Z Gerontol Geriat 39:288–291 (2006) DOI 10.1007/s00391-006-0398-y
CONTRIBUTION TO THE MAIN TOPIC
The Tinetti test
S. Köpke G. Meyer
Babylon in geriatric assessment
Der Tinetti-Test – Babylon im geriatrischen Assessment " Summary The Tinetti test has been recommended and widely used in the elderly to assess mo-
Received: 22 May 2006 Accepted: 13 June 2006
Sascha Köpke ()) Dr. phil. Gabriele Meyer Universität Hamburg MIN-Fakultät Fachwissenschaft Gesundheit Martin-Luther-King-Platz 6 20146 Hamburg, Germany Tel.: +49-40 / 4 28 38-72 24 Fax: +49-40 / 4 28 38-37 32 E-Mail:
[email protected]
bility, balance and gait, and predict falls. Different versions can be found. A systematic literature search identified 37 publications on the Tinetti test and falls. Wide variations were found concerning name of the instrument, test items, scoring, and cut-off values. This heterogeneity interferes with evaluations of the test’s validity, reliability and generalisability. Researcher and clinicians should be aware of this fact, when dealing with the Tinetti test. " Key words Aged – accidental falls – risk assessment – geriatric assessment
sessment von Mobilität, Balance und Gang sowie zur Sturzvorhersage. Verschiedene Versionen des Instruments liegen vor. Eine systematische Literatursuche identifizierte 37 Publikationen zum Tinetti-Test im Zusammenhang mit Stürzen. Große Variationen fanden sich in Bezug auf Name des Instruments, Items, Scoring und Schwellenwert. Diese Heterogenität erschwert die Evaluation von Validität, Reliabilität und Generalisierbarkeit des Instruments. Wissenschaftler und Kliniker, die dieses Instrument einsetzen, sollten sich dieser Problematik bewusst sein.
" Zusammenfassung Der TinettiTest ist ein empfohlenes und weit verbreitetes Instrument zum As-
" Schlüsselwörter Alter – Stürze – Vorhersageinstrumente – Geriatrisches Assessment
Introduction Fall prevention in the elderly has been recognised as an important issue in research and clinical practice. Numerous studies have presented combinations of fall-related risk factors and a number of risk assessment tools have been developed. A recent systematic review found that the “Tinetti Test” or “Performance Oriented Mobility Assessment (POMA)” is the most frequently cited assessment tool [19]. The tool has been claimed to be the gold standard in assessing mobility dysfunctions in the elderly [10] and an important fall risk assessment measure in various populations [20, 26]. Despite its wide clinical use, different
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versions with different means of scoring can be found [41], potentially causing problems when reporting results for validity and reliability of the Tinetti test. The aim of this article is to review publications on the use of the Tinetti-test in fall prediction.
Methods The PubMed database was searched using the terms “Tinetti” or “POMA” or “Performance Oriented Mobility Assessment” (in title or abstract). Abstracts were scanned to identify articles on falls in the elderly either assessing the validity of the instrument
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Table 1 Results Article
[1] [2] [3] [4] [5] [6] [7] [8] [9] [11] [12] [13] [14] [15] [16] [18] [21] [22] [23] [24] [25] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [42] [43]
Name
Tinetti Gait and Balance Examination Tinetti’s Mobility Index Tinetti Balance and Gait Assessment Tinetti Test Tinetti Mobility Score POMA Tinetti Balance and Gait Assessment BPOMA (Balance Portion of Tinetti’s POMA) Tinetti Balance and Gait Tool B-POMA (Tinetti Performance-Oriented Mobility Assessment) Tinetti Balance and Gait Score Tinetti Scale Tinetti’s Mobility Test Tinetti’s Condensed Mobility Score (Balance Subscale of) Tinetti POMA POMA Ia Tinetti Gait and Balance Scale Tinetti Balance Scale Tinetti Gait and Balance Assessment Scale (TGBA) Tinetti Balance Scale POMA POAM-B (Performance Oriented Assessment of Mobility – Balance Subscale) POMA Tinetti Balance Scale Tinetti Scale Tinetti Test Performance Oriented Mobility Test Tinettiscore Tinetti’s Performance Oriented Mobility Index (Balance Subscale) B-POMA (Balance Subsection of the POMA) No Name (Balance and Gait Evaluations) Performance Oriented Mobility Evaluation No Name (Mobility Maneuvers) No Name (Balance and Gait Assessment) Activity Based Balance-and-Gait Test Abbreviated version Tinetti POMA Tinetti Fall Risk Index Tinetti Balance and Mobility Score (TBMS)
Reference
Number of items
Scoring
Cut-off
Balance
Gait
Balance
Gait
[38] [36] [36] [36] [37] [38] [36] [35, 36] [36] [36]
n. r. n. r. 10 9 14 n. r. n. r. 8 n. r. 13
n. r. n. r. 8 7 N/A n. r. n. r. N/A n. r. N/A
0–16 n. r. a 0–16 0–16 0–24 n. r. b n. r. 0–16 n. r.c 0–26
0–12 n. r. a 0–12 0–12 N/A n. r. b n. r. N/A n. r.c N/A
27/28 n. r. 19/20 n. r. 22/23 n. r. n. r. n. r. 18/19 n. r.
[36] [36] [36] [38] [36, 37] [36] [35] [36] [36] [36] [35] [36]
n. r. 9 n. r. n. r. e 9 13 n. r. 13 8 n. r. 10 9
n. r. 8 n. r. n. r. e N/A 9 n. r. 9 8 n. r. 8 N/A
n. r. 0–16 n. r. n. r. 0–16 0–26 n. r. c 0–26 n. r. n. r. d n. r.c 0–16
n. r. 0–12 n. r. n. r. N/A 0–9 n. r.c 0–9 n. r. n. r. d n. r.c N/A
n. r. 20/21 29/30 d n. r. 14/15 32/33 n. r. n. r. n. r. 36/37 n. r. 12/13
[35] [36] [35, 36] [38] [36] n. r. [36]
8 14 n. r. n. r. n. r. n. r. 6
8 10 n. r. n. r. n. r. n. r. N/A
0–16 0–24 0–11 0–13 n. r. f n. r.c 0–12
0–12 0–16 0–11 0–9 n. r. f n. r.c N/A
n. r. 36/37 n. r. n. r. n. r. n. r. n. r.
[35] [35] [36] [37] [38] [35] [38] [35] [35] [35, 38]
n. r. 8 13 3 4 13 4 n. r. i n. r. k 9
n. r. 8 9 1 3 10 3 n. r. i n. r. k N/A
n. r. g 0–15 0–26 h n. r. 0–4 a 0–24 0–4 0–16 n. r. k 0-1-6
n. r. 0–13 0–9 h n. r. 0–3 a 0–16 0–3 0–12 n. r. k N/A
10/11 18/19 n. r. n. r. n. r. n. r. n. r. 19/21 j 3/4 10/11
a
Higher value reflects lower status; b Reported mean score: 25 ± 5 (SD); c Total score: 0–28; d Total score: 0–40; e Total item number: 7; f Reported mean scores range from 6.2–9.5; g Reported mean scores range from 9.3–12.2; h No score given: balance items are scored normal, adaptive or abnormal, gait items normal and abnormal; i Total item number: 16; j Separate cut-off scores for balance (10/11) and gait (9/10); k Total item number 9: only one item referring to mobility; n. r. Not reported; N/A Not applicable (only balance assessment)
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or using it as an outcome measure. Relevant articles from the systematic review [19] were also included. Articles were analysed for name of the instrument, references given, test items included, scoring, and cut-off value.
Results The PubMed search yielded 153 abstracts, of which 27 were included, 23 relevant articles had been included in the systematic review [19], 10 of which were not retrieved by the PubMed search. Accordingly, 37 articles were included (Table 1), referring to one or more of 4 articles by Tinetti and co-workers [35–38]. There were almost as many names for the instrument as there were articles. Most frequently used were “Performance Oriented Mobility Assessment” or “POMA” or POMA-related, e.g. POAM-B [sic], POMA Ia, POMA-B, B-POMA in 13 articles. Of these, 8 referred to reference [36] as the main reference whereas 4 cited reference [35]. Nine articles used Tinetti Balance and Gait Assessment or similar e.g. Activity Based Balance-and-Gait Test or Tinetti Balance and Mobility Score. Five articles used Tinetti test, Tinetti score or Tinetti scale. There was a wide variation of included items ranging from 4 [37] to 24 [28]. Overall 25 different items were used (15 for balance and 10 for gait assessment). 23 articles reported a score for balance, with a range from 0–16 used most frequently (10 times) and maximum values ranging from 4–26. 16 articles reported a score for gait, with a range from 0–12 used most frequently (6 times), maximum values ranging from 3– 16. Higher scores usually reflected a better mobility status. In contrast, in two publications [2, 38] lower scores stood for better mobility. Cut-off scores were reported 16 times with 14 different scores.
Discussion Justice et al. [17] proposed a hierarchy of external validity for predictive systems to rate an instrument’s generalisability. At first glance the highest level of validation seems to be attained by the Tinetti test. After the analysis the picture seems less clear. The wide variations of the Tinetti test challenge reports of the instrument’s ability, quality, and validity. For example, a total score of 28 (15 for balance and 13 for gait) reported by Tinetti [35] and recently recommended by the “Kompetenz-Centrum Geriatrie” (KCG) in Germany [20] was only found in three further publications [9, 24, 32], one using the original cut-off score of 18 or less. In contrast, the KCG gives a cut-off score of 19 or less for predicting a high risk of falling and of 15 or less for a very high risk. Poor predictive values have been reported for the Tinetti test in predicting future falls [19]. In summary, this systematic analysis has shown wide variations of the instrument with varying cut-off scores, further challenging its value in fall prediction. The results are limited by restricting the search to the PubMed database, other databases and reference lists were not checked. However, it seems likely that a broader search would add to the reported heterogeneity.
Conclusion Descriptions of the Tinetti test offer an almost “babylonic” number of variations, making the evaluation of the instrument’s validity and reliability problematic. Researchers and clinicians should be aware of this limitation when using one of the various versions of the Tinetti test.
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