Why Is Fall Risk Assessment So Critical?
Falls are a serious health concern, especially for older adults. They can lead to severe injuries, prolonged hospital stays, loss of independence, and increased healthcare costs. For caregivers, family members, and medical professionals, proactively identifying an individual’s risk of falling is the first step toward effective prevention. Fall risk assessment scales provide a structured, evidence-based method for evaluating a person’s vulnerability, allowing for the creation of tailored interventions to improve safety and quality of life.
The Morse Fall Scale (MFS): The Standard in Inpatient Settings
One of the most widely used and well-known fall risk assessment tools in acute care and skilled nursing facilities is the Morse Fall Scale (MFS). It is valued for its speed, simplicity, and predictive validity. The MFS is used to systematically assess six key variables that contribute to a patient's fall risk.
MFS Assessment Categories
The Morse Fall Scale assigns a numerical score based on the following six components:
- History of Falling: A score of 25 points is given if the patient has a recent history of falling, either immediately prior to admission or within the last three months. No history results in 0 points.
- Secondary Diagnosis: Having more than one medical diagnosis adds 15 points, reflecting the complexity of care and potential for comorbidities to affect stability. A single diagnosis scores 0 points.
- Ambulatory Aid: The type of assistance a patient uses to walk is a key indicator. Points are assigned as follows: 0 points for bed rest or nurse assistance, 15 points for crutches, a cane, or a walker, and 30 points for using furniture for support.
- IV Therapy/Heparin Lock: The presence of an intravenous line or heparin lock can interfere with mobility and is considered a risk factor, adding 20 points.
- Gait: A patient's manner of walking is a strong predictor of fall risk. A normal or immobile gait scores 0 points. A weak gait (stopping or shuffling) scores 10 points, while an impaired gait (difficulty rising, head down, impaired balance) scores 20 points.
- Mental Status: This assesses the patient's awareness of their own limitations. A patient who is aware and understands their abilities scores 0 points, whereas one who overestimates their capabilities or is forgetful scores 15 points.
Calculating the MFS Risk Level
Once the individual points are tallied, the total score categorizes the patient's fall risk:
- 0–24 points: Low risk
- 25–45 points: Moderate risk
- Over 45 points: High risk
The Hendrich II Fall Risk Model: A Different Approach for Acute Care
The Hendrich II Fall Risk Model is another widely used tool, particularly in acute care settings. It differs from the MFS by focusing on a specific set of modifiable risk factors and emphasizing targeted interventions.
Hendrich II Risk Factors
The Hendrich II Model uses eight factors to determine risk:
- Confusion/Disorientation/Impulsivity (4 points)
- Symptomatic Depression (2 points)
- Altered Elimination (1 point)
- Dizziness/Vertigo (1 point)
- Gender (Male) (1 point)
- Antiepileptics (2 points)
- Benzodiazepines (1 point)
- Get-Up-and-Go Test: The patient’s ability to rise from a seated position (4 points)
Unlike the MFS, the Hendrich II often focuses on how these specific factors can be addressed to lower the risk, rather than a single total score.
Functional Mobility and Balance Assessments
Beyond clinical scoring scales, other functional assessments are used to evaluate specific aspects of a person’s mobility and balance. These tests are often part of a more comprehensive fall risk evaluation.
The Timed Up and Go (TUG) Test
The TUG test is a simple and quick assessment of a patient's mobility. A healthcare provider times the patient as they rise from a standard chair, walk 3 meters, turn, walk back to the chair, and sit down. The time it takes to complete the task is used to indicate fall risk. A longer time suggests a higher risk of falling.
The Berg Balance Scale (BBS)
The Berg Balance Scale is a 14-item performance-based test designed to measure balance in older adults. The tasks range from simple sitting balance to more complex movements like tandem standing. Each task is scored, and the total score indicates the level of balance impairment and associated fall risk.
Comparison of Major Fall Risk Assessment Scales
| Feature | Morse Fall Scale (MFS) | Hendrich II Fall Risk Model | Timed Up and Go (TUG) Test | Berg Balance Scale (BBS) |
|---|---|---|---|---|
| Primary Setting | Acute care, skilled nursing | Acute care, rehabilitation | General clinical use | Rehabilitation, outpatient |
| Primary Focus | General fall risk prediction | Specific modifiable risk factors | Mobility and dynamic balance | Static and dynamic balance |
| Factors Assessed | History, diagnosis, aids, IV, gait, mental status | Confusion, depression, elimination, dizziness, gender, meds, TUG | Time to complete a specific task | 14 performance-based balance tasks |
| Format | Point-based scoring | Point-based scoring | Timed observation | Performance-based scoring |
| Key Intervention Insight | High-level risk categories | Targeted interventions for specific factors | Speed and stability of movement | Specific balance deficits |
Choosing and Using the Right Assessment Tool
As seen in the comparison, no single tool provides a perfect assessment for every situation. The best approach is a comprehensive one, often using a combination of tools and clinical judgment. The choice of scale should be guided by the patient's specific risk factors and the healthcare setting. For instance, a hospital might use the MFS or Hendrich II on admission, while a physical therapist might rely on the TUG or BBS for detailed functional mobility data.
The Importance of Intervention
Assessment is only the first step. The real value lies in using the results to implement effective prevention strategies. These strategies can include:
- Medication Review: Identifying and adjusting medications that cause dizziness or drowsiness.
- Strength and Balance Exercises: Incorporating exercises to improve mobility and stability, like those found in the CDC's STEADI program.
- Environmental Modifications: Removing tripping hazards, improving lighting, and installing grab bars and handrails.
- Patient and Caregiver Education: Teaching proactive safety behaviors and raising awareness of risk factors.
For a deeper dive into evidence-based fall prevention strategies, refer to the resources from the Centers for Disease Control and Prevention's (CDC) STEADI program CDC STEADI Program.
Conclusion: A Proactive Approach to Patient Safety
Fall risk assessment is a fundamental component of quality senior care. By using tools like the Morse Fall Scale, Hendrich II Fall Risk Model, TUG, and Berg Balance Scale, healthcare professionals and caregivers can objectively measure an individual's risk. The information gathered from these assessments is invaluable, enabling the creation of personalized care plans that focus on prevention, improving patient outcomes, and helping seniors maintain their independence and safety for as long as possible.
