Understanding Fall Risk Assessment Scores
A fall risk assessment is a clinical tool used by healthcare professionals to evaluate an individual's likelihood of experiencing a fall. The results help caregivers implement appropriate preventive measures. Because multiple scales are in use, there is no single 'highest score.' The Morse Fall Scale (MFS) and the Hendrich II Fall Risk Model are two of the most common and illustrate the variation in scoring.
The Morse Fall Scale (MFS): Highest Score of 125
Developed in the 1980s, the MFS is a widely used tool for assessing patient fall risk, particularly in hospital and nursing home settings. It evaluates six key factors and assigns a point value to each. The scores are added together, resulting in a total score that ranges from 0 to 125. A higher score indicates a greater risk of falling.
MFS Scoring and Interpretation
- Low Risk: A score of 0-24 is considered minimal to low risk.
- Moderate Risk: A score of 25-45 indicates a moderate risk for falls, and healthcare providers should give extra attention to the patient.
- High Risk: A score of 46 or higher (up to the maximum of 125) signifies a high risk of falling and requires the implementation of high-risk fall prevention interventions.
Components of the Morse Fall Scale
- History of falling: Past falls are a strong predictor of future falls. A fall within the last three months adds 25 points.
- Secondary diagnosis: If a patient has more than one medical diagnosis, it increases their risk. This adds 15 points.
- Ambulatory aid: The type of assistance a patient uses for walking, or their lack thereof, impacts their score. Using crutches or a cane adds 15 points, while relying on furniture adds 30.
- IV or Heparin lock: These can interfere with movement and are a potential hazard, adding 20 points.
- Gait: A patient's manner of walking is assessed. A weak gait adds 10 points, while an impaired gait (shuffling, poor balance) adds 20.
- Mental status: This evaluates the patient's understanding of their own physical limitations. If they overestimate their abilities, 15 points are added.
The Hendrich II Fall Risk Model: Highest Score of 16
Unlike the MFS, the Hendrich II Fall Risk Model focuses on eight independent risk factors for anticipated physiological falls. Each factor is assigned a specific point value, and the sum of the points determines the patient's risk level. The highest possible score on this model is 16.
Hendrich II Scoring and Interpretation
In the Hendrich II model, a patient with a total score of 5 or higher is considered at high risk for falling. The tool also incorporates the 'Get-Up-and-Go' test to assess mobility, which adds a variable score to the total.
Comparison of Different Fall Risk Scales
This table provides a concise overview of the scoring differences between several common fall risk assessments.
| Assessment Tool | Maximum Score | Cutoff for High Risk | Setting | Key Factors |
|---|---|---|---|---|
| Morse Fall Scale (MFS) | 125 | 45 or higher | Inpatient (hospital, nursing home) | History of falls, secondary diagnosis, ambulatory aid, gait, mental status, IV therapy |
| Hendrich II Model | 16 | 5 or higher | Inpatient (acute care) | Confusion, depression, elimination, dizziness, gender, medication, 'Get-Up-and-Go' test |
| STRATIFY | 5 | 2 or higher | Inpatient (geriatric, hospital) | History of falls, agitation, visual impairment, incontinence, transfers/mobility |
| Johns Hopkins Fall Risk Assessment Tool (JHFRAT) | 35 | 14 or higher | Inpatient (hospital) | Age, fall history, medications, mobility, cognitive status, elimination |
Mitigating Fall Risk Based on Assessment
Regardless of the specific assessment tool used, a high score signals the need for intervention. Caregivers and individuals can work together on a fall prevention strategy. Here are a few common steps:
- Conduct a Home Safety Assessment: Identify and remove potential hazards like loose rugs, clutter, and poor lighting.
- Review Medications: Discuss any medications that cause drowsiness, dizziness, or confusion with a doctor or pharmacist, as these can increase fall risk.
- Incorporate Balance Exercises: Physical therapy can be instrumental in improving strength and balance. The Centers for Disease Control and Prevention (CDC) offers a range of exercise resources, which can be found on their website.
- Manage Health Conditions: Conditions like vision problems, osteoporosis, or foot pain should be managed to reduce fall risk. Regular checkups can help address these issues.
- Utilize Mobility Aids: For those with impaired mobility, using appropriate aids like canes, walkers, or wheelchairs can significantly improve safety.
Conclusion: No Single Highest Score
In summary, the highest score on a fall risk assessment is not a fixed number across all tools. The most widely cited maximum is 125 for the Morse Fall Scale, but other respected tools like the Hendrich II have much lower maximums. The key takeaway for anyone, whether a patient or a caregiver, is to focus less on the numerical score itself and more on the risk classification it represents (low, moderate, or high). This classification should inform specific, proactive measures to reduce the likelihood of a fall and improve overall safety and well-being. A high score is a signal for action, not a cause for alarm, and effective prevention strategies can dramatically lower the risk of injury.
