Hendrich II Fall Risk Model Calculator (HIIFRM)
Score the Hendrich II Fall Risk Model for hospital inpatients — confusion, depression, altered elimination, dizziness, male sex, antiepileptics, benzodiazepines and the Get-Up-and-Go test — where 5 or more is high risk.
How it works
Confusion/disorientation/impulsivity 4 + symptomatic depression 2 + altered elimination 1 + dizziness/vertigo 1 + male sex 1 + any antiepileptic 2 + any benzodiazepine 1 + Get-Up-and-Go (single movement 0, pushes up in one attempt 1, multiple attempts 3, unable without help 4); total 0–16. 5 or more = high fall risk.
The Hendrich II Fall Risk Model (Hendrich, Bender and Nyhuis, Applied Nursing Research 2003) was derived in a case-control study of hospital inpatients in an academic tertiary care center and kept only the risk factors that independently predicted falls. It is quick to complete at admission, at each shift or after a change in condition, and it adds an objective Get-Up-and-Go test to the history. A score of 5 or more identifies high fall risk and should trigger an individualized fall-prevention plan, such as supervised toileting, medication review, bed alarms and safe footwear.
Worked example
A man in hospital has symptomatic depression (2), takes a benzodiazepine (1), and pushes up with his arms but stands in one attempt (1); male sex adds 1: Hendrich II = 2 + 1 + 1 + 1 = 5 / 16 — high fall risk.
Sources: Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res 2003;16:9–21 · Hartford Institute for Geriatric Nursing — Try This: Fall Risk Assessment (Hendrich II)
Frequently asked questions
What Hendrich II score is high risk?
A total of 5 or more is high risk for falls and should prompt fall-prevention interventions. Lower scores still need reassessment when the patient’s condition or medications change.
Why does male sex add a point?
In the derivation study, male sex was an independent risk factor for falls in hospital after controlling for the other factors, possibly because men are less likely to ask for help.
How do I do the Get-Up-and-Go test?
Ask the patient to rise from a chair, ideally without using the arms, and walk a few steps. Score 0 if they rise in one movement without losing balance, 1 if they push up and succeed in one attempt, 3 if they need several attempts, and 4 if they cannot rise without help.
How is Hendrich II different from the Morse Fall Scale?
Both are inpatient fall-risk tools. Hendrich II focuses on confusion, depression, elimination, dizziness, sex, high-risk drugs and a performance test, while Morse includes history of falls, secondary diagnosis, walking aids, IV access and gait.
Related calculators
Clinical decision tool for education and for use by trained clinicians alongside clinical judgement — not a diagnosis and not a substitute for medical assessment. Scores and cut-offs come from the cited validation studies and may not apply to every patient; follow local protocols.