Fall Risk Index for elderly patients

Fall Risk Index for Elderly Patients Based on the Number of Chronic Disabilities, Tinetti ME, Williams TF, Mayewski R.

American Journal of Medicine, vol. 80, pp. 429-434, 1986.

NAME OF THE PATIENT D.O.B. _____________________ Ward

SECTION OF HARMONY

The patient is sitting in a rough, armless chair.

Date

Sitting Equilibrium

Chair leans or slides = 0 1 stable, secure = 1

Unable to rise from chair without assistance = 0 1 Able, uses arms to assist = 1 Able without the use of arms = 2 Tries to rise Unable to without assistance = 0 2 Capable, but requires > 1 attempt = 1 capable of rising, 1 attempt = 2 immediate standing Balance (first 5 seconds. Unsteady (staggers, moves feet, trunk sway) = 0 2

Steady but uses walker or other support = 1

Steady without walker or other support = 2

Standing balance

Unsteady = 0 2

Steady but wide stance and uses support = 1

Narrow stance without support = 2

Nudged

Begins to fall = 0 2

Staggers, grabs, catches self = 1

Steady = 2

Eyes closed

Unsteady = 0 1

Steady = 1

Turning 360 degrees

Discontinuous steps = 0

Continuous = 1 2

Unsteady (grabs, staggers) = 0

Steady = 1

Sitting down

Unsafe (misjudged distance, falls into chair) = 0 2

Uses arms or not a smooth motion = 1

Safe, smooth motion = 2

Balance score 15/16

GAIT SECTION

Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace.

Date

Indication of gait

(Immediately after told to ‘go’.)

Any hesitancy or multiple attempts = 0 0

No hesitancy = 1

Step length and height

Step to = 0

Step through R = 1 1

Step through L = 1

Foot clearance

Foot drop = 0

L foot clears floor = 1

R foot clears floor = 1 1

Step symmetry

Right and left step length not equal = 0

Right and left step length appear equal = 1 1

Step continuity

Stopping or discontinuity between steps = 0 0

Steps appear continuous = 1

Path

Marked deviation = 0

Mild/moderate deviation or uses w. aid = 1 2

Straight without w. aid = 2

Trunk

Marked sway or uses w. aid = 0

No sway but flex. knees or back or

uses arms for stability = 1

No sway, flex., use of arms or w. aid = 2 2

Walking time

Heels apart = 0

Heels almost touching while walking = 1 1

Gait score 8/12

Balance score carried forward 15/16

Total Score = Balance + Gait score 23 /28

Risk Indicators:

Tinetti Tool Score Risk of Falls

≤18 High

19-23 Moderate

≥24 Low