What is the range of the fall risk assessment score? A Guide to Understanding Your Results

Did you know that over one in four older adults experiences a fall each year, with less than half reporting it to their doctor? Understanding the results of a fall risk assessment is a critical step in proactive senior care, which is why knowing what is the range of the fall risk assessment score is so important. These tools provide valuable insights for healthcare providers and individuals alike, guiding personalized prevention strategies.

Quick Summary

The range for a fall risk assessment score varies depending on the specific tool used, with popular examples including the Morse Fall Scale (0–125) and the Hendrich II Fall Risk Model (0–16), each defining risk levels differently.

Key Points

• No Single Range: The fall risk assessment score range is not standardized and depends entirely on the specific tool being used, with different thresholds for high risk.

• Morse Fall Scale: Scores on the Morse scale range from 0 to 125, with a score of 45 or higher typically indicating high risk, based on factors like history of falls, gait, and mental status.

• Hendrich II Model: The Hendrich II model scores from 0 to 16, with a score of 5 or higher indicating high risk, and focuses on factors like confusion, depression, medication use, and the “Get Up and Go” test.

• STRATIFY Tool: The STRATIFY score ranges from 0 to 5, and a score of 2 or more identifies a patient as being at high risk based on history, mobility, and other indicators.

• Assessment is a Guide: A high score is not a final judgment but a call to action. It should prompt personalized, multi-faceted interventions including exercise, medication review, and home safety modifications.

• Actionable Steps: Interventions based on assessment scores often involve strength and balance training, home modifications, and medication review, all of which are proven strategies for fall prevention.

Multiple Scales, Different Scores

There is no single universal fall risk assessment score range. Instead, various validated clinical tools are used in different healthcare settings, each with its own scoring system and threshold for defining risk. Understanding which tool was used and what its score means is the first step toward effective fall prevention. Below, we break down some of the most widely used fall risk assessment tools, detailing their score ranges and what the numbers signify for your health and safety.

The Morse Fall Scale (MFS)

Developed in the 1980s for hospital patients, the Morse Fall Scale is one of the most common assessment tools. It evaluates a patient's risk based on six variables, assigning a numerical score that is tallied for a final risk level. The total MFS score provides an indication of the likelihood of a patient falling.

The MFS range is 0 to 125, and scores are typically interpreted as follows:

• Low Risk (0–24): Patients in this range are considered to be at low or minimal risk. Standard nursing care and general fall precautions are typically implemented.
• Moderate Risk (25–45): This score suggests a moderate risk of falling. Extra attention and standard fall prevention interventions are usually required.
• High Risk (≥45): A score of 45 or higher indicates a significant risk of falling, necessitating close supervision and individualized, high-risk fall prevention strategies.

The six components of the MFS, each assigned points, include:

• History of falling
• Secondary diagnoses
• Ambulatory aid (how the patient mobilizes)
• IV or heparin lock
• Gait (walking ability)
• Mental status

The Hendrich II Fall Risk Model

This model is another popular tool, developed by nurses specifically for use in acute care hospital settings. It is quick to administer and focuses on eight independent risk factors. The score range for the Hendrich II model is 0 to 16.

A patient with a score of 5 or greater is considered at high risk for falls. The risk factors assessed include:

• Confusion/Disorientation/Impulsivity
• Symptomatic depression
• Altered elimination
• Dizziness/Vertigo
• Male gender
• Antiepileptic medications
• Benzodiazepine medications
• The "Get Up and Go" test, which assesses mobility and balance

The St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY)

The STRATIFY tool is used in hospital settings, especially with older adults, to identify patients at risk of falling. It is a very fast assessment to perform, assigning a score based on five factors. The STRATIFY score range is 0 to 5.

A score of 2 or greater indicates a high risk of falling. The tool considers:

• History of falls
• Agitation
• Visual acuity
• Need for frequent toileting
• Transfer/mobility status

Comparing Different Fall Risk Assessment Tools

Assessment Tool	Score Range	Key Components	High Risk Threshold
Morse Fall Scale (MFS)	0–125	History of falls, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, mental status	≥ 45
Hendrich II Model	0–16	Confusion, depression, elimination, vertigo, male gender, medications, Get Up and Go test	≥ 5
STRATIFY	0–5	History of falls, agitation, visual acuity, toileting, mobility	≥ 2

Interpreting Your Score and Taking Action

Receiving a fall risk score is not a final verdict, but rather a starting point for developing a personalized prevention plan. The numerical score is a guide, but a holistic assessment of your health and environment is equally important. Based on your assessment results, a healthcare provider can recommend targeted interventions to reduce your risk.

Evidence-Based Fall Prevention Strategies

1. Engage in Regular Exercise: Programs that focus on improving balance, strength, and coordination are highly effective. Activities like Tai Chi have been shown to significantly reduce the risk of falls.
2. Review Medications: Certain medications, or combinations of them, can cause side effects like dizziness, drowsiness, or confusion. A doctor or pharmacist can review your prescriptions to identify and potentially adjust high-risk drugs.
3. Perform Home Safety Modifications: The living environment is a significant factor in fall risk. Making simple changes can have a large impact.
   • Remove throw rugs, clutter, and cords from walkways.
   • Install grab bars in bathrooms and secure handrails on both sides of stairs.
   • Improve lighting in all areas, especially at night.
4. Manage Health Conditions: Treat underlying conditions that can affect balance and stability. This includes getting regular vision and hearing checks, as well as managing conditions like osteoporosis and foot problems.
5. Address Fear of Falling: A previous fall can lead to a fear of falling again, which in turn can cause a person to limit their activity, ironically increasing their actual fall risk. Discuss these fears with a healthcare provider and consider programs designed to build confidence.

Using Your Assessment Proactively

Your fall risk assessment is not a one-time event. Reassessment should occur regularly, especially after a fall or a change in your medical condition. By focusing on the specific areas highlighted by your score, you can work with your healthcare team to address vulnerabilities and maintain independence. For instance, if your score was elevated due to an impaired gait, a referral to a physical therapist for targeted balance training may be the most important next step.

For more evidence-based information and resources on fall prevention, you can visit the Centers for Disease Control and Prevention's STEADI initiative, which provides guidance for both healthcare providers and older adults.(https://medlineplus.gov/lab-tests/fall-risk-assessment/)

Conclusion

Fall risk assessment scores provide a crucial quantitative measure of an individual's risk of falling, but they are most effective when used as a guide for personalized, proactive prevention. Since different scales have different ranges, it is important to know which tool was used and what your specific result means. By combining the insights from these assessments with practical interventions like exercise, medication management, and home safety improvements, individuals can significantly reduce their risk of falls and enjoy a safer, more independent life. Taking control of your health and environment is the most powerful step you can take toward preventing future injuries.

Frequently Asked Questions

What is the typical range of a fall risk assessment score?

The score range is not universal and depends on the assessment tool. For example, the Morse Fall Scale ranges from 0 to 125, while the Hendrich II Fall Risk Model ranges from 0 to 16.

Does a high fall risk assessment score mean I will definitely fall?

No, a high score indicates an increased likelihood of a fall, not a certainty. It serves as a prompt for healthcare providers and individuals to implement targeted prevention strategies to lower the risk.

How often should a fall risk assessment be performed?

Assessments should ideally be performed upon admission to a care setting, after a fall, when a patient's condition changes, and at regular intervals as part of routine care. In community settings, it should be done annually or following a health event.

What factors are included in a fall risk assessment score?

Factors vary by tool but commonly include a history of recent falls, mobility or gait issues, balance problems, use of certain medications, vision impairment, and mental status or confusion.

Who performs a fall risk assessment?

Fall risk assessments are typically performed by trained healthcare professionals, such as a registered nurse, doctor, or physical therapist, depending on the care setting.

Can my fall risk assessment score improve?

Yes, absolutely. By addressing the specific risk factors identified in your assessment through exercise, home modifications, medication review, and other interventions, you can reduce your risk and potentially lower your score over time.

What should I do if my fall risk assessment score is high?

If your score is high, work with your healthcare provider to create a personalized prevention plan. This may involve physical therapy, reviewing medications, making your home safer, or participating in a balance-focused exercise program.