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 | |
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