Older Adult Assessments Flashcards
Administration of the Functional Reach Test
Requires ruler or yard stick
- Place measuring instrument parallel to floor at shoulder height
- Pt makes a fist and reaches forward as far as possible without taking a step or touching the wall
- Measure distance (in inches or cm) between start and end of reach using 3rd metacarpal as your end point
- Pt receives 1 practice trial and 2 measured trials
- Average if 2 trials is taken
Scoring the Functional Reach Test
- Scores less than 6 inches indicates limited functional balance and significant fall risk
- Scores between 6 and 10 indicates moderate fall risk
- Healthy older adults will score around 10 inches
Functional Reach Test Norms for 70-87 year olds
Men: 13.16 inches
Women: 10.47 inches
Five Times Sit to Stand Administration
Need 16 inch chair with solid seat and straight back and stopwatch
- Instruct to sit with arms folded across chest
- “When I say go, stand up and sit down as quickly as possible five times, keeping your arms folded across your chest. Ready go.”
- Start stopwatch when you say go and stop when individual stands the fifth time
Scoring for Five Times Sit to Stand
Norm referenced
Inability to rise from chair five times in less than 13.6 seconds is associated with increased disability and morbidity
Five Time Sit to Stand norms for 70-79
12.6 seconds
Timed Up and Go Administration
Need arm chair, tape measure, tape, and stop watch
- Patient should be sitting with good posture in chair with marker on floor 10 feet away
- “When I say go you will stand up, walk to the line on the floor, turn away and walk to the chair and sit down. Walk at your regular pace. Ready go.”
- Start timer on word go and stop timer when patient is seated again
- Patient should be given an untimed practice trial
- Pt may use walking aid but document
Safety precautions for Timed Up and Go
No slip socks/shoes
Gait belt
Environmental set up
Make sure they have their glasses on
Guard person and have a sturdy chair behind
Modify assessment if needed
Scoring for Timed Up and Go
Norm-referenced
Healthy older adults will complete test in 10 seconds or less
For community dwelling frail older adults, a score greater than 14 is associated with high fall ris
Timed Up and Go Norms for 70-79 years
9.2 seconds
Fall Risk for Older People in the Community (Frop-COM)
Free, unstandardized assessment to provide information about predictive and future fall risks with individuals 65 and older while in the community
Assessment rates 13 fall risk factors on a scale for 0-3 with 0 being low risk and 3 being high risk
Fall Risk for Older People in the Community (FROP-Com) Scoring
Total score is added up to determine risk of falling
Score of 0-11 indicates mild fall risk
Score of 12-18 indicates moderate fall risk
Score of 19-60 indicates high fall risk
Fall Behavioral Scale for the Older Person (FaB)
Free, unstandardized assessment to identify behaviors and habits that may reduce or increase the fall risk for older adults
Client fills out 30 item survey or interview where they describe the frequency of statements by circling never, sometimes, often, or always
Scoring for the Fall Behavioral Scale for the Older Person
Higher scores indicate greater protective behavior and lower scores indicate increase unsafe behavior that may increase risk
Berg Balance Scale
Free, criterion-referenced, 10-15 minute assessment to measure balance and fall risk in older adults
Examiner will have client perform 14 different movements that require balance and score each item from 0-4
