCIs and gathering data for
a population whose characteristics were similar to those of the population that was the object of the
study by means of observation and interviews with professionals allowed the authors to understand
the context. Over the course of one month, visits were paid to one LTCI, which had authorized the
presence of the researcher so the professionals’ practices could be observed. Notes and excerpts of
witnessed dialogues were recorded in a eld diary. Three nurses with experience in working in LTCIs
were consulted during this period to obtain clarication regarding organizational aspects of care and
identify resources the institution had or did not have, fall risks, and the level of importance given to
training in this topic.
Resorting to experts in the subject addressed by the tool to be produced and in the eld
of design and validation of measuring instruments was fundamental to complementarity between
theory and practice. As pointed out by some authors, collecting material for item selection is a mix
of interesting and boring work, science and art, and, therefore, researchers need help to do that14.
After these steps, an initial version of SPERFI was formulated, with 28 indicators. Only
statements were used, and the responses were scored on a ve-point Likert scale: 1 = “never” and
5 = “always.” Higher scores indicated better practices in risk evaluation13–14.
The population of the present study was professionals at six Portuguese LTCIs, which authorized
the implementation of the study in their facilities. The inclusion criteria for the sample were: being
an LTCI professional who was providing direct care to institutionalized elderly people (management
positions were excluded); and freely agreeing to participate in the study. The criterion of ve respondents
per item14 was applied, which resulted in a sample of 152 professionals. The reply rate was 65.52%
(232 instruments were distributed).
Once the rst version of the scale was ready, a discussion was carried out with six LTCI
professionals to test the target population’s understanding. The clarity criterion is closely related
to the item intelligibility. Consequently, and taking into account the low level of education of the
professionals who work in these institutions, the authors of the present study opted for short and
simple sentences14.
The respondents were asked to give their opinion of the clarity of the items, di󰀩culties with
understanding them, and di󰀩culties with completion of the instrument. This discussion allowed the
items to be improved by means of sharing of comments and verication of item intelligibility and Item
completion instructions13–14.

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The data collection instrument had two parts: the rst was intended for sociodemographic
characterization and the second was the scale itself.
Sociodemographic data included gender, age, time of professional practice (at the current
institution and in LTCIs in general), and professional training (previous and current).
Data collection occurred between October and December 2018, and the questionnaire was
self-administered (lled out by the participants without the presence of the researcher). Two ballot
boxes were placed in the institutions and kept there for 15 days, one for free and informed consent
forms and the other for completed instruments. This guaranteed participant anonymity. The boxes
were then collected by one of the researchers.
Data were treated statistically by using SPSS version 23.0. The construct validity was assessed
by applying exploratory factor analysis, with principal component extraction, Varimax orthogonal
rotation, and extraction of factors with values higher than one. Cattell’s scree plots were obtained to
conrm the number of factors to be extracted, and the Kaiser-Meyer-Olkin test (KMO) and Bartlett’s
index were used to measure the quality of correlations between the variables and test the validity of
the factor matrix. Internal consistency was evaluated by calculating Cronbach’s alpha13–14.
The practices were presented by using descriptive statistics, including calculation of absolute
and relative frequencies, and central tendency, dispersion, and variability measures.
To determine the relationship between practices of evaluation of fall risk factors to which
elderly people were exposed during institutionalization and some variables, parametric inferential
statistics were used, specically the Student’s t-test and Pearson’s correlation. Although not all
variables showed normal distribution (according to the Kolmogorov-Smirnov test) and homogeneity
of variance (according to Levene’s test), parametric statistics were applied by resorting to the central
limit theorem (n>30)14.
The present study was developed in the context of the project entitled Management of Fall
Risk in Institutions for Elderly People. It was approved by the Research Ethics Committee of the
Universidade Católica Portuguesa. The ethical principles described in the Declaration of Helsinki,
namely consent, privacy, and condentiality, were observed.
RESULTS
The sample was 152 LTCI professionals, all women. On average, they were 47.0 ± 10.3
years old, had been developing their professional practice for 13.1 ± 8.35 years, and had been
working at that specic institution for 11.9 ± 8.19 years. Only 32% had initiated their professional
career in this area after obtaining training that qualied them to perform the function, and 66.7%
acquired training over the period of professional practice. The duration of their training was: <50
hours (27%), 50 to 100 hours (11.9%), 100 to 150 hours (11.9%), 150 to 200 hours (11.1%), and
>200 hours (38.1%).
The version of the scale that was distributed to the participants had 28 items. Eight were
eliminated because they did not show statistical signicance (as indicated by Pearson’s correlations
lower than 0.20 and Cronbach’s alpha values for each item higher than the overall value). Therefore,
the nal number of items in the instrument was 20.
Internal consistency of the scale was expressed as α=0.949, considered excellent. None of
the items that were kept in the instrument showed Cronbach’s alpha values higher than the overall
value. The item/overall ratio ranged from 0.605 to 0.758 (Table 1).

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Table 1 – Pearson’s correlation of the items making up SPERFI and Cronbach’s alpha without the contribution
of each item. Lisbon, Portugal, 2018 (n=152).
Item number and content
Overall
Pearson’s
correlation
without the
item
Overall
Cronbach’s
alpha without
the item
1. I identify whether the elderly person has muscle strength .758 .945
2. I observe whether the elderly person has di󰀩culty walking .676 .947
3. I observe whether the elderly person has balance alterations .672 .947
4. I identify whether the elderly person has vision alterations .686 .946
5. I identify whether the elderly person has hearing alterations .665 .947
6. I identify whether the elderly person has alterations in their state of
consciousness .629 .947
7. I observe whether the elderly person is dependent in carrying out
activities of daily living .682 .946
8. I ask the elderly person if they are afraid to fall .694 .946
9. I evaluate whether the elderly person has sedentary behavior .605 .948
10. I observe whether the elderly person looks thin .680 .946
11. I verify whether the elderly person has foot problems .673 .947
12. I evaluate whether the elderly person has incontinence .627 .947
13. I verify whether the elderly person’s footwear is appropriate .716 .946
14. I verify that the elderly person’s clothing is neither too large nor
dragging on the oor .677 .946
15. I nd out whether the elderly person has chronic diseases .696 .946
16. Before taking action, I take time to dene fall risk factors .727 .946
17. I try to deepen my knowledge of the elderly person’s health problems .657 .947
18. I listen and talk to the elderly person about fall risk factors .666 .947
19. I communicate the identied fall risk factors to nurses .687 .946
20. I try to keep my knowledge of fall risks updated .705 .946
Total Cronbach’s alpha 0.949
Construct validity
Table 2 shows the results of factor analysis of the 20 items that make up the scale. By taking
into account interpretability and statistical criteria, it was found that the 20 items grouped into three
factors that accounted for 64.058% of variance. It must be emphasized that the KMO value of 0.88
(considered good
14
) and Bartlett’s sphericity with p<0.001 show that the factor analysis was satisfactory.
The good commonality values (from 0.498 to 0.791) were also noteworthy.
Table 2 – Principal component matrix after application of Varimax rotation to the 20 items that make up SPERFI.
Lisbon, Portugal, 2018 (n=152).
Item number and content H2 Factor 1 Factor 2 Factor 3
1. I identify whether the elderly person has muscle strength .681 .640
2. I observe whether the elderly person has di󰀩culty walking .748 .805
3. I observe whether the elderly person has balance alterations .701 .744

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Item number and content H2 Factor 1 Factor 2 Factor 3
4. I identify whether the elderly person has vision alterations .559 .493
5. I identify whether the elderly person has hearing alterations .498 .485
6. I identify whether the elderly person has alterations in their
state of consciousness .676 .758
7. I observe whether the elderly person is dependent in
carrying out activities of daily living .553 .573
9. I evaluate whether the elderly person has sedentary
behavior .603 .643
10. I observe whether the elderly person looks thin .564 .537
12. I evaluate whether the elderly person has incontinence .604 .540
15. I nd out whether the elderly person has chronic diseases .607 .625
8. I ask the elderly person if they are afraid to fall .513 .346
16. Before taking action, I take time to dene fall risk factors .716 .736
17. I try to deepen my knowledge of the elderly person’s health
problems .647 .737
18. I listen and talk to the elderly person about fall risk factors .594 .668
19. I communicate the identied fall risk factors to nurses .709 .773
20. I try to keep my knowledge of fall risks updated .691 .740
11. I verify whether the elderly person has foot problems .706 .756
13. I verify whether the elderly person’s footwear is appropriate .751 .756
14. I verify that the elderly person’s clothing is neither too large
nor dragging on the oor .791 .799
% of variance explained by factor 23.880 22.004 18.174
Total of explained variance 64.058
Kaiser-Meyer-Olkin measure .895
Bartlett’s Test of Sphericity 2,083.680
Taking into account the literature and the content of the items by factor, the following denominations
were given to the factors: F1 - practices of evaluation of biophysiological risk factors to which elderly
people are exposed (α=0.934); F2 - practices of communication and training (α=0.912); and F3 -
practices of evaluation of risks associated with putting on clothing and footwear (α=0.860).
Table 3 shows that the two items professionals evaluated more often out of the 20 included
in the scale were being dependent in carrying out activities of daily living (4.47 ± 0.83) and di󰀩culty
walking (4.44 ± 0.85). The indicators that were least frequently assessed were evaluation of fear of
falling (3.90 ± 1.15) and of vision alterations (3.91 ± 1.06).
The 20 items that make up SPERFI result in a score ranging from 20 to 100 points. The average
value obtained for the sample in the present study was 78.58 ± 19.46.
According to the results, communication and training were present during institutionalization
in the following areas: keeping knowledge of fall risk factors updated (4.23 ± 1.02); communicating
the identied risk factors to nurses (4.16 ± 1.17); deepening knowledge of the elderly person’s health
(4.12 ± .92); taking time to dene fall risk factors before taking action (4.01 ± 1.03); and listening and
talking to the elderly person about fall risk factors (4.01 ± 1.07).
Table 2 – Cont.

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Table 3 – Characterization of the sample regarding practices of evaluation of fall risk factors to which elderly
people are exposed during institutionalization. Lisbon, Portugal, 2018 (n=152).
Item number and content
Average
SD
1. I identify whether the elderly person has muscle strength 4.11 1.03
2. I observe whether the elderly person has di󰀩culty walking 4.44 .85
3. I observe whether the elderly person has balance alterations 4.32 .85
4. I identify whether the elderly person has vision alterations 3.91 1.06
5. I identify whether the elderly person has hearing alterations 3.93 1.08
6. I identify whether the elderly person has alterations in their state of consciousness 4.34 .97
7. I observe whether the elderly person is dependent in carrying out activities of daily living 4.47 .83
10. I observe whether the elderly person looks thin 4.07 1.04
12. I evaluate whether the elderly person has incontinence 4.15 1.05
15. I nd out whether the elderly person has chronic diseases 4.22 1.04
8. I ask the elderly person if they are afraid to fall 3.90 1.15
16. Before taking action, I take time to dene fall risk factors 4.01 1.03
17. I try to deepen my knowledge of the elderly person’s health problems 4.12 .92
18. I listen and talk to the elderly person about fall risk factors 4.01 1.07
19. I communicate the identied fall risk factors to nurses 4.16 1.17
20. I try to keep my knowledge of fall risks updated 4.23 1.02
11. I verify whether the elderly person has foot problems 3.95 1.12
13. I verify whether the elderly person’s footwear is appropriate 4.06 1.04
14. I verify that the elderly person’s clothing is neither too large nor dragging on the oor 4.13 1.06
Total 78.53
19.46
Factor 1 (practices of evaluation of biophysiological risk factors) 41.96 9.84
Factor 2 (practices of communication and training) 24.43 6.39
Factor 3 (practices of evaluation of risks associated with putting on clothing and footwear) 12.14 3.23
SD = standard deviation
No signicant statistical correlation was found between practices, age, and time of professional
practice (p≤0.05).
The professionals who took a training course concomitantly to the development of their
professional activities carried out correct practices more often. However, this di󰀨erence was not
statistically signicant (Table 4).
Table 4 – Results of application of Student’s t-test regarding practices and frequency of training courses taken
when the professional’s career was already in progress. Lisbon, Portugal (n=152).
Scales/course during
professional practice N* Average SD t†p§
SPERFI – Factor 1 yes 94 46.98 8.12 1.736 .085
no 43 44.41 7.86
SPERFI – Factor 2 yes 95 24.87 5.03 1.011 .314
no 48 23.95 5.25
SPERFI – Factor 3 yes 98 12.42 2.92 1.515 .132
no 46 11.65 2.69
SPERFI – Total yes 98 84.47 15.00 .886 .377
no 46 82.07 11.65
*N = number; †t = Student’s t-test; SD = standard deviation; §p = signicance probability value

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DISCUSSION
Studies about recognition of the importance of fall risk factors by caregivers of institutionalized
elderly people were not found in the literature. The scale designed and validated in the present study
is an alternative to measure these types of practices and allows evaluation of interventions by teams
and/or training oriented toward systematizing fall risk assessment in LTCIs.
The internal consistency of the 20 items in the scale (α=0.949) conrmed their accuracy and
indicated the instrument’s ability to measure practices of evaluation and communication of fall risks
to which institutionalized elderly people are exposed.
Recognizing the importance of fall risks by applying valid instruments that have predictive
capacity is key to determining which elderly people will fall1,15. However, their use must be associated
with the recognition of the importance of these risks by caretakers, so the decisions about preventive
measures to be introduced is a central element in fall prevention programs in LTCIs1,15.
The scale produced and validated in the present study has three factors that allow evaluation
of practices of fall risk assessment. These factors are related, not only to biophysiological risks and
risks related to the self-care activity of putting on clothing and footwear, but also to practices of
communication and training. Comparison of the values obtained in the scale domains with the total
possible value showed that practices were carried out frequently, but neither always nor by all team
members.
Regarding biophysiological risk factors, professionals favored evaluation of gait capacity,
balance, and being dependent in the execution of activities of daily living, which showed the perception
that these are the main risk factors for falls5,7,8 and those that most inuence the delivery of care of
elderly people16. The reasoning behind this is that the greater their dependence, the greater the need
for replacement and support in the fulllment of activities of daily living. Future studies must explore
the relationship between recognition of the importance of fall risks, care organization, and evolution
of elderly people’s functioning during institutionalization.
The data mentioned above reinforced what is described in the literature: Alterations in gait and
balance are perceived by caregivers as being worrying risk factors to which they pay special attention12.
Exploring how the perception of risk by caregivers a󰀨ects their practices regarding promoting
independence and participation of elderly people in social and leisure activities in LTCIs was not an
objective of the present study. However, other studies have warned that caretakers, out of fear of the
consequences of falls, tend to overprotect elderly people, making them more passive and limiting
their participation and decision-making in their self-care6,11–12,17.
A study carried out with people living in the community concluded that caregivers, especially
those who looked after their parents, experienced di󰀩culties communicating fall risks to care receivers,
who felt annoyed and were under the impression that caretakers wanted to control them when warnings
about fall risks were given repeatedly12.
Analysis of communication practices in the sample in the present study showed that there was
concern about obtaining information on fall risk factors during institutionalization and communicating
that information to members of work teams, namely health professionals. These results corroborated
the ndings of a study which reported that fall risk factors were always discussed by the teams in
38.8% of the situations. For preventive measures and decisions regarding the preventive measures
to be applied, these numbers were 31.6% and 33.6% of the professionals, respectively17.
Communication, as well as organizational policies, leadership, and training of all professionals,
is a crucial element in reducing prevalence of fall episodes
10,17–20
. An international study whose objective
was evaluating the e󰀩cacy of a fall prevention curriculum demonstrated that associating training of
teams and communication about fall risks in the elderly population was e󰀨ective in decreasing fall

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prevalence18. This is evidence that practices of communication and training in LTCIs must be always
maintained to guarantee the safety of institutionalized elderly people.
Communicating with health professionals, mainly nurses, is important because they play
a major role in detecting and minimizing risks
21
. Investment in professional training must include
development of intra-team communication skills, including elderly people and giving them special
attention, because these competencies can help residents express their concerns regarding falls.
Educating professionals about factors related to fall occurrence is a way to show their importance in
controlling this type of accident. Additionally, it favors the understanding that risk assessment must
be combined with preventive interventions to ensure the safety of elderly people19,22.
It must be emphasized that the indicator that got the lowest score in the second domain of the
scale was “I ask the elderly person if they are afraid to fall,” which may have indicated nonrecognition of
fear as a risk factor. Fear is an invisible risk, not measurable by observation, and, when not addressed
by means of questions, goes unnoticed. However, it is present in LTCIs. Around 88% of elderly people
who fall are afraid of experiencing a new episode23.
Fear can become a vicious cycle for both elderly people and caregivers: When a fall episode
happens, elderly people become apprehensive, restrict their movements, and, consequently, decrease
their balance and mobility, predisposing themselves to fall again23–24. Caregivers, in turn, out of fear
that the rst event will be followed by other episodes, seek to preventively limit some activities that
were carried out by elderly people before and replace them, which increases their dependence12,23.
This vicious cycle has to be dealt with in LTCIs, where the presence of health technicians,
employees, and other elderly people can introduce variables di󰀨erent from those found in the community
and hospitals20.
The indicators for the third factor of the scale are related to putting on clothing and footwear.
It should be stressed that the eight indicators that did not show statistical signicance to integrate
this scale were part of other spheres of self-care. The three indicators that were kept in the scale
addressed gait capacity and safe mobility of elderly people. Alterations in bipedal support, inappropriate
footwear, and clothes that are too tight or too loose a󰀨ect safe mobility and independence to carry
out activities of daily living3,4,5,8,24.
The present study found that obtaining training over the period of professional practice has a
positive impact on practices of evaluation of biophysiological risk factors in the elderly population. This
result corroborated other studies that pointed to leadership, teamwork, and training as key elements
to bring together risk assessment and individualization of preventive measures11,17,25.
The present study had limitations related to intentional choice of institutions and sampling.
Consequently, generalization of its results is not possible. The instrument type (with indicators designed
as statements) and data collection method (the fact that the deadline to complete the scale was 15
days) may have led respondents to provide answers that they felt were socially acceptable.
Despite these limitations, the scale allows a description of the practices of risk assessment
and can facilitate control of fall risk factors, if the results obtained by the scale are combined with
preventive measures.
The authors of the present study share in the opinion of other authors that the increase in the
elderly population and the number of institutionalized elderly people make it economically and morally
reasonable to try to preserve their abilities. Therefore, understanding how caregivers perceive fall risk
factors and measures to prevent this type of accident, and investing in their education so evidence-
based preventive measures can be applied, allow improvement of their ability to provide good care
of elderly people and foster good quality of life for those who are more vulnerable19,22.

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CONCLUSION
The good psychometric characteristics of the Scale of Practices of Evaluation of Fall Risk
Factors during Institutionalization of Elderly People, which had a Cronbach’s alpha of 0.949 for its 20
items, reect its potential to evaluate the latent variable.
Factor analysis showed that the scale had three practice domains: evaluation of biophysiological
risk factors to which elderly people are exposed (α=0.934); communication and training (α=0.912);
and evaluation of risk associated with putting on clothing and footwear (α=0.860). Comparison of
the value calculated for each scale item with the possible total value allowed the conclusion that the
practices were carried out frequently, but neither always nor by all members of teams.
Future studies must associate the total score on the scale total and the score for each
dimension with the prevalence of falls in institutions and their recurrence. It is also recommended that
assessment of the e󰀨ectiveness of fall prevention programs invest resources focused on the scale’s
second dimension (practices of communication and training), aiming to measure them and combine
them with other practices.
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NOTES
ORIGIN OF THE ARTICLE
Original article of the project “Management of fall risks in institutions for elderly people”, linked to the
Center for Innovative Care and Health Technology (2018-2022).
CONTRIBUTION OF AUTHORITY
Study desing: Baixinho CL, Dixe MA.
Data collection: Baixinho CL, Dixe MA.
Data analysis and interpretation: Baixinho CL, Dixe MA.
Results discussion: Baixinho CL, Dixe MA.
Manuscript writing and/or critical review of its content: Baixinho CL, Dixe MA.
Review and approval of the manuscript nal version: Baixinho CL, Dixe MA.
APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research with Human Beings of the Universidade Católica
Portuguesa as per report Ref. ICS/268/2012.
CONFLICT OF INTEREST
There are no conicts of interests.
EDITORS
Associated Editors: Selma Regina de Andrade, Gisele Cristina Manfrini, Natália Gonçalves, Ana
Izabel Jatobá de Souza.
Editor-in-chief: Roberta Costa.
HISTORICAL
Received: July 17, 2020.
Approved: December 08, 2020.
CORRESPONDING AUTHOR
Cristina Rosa Soares Lavareda Baixinho
crbaixinho@esel.pt