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The Hendrich II Fall Risk Model is an evidence-based inpatient fall-risk screening instrument developed by nursing researcher Ann L. Hendrich, MSN, RN, FAAN, and colleagues in 2003 (Applied Nursing Research, 2003) to identify hospitalized adults at high risk for physiological falls. Unlike multifactorial tools that weight chronological age or historical falls heavily (such as the Morse Fall Scale), the Hendrich II Fall Risk Model evaluates eight independent intrinsic and pharmacological risk factors—including antiepileptic and benzodiazepine administration and a bedside chair-rise mobility test—with a score of ≥ 5 points designating high fall risk.
What Is the Hendrich II Fall Risk Model?
Validated in a concurrent hospital case-control study of 355 inpatient fallers and 780 non-faller controls at an acute care tertiary facility, the Hendrich II Fall Risk Model was designed to take less than two minutes to administer during admission, shift change, or clinical status change. In the original validation cohort, a cutoff score of ≥ 5 achieved a sensitivity of 74.9% and a specificity of 73.9% (AHRQ Hospital Fall Prevention Toolkit).
A defining methodological feature in fall risk assessment tools compared is that logistic regression modeling in the Hendrich II study showed chronological age was confounded by underlying mobility impairment, cognitive status, and central nervous system medications. By scoring those modifiable clinical factors directly, the instrument links each positive score item to a specific nursing or pharmacist intervention.
The 8 Hendrich II Risk Factors and Point Scoring Table (0–16 Points)
The Hendrich II Fall Risk Model assigns statistically derived integer weights across seven clinical/medication binary items (totaling up to 12 points) plus one 4-level functional mobility item (the Get-Up-and-Go test, 0 to 4 points), yielding a maximum possible score of 16 points:
| Risk Factor / Parameter | Clinical Assessment Criteria | Assigned Points |
|---|---|---|
| 1. Confusion / Disorientation / Impulsivity | Documented delirium, dementia, disorientation to person/place/time, or impulsive bed-exiting behavior | 4 points |
| 2. Symptomatic Depression | Active depressive symptoms (tearfulness, flat affect, withdrawal, or hopelessness); does not score controlled history alone | 2 points |
| 3. Altered Elimination | Urinary or fecal incontinence, urgency, frequency, nocturia, or indwelling catheter/ostomie requiring frequent bathroom assistance | 1 point |
| 4. Dizziness / Vertigo | Subjective complaint of dizziness, lightheadedness, orthostatic unsteadiness, or vestibular vertigo | 1 point |
| 5. Male Sex | Biological male sex (statistically associated in inpatient cohorts with higher likelihood of attempting unassisted transfers) | 1 point |
| 6. Any Administered Antiepileptics | Administration of anticonvulsant medications (e.g., phenytoin, carbamazepine, valproate, gabapentin, levetiracetam)—whether prescribed for seizures, neuropathy, or mood stabilization | 2 points |
| 7. Any Administered Benzodiazepines | Administration of any benzodiazepine sedative/anxiolytic (e.g., lorazepam, diazepam, alprazolam, midazolam, clonazepam, temazepam) | 1 point |
| 8. “Get-Up-and-Go” Test (Rising from Chair) | 0 points: Able to rise in a single movement without loss of balance 1 point: Pushes up from armrests/bed, successful in one attempt 3 points: Multiple attempts required, but successful 4 points: Unable to rise without assistance during test (or medically immobilized/untested due to safety) |
0, 1, 3, or 4 points |
Note on the Get-Up-and-Go subtest: Unlike the full 3-meter Timed Up and Go (TUG) test or the 14-item Berg Balance Scale, the Hendrich II Get-Up-and-Go item specifically evaluates proximal lower-extremity strength and truncal stability during the sit-to-stand transition.
How Is the Hendrich II Fall Risk Model Used in Clinical Research and Healthcare?
In hospital fall prevention program design, electronic health record (EHR) nursing flowsheets, and geriatric clinical trials, the Hendrich II score drives risk-stratified clinical action:
- Threshold Interpretation (< 5 vs. ≥ 5 Points): Patients scoring 0 to 4 points receive universal fall precautions (bed in lowest locked position, call light within reach, non-slip footwear). Patients scoring ≥ 5 points are classified as High Fall Risk, triggering targeted protocol bundles.
- Factor-Specific Care Planning: Rather than applying a generic “high fall risk” wristband alone, EHR clinical decision support maps each positive Hendrich II item to a root-cause intervention: pharmacist medication review for Antiepileptics (+2) or Benzodiazepines (+1), scheduled toileting rounds every 2 hours for Altered Elimination (+1), physical therapy consultation and assistive transfer devices for Get-Up-and-Go ≥ 3, and close-observation bed placement for Confusion/Impulsivity (+4).
- EHR Auto-Population: Modern inpatient EHRs (such as Epic and Oracle Health) automatically pull active MAR (Medication Administration Record) administrations of ATC anticonvulsant and benzodiazepine classes alongside patient sex into the Hendrich II flowsheet calculator so bedside nurses only assess the four clinical observation items and the chair-rise test.
Frequently Asked Questions
What is the Hendrich II Fall Risk Model?
The Hendrich II Fall Risk Model is an 8-item inpatient fall-risk assessment tool developed by Ann Hendrich in 2003 that scores confusion/impulsivity (4 points), symptomatic depression (2 points), altered elimination (1 point), dizziness/vertigo (1 point), male sex (1 point), antiepileptic medications (2 points), benzodiazepines (1 point), and a chair-rise Get-Up-and-Go test (0–4 points), where a total score of 5 or higher indicates high risk for falling.
How is the Hendrich II Fall Risk Model used in clinical research and healthcare?
In acute care hospitals, rehabilitation units, and long-term care facilities, nurses administer the Hendrich II model at admission, upon transfer, after a fall, and once per shift to identify high-risk patients (score ≥ 5) and trigger targeted interventions such as medication deprescribing, scheduled toileting, and assisted mobility protocols.
