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Hendrich II Fall Risk Model
Hendrich II: Evaluates intrinsic fall risks including specific high-risk medications and altered elimination, plus a functional mobility observation.
Rate all 8 risk factors
Confusion, Disorientation, Impulsivity
Patient lacks understanding of their limitations.
Symptomatic Depression
Tearful, withdrawn, or has diagnosis.
Altered Elimination
Incontinence, nocturia, frequent toileting.
Dizziness or Vertigo
Subjective report or observed swaying.
Male Gender
Statistical risk factor in acute care.
Any Prescribed Antiepileptics
e.g., phenytoin, gabapentin, levetiracetam.
Any Prescribed Benzodiazepines
e.g., lorazepam, diazepam, temazepam.
Get Up & Go Test
Observe patient rising from a chair.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Routine fall risk screening for adults in acute care settings.
Evaluating the pharmacological and physical drivers of falls in hospitalised older adults.
Shift-by-shift nursing assessment to implement fall precautions.
Focus on Medications and Elimination
Unlike the Morse Fall Scale, the Hendrich II model specifically scores the use of high-risk medications (benzodiazepines, antiepileptics) and altered elimination (e.g., urgency), which are major precipitating factors for inpatient falls.
Section 2
Formula & Logic
Scoring
8 risk factors assessed.
Score ≥ 5 indicates High Risk for falls.
Incorporates a modified "Get Up and Go" test natively into the score.
Risk Factors
Confusion/Disorientation
Score 4
Symptomatic Depression
Score 2
Altered Elimination
Incontinence, urgency, nocturia. Score 1
Dizziness/Vertigo
Score 1
Gender: Male
Score 1 (Males statistically fall more often in acute care)
Antiepileptics
Score 2 (e.g., gabapentin, phenytoin)
Benzodiazepines
Score 1
Get Up & Go Test
Able to rise (0), pushes up in 1 attempt (1), multiple attempts (3), unable (4)
Section 3
Pearls/Pitfalls
Male Gender as a Risk Factor
The inclusion of male gender as a risk factor often surprises clinicians. However, multivariate analysis in acute care populations consistently shows men are more likely to fall, often due to risk-taking behaviours or reluctance to call for assistance with toileting.
Section 4
Next Steps
Management
Section 5
Evidence Appraisal
Primary Reference
Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients.
Hendrich AL et al. • Appl Nurs Res.. 2003;16(1):9-21. Validation demonstrating 74.9% sensitivity and 73.9% specificity for predicting falls.
Section 6
Origins
Ann Hendrich
Developed by Ann Hendrich to improve upon early fall scales. It was designed specifically to be integrated into electronic health records and nursing workflows, shifting the focus towards modifiable intrinsic factors rather than simply asking about past falls.
