Hendrich II Fall Risk Model

Eight-item weighted fall-risk model for adult acute-care inpatients (confusion, depression, altered elimination, dizziness, male sex, antiepileptic and benzodiazepine use, Get-Up-and-Go) that flags high fall risk to trigger the fall-prevention bundle.

Confusion, disorientation, or impulsivity

0 - No 4 - Yes

Symptomatic depression

0 - No 2 - Yes

Altered elimination (urinary frequency, incontinence, urgency, nocturia, diarrhea)

0 - No 1 - Yes

Dizziness or vertigo

0 - No 1 - Yes

Sex

0 - Female 1 - Male

Any administered antiepileptic / anticonvulsant

(scheduled or PRN within the assessment window)

0 - No 2 - Yes

Any administered benzodiazepine or Z-drug (non-benzodiazepine benzodiazepine-receptor agonist)

(scheduled or PRN within the assessment window; includes zolpidem, zopiclone, eszopiclone, and the benzodiazepine class)

0 - No 1 - Yes

Get-Up-and-Go (rising from a chair)

(observe the patient stand from a seated position without using arms if possible)

0 - Able to rise in a single movement, no loss of balance 1 - Pushes up successfully in one attempt 3 - Multiple attempts but successful 4 - Unable to rise without assistance during the test