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Geriatric Outcome Measures Cheat Sheet by

Outcome Measures evaluating balance in Geriatric Theray

Sitting Standing and Transfers

 
SITTING TO STANDING INSTRU­CTIONS: Please stand up. Try not to use your hands for support.
STANDING TO SITTING INSTRU­CTIONS: Please sit down.
TRANSFERS INSTRU­CTIONS: Arrange chairs(s) for a pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair.
4
able to stand without using hands and stabilize indepe­ndently
sits safely with minimal use of hands
able to transfer safely with minor use of hands
3
able to stand indepe­ndently using hands
controls descent by using hands
able to transfer safely definite need of hands
2
able to stand using hands after several tries
sits indepe­ndently but has uncont­rolled descent
able to transfer with verbal cueing and/or superv­ision
1
needs minimal aid to stand or to stabilize
sits indepe­ndently but has uncont­rolled descent
needs one person to assist
0
needs moderate or maximal assist to stand
needs assistance to sit
needs two people to assist or supervise to be safe
Think:
- Hands
- Stability
- Assistance
- Supervison

AMTs

What is your age?
. Give the patient an address, and ask him or her to repeat it at the end of the test e.g. 42 West Street
What is the time to the nearest hour?
What is the year?
What is the name of the hospital or number of the residence where the patient is situated?
Can the patient recognize two persons (the doctor, nurse, home help, etc.)?
What is your date of birth? (day and month suffic­ient)
. In what year did World War 1 begin?
Name the present monarc­h/prime minist­er/­pre­sident.
Count backwards from 20 down to 1
A score of 6 or less suggests delirium or dementia, although further tests are necessary to
confirm

Barthel Part 1 Mobility

Transfers
Indepe­ndent
 
Needs minor help
 
Needs major help
 
Unable
Mobility
Indepe­ndent (may use a stick) >50 yards
 
Walks with physical or verbal help of one other > 50 yards
 
Wheelchair indepe­ndent > 50 yards
 
Immobile < 50 yards
Stairs
Indepe­ndent
 
Needs help (other person, aid)
 
Unable
 

Standing and Sitting

 
STANDING UNSUPP­ORTED
SITTING WITH BACK UNSUPP­ORTED BUT FEET SUPPORTED
STANDING UNSUPP­ORTED ONE FOOT IN FRONT
STANDING ON ONE LEG
4
able to stand safely 2 minutes
able to sit safely and securely 2 minutes
able to place foot tandem indepe­ndently and hold 30 seconds
able to lift leg indepe­ndently and hold >10 seconds
3
able to stand 2 minutes with superv­ision
able to sit 2 minutes with superv­ision
able to place foot ahead of other indepe­ndently and hold 30 seconds
able to lift leg indepe­ndently and hold = or >3 seconds
2
able to stand 30 seconds unsupp­orted
able to sit 30 seconds unsupp­orted
able to take small step indepe­ndently and hold 30 seconds
tries to lift leg unable to hold 3 seconds but remains standing indepe­ndently
1
needs several tries to stand 30 seconds unsupp­orted
able to sit 10 seconds unsupp­orted
needs help to step but can hold 15 seconds
tries to lift leg unable to hold 3 seconds but remains standing indepe­ndently
0
unable to stand 30 seconds unassisted
unable to sit without support 10 seconds
loses balance while stepping or standing
tries to lift leg unable to hold 3 seconds but remains standing indepe­ndently

Risk Factor Checklist

Vision
Dificulty seeing or finding way around
Mobility
Unsafe, impulsive, forgets aid
Transfers
Over=r­eaches, impusive
Behaviours
Aginta­tion, confusion or non-co­mpliant
ADLs
Riskpt­aking, unsafe equiment or footwear
Enviro­nment
Diffcu­lties with orient­ation
Nutrition
Underw­eig­ht/low appetite
Contience
Urgency, nocturia, accidents

Barthel Part 1 ADLS

Cleaning
Bathing
Indepe­ndent +10
 
Needs Help +5
 
Unable 0
Grooming
Indepe­ndent
 
Unable
Dressing
Indepe­ndent
 
Needs Help
 
Unable
Toileting
Bowel Control
Continent
 
Occasional Accident
 
Incont­inent
Bladder
Continent
 
Occasional Accident
 
Incont­inent
Toilet Use
Indepe­ndent
 
Needs Help
 
Unable
Feeding
Indepe­ndent
 
Needs Help
 
Unable
 

Reaching

 
REACHING FORWARD WITH OUTSTR­ETCHED ARM WHILE STANDING
PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION
4
can reach forward confid­ently >25 cm (10 inches)
able to pick up slipper safely and easily
3
can reach forward >12 cm safely (5 inches)
able to pick up slipper but needs superv­ision
2
can reach forward >5 cm safely (2 inches)
unable to pick up but reaches 2-5cm (1-2 inches) from slipper and keeps balance indepe­ndently
1
reaches forward but needs superv­ision
unable to pick up and needs superv­ision while trying
0
loses balance while trying­/re­quires external support
unable to try/needs assist to keep from losing balance or falling

Berg Balance Tests

 
TURN 360 DEGREES
TURNING TO LOOK BEHIND
4
able to turn 360 degrees safely in 4 seconds or less
looks behind from both sides and weight shifts well
3
able to turn 360 degrees safely one side only in 4 seconds or less
looks behind one side only other side shows less weight shift
2
able to turn 360 degrees safely but slowly
turns sideways only but maintains balance
1
needs close superv­ision or verbal cueing
needs superv­ision when turning
0
needs assistance while turning
needs assist to keep from losing balance or falling

Falls Risk Assessment Tool

 
Have you had a fall in the previous year?
Are you taking four or more medica­tions per day? Out of sedatives, anti-d­epr­ess­sants, parkin­son's, diuretics, anti-h­ype­rti­ensives and hypnotics
Psycol­ogical (Anexity, depres­sion, stroke, Parkisons, cooper­ation, insight or judgement)
Have you had a stroke? Have you been diagnosed with Parkin­son’s disease?
Are you unable to stand up from a chair of knee height without using your arms?
 
0 in last 12
0
0
 
0 or more in last 3 months
1
mildly by 1 or more
 
one or more in last 3 months
2
moderately by one or more
 
3 or more whilst ination
>2
sever in one or more
 

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