Understanding the Morse Fall Scale (MFS)
The Morse Fall Scale is one of the most common and rapid methods for assessing a patient's risk of falling, especially in acute and long-term care settings. It is a simple scoring system that helps medical professionals determine the likelihood of a fall, allowing them to implement preventive measures early. The MFS evaluates six specific variables to calculate a total score, which corresponds to a risk level: low, moderate, or high.
The Six Key Variables of the MFS
- History of Falling: A recent history of falls, either in the immediate past or within the last three months, significantly increases a patient's score.
- Secondary Diagnosis: The presence of more than one medical diagnosis, beyond the primary one, often adds to the fall risk.
- Ambulatory Aid: This assesses a patient's use of mobility aids, such as canes, walkers, or furniture for support.
- IV Therapy / Heparin Lock: The presence of an intravenous line can interfere with a patient's movement and increase risk.
- Gait / Transferring: A patient's manner of walking is a critical factor. An impaired gait, such as shuffling or unsteady walking, raises the score compared to a normal gait.
- Mental Status: This variable considers a patient's awareness and ability to understand their own limitations. Forgetting limitations or impulsivity can lead to a higher risk score.
The Hendrich II Fall Risk Model
Another widely used tool, particularly in acute care, is the Hendrich II Fall Risk Model. This model was developed to be quick and easy to administer. It focuses on eight key risk factors and provides targeted interventions based on specific areas of risk, rather than a single, general score. A score of 5 or greater indicates a high risk for falling.
Hendrich II Model Components
- Eight Risk Factors: The model includes five intrinsic risk factors, two medication classes associated with higher risk, and a simple gait and balance test.
- Get Up and Go Test: Part of the Hendrich model, this can also be administered separately. It evaluates balance, gait, speed, and mobility.
- Targeted Interventions: A major strength of this model is its connection to specific interventions that can be implemented to address the identified risk factors.
Other Specific Balance and Mobility Tests
While scales like the MFS and Hendrich II provide a comprehensive risk profile, other specific tests are often used to assess components of fall risk more deeply, particularly balance and mobility.
Berg Balance Scale (BBS)
The Berg Balance Scale consists of 14 tasks to assess a person's functional balance. Scores range from 0 to 56, with a score of 44 or less suggesting an increased risk of falls. The BBS is valuable for quantifying balance deficits but is often used alongside other assessments to predict overall fall risk.
Timed Up and Go (TUG) Test
This is a simple, quick test that measures functional mobility. A patient is timed as they stand up from a chair, walk 10 feet, turn around, walk back, and sit down. A result of 12 seconds or more for an older adult suggests an increased risk of falling. The TUG test also allows healthcare professionals to observe a patient's gait and balance qualitatively.
Comparison of Major Fall Risk Assessment Tools
| Tool | Primary Purpose | Setting | Key Factors Evaluated | Assessment Format |
|---|---|---|---|---|
| Morse Fall Scale (MFS) | Comprehensive fall risk assessment | Acute care, long-term care | History of falls, secondary diagnosis, ambulatory aid, IV therapy, gait, mental status | Clinical observation and patient interview |
| Hendrich II Fall Risk Model | Rapid fall risk assessment | Acute care | Intrinsic risk factors, medication categories, Get Up and Go Test | Clinical observation and review of patient data |
| Berg Balance Scale (BBS) | Quantify functional balance | Rehabilitation, outpatient | 14 specific tasks covering sitting, standing, and movement | Performance-based testing |
| Timed Up and Go (TUG) | Screen for functional mobility | All settings | Time to complete a set course, qualitative observation of gait | Performance-based testing |
Key Factors Contributing to Fall Risk
Beyond the scores from specific scales, healthcare providers and individuals must consider a variety of intrinsic and extrinsic factors that contribute to fall risk.
Intrinsic Factors
- Age-Related Changes: Decreased muscle strength, vision changes, and slower reflexes.
- Medical Conditions: Chronic diseases like Parkinson's, arthritis, and stroke can impair mobility.
- Medications: Certain medications, including sedatives, antidepressants, and blood pressure drugs, can cause dizziness or drowsiness.
- Cognitive Impairment: Conditions like dementia or confusion can affect judgment and spatial awareness.
Extrinsic (Environmental) Factors
- Home Hazards: Loose rugs, poor lighting, clutter, or uneven flooring.
- Footwear: Ill-fitting or unsupportive shoes can increase the risk of slipping or tripping.
- Lack of Assistive Devices: Not using canes, walkers, or grab bars when needed.
Proactive Strategies for Fall Prevention
An assessment is just the first step. Effective fall prevention requires a multifactorial approach based on the identified risks.
- Exercise Programs: Engage in exercise focused on improving balance, strength, and gait. Tai Chi and other specialized programs have been shown to be effective.
- Medication Management: Regularly review medications with a doctor or pharmacist to minimize or withdraw high-risk drugs where possible.
- Home Environment Modification: Make homes safer by removing hazards, improving lighting, and installing grab bars or railings.
- Vision and Hearing Checks: Regular checkups are crucial, as even small changes can impact balance.
- Proper Footwear: Wear supportive, nonskid, rubber-soled shoes to ensure better stability.
- Vitamin D Supplementation: Some studies support Vitamin D supplementation to reduce fall risk, especially for high-risk individuals.
Comprehensive guidelines on fall prevention can be found from reputable sources such as the American Academy of Family Physicians, which outlines recommendations for addressing falls in older persons AAFP.
Conclusion
In summary, there is no single scale for assessing fall risk, but rather a suite of tools that are chosen based on the specific healthcare setting and patient population. The Morse Fall Scale, Hendrich II Model, and tests like the TUG are all part of a comprehensive approach to identifying and managing fall risk. By understanding these assessment tools and implementing proactive prevention strategies, it is possible to significantly reduce the incidence of falls and improve patient safety and well-being.
