Original Contribution
Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED

https://doi.org/10.1016/j.ajem.2018.06.015Get rights and content

Abstract

Objective

We sought to evaluate the effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex.

Methods

This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow-up and asked to self-report interim falling.

Results

Data from 192 subjects were analyzed. At baseline, 71.4% (n = 137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n = 148) scored below average on the Chair test. There were no differences by patient sex.

By the six-month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non-significant higher prevalence of falls compared to males (29.7% versus 22.2%, p = 0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%–82.5%), a specificity of 28.4% (95% CI: 21.1%–36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%–34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%–83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%–88.7%), a specificity of 23.4% (95% CI: 16.7%–31.3%), a PP value 27.0% (95% CI: 20.1%–34.9%) and a NP value of 75.0% (95% CI: 59.7%–86.8%). No significant differences were observed between sexes.

Conclusions

There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting.

Introduction

Falls remain one of the top 20 most expensive medical conditions with hospital costs averaging over $30,000 per encounter; in 2015, alone, the costs for falls for those aged 65 and above to Medicare totaled $31 billion [1]. Recent research efforts of fall interventions in older adults have identified many differences in risk factors associated with sex in determining geriatric fall risks—in one example, a recent longitudinal study in Age and Aging found that age, depressive symptoms, and performance on standing balance tests were separate determinants for men, while incontinence and frailty increased fall risks in women [2]. Another cross-sectional study found unique associations to each sex such as nutritional risks, osteoporosis and even levels of household income [3].

Contrary to these reported differences, fall risks are clinically assessed the in the same manner for both sexes. These assessments tend to be functional in nature despite the limited success in predicting fall risk [4]. A recent systematic review identified a protective bias towards women needing fall prevention programs more than men (though increased activity is protective for both males and females), while males consistently sustain higher death rates and Disability-Adjusted Life Years (DALYs) lost worldwide [5]. More research is required to identify and validate sex differences in fall risk, so that practitioners may be better equipped to assess them.

Serving as the frontline of acute healthcare, the Emergency Department (ED) may be an ideal place to recognize these factors and initiate a pathway for early multidisciplinary interventions. Already, unintentional falls account for about 13.5% of Emergency Department (ED) visits, a staggering 3 million emergency department visits annually [6, 7]. There is a dearth of studies that seek to identify those at risk of falls during an encounter, including for non-traumatic visits in the ED. There has been a call for streamlined screening protocols in the ED for the geriatric population [8].

The Timed Up and Go Test (TUG) and the 30-Second Chair test are proposed by the CDC [9, 10] as a means of screening elderly patients for increased risk for falls. While the TUG test has shown a decreased performance in females compared to males among the geriatric mild cognitive impairment (MCI) population [11], the Chair test has not been evaluated for effectiveness by sex. Neither test has been evaluated in the ED setting. In this setting, a desirable test would offer an objective means of screening while being effortless enough to be performed within the time constrained environment. Such a tool would optimally assist clinicians in mitigating future morbidity/mortality of their elderly patients. In this study, we sought to evaluate the effectiveness of the TUG and Chair test in the ED setting, stratified by sex.

Section snippets

Methods

After hospital IRB review and approval, this prospective trial was conducted in the ED of a Level 1 Trauma Center in Northeastern Pennsylvania with an annual census of over 90,000 adult visits per year. Participants were screened and included in the study if they were ≥65 years old, being discharged from the ED, English speaking, had capacity for consent, and personally identified a risk factor for falling. Risk factors for falling were based on Centers for Disease Control (CDC) guidelines [ 12

Results

Two hundred participants were enrolled into this study. Of these, 8 were excluded from analysis because they: withdrew consent (n = 3), were lost to follow-up (n = 2), died prior to 6-month follow-up evaluation (n = 2), or were deemed ineligible after enrollment (n = 1) (See Fig. 1). The resultant sample size was 192 participants. The characteristics of the study sample, stratified by participant gender, are presented in Table 1. A majority of the participants were female (n = 111, 57.8%). The

Discussion

In 2014, at a Society for Academic Emergency Medicine consensus conference, it was determined that a prioritized research agenda should include finding the most feasible falls-risk tool for men and women in the ED setting [13]. Our study indicates that the reliance on using TUG and Chair tests as a means of predicting fall risk shows limited predictive ability. In our study, simply asking a patient if they have fallen in the past year was found to be a better screening tool. CDC recommendations

Conclusions

In our study, the TUG and Chair tests, applied at the given thresholds, do not add significant additional screening performance when added to the screen already applied by the inclusion criteria (patients reporting that they had either fallen in the last year, worried about falling, or admitted that they felt unsteady when standing or walking). Additionally, there were no sex specific significant differences in TUG or Chair test screening performance. Further research to determine what might be

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Cited by (0)

The authors have no outside support information, conflicts or financial interest to disclose. This study, in part, was funded by an unrestricted community grant from the Ann and Carl Anderson Trust and this work has been presented, in part, as an abstract at the 2017 IGM Congress in Sendai, Japan.

Authors would like to acknowledge the research operations management of Anita Kurt, PhD, RN, the team member assistance for screening, enrolling, coordinating, and or phone follow-up of Tyler M. Adams, BS, Steven J. Berk, DO, Vartika Bhardwaj, MD, Tracy M. Bishop, DO, Ryan Day, MD, Danielle Mills, MD, Bernadette Glenn-Porter, BS, Shaye M. Glovas, BS, Victoria Goodheart, DO, Michael Goodwin, MD, Kyli N. Krape, DO, Stephanie S. Merrick, MD, Kayley J. Miller, MSPAS, PA-C, Elizabeth C. Moore, DO, Sofia M. Murillo, BS, Samantha L. Myles BSN, RN, Cameron Paterson, MD, Todd Remaley, DO, Rolando E. Rios, MD, Lauren E. Semler, MS, MSPAS, PA-C, Ryan M. Surmaitis, DO, Kara Mia Villanueva, MS, Michael Wagner, DO, Deirdre Warner, DO, Adison Weseloh, MD, Alexander Youngdahl, DO, and Phillip Zegelbone, MD.

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