Other Fall Risk Assessment Tools

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.

Patient Instruction
Assess

  1. Sit comfortably in a straight-backed chair.

  2. Stand up from the chair Walk to the line (10 ft.) on
    the floor at your normal pace.

  3. Turn around.

  4. Return to chair at your normal pace

  5. Sit down in the chair.

( ) 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.
http://www.rehab.research.va.gov/jour/00/37/1/wall.htm

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. 

Patient Instruction
Scoring

  1. Sit comfortably in a straight-backed chair.

  2. Rise from the chair.

  3. Stand still momentarily.

  4. Walk 10 feet.

  5. Turn around.
  6. Return to chair and sit down.

1= Normal

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

    1. Gait on level surface
    2. Gait with speed changes
    3. Horizontal head turns
    4. Vertical head turns
    5. Gait and pivot turn
    6. Step over obstacle
    7. Step around obstacles
    8. Stair steps
      https://www.youtube.com/watch?v=UQ4w_Gn4X_Q

Tinetti Performance Oriented Mobility Assessment (POMA)

Designed to measure balance and lower and upper body extremity strength.  Administration time is 10 to 15 minutes.
http://www.nyc.gov/html/doh/downloads/pdf/win/tinetti-test.pdf

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

 

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References