Tinetti_Balance_Test v.1
An assessment score used to predict the risk of falling in patients.
To calculate the total score and assessment of the Tinetti balance test.
Use to predict the risk of falling in patients. The score is calculated by adding the points of the individual variables. **Variables** | Variable | Answers | Points | | ----------- | ----------- | --------- | | 1 - Sitting balance | Leans or slides in chair | 0 | || Steady, safe | 1 | | 2 - Rises from chair | Unable to without help | 0 | || Able, uses arms to help | 1 | || Able without use of arms | 2 | | 3 - Attempts to rise | Unable to without help | 0 | || Able, requires >1 attempt | 1 | || Able to rise, 1 attempt | 2 | | 4 - Immediate standing balance (first 5 seconds) | Unsteady (staggers, moves feet, trunk sway) | 0 | || Steady but uses walker or other support | 1 | || Steady without walker or other support | 2 | | 5 - Standing balance | Unsteady | 0 | || Steady but wide stance and uses support | 1 | || Narrow stance without support | 2 | | 6 - Nudged | Begins to fall | 0 | || Staggers, grabs, catches self | 1 | || Steady | 2 | | 7 - Eyes closed | Unsteady | 0 | || Steady | 1 | | 8A - Turning 360 degrees - steps | Discontinuous steps | 0 | || Continuous | 1 | | 8B - Turning 360 degrees - steadiness | Unsteady (grabs, staggers) | 0 | || Steady | 1 | | 9 - Sitting down | Unsafe (misjudged distance, falls into chair) | 0 | || Uses arms or not a smooth motion | 1 | || Safe, smooth motion | 2 | | 10 - Indication of gait (Immediately after told to ‘go’.) | Any hesitancy or multiple attempts | 0 | || No hesitancy | 1 | | 11A - Step length and height - Right | Step to | 0 | || Step through R | 1 | | 11B - Step length and height - Left | Step to | 0 | || Step through L | 1 | | 12A - Foot clearance - Right | Foot drop | 0 | || R foot clears floor | 1 | | 12B - Foot clearance - Left | Foot drop | 0 | || L foot clears floor | 1 | | 13 - Step symmetry | Right and left step lengths not equal | 0 | || Right and left step lengths appear equal | 1 | | 14 - Step continuity | Stopping or discontinuity between steps | 0 | || Steps appear continuous | 1 | | 15 - Path | Marked deviation | 0 | || Mild/moderate deviation or uses w. aid | 1 | || Straight without w. aid | 2 | | 16 - 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 | | 17 - Walking time | Heels apart | 0 | ||Heels almost touching while walking | 1 | **Score interpretation** | Tinetti score | Fall risk interpretation | | ---------------- | ------------------------------ | | 24 and above | Low fall risk | | 19 - 23 | Moderate fall risk | | Below 19 | High fall risk |
1. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986 Mar;80(3):429-34. doi: 10.1016/0002-9343(86)90717-5. PMID: 3953620.
openEHR-EHR-OBSERVATION.poma, openEHR-EHR-EVALUATION.tinetti_assessment
