Comprehensive Fall Risk Assessment in an Older Adult Male with Diabetes Mellitus, Hypertension, and a History of Transient Ischemic Attack Using the Morse Fall Scale and Berg Balance Test: A Case Report

Ummi Malikal Balqis; Rizkiyani Istifada; Agnestria Winarto; Lailiyatul Munawaroh

doi:10.58545/jrcnp.v4i1.666

Authors

Ummi Malikal Balqis Faculty of Nursing, Universitas Jember, Indonesia https://orcid.org/0000-0001-9602-8363
Rizkiyani Istifada Faculty of Nursing, Universitas Jember, Indonesia https://orcid.org/0000-0002-0230-9592
Agnestria Winarto Faculty of Nursing, Universitas Jember, Indonesia https://orcid.org/0000-0001-6534-7871
Lailiyatul Munawaroh Faculty of Nursing, Universitas Jember, Indonesia https://orcid.org/0009-0008-6815-8775

DOI:

https://doi.org/10.58545/jrcnp.v4i1.666

Abstract

Background: Fall risk in older adults is a multifactorial condition associated with balance impairment, muscle weakness, and chronic as well as neurological diseases, requiring a comprehensive assessment. Purpose: This case report aims to analyze fall risk in an older adult with chronic comorbidities using the Morse Fall Scale (MFS) and the Berg Balance Test (BBT). Method: A descriptive case study was conducted on a 70-year-old older adult male with a history of diabetes mellitus, hypertension, and a transient ischemic attack (TIA) in 2025, accompanied by left upper extremity weakness with a muscle strength of 4. Assessment was performed through direct clinical examination using the MFS and BBT instruments. Results: The patient scored 35 on the MFS, indicating a moderate fall risk, and 38 out of 56 on the BBT, indicating moderate balance impairment, particularly in dynamic activities. Conclusions: These findings suggest that the patient’s fall risk is influenced by a combination of post-TIA neurological factors, muscle strength imbalance, and chronic diseases. The combined use of the MFS and BBT provides a comprehensive overview of fall risk, serving as a basis for planning targeted and sustainable nursing interventions.

Keywords:

Older adult, Fall risk, Morse Fall Scale, Berg balance test, TIA

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