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NUR 3289 Miami Dade College Ch 12 Fall Risk Assessment for Older Adults Paper

NUR 3289 Miami Dade College Ch 12 Fall Risk Assessment for Older Adults Paper

Question Description

T.J. is a 76-year-old man that recently lost his wife. He lives alone now in an ALF where he has some friends that he associates with. They are “good for his overall well-being” claims the administrators of the facility who befriended T.J. when he lost his wife six months ago. The facility that T.J. lives in is convenient for many aspects of his life, including entertainment and even some of the healthcare associates from neighboring clinics that have partnered with the facility to allow visits with the residents.

Over the years, the associates from the neighboring clinic have grown close to some residents and have followed them during some of their crisis, both emotional and physical. Christine, a nurse practitioner from a neighboring clinic, has followed T.J. for many years and is now assessing his fall risk through a tool called the “Hendrick Fall Risk Tool II” a popular means of assessing the fall risk that may exist for an elderly person.

An entry by the ARNP recently on T.J. demonstrated that there was enough information, recognizing previous and present knowledge to utilize the tool to give T.J. a score representing his fall risk. the entry reads: “T.J. is a 76-year-old that is evaluated today for his fall risk. He has a MedHx of BPH, COPD, seizures, eczema, and anxiety. He has been seen monthly and he described some episodes of nocturia that still persists. A list of his recent mediation includes Alprazolam, Phenytoin, Dutasteride, and ibuprofen prn. By administering the Get Up and Go Test, we find that he only had a brief episode of not being able to rise but he performed well after that completing it in 12 seconds. He demonstrates an improvement in his depression experienced in the past exhibited for several months after the loss of his spouse. His friends at the facility keep him busy and he is much improved in his outlook for the future.” C. Miller ARNP


  1. Read the Fall Risk Assessment for Older Adults article.
  2. Complete the Hendrich II Fall Risk Model tool form completely.
    • Assign the correct scores for the Fall Risk Tool.
    • Summarize the scores derived as per fall risk.
  3. Develop a summary of the risks for T.J., so that the facility can respond to those risks and provide a safe environment.
  4. Describe the level of safety that the facility should plan to give T.J.
  5. Finally, explain whether you feel like the score from the Fall Risk Tool is accurate and if the tool is worth the effort to develop.
  6. Your paper should be:
    • One (1) page or more.
    • Use factual information from the textbook and/or appropriate articles and websites.
    • Cite your sources – type references according to the APA Style Guide.

This is for the Fall Risk Assessment for Older adults.

Issue Number 8, Revised 2016 Editor-in-Chief: Sherry A. Greenberg, PhD, RN, GNP-BC
New York University Rory Meyers College of Nursing

Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk ModelTM

By: Ann Hendrich, PhD, RN, FAAN
Patient Safety Organization (PSO); Ascension Health

WHY: Falls among older adults, unlike other ages tend to occur from multifactorial etiology such as acute1,2 and chronic3,4 illness, medications,5 as a prodrome
to other diseases,6 or as idiopathic phenomena. Because the rate of falling increases proportionally with increased number of pre-existing conditions and
risk factors,7 fall risk assessment is a useful guideline for practitioners. One must also determine the underlying etiology of why a fall occurred with a
comprehensive post-fall assessment.8 Fall risk assessment and post-fall assessment are two interrelated but distinct approaches to fall evaluation, both
recommended by national professional organizations.9

Fall assessment tools have often been used only on admission or infrequently during the course of an illness or in the primary care health management of an
individual. Repeated assessments, yearly, and with patient status changes, will increase the reliability of assessment and help predict a change in condition
signaling fall risk.

BEST PRACTICE APPROACH: In acute care, a best practice approach incorporates use of the Hendrich II Fall Risk ModelTM, which is quick to administer
and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications
increasing risk.10 This tool screens for fall risk and is integral in a post-fall assessment for the secondary prevention of falls.

TARGET POPULATION: The Hendrich II Fall Risk ModelTM is intended to be used in the adult acute care, ambulatory, assisted living, long-term care, and
population health settings to identify adults at risk for falls and to align interventions that will reduce the risk factor’s presence whenever possible.

VALIDITY AND RELIABILITY: The Hendrich II Fall Risk ModelTM was originally validated in a large case control study in an acute care tertiary facility with
skilled nursing, behavioral health, 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). Content validity was established through an exhaustive literature review, accepted nursing nomenclature, and the
extensive experience of the principal investigators in this area.11

The instrument is sensitive (74.9%) and specific (73.9%), with inter-rater reliability measuring 100% agreement.11 Numerous national and international
published and unpublished studies and presentations have tested the Hendrich II Fall Risk ModelTM in diverse settings. For example, the Model has
demonstrated high sensitivity and specificity for fall risk prediction in general acute-care patients and, recently, in psychiatric patients, suggesting utility in
this patient population.11,12

Further, the Model has been used successfully in multiple international studies. For example, the Model has been translated into Portuguese and evaluated
in inpatient settings in Portugal.13 The authors of this study reported a sensitivity of 93.2% at admission and 75.7% at discharge, with positive and negative
predictive values of 17.2% and 97.3%, respectively. The Model has also been adapted for use in Italian geriatric acute care settings, showing high specificity,
sensitivity, and inter-rater reliability in one study.14 A comparison of the Hendrich II ModelTM to other fall risk models in the acute care setting in Australia
found similar, strong sensitivity compared to other models, but acceptable specificity only with the Hendrich II ModelTM.15 Recently, a study from Lebanon
reported higher sensitivity with the Hendrich II ModelTM when compared to the Morse Fall Scale for fall prediction in 1815 inpatients.16 Finally, the Model
was translated into Chinese and evaluated in elderly inpatients at a hospital in Peking, China.17 The Chinese version of the Model demonstrated excellent
repeatability, inter-rater reliability, content validity, and, most importantly, high sensitivity (72%) and specificity (69%) for fall risk prediction.

STRENGTHS AND LIMITATIONS: The major strengths of the Hendrich II Fall Risk ModelTM are its brevity, the inclusion of “risky” medication categories, and
its focus on interventions for specific areas of risk, rather than on a single, summed general risk score. Categories of medications increasing fall risk, as well
as adverse side effects from medications leading to falls are built into this tool. Further, with permission, the Hendrich II Fall Risk ModelTM can be inserted
into existing electronic health platforms, documentation forms, or used as a single document. It has been built into electronic health records with targeted
interventions that prompt and alert the caregiver to modify and/or reduce specific risk factors present.11

FOLLOW-UP: Fall risk warrants thorough assessment as well as prompt intervention and treatment. The Hendrich II Fall Risk ModelTM may be used to
monitor fall risk over time, minimally yearly, and with patient status changes in all clinical settings. Post-fall assessments area also critical for an evidenced-
based approach to fall risk factor reduction.


Best practice information on care of older adults: www.ConsultGeri.org.
1. Gangavati, A., Hajjar, I., Quach, L., Jones, R.N., Kiely, D.K., Gagnon, P., & Lipsitz, L.A. (2011). Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling
elderly population: The maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. JAGS, 59(3), 383-389.
2. Sachpekidis, V., Vogiatzis, I., Dadous, G., Kanonidis, I., Papadopoulos, C., & Sakadamis, G. (2009). Carotid sinus hypersensitivity is common in patients presenting with hip
fracture and unexplained falls. Pacing and Clinical Electrophysiology, 32(9), 1184-1190.
3. Stolze, H., Klebe, S., Zechlin, C., Baecker, C., Friege, L., & Deuschl, G. (2004). Falls in frequent neurological diseases-prevalence, risk factors and etiology. Journal of Neurology,
251(1), 79-84.
4. Roig, M., Eng, J.J., MacIntyre, D.L., Road, J.D., FitzGerald, J.M., Burns, J., & Reid, W.D. (2011). Falls in people with chronic obstructive pulmonary disease: An observational
cohort study. Respiratory Medicine, 105(3), 461-469.
5. Cashin, R.P., & Yang, M. (2011). Medications prescribed and occurrence of falls in general medicine inpatients. The Canadian Journal of Hospital Pharmacy, 64(5), 321-326.
6. Miceli. D.L., Waxman, H., Cavalieri, T., & Lage, S. (1994). Prodromal falls among older nursing home residents. Applied Nursing Research, 7(1), 18-27.
7. Tinetti, M.E., Williams, T.S., & Mayewski, R. (1986). Fall risk index for elderly patients based on number of chronic disabilities. American Journal of Medicine, 80(3), 429-434.
8. Gray-Miceli, D., Johnson, J, & Strumpf, N. (2005). A step-wise approach to a comprehensive post-fall assessment. Annals of Long-Term Care, 13(12), 16-24.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers College of Nursing is cited as the source. This material may be downloaded and/or distributed in
electronic format, including PDA format. Available on the internet at www.hign.org and/or www.ConsultGeri.org. E-mail notification of usage to: hartford.ign@nyu.edu.


9. Panel on Prevention of Falls in Older Persons. American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention.
(2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. JAGS, 59(1), 148-157.
10. 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.

11. Hendrich, A., Nyhuuis, A., Kippenbrock, T., & Soga, M.E. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8(3), 129-139.
12. Van Dyke, D., Singley, B., Speroni, K. G., & Daniel, M. G. (2014). Evaluation of fall risk assessment tools for psychiatric patient fall prevention: a comparative study. Journal of
Psychosocial Nursing and Mental Health Services, 52(12), 30-35.
13. Caldevilla, M.N., Costa, M.A., Teles, P., & Ferreira, P.M. (2012). Evaluation and cross-cultural adaptation of the Hendrich II Fall Risk Model to Portuguese. Scandinavian Journal
of Caring Sciences. doi: 10.1111/j.1471-6712.2012.01031.x

14. Ivziku, D, Matarese, M., & Pedone, C. (2011). Predictive validity of the Hendrich Fall Risk Model II in an acute geriatric unit. International Journal of Nursing Studies, 48(4),
15. Kim, E.A., Mordiffi, S.Z., Bee, W.H., Devi, K., & Evans, D. (2007). Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing, 60(4), 427-
16. Nassar, N., Helou, N., & Madi, C. (2014). Predicting falls using two instruments (the Hendrich Fall Risk Model and the Morse Fall Scale) in an acute care setting in Lebanon.
[Evaluation Studies]. Journal of Clinical Nursing, 23(11-12), 1620-1629.
17. Zhang, C., Wu, X., Lin, S., Jia, Z., & Cao, J. (2015). Evaluation of Reliability and Validity of the Hendrich II Fall Risk Model in a Chinese Hospital Population. PLoS One, 10(11),

Hendrich II Fall Risk Model TM






Symptomatic Depression


Altered Elimination




Gender (Male)


Any Administered Antiepileptics (anticonvulsants):

(Carbamazepine, Divalproex Sodium, Ethotoin, Ethosuximide, Felbamate, Fosphenytoin, Gabapentin,
Lamotrigine, Mephenytoin, Methsuximide, Phenobarbital, Phenytoin, Primidone, Topiramate, Trimethadi-
one, Valproic Acid)1


Any Administered Benzodiazepines:2

(Alprazolam, Chloridiazepoxide, Clonazepam, Clorazepate Dipotassium, Diazepam, Flurazepam,
Halazepam3, Lorazepam, Midazolam, Oxazepam, Temazepam, Triazolam)


Get-Up-and-Go Test: “Rising from a Chair”
If unable to assess, monitor for change in activity level, assess other risk factors, document both on patient chart with date and time.

Ability to rise in single movement – No loss of balance with steps


Pushes up, successful in one attempt


Multiple attempts but successful


Unable to rise without assistance during test
If unable to assess, document this on the patient chart with the date and time.


(A score of 5 or greater = High Risk) TOTAL SCORE

© 2013 AHI of Indiana, Inc. All rights reserved. United States Patent No. 7,282,031 and U.S. Patent No. 7,682,308.
Reproduction of copyright and patented materials without authorization is a violation of federal law.

On-going Medication Review Updates:

Levetiracetam (Keppra) was not assessed during the original research conducted to create the Hendrich Fall Risk Model. As an antieptileptic, levetiracetam does have a side effect of somnolence and
dizziness which contributes to its fall risk and should be scored (effective June 2010).

The study did not include the effect of benzodiazepine-like drugs since they were not on the market at the time. However, due to their similarity in drug structure, mechanism of action and drug effects,
they should also be scored (effective January 2010).

Halazepam was included in the study but is no longer available in the United States (effective June 2010).

© 2012 AHI of Indiana, Inc. All Rights Reserved.
Upright Fall Prevention Program
The Hendrich II Fall Risk ModelTM and all related materials may be used and reproduced only under license from AHI of Indiana, Inc. www.ahiofindiana.com.

The Hartford Institute would like to acknowledge the original author of this Try This:®, Deanna Gray-Miceli, DNSc, APRN, BC, FAANP

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