TINETTI BALANCE ASSESSMENT TOOL - TriPoint Healthcare

TINETTI BALANCE ASSESSMENT TOOLTinetti ME, Williams TF, Mayewski R, Fall Risk: Index for elderly patients based on number of chronicdisabilities. Am J Med 1986:80:429-434.PATIENTS NAME: _____________________________ __________________________________________BALANCE SECTION:Patient is seated in hard, armless chair:Date PT: PT:Leans or slides in chair = 0Sitting BalanceSteady safe = 1Unable to without help = 0Rises from chair Able, uses arms to help = 1Able to rise 1 attempt = 2Unable to without help = 0Attempts to riseAble, requires > 1 attempt =1Able to rise, 1 attempt = 2Unsteady (staggers, moves feet, trunk sway) = 0Immediate standing Steady but uses walker or other support = 1Balance (first 5 seconds) Steady without walker or other support = 2Unsteady = 0Standing Balance Steady but wide stance & uses support = 1Narrow stance without support = 2Begins to fall = 0NudgedStaggers, grabs, catches self = 1Steady = 2Unsteady = 0Eyes ClosedSteady = 1Discontinues steps = 0Turning 360 Degrees Continuous = 1Unsteady (grabs, staggers) = 0Steady = 1Unsafe (misjudged distance, falls into chair) = 0Sitting DownUses Arms or not a smooth motion = 1Safe, smooth motion = 2Balance Score /16 /16P.T.O.

TINETTI BALANCE ASSESSMENT TOOLGAIT SECTIONPatient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace.Indication of gait(immediate after told to ‘go’)Step length & heightFoot ClearanceStep SymmetryStep ContinuityPathTrunkWalking timeDateAny hesitancy or multiple attempts = 0No hesitancy = 1Step to = 0Step through R = 1Step through L = 1Foot drop = 0L foot clears floor = 1R foot clears floor = 2Right & left step length not equal = 0Right & left step length appear equal = 1Stopping or discontinuity between steps = 0Steps appear continuous = 1Marked deviation = 0Mild/moderate deviation or uses w. aid = 1Marked sway or uses w. aid = 0No sway but flex knees or back or usesArms for stability = 1No sway, flex, use of arms or w/aid = 2Heels apart = 0Heels amost touching while walking = 1Gait Score /12 /12Balance Score Carried Forward /16 /16Total Score = Balance + Gait Score /28 /28Risk Indicators: Tinetti Tool Score Risk of Falls< 18 High19 – 23 Moderate> 24 Low