Currently used scoring system is modified Hendrich Fall Risk Score and is termed as Hendrich II Fall Risk Model.
It takes into account following parameters and assigns a score to each parameter. The final score is calculated by addition of all individual scores.
Here is a brief outline
| Confusion, disorientation,impulsivity |
4 |
| Symptomatic Depression |
2 |
| Altered Elimination |
1 |
| Dizziness, Vertigo |
1 |
| Male Gender |
1 |
| Any administered antiepileptics |
2 |
| Any administered benzodiazepines |
1 |
| Get Up & Go Test | |
| Able to rise in a single movement-No loss of balance with steps |
0 |
| Pushes up, successful in one attempt |
1 |
| Multiple attempts but successful |
2 |
| Unable to rise without assistance during test |
3 |
| A score of 5 or greater=High risk | |
Confusion and Disorientation
If any or all of the following are present, the patient receives a score of 4 for this risk factor:
- Impulsive or unpredictable behavior
- Hallucinations
- Agitation
- Changes in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycles
- Unrealistic, inappropriate, or unusual behavior
- Disorientation to person, place, or time
- Inability to follow directions or retain instructions in self-care or activities of daily living
Depression
Depression is assigned a score of 2.
[A patient of diagnosed depression who isn’t displaying symptoms doesn’t receive a positive score-the depression is considered to be under therapeutic control.]
- Prolonged feelings of helplessness, hopelessness, or being overwhelmed
- Tearfulness
- Flat affect or lack of interest
- Loss of interest in life events
- Melancholic mood
- Withdrawal
- The patient’s statement of depression
Altered Elimination
Score of 1 in following cases
- Urinary or fecal incontinence
- Urgency or stress incontinence
- Diarrhea
- Frequent urination
- Nocturia
Dizziness or vertigo, male sex, medications antiepileptics and benzodiazepines, each receive score of 1.
For the patient to receive a positive score, one of these drugs must be administered.
Get Up and Go Test
Get up and go test scores range from 0 to 4 based on the patient’s ability to rise from a seated position as shown in the table at the beginning of the article.
Total Score and Interpretation
The individual score is added to calculate the final score. A total score of 5 or more puts the patient into a high-risk category.
Original Hendrich Fall Risk Score
Just for the mention, here is a brief summary of original Hendrich Fall Risk Score
| Hendrich Fall Risk Assessment | ||
| Risk Factor |
Scale |
Score |
| Recent History of Falls | Yes | 7 |
| No | 0 | |
|
Altered Elimination (incontinence, nocturia, frequency) |
Yes | 3 |
| No | 0 | |
|
Confusion / Disorientation |
Yes | 3 |
| No | 0 | |
|
Depression |
Yes | 4 |
| No | 0 | |
|
Dizziness / Vertigo |
Yes | 3 |
| No | 0 | |
|
Poor Mobility / Generalized Weakness |
Yes | 2 |
| No | 0 | |
|
Poor Judgment (if not confused) |
Yes | 3 |
| No | 0 | |
