Last Updated on October 30, 2023
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 | |
