Primarily used to measure gate and balance
Timed Up and Go (TUG)
This is a simple test often used in non-acute settings. The patient is asked to stand up without using arm assistance from a straight backed chair. Then the patient is asked to walk 10 feet, turn around and come back to the chair. These activities should be performed under 10 seconds.
( ) Slow tentative pace
( ) Loss of balance
( ) Short strides
( ) Little or no arm swing
( ) Steadying self on walls
( ) Shuffling ( ) En bloc turning
( ) Not using assistive device properly
|An older adult who takes ≥12 seconds to complete the TUG is at high risk for falling.
Get Up and Go Test
This is part of the Hendrich Fall Risk Model but can be administered separately. It takes five minutes to administer and tests balance, gait, speed and mobility.
2= Very slightly abnormal
3= Mildly abnormal
4= Moderately abnormal
5= Severly abnormal
|A score of 3 or more on the Get-up and Go Test is at risk of falling
Dynamic Gait Index
Used to assess the eight facets of gait. Score each of 8 stages as: (3) Normal, (2) Mild Impairment, (1) Moderate Impairment, (0) Severe Impairment
Tinetti Performance Oriented Mobility Assessment (POMA)
Designed to measure balance and lower and upper body extremity strength. Administration time is 10 to 15 minutes.
St. Thomas Risk Assessment Tool (STRATIFY)
Used mostly to predict fall risk factors in the elderly
Available by contacting author: http://www.bmj.com/cgi/content/full/315/7115/1049
Mini Mental State Examination (MMSE)
Most popular screening tool for cognitive impairment. Measures orientation, immediate recall, short-term verbal memory, calculation, language, and construct ability https://en.wikipedia.org/wiki/Mini–mental_state_examination