Understanding the Hendrich II Fall Risk Model: Which falls assessment tool assesses a patient's risk of falling based on their history of falls, medications, continence, mobility, and mental status?

According to the CDC, over one in four adults age 65 and older fall each year, with many injuries leading to emergency department visits. Healthcare professionals use specialized tools to identify at-risk individuals, and a key example is the Hendrich II Fall Risk Model, a tool that assesses a patient's risk of falling based on specific criteria.

Quick Summary

The Hendrich II Fall Risk Model is a comprehensive tool that assesses a patient's fall risk by evaluating key factors like mental status, mobility, medications, elimination (continence), and specific risk indicators like dizziness and male gender.

Key Points

• Hendrich II is Multifactorial: The model assesses risk based on a combination of factors including mental status, medications, continence, and mobility, offering a more complete picture of a patient's vulnerability.

• Specific Criteria are Key: Unlike more general tools, Hendrich II specifically evaluates factors like altered elimination (continence) and certain high-risk medications (antiepileptics, benzodiazepines).

• Get-Up-and-Go Test is Included: Mobility is directly assessed through the observational 'Get-Up-and-Go' test, which provides immediate insight into a patient's balance and functional ability.

• Scoring Guides Interventions: A score of 5 or higher on the Hendrich II indicates high risk, prompting the healthcare team to implement specific, tailored fall prevention interventions.

• Clinical Judgment is Paramount: While the tool provides a useful score, it should always be used alongside expert clinical judgment to create the most effective, individualized care plan.

• Designed for Acute Care: The Hendrich II model was developed for quick, efficient use in hospitals, though it can be adapted to other settings with clinical insight.

Introduction to Fall Risk Assessment

For older adults and those with complex health conditions, identifying the risk of falling is a critical aspect of safe and effective care. A fall can lead to significant injury, decreased mobility, and a loss of confidence, negatively impacting a person's quality of life. The challenge for healthcare providers lies in using a standardized, efficient, and accurate tool to assess these risks across various clinical settings. While several tools exist, few offer the multifactorial approach required to capture the full picture of a patient's vulnerabilities.

The Hendrich II Fall Risk Model

Developed to be a quick and effective screening instrument, the Hendrich II Fall Risk Model (HIIFRM) is widely utilized in acute care hospitals. It moves beyond just a simple history of falling to include additional physiological and cognitive factors that are known to contribute to a patient's risk. The model's strength lies in its ability to be administered efficiently, even at the bedside, making it a practical choice for busy hospital environments. A total score is calculated based on the sum of points from several weighted categories, which then categorizes a patient's risk level, guiding subsequent preventative interventions.

Key Components Assessed by the Hendrich II Model

The Hendrich II model systematically evaluates a patient based on seven specific risk factors, each assigned a weighted score.

• Mental Status (Confusion, Disorientation, Impulsivity): A patient's cognitive state significantly impacts their fall risk. Impulsivity, confusion, or disorientation can lead to poor judgment regarding their physical limitations, increasing the likelihood of an unassisted movement and subsequent fall. This factor receives a weighted score of 4 points.

• Altered Elimination (Continence): Issues with continence, specifically the need for frequent or urgent toileting, can prompt a patient to rush to the bathroom, increasing the risk of a fall. The model acknowledges this by assigning a score of 1 point to this factor.

• Medication Use (Antiepileptics & Benzodiazepines): Certain medications are known to increase fall risk due to side effects such as drowsiness, dizziness, or altered balance. The Hendrich II model specifically scores the use of antiepileptics (2 points) and benzodiazepines (1 point), which are known to affect cognitive and motor function.

• Mobility (Get-Up-and-Go Test): A patient's mobility is directly assessed using the 'Get-Up-and-Go' test. This is a practical, observational component of the tool that assesses the patient's ability to rise from a chair. The scoring for this test ranges from 0 to 4 points, depending on the patient's performance.

• Additional Risk Factors: The model also includes several other critical indicators:

  • Dizziness or Vertigo (1 point): Feelings of unsteadiness or spinning can compromise balance and lead to a fall.
  • Symptomatic Depression (2 points): Depression can be associated with decreased energy, cognitive impairment, and lack of motivation, all of which can increase fall risk.
  • Male Gender (1 point): Though the rationale is complex and debated, male gender is included as a specific risk factor in the model, though clinical judgment is always paramount.

Comparison with Other Fall Risk Tools

Feature	Hendrich II Fall Risk Model	Morse Fall Scale (MFS)
Inclusivity of Factors	Mental Status, Altered Elimination, Medications, Mobility, Dizziness, Depression, Gender	History of Falls, Secondary Diagnosis, Ambulatory Aid, IV/Heparin Lock, Gait, Mental Status
Continence Assessment	Directly addresses via "altered elimination."	Indirectly addressed, if at all.
Medication Specificity	Focuses on specific classes (antiepileptics, benzodiazepines).	More general, addresses 'secondary diagnosis' which can relate to medication side effects.
Mobility Assessment	Includes an observational 'Get-Up-and-Go' test.	Assesses gait and use of ambulatory aids.
Setting	Developed for use in acute care settings.	Primarily used in acute care and long-term care settings.
Ease of Use	Considered quick and efficient for bedside use.	Simple scoring system, very popular for quick screening.

Interpreting the Results and Implementing Interventions

After administering the Hendrich II and summing the points, a total score is calculated. A score of 5 or higher indicates a high risk for falling. Based on this risk stratification, a tailored care plan can be developed. Interventions may include:

1. Environmental Modifications: Ensuring the patient's room is free of clutter, call bells are within reach, and lighting is adequate.
2. Medication Review: Consulting with a pharmacist to identify and potentially adjust or discontinue medications that increase fall risk.
3. Physical Therapy: Ordering a physical therapy consultation to address specific mobility deficits, balance issues, and gait training.
4. Assisted Mobility: Providing appropriate ambulatory aids and ensuring the patient uses them consistently.
5. Continence Management: Implementing regular toileting schedules to address altered elimination patterns.
6. Cognitive Support: Engaging staff to provide clear, simple instructions and orienting confused patients to their surroundings.
7. Patient and Family Education: Educating the patient and family about the identified risks and how to participate in the fall prevention plan.

Healthcare teams must not rely solely on the numerical score but use it in conjunction with their expert clinical judgment. For instance, a patient with a history of falls might warrant heightened attention even with a low score from a specific tool. For further information and guidelines on fall prevention, the Centers for Disease Control and Prevention provides comprehensive resources through their STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative, a useful program for clinicians. Learn more about CDC's initiative at cdc.gov/steadi.

Limitations and Clinical Considerations

While the Hendrich II Fall Risk Model is a valuable instrument, it is not without limitations. No single tool is perfect, and healthcare providers must be mindful of a few key points. The model was primarily developed for acute care settings and may not be as sensitive or predictive in other environments like long-term care or community living. Furthermore, some studies suggest that while instruments like Hendrich II can have high specificity (good at identifying those not at risk), their sensitivity (identifying those who will fall) can vary. The true power of any assessment tool lies in its ability to initiate proactive and customized intervention strategies, not simply in providing a score.

Conclusion

The Hendrich II Fall Risk Model provides a robust and multifactorial approach for assessing a patient's risk of falling in an acute care setting. By systematically evaluating factors such as medication use, mental status, continence issues, and mobility, healthcare professionals can move beyond generic fall precautions to implement targeted, effective interventions. Acknowledging the role of clinical judgment alongside standardized tools is essential for developing comprehensive and person-centered fall prevention strategies that significantly improve patient safety and outcomes.

Frequently Asked Questions

What is the primary purpose of the Hendrich II Fall Risk Model?

The primary purpose of the Hendrich II Fall Risk Model is to quickly and effectively screen hospitalized patients to identify their risk of falling, enabling healthcare staff to implement appropriate preventative measures.

How does the Hendrich II model incorporate medication use into the assessment?

The Hendrich II model specifically factors in the use of certain high-risk medications, such as antiepileptics and benzodiazepines, which are known to increase the likelihood of falls due to side effects like dizziness and altered mental status.

Does the Hendrich II tool specifically assess continence?

Yes, the Hendrich II model includes a specific item for "altered elimination," which directly addresses issues related to continence, as the urgency and frequency of needing to use the restroom are significant fall risk factors.

What does the 'Get-Up-and-Go' test measure within the Hendrich II?

The 'Get-Up-and-Go' test is an observational component of the Hendrich II model that assesses a patient's mobility, balance, and stability while rising from a chair, walking a short distance, and returning to a seated position.

How is a patient's mental status evaluated in the Hendrich II model?

The Hendrich II assesses mental status by evaluating for confusion, disorientation, or impulsivity, as these cognitive impairments can lead to poor judgment and an inability to follow safety instructions.

Why is a patient's history of falls considered in a falls assessment tool?

A patient's history of falls is a strong predictor of future falls. Although not a scored item in the Hendrich II tool itself, a history of falls is a primary screening question that would prompt further investigation using a tool like the HIIFRM.

Can the Hendrich II Fall Risk Model be used in non-hospital settings?

While developed for acute care settings, the principles of the Hendrich II model can be adapted for other environments like long-term care or community settings, but its predictive value may vary. Clinical judgment is always essential.