Falls are a major concern in hospitalized patients, particularly in older adults and those with frailty.¹⁾ Falls can result in a range of negative outcomes, including fractures and head injuries, leading to longer hospital stays and significant morbidity and mortality.²⁾ Moreover, falls can cause psychological distress, fear of falling, and a loss of confidence in one’s ability to move safely.²⁾ Falls also create a significant burden on healthcare systems by increasing healthcare costs and diverting resources from other areas of care.^3,4) Therefore, it is crucial to screen patients who are at high risk of falling and implement preventive measures in a hospital setting.

The Morse Fall Scale (MFS), developed in 1986, is a widely used tool in healthcare settings to assess a patient’s risk of falling.⁵⁾ It considers six factors: history of falling, current medications, mobility, mental status, presence of equipment (such as intravenous lines or catheters), and age. Each factor is assigned a score, and the total scores determine a patient’s overall fall risk. The MFS is one of the most commonly used screening tools for high fall risk in hospitalized patients; however, the optimal cutoff value remains controversial.^6,7) Furthermore, studies have shown that the screening value of MFS might be insufficient.^8,9)

Falls are considered a geriatric syndrome, a condition closely related to frailty,¹⁰⁾ which is a state of increased vulnerability and reduced physiological reserves due to the accumulation of aging processes in older adults.^11,12) Numerous studies have demonstrated a higher risk of falls among hospitalized patients with frailty.^13,14) Consequently, it may be logical to screen patients for frailty to more effectively predict and prevent falls. Indeed, the MFS itself includes items reflecting the spectrum of frailty, such as a history of falls, mobility, mental status, and age.

Among the tools to assess frailty, the Clinical Frailty Scale (CFS), with scores ranging from 1 (very fit) to 9 (terminally ill), has been widely used in various clinical settings.¹⁵⁾ In acute medical conditions, the CFS is generally applied to assess a patient’s baseline functional status 2 weeks before they fall ill.¹⁶⁾ Meanwhile, the at-point CFS, which incorporates the baseline functional status and severity of an acute illness, can assess the health status of patients at the time of evaluation.^16,17) A previous study showed that at-point CFS predicted various adverse health outcomes, such as falls, in hospitalized patients aged >65 years.¹⁷⁾ However, despite the general applicability of frailty in younger and middle-aged adults,^18,19) no study has established the efficacy of the CFS as a screening tool for falls in this population. Hence, we aimed to assess the screening ability of the at-point CFS and MFS in identifying hospitalized adults aged >18 years at high risk for falls.

In this comparative study, we aimed to assess the screening ability of the at-point CFS and MFS to identify hospitalized adults with high risk of falls. We found optimal cutoff points of 5 and 45 for the at-point CFS and MFS, respectively. Although the at-point CFS had higher explanatory power than the MFS, the AUC values did not differ significantly between the two tools. To our knowledge, this is the first study to compare the screening values of the at-point CFS and MFS in an acute-care hospital.

In this study, we used the at-point CFS, which is different from the original CFS that reflect baseline health status. However, our findings are consistent with those of previous studies that reported the optimal cutoff point for CFS in determining frailty status.²³⁾ Our current observations are also concordant with our previous report showing that a cutoff point of 5 for the at-point CFS can predict various geriatric adverse events such as pressure ulcers, delirium, longer duration of hospitalization, unexpected emergency department visits after discharge, and institutionalization after discharge in hospitalized patients aged ≥65 years.¹⁷⁾ This consistency lends further credibility to our results and suggests that the at-point CFS may serve as a useful tool for predicting fall risk among hospitalized adults.

Falls are the result of a complex system failure rather than a single cause, making them a component of geriatric syndromes, which are multifactorial health conditions that arise from accumulated impairments in multiple systems.^10,24) Frailty is a common and important geriatric syndrome that is closely associated with falls.²⁵⁾ Physical frailty, characterized by a decline in physical function and muscle strength, can lead to a loss of balance and increased risk of falls.²⁶⁾ Furthermore, falls are often a consequence of the inability to perform multiple tasks due to cognitive decline and inability to integrate sensory inputs.²⁴⁾ Polypharmacy, another phenotype that reflects deficits in systemic integrity, is also an important risk factor for falls.²⁷⁾ Various studies have demonstrated that frailty is an important risk factor for falls among different populations.^26,28,29) Hence, falls result from a systemic failure, a concept that may be applicable not only to older adults but also to younger populations.

The CFS is a simple and rapid tool for assessing frailty and has shown promising results in predicting falls. Church et al.²³⁾ showed the predictive ability of CFS in 71% of fall cases in a scoping review. Hatcher et al.³⁰⁾ demonstrated that the CFS score at admission predicted readmission for falls after trauma-related injuries. The Center for Effective Practice recommends the CFS as a screening tool to evaluate the risk of falls in community-dwelling adults.³¹⁾ Jung et al.¹⁷⁾ showed that an at-point CFS ≥5 was associated with an increased risk of falls, with an odds ratio of 1.74 in older hospitalized patients. However, none of the studies utilized the at-point CFS in acute medical conditions in populations including young adults.

The MFS is a tool commonly used to assess fall risk among hospitalized patients; however, it has several limitations compared to those of the CFS. One major advantage of the CFS is because it was initially developed to evaluate frailty, it can predict a wide range of geriatric syndromes other than falls, including outcomes such as delirium and pressure ulcers.^17,23,32) In contrast, the MFS measures only the risk of falls, although some of its components include a range of frailties, such as a history of falls and cognitive function. Another limitation of the MFS is the burden to ask six questions to every individual, whereas the CFS requires only one question. Furthermore, the accuracy and cutoff score of the MFS are controversial, as previous studies have shown mixed results.^8,9)

One of the key strengths of this study was its comparative approach, which allowed for a more comprehensive assessment of the at-point CFS and MFS to identify hospitalized adults with a high risk of falls. To our knowledge, this is the first study to compare the screening values of the two assessment tools in an acute-care hospital setting, making the result an important contribution to the existing literature. Furthermore, our findings are consistent with previous research on the optimal CFS cutoff points for determining frailty status, providing further support for the at-point CFS as a valuable screening tool for fall risk. Additionally, our study builds on prior research by demonstrating the ability of the at-point CFS to predict various geriatric adverse events, further highlighting its potential clinical utility.

Despite its strengths, our study had several limitations. First, this study was conducted in a single acute-care hospital, which might limit the generalizability of our results to other healthcare settings and patient populations. Second, although we found no significant differences in AUC values between the assessment tools, the sample size might not have been sufficient to detect subtle differences in their predictive abilities. Third, our study did not evaluate other potentially relevant risk factors of fall such as clinical, environmental, or situational factors, which could have provided additional insights into the most effective strategies for fall prevention and intervention. Fourth, only two participants aged <60 years experienced falls, which might appear insufficient. However, as younger patients are less prone to falls, this situation was unavoidable. As shown in Supplementary Fig. S3, the exclusion of younger participants from the analysis did not affect the overall results. Finally, the inclusion of two distinct groups assessed by emergency room nurses and experienced geriatric nurses could potentially affect the reliability of the at-point CFS measurement. However, the results of the subgroup analysis comparing these two groups showed that this factor did not significantly affect the main results. Nonetheless, further investigations are needed in future studies.

In conclusion, the results of our study demonstrated that the at-point CFS is an effective tool for identifying fall risk among hospitalized adults, with a performance comparable to that of the MFS. Therefore, the at-point CFS may be a valid screening tool for fall risk in hospitalized adults.