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get up & go test mobility screen fall risk checklist

home wellness fall prevention assessing fall risk mobility screen

mobility screen (*)

by Rein Tideiksaar, PhD

A mobility screen test allows the observer to see an elder's level of mobility and develop a fall risk score. Fall risk scores can help pinpoint elders who are at risk for falls and illustrate where fall prevention interventions can make a big difference.

Instructions for mobility screen test:

1. Ask elder to perform the following maneuvers and score each maneuver. If elder uses cane or walker, allow him/her to use device during maneuvers.
   
   
2. Fall risk score is calculated as follows: Low fall risk (all maneuvers are normal); "at risk for falls" (one or more adaptive or abnormal maneuvers).

Maneuvers:

Maneuver	Normal	Adaptive	Abnormal
Sitting Balance Ask elder to sit comfortably in straight-backed chair.	Steady, stable		Holds onto chair to keep upright Leans or slides down in chair.
Rising Balance Ask elder to rise from chair, without use of armrest support.	Able to rise without using armrests.	Needs armrests or walking aid to rise and/or moves forward in chair before rising.	Multiple attempts required or unable to rise without human assistance.
Standing Balance- Eyes Open Ask elder to stand still for 3-5 seconds.	Steady, able to stand without support.	Steady but needs walking aid or other object for support.	Any sign of unsteadiness.
Standing Balance-Eyes Closed Ask elder to remain standing with eyes closed for 3-5 seconds	Steady, able to stand without support.		Any sign of unsteadiness.
Walking Balance Ask elder to walk straight path (10 feet).	Walks without hesitation, deviation of straight path or shuffling gait.		Any sign of hesitation, path deviation or shuffling gait.
Turning Balance Ask elder to turn around and return back to the chair.	Steady, no staggering or need to hold onto objects/furnishings for support.		Any sign of unsteadiness or holding onto objects/ furnishings for support.
Sitting Balance Ask elder to sit back down in the chair.	Able to sit down without using armrests.	Needs to use armrests to guide self into chair	Plops into chair or unable to sit down without human assistance.

(*) Adapted from: Tinetti ME. Performance-Oriented Assessment of Mobility Problems in Elderly Patients. JAGS 1986; 34:119-126; and Tideiksaar R. Falls in Older Persons (3rd Edition). Health Professions Press, pg 177.

This and other helpful fall risk assessment tools are available as a printable pdf file.

Posted October 2005
Last Updated October 2009 

26 South Main Street, PMB #162 . Concord, NH 03301 . Phone: 603 397-0103