FIM & FAM I. Areas assessed a. Self-care b. Sphincters c. Mobility d. Communication e. Psychosocial f. Cognition Scoring a. 7 complete indep b.

. 6 mod indep c. 5 supervision d. 4 min assist e. 3 mod assist f. 2 max assit g. 1 total assist

II.

II. III.

IV.

Turning to look behind over left & right shoulder k. Turning 360deg l. # of times stool touched while stepping m. Standing unsupported, 1 foot in front of the other n. Standing one leg Total score = 56 Interpretation a. 41-56 = low risk b. 21-40 = medium c. 0-20 = high <45 = predictive of falls in older adults

j.

FUNCTIONAL REACH TEST I. II. III. IV. V. VI. Max distance one can reach forward beyond arms length Yardstick @ wall, || to floor, shoulder level Head of 3rd MC 6 = falls in elderly Dynamic postural control Advantages a. Quick, precise, portable b. Min equipment c. Single task d. Sensitive to change ff bal training Lateral reach test a. Mediolat postural control b. No knee flex, trunk rot c. 10-36cm d. Results dec i. Inc age ii. Dec height iii. Dec arm length

STRATIFY FALLS RISK ASSESSMENT TOOL I. Areas assessed a. Transfers i. Unable = 0 ii. Major help = 1 iii. Minor help = 2 iv. Indep = 3 b. Mobility i. Immob = 0 ii. Indep w/ aid of w/c = 1 iii. Walking aid = 2 iv. Walks w/ aid of person = 2 v. Indep = 3 c. Combined trans & mob d. Hx of falls last 3mos e. Visually impaired f. Agitated g. Freq toileting Scoring a. 0 = low risk b. 1 = mod c. 2 0r above = high

VII.

TINETTI BALANCE TEST I. Scoring (0-2) a. 0 = max impairment b. 2 = indep Components a. Balance portion i. 9 maneuvers ii. N adaptive/abn iii. Max score = 16pts b. Gait portion i. 7 gait chac ii. N/abn iii. Max score = 12pts iv. 1st @ usual pace, then rapid but safe pace Max possible score = 28pts Scoring a. 18 = high risk b. 19-23 = moderate c. 24 = low

II.

II.

BERG BALANCE SCALE I. Areas assessed a. Sitting to standing b. Standing unsupported c. Sitting unsupported, feet on floor d. Standing to sitting e. Transfers f. Standing unsupported, eyes closed g. Standing unsupported, feet together h. Reaching forward, outstretched arm i. Picking up item from floor

III. IV.

V. VI.

VII.

<18 = inc risk of falls Balance a. Sitting balance b. Arises c. Attempts to arise d. Immediate standing balance (1st 5 secs) e. Standing balance f. Nudged stand, feet so close, push lightly @ sternum w/ palm 3x g. Eyes closed @ 6 h. Turning 360deg i. Sitting down Gait a. Initiation of gait b. Step length & height c. Step symm d. Step continuity e. Pathy 12in diameter, excursion of 1 foot over ~10ft f. Trunk g. Walking stance

TIMED UP AND GO TEST I. II. III. Chair, stand, walk 10ft, turn, walk back to chair Normal pace Scoring a. <10sec = freely mobile b. <20 = mostly indep c. 20-29 = variable mobility d. >20 = impaired mob