2.1 Fall, Depression & Pressure-Injury Risk Tools

ANCC GERO-BC Domain I (Assessment and Diagnosis) expects you to select and interpret tools and techniques for physical examination and psychosocial assessment. Fall risk, depression screening, and pressure-injury risk tools are high-yield examples: they are standardized, widely taught, and directly tied to safety and quality outcomes in older adults. Treat every score as a screen—a structured signal that prompts deeper clinical assessment—not as a stand-alone diagnosis.

Fall-Risk Screening Tools

Falls are a leading cause of injury, loss of independence, and hospital admission in older adults. Validated tools help teams identify who needs a multifactorial fall evaluation (history, gait/balance, medications, vision, orthostatics, environment, footwear).

Morse Fall Scale

The Morse Fall Scale rates six items: history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, gait/transferring, and mental status. Commonly taught risk bands are:

Clinical use: Morse is quick, familiar in many acute and post-acute settings, and useful for trending risk after surgery, delirium, or a new assistive device.

Limits: Scores can be inflated by temporary hospital factors (IV therapy) and may under-capture home hazards. A “low” score does not eliminate fall risk after sedation, overnight toileting, or orthostatic hypotension. Always combine Morse with observation of actual gait and a medication review (especially sedatives, antihypertensives, and anticholinergics).

Hendrich II Fall Risk Model

The Hendrich II Fall Risk Model emphasizes confusion/disorientation/impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, male sex, antiepileptics, benzodiazepines, and a Get-Up-and-Go performance item. A total score of ≥5 is commonly taught as high risk.

Clinical use: Hendrich II is particularly useful when cognition, elimination urgency, and psychoactive medications drive risk—common patterns on medical-surgical and geriatric units.

Limits: Facility adoption varies; do not mix Morse and Hendrich II cutoffs. The tool still cannot quantify environmental risk or caregiver availability after discharge.

Timed Up and Go (TUG)

The Timed Up and Go test times rising from a chair, walking about 3 meters, turning, returning, and sitting. Many gerontology references teach that times greater than about 12 seconds in community-dwelling older adults raise concern for increased fall risk and need for further balance/gait evaluation (exact institutional cutoffs may vary slightly).

Clinical use: TUG adds an objective performance measure when self-report of falls is unreliable or when you need a quick functional screen before discharge.

Limits: TUG requires the person to understand instructions and attempt the maneuver safely. Do not force the test in severe frailty, acute dizziness, or non-weight-bearing status. A normal TUG does not rule out falls related to nighttime confusion, polypharmacy, or cluttered home pathways.

Integrating Fall Tools Into Practice

1. Screen on admission, after a fall, after significant change in cognition/mobility/medications, and at transitions of care.
2. Document tool name, score, risk band, and interventions initiated.
3. Escalate abnormal screens to a multifactorial assessment rather than stopping at the numeric score.
4. Re-screen after interventions to evaluate whether risk changed.

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Depression Screening Tools

Late-life depression is under-recognized, especially when somatic complaints, apathy, or cognitive impairment dominate the picture. Screening tools improve detection; positive screens require clinical interview, suicide risk assessment, medical workup for mimics (hypothyroidism, B12 deficiency, grief, medication effects), and appropriate referral.

Geriatric Depression Scale–15 (GDS-15)

The GDS-15 uses yes/no items focused on mood and interest with relatively few somatic questions—helpful because older adults often have legitimate medical symptoms that inflate somatic depression scales. A score of ≥5 is commonly taught as a positive screen warranting further evaluation (higher scores increase likelihood of clinically significant depression).

Choose GDS-15 when: the older adult can answer simple yes/no questions, cognition is relatively intact or only mildly impaired, and you want a geriatric-specific brief screen in clinic, home care, or long-term care.

Patient Health Questionnaire–9 (PHQ-9)

The PHQ-9 maps to DSM symptom criteria and includes an item on thoughts of self-harm. Commonly taught severity bands include 5–9 mild, 10–14 moderate, 15–19 moderately severe, and ≥20 severe; a score of ≥10 is frequently used as a clinical threshold for probable major depression needing evaluation and treatment planning.

Choose PHQ-9 when: the setting already uses PHQ workflows (primary care, behavioral health), you need severity tracking over time, or you must screen for suicidal ideation as part of the instrument. Confirm the person can understand and report symptoms over the past two weeks.

Cornell Scale for Depression in Dementia (CSDD)

When dementia impairs reliable self-report, use an informant- and observation-based tool. The Cornell Scale for Depression in Dementia incorporates caregiver/clinician observations across mood, behavioral disturbance, physical signs, cyclic functions, and ideational disturbance. Cutoffs taught in many curricula treat scores around ≥8 to ≥10 as suggestive of significant depressive symptoms; follow your facility protocol and always interpret with clinical context.

Choose Cornell when: moderate-to-severe dementia limits valid GDS/PHQ responses, caregivers can provide collateral history, and staff can observe affective and vegetative signs over days.

Choosing Among Depression Screens

Limits across tools: Screens do not diagnose depression by themselves. False positives occur with bereavement, pain, hypothyroidism, and medication effects. False negatives occur when stigma, hearing loss, or alexithymia reduce disclosure. Always ask directly about hopelessness and suicidal ideation when clinically indicated—even if the tool is “negative.”

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Pressure-Injury Risk: Braden Scale

Pressure injuries are largely preventable with early risk identification. The Braden Scale is the most commonly tested pressure-injury risk tool in gerontological nursing.

Subscales

Braden includes six subscales:

• Sensory perception — ability to feel and report discomfort
• Moisture — skin exposure to perspiration, urine, or feces
• Activity — degree of physical activity
• Mobility — ability to change and control body position
• Nutrition — usual food intake pattern
• Friction and shear — sliding, dragging, or poor positioning mechanics

Lower subscale scores mean higher vulnerability in that domain. The total score ranges from 6–23.

Commonly Taught Cutoffs

Many facilities treat ≤18 as “at risk” and trigger a prevention bundle. Know your organization’s policy, but for exam purposes remember that lower totals mean higher risk and that subscale patterns drive interventions.

Linking Subscales to Skin Assessment

A useful clinical habit is to translate each low subscale into action and into what you inspect:

1. Low mobility/activity → scheduled repositioning, pressure-redistributing support surfaces; inspect sacrum, heels, ischia, trochanters.
2. Low moisture → toileting schedule, barrier products, moisture-wicking fabrics; inspect perineum and skin folds.
3. Low nutrition → dietitian referral, protein/calorie support, monitor weight and intake.
4. Low friction/shear → lift devices, HOB elevation limits when feasible, heel offloading.
5. Low sensory perception → do not rely on patient report of pain; inspect thoroughly and educate caregivers.

Perform a head-to-toe skin assessment on admission, regularly thereafter, and whenever Braden risk worsens (after surgery, hypotension, fever, incontinence escalation, or immobility). Document blanchable erythema, non-blanchable redness, moisture-associated skin damage versus pressure injury, and device-related pressure points (oxygen tubing, catheters, boots).

Limits of Braden Alone

Braden does not stage wounds and does not replace wound photography, measurement, or differential diagnosis (arterial ulcers, venous stasis, moisture-associated dermatitis). Critically ill or cachectic patients may deteriorate faster than the score suggests. Reassess after any meaningful change in mobility, continence, perfusion, or nutrition.

Exam Focus

GERO-BC items often ask which tool fits the patient, what a score implies for risk (not diagnosis), and what you do next. Match fall tools to mobility/safety planning, depression tools to cognition and setting, and Braden subscales to targeted skin interventions.