Morse Fall Scale

Fall risk factors

The Morse fall scale can be employed to screen elderly patients from clinical and long term care inpatient settings.

This risk assessment helps prevent falls and their consequences, which are the more serious in patients at risk.

The tool consists of 6 fall risk parameters:

■ History of falling looks at whether the patient had an episode of falling during current stay or has a history of falls, regardless of their cause (for example, gait type or seizures).

■ If the patient has a secondary diagnosis, meaning 2 or more diagnoses in the patient chart, the risk of fall increases.

■ Ambulatory aid refers to the patient making use of walking aid (cane, crutches or wheelchair).

■ Intravenous therapy/ heparin lock checks whether the patient is under IV medication.

■ The Gait item* evaluates the patient’s balance status.

■ Mental status is assessed through the consistency of the patient’s answers.

*Weak gait means that the patient is in a stooped state but able to lift head, seeking support from furniture for reassurance, while walking with small steps.

Impaired gait is when the patient walks with short steps and his or her head down. The patient rises from chair with difficulty, walking aid may be required and impaired balance is noticed.

Often, the Morse fall scale is administered in conjunction with other tests, during clinical examinations and during reviews of current therapy.

It is important for the assessor to consider local circumstances as well and other patient signs that may become obvious during assessment.

Morse scale scoring

The table below introduces the items in the scale and the number of points awarded depending on the answer choice:

There are three types of fall risk to be extracted from the final score and each of these has a different recommendation for intervention:

About the study

Morse et al. have conducted a study on the morbidity and mortality of the elderly patient, in 1989, with specific interest into patient falls.

The discriminant analysis performed on the above six items, correctly classified 80.5% of the patients. During validation, similar results were obtained.

The characteristics of the scale were:

■ 78% sensitivity;

■ 83% specificity;

■ 3% positive predictive value;

■ 3% negative predictive value.

The scale was also found to be sensitive to factors such as patient condition and length of stay. The Morse fall scale can be used to screen the patients that need to be targeted with prevention strategies.

Original source

Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging. 1989; 8:366-7.

Other references

1. O'Connell B, Myers H. The sensitivity and specificity of the Morse Fall Scale in an acute care setting. J Clin Nurs. 2002; 11(1):134-6.

2. Schwendimann R, De Geest S, Milisen K. Evaluation of the Morse Fall Scale in hospitalised patients. Oxford Journals Medicine & Health Age and Ageing. 2006; 35(3Pp): 311-313.

3. Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004; 33(2):122-30.