Demystifying Fall Risk Assessment Scales
Fall risk assessment scales are standardized screening tools used by healthcare professionals to evaluate an individual's likelihood of experiencing a fall. These tools consider various factors, from a person's medical history to their physical and mental status, to produce a numerical score. Interpreting this score is essential for tailoring effective fall prevention strategies. While different scales exist, two of the most widely recognized are the Morse Fall Scale (MFS) and the Hendrich II Fall Risk Model.
The Morse Fall Scale (MFS): Interpreting Your Numbers
The Morse Fall Scale is a quick and reliable method commonly used in hospitals and nursing homes to determine a patient's fall risk. It evaluates six specific risk factors, each assigned a point value. The final score, ranging from 0 to 125, is then used to classify the risk level.
MFS Scoring and Risk Levels
- Low Risk (0-24): A score in this range indicates a low risk of falling, and interventions typically include standard, basic nursing care.
- Moderate Risk (25-44): Patients in this category require a higher level of supervision and specific fall prevention interventions.
- High Risk (45 and above): A score of 45 or greater signifies a high likelihood of falling, necessitating aggressive, high-risk fall prevention interventions.
Each of the six variables contributes points to the total score, with higher points assigned to greater risk factors:
- History of falling: 25 points if the patient has fallen within the last three months.
- Secondary diagnosis: 15 points if the patient has more than one medical diagnosis.
- Ambulatory aid: 15 points for crutches/cane/walker, 30 points for using furniture for support, and 0 points if using no aid.
- IV/Heparin lock: 20 points if an IV or heparin lock is present.
- Gait: 10 points for a weak gait, 20 for an impaired gait, and 0 for a normal gait.
- Mental status: 15 points if the patient forgets their limitations and 0 if they are aware of their abilities.
The Hendrich II Fall Risk Model: Key Indicators and Score
The Hendrich II Fall Risk Model (HIIFRM) is another tool used to screen for fall risk, particularly effective for inpatients. Unlike the MFS, it consists of eight weighted items and has a different scoring threshold. A total score of 5 or greater indicates a high risk for falls.
HIIFRM Risk Factors and Points
- Confusion/Disorientation/Impulsivity: 4 points
- Symptomatic Depression: 2 points
- Altered Elimination: 1 point
- Dizziness/Vertigo: 1 point
- Male Gender: 1 point
- Antiepileptic medications: 2 points
- Benzodiazepine medications: 1 point
- Get-Up-and-Go Test: 0-4 points, based on ability to rise from a chair.
Comparing the Morse and Hendrich II Scales
| Feature | Morse Fall Scale (MFS) | Hendrich II Fall Risk Model |
|---|---|---|
| Primary Use Setting | Inpatient hospital, nursing homes, rehab | Acute care, inpatient settings |
| Total Score Range | 0 to 125 | 0 to 16 |
| Risk Threshold | 0-24 (Low), 25-44 (Moderate), 45+ (High) | 5 or greater indicates high risk |
| Primary Factors | History of falls, diagnosis, ambulatory aid, IV, gait, mental status | Confusion, depression, elimination, dizziness, gender, medications, Get-Up-and-Go test |
| Interpretation | Risk level defined by score ranges | Single threshold (5+) for high risk |
Beyond the Score: A Multifactorial Approach
It is important to remember that fall risk scales are only one part of a comprehensive assessment. An individual's total score is a crucial piece of data, but it doesn't tell the whole story. Many other factors contribute to fall risk, and a healthcare provider should always consider them. For example, environmental hazards in the home, such as loose rugs or poor lighting, can increase risk regardless of an assessment score. A provider will also review medications, check vision, and assess other health conditions to develop a personalized prevention plan. The CDC's STEADI program is a great example of a multifactorial approach that combines screening, assessment, and intervention to reduce falls.
Practical Strategies for Reducing Fall Risk
Based on your risk assessment, your healthcare provider may recommend a number of interventions to help reduce your likelihood of falling. These can include:
- Medication Management: Reviewing your medications with your doctor or pharmacist is vital, as some drugs can cause side effects like dizziness or drowsiness. Your provider may suggest adjusting dosages or switching medications.
- Exercise and Balance Training: Regular physical activity, especially exercises focused on improving balance, strength, and coordination, can significantly lower your risk of falling. Tai Chi and other gentle exercise programs are often recommended.
- Vision and Foot Care: Poor vision and foot problems are major contributors to falls. Keep your eyeglass prescription up to date, and see a podiatrist if you have concerns about your feet or footwear.
- Home Safety Modifications: Make your living environment safer by removing tripping hazards, installing grab bars in bathrooms, adding handrails to stairs, and improving lighting throughout your home. The CDC offers excellent resources for making a home safer for older adults. You can find more information on their website.
- Assistive Devices: For those with higher scores, using a cane or walker can provide added stability and confidence while moving around.
Conclusion
Understanding what are the numbers on the fall risk scale is a proactive step toward maintaining your health and independence. Fall risk assessments are not meant to be a source of fear but a tool to inform and empower. By working with your healthcare provider to understand your score and implementing targeted prevention strategies, you can minimize your risk and stay safe on your feet for years to come. Recognizing your risk is the first step; taking action to address it is the key to preventing injuries and promoting a higher quality of life.
