BioPsychoSocial Assessment Tools for the Elderly - Assessment Summary Sheet

Test: Hendrich II Fall Risk Model

Year: 2003

Domain: Biological

Assessment Tool Category: Mobility/Function

Variations/Translations: The inclusion of the “Get Up and Go test” in the Heinrich II tool was the major change between version I and version II. It is also available in Spanish.

Setting: The Hendrich II Fall Risk Model is intended to be used in the acute care setting to identify adults at risk for falls.

Method of Delivery: The model requires hospital nurses to evaluate the patient for each risk factor either by objective performance testing or by subjective nursing judgment.

Description: Falls among older adults, unlike other ages tend to occur from multifactorial etiology. Designed to be administered quickly, The Hendrich II Fall Risk Model is an evidence based tool which focuses on eight independent risk factors: confusion, disorientation, and impulsivity; symptomatic depression; altered elimination; dizziness or vertigo; male sex; administration of antiepileptics (or changes in dosage or cessation); administration of benzodiazepines; and poor performance in rising from a seated position in the Get-Up-and-Go test. This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls. Once the risk factors are identified nursing interventions should be matched against individual factors to manage or reduce the risk of falling.

Scoring/Interpretation: The highest point values have been assigned to those factors that were found to have the highest Odds Ratio. Points given for various risk factors are summed up and thus the higher the point risk scores the greater the risk of falling. A score of 5 or greater = high risk.

Time to Administer: Estimated to take around 5 to 10 minutes (Gray-Miceli, 2007).

Availability: Hospitals and Institutions can acquire a license to incorporate “The AHI Fall Prevention Program with the Hendrich II Fall Risk Model©” in their patient health records. An interactive computer-based program “A Vital Sign for Safety”™ ©2007 Fall Risk Assessment Using the HFRM II Tool©2007 is available to train clinicians.

Software: N/A

Website(s):

http://www.ahincorp.com/license/index.php

http://www.ahincorp.com/hfrm/calculator.htm

http://www.annalsoflongtermcare.com/article/6786

Quantitative/Qualitative: Quantitative

Validity (Quantitative): The Hendrich II Fall Risk Model was validated in a large case control study in an acute care tertiary facility with skilled nursing and rehabilitation populations. The risk factors in the model had a statistically significant relationship with patient falls (Odds Ratio 10.12-1.00, .01 > p <.0001). The instrument has a sensitivity of 74.9%, and a specificity of 73.9%. Content validity was established through an exhaustive literature review, use of accepted nursing nomenclature and the extensive experience of the principal investigators in this area.

Reliability (Quantitative): Interrater reliability measuring 100% agreement was obtained.

References:

Gray-Miceli, D. (2007) Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model. Hartford Institute for Geriatric Nursing: Issue Number 8.

Heinze, C., Halfens, R.J.G., Roll, S. & Dassen, T. (2006). Psychometric evaluation of the Hendrich Fall Risk Model, Journal of Advanced Nursing, 53(3): 327–332.

Hendrich, A.L. (2007). Predicting Patient Falls. AJN, American Journal of Nursing, 107(11): 50-58

Hendrich, A.L. Bender, P.S. & Nyhuis, A. (2003). Validation of the Hendrich II Fall Risk Model: A Large Concurrent CASE/Control Study of Hospitalized Patients. Applied Nursing Research, 16(1), 9-21.

Hendrich, A.L. Nyhuuis, A., Kippenbrock, T., & Soga, M.E. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8, 129-139

Comments: In 2005, Heinz and her colleagues established that this model is not appropriate for assessing patients in nursing homes and suggest that the use of this instrument is limited to assessment in hospitals, and only if the unweighted items are used.