Morse Fall Scale

Predicts risk of falling based on personal fall history, mental status and other risk factors.

In the text below the calculator there is more information on patient parameters used, scoring method and about the original study.


The Morse fall scale screens elderly patients for risk of falling to help the initiation of fall prevention measures.

The scale is based on six patient parameters which were found by Morse et al. (in a study from 1989) to increase fall risk.

This method is to be used in clinical and in long term care inpatient settings and can be administered in less than 5 minutes, usually by nurses.


Each of the six parameters are awarded a number of points and their sum makes up for the final score.

Scores below 25 indicate a low fall risk, scores between 25 and 45 indicate a moderate risk whilst scores above 45 suggest the patient is at a high fall risk.


1

History of falling (immediate or previous)

2

Secondary diagnosis (2 or more medical diagnoses in chart)

3

Ambulatory aid

4

Intravenous therapy/ heparin lock

5

Gait

6

Mental status

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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:

Scale items Answer choices (points)
History of falling (immediate or previous) Yes (25)
No (0)
Secondary diagnosis (2 or more medical diagnoses in chart) Yes (0)
No (15)
Ambulatory aid None/ bed rest/ nurse assist (0)
Crutches/ cane/ walker (15)
Furniture (30)
Intravenous therapy/ heparin lock Yes (0)
No (20)
Gait Normal/ bed rest/ wheelchair (0)
Weak (10)
Impaired (20)
Mental status Oriented to own ability (0)
Overestimates/ forgets limitations (15)

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

Morse score Fall risk Recommendation
Below 25 Low Continue with basic nursing care
25 - 45 Moderate Activate standard fall prevention intervention
Above 45 High Ensure fall prevention is in place and is effective
 

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.


App Version: 1.0.1

Coded By: MDApp

Specialty: Disability

System: Musculoskeletal

Objective: Risk Predictor

Type: Scale

No. Of Items: 6

Year Of Study: 1989

Article By: Denise Nedea

Published On: May 29, 2017 · 08:05 AM

Last Checked: May 29, 2017

Next Review: May 29, 2018