Question 1

What is the get-up-and-go test and how is it scored?

Accepted Answer

The patient rises from a seated position (without using arms if possible). Scoring: 0 = rises without assistance, steady; 1 = rises with one attempt, steady; 2 = pushes up, unsteady; 3 = unable to sit without assistance (score automatically assignable from chart review, e.g., bed rest orders). The highest applicable score is recorded.

Question 2

How does Hendrich II differ from the Morse Fall Scale?

Accepted Answer

Both are validated fall risk tools. Hendrich II includes a brief functional mobility assessment (get-up-and-go) and specific medication categories. Morse Fall Scale includes history of falling, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status. Both have similar predictive accuracy (AUC 0.70–0.76). Choice depends on institutional preference.

Question 3

Should Hendrich II be used in community or outpatient settings?

Accepted Answer

The Hendrich II was developed and validated predominantly in hospital and long-term care settings. For community-dwelling older adults, the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool or the Falls Risk Assessment Tool (FRAT) may be more appropriate. However, the Hendrich II risk factors are broadly applicable.

Question 4

What is the evidence that Hendrich II-based interventions prevent falls?

Accepted Answer

Observational studies show that implementing Hendrich II screening with a bundled prevention protocol reduces fall rates by 20–40% in hospital settings. However, falls prevention trials often bundle multiple interventions (education, environmental, exercise) making the independent contribution of any single risk tool difficult to isolate.