Limitations of Timed Up and Go (TUG)

A key aspect of fall prevention is fall risk assessment, and the gold standard in fall risk assessment in recent decades has been the Timed Up and Go (TUG) test. The TUG test has the virtue of being a quick and simple assessment. It simply entails timing a patient as he or she rises from a chair, walks three meters (10 feet), and returns to a seated position. The time it takes to complete the task (assuming the patient is able to complete the test at all) has been correlated to fall risk in some studies. Depending on the source, cutoff times ranging from 10 seconds and up, to 30 seconds and up, indicate a patient who is at high risk of falling.

It is the simplicity of the test and the unambiguous nature of the results that makes TUG so seductive, and is perhaps why, despite its shortcomings, it has become ubiquitous in the healthcare field and in the senior care industry as an indicator of fall risk.

Recent studies have revealed the limitations of Timed Up and Go. New approaches to fall risk assessment, which supplement rather than necessarily replace TUG, may lead healthcare providers and the senior care industry into a new era of fall risk assessments.

Despite its ubiquity, Timed Up and Go has significant limitations in its ability to determine fall risk. Those include:

Timed Up and Go is a static assessment

When providers perform the TUG test upon admission, they merely have one data point about a patient’s fall risk at a particular point in time. Seniors’ needs can change rapidly, and it is neither realistic nor practical to expect providers to perform the TUG test daily. A senior who performed adequately during an assessment at admission may gradually decline and become at increased risk of falls, and because subsequent TUG tests weren’t performed on a regular or frequent enough basis, this change in status may not necessarily be recognized. This suggests the need for supplemental fall risk assessment that is ongoing and passive (or ambient), rather than periodic and demanding of patients’ and providers’ time.

Timed Up and Go does not take into account the assessor’s judgments

Timed Up and Go ultimately provides a number: the time it takes to complete the test. It does not take into account the expert opinion of the medical professional performing the test, nor does it take into account the resident’s or patient’s medical history. Yet the judgment of professionals and the history of the senior has been shown to be a more accurate predictor of fall risk than the TUG test.

Timed Up and Go only looks at recorded time, not the patient’s movements

With the TUG test, “movement deficiencies exhibited on the complex subtasks are ignored. The effects of a new medication or therapy could go unnoticed when only analyzing the course-grained measurement of duration.” A patient who is a high fall risk could present with a very abnormal gait and poor balance, yet still be deemed a low fall risk if he or she somehow manages to complete the test before the cutoff time.

There is conflicting information and opinion about interpreting TUG test results

Depending on the source, a TUG test time indicating an individual is at “high fall risk” ranges from anywhere between 10 seconds to 30 seconds. One nursing home may consider a resident a high risk when TUG test time is over 12.5 seconds, while another may not come to that conclusion unless the test time is over 20 seconds. For example, the authors of one study “felt that a cutoff time of 10 to 12 seconds separated fallers from nonfallers in a group of older adults. A 20-second cutoff time had previously been used when testing elderly people who were frail for independence in functional mobility.” The lack of an agreed upon standard for interpreting TUG test results raises concerns about the predictive value of the test and the ability of providers to assess the fall risk of their residents using Timed Up and Go in isolation.

Timed Up and Go cannot be performed in a small area like an assisted living resident’s living space

Timed Up and Go requires at least three meters of moving space in order to complete, meaning that it often cannot easily be performed in living spaces of residents at nursing homes and assisted living communities, where residents spend most of their time and are at greatest risk of falling. This means that at many communities, residents must be moved to an examination area to perform the test rather than having the test conducted in their own living spaces.

The three meter walk in Timed Up and Go may not be long enough

There has been some debate about the distance patients taking the TUG test must traverse. As one study suggested, “Three meters is not long enough to produce high reliability and discriminate amongst health and [high fall risk] populations.”

Footwear changes and assistive devices can dramatically alter test results in unpredictable ways

In any test, consistent and reproducible results are important for validity, but the TUG test has been shown to produce widely variable results depending on factors such as footwear and the use of a walker or cane. As researchers have noted, “The TUG is fairly sensitive to subject and environmental conditions. For example, test-retest reliability is low when subjects wear different footwear. A similar conclusion has been formed regarding the usage of assistive devices during the TUG test. ”

The chair used can unpredictably impact the results

Just as footwear and assistive devices can skew results of Timed Up and Go, the style of chair where patients begin and end the test can have great influence on their results. The aforementioned study also notes “The choice of chair can introduce variability. For example, if the chair has arms they can be used for assistance rising from or lowering to the chair. For this reason, several studies opt to explicitly use armless chairs.”

Considering the limitations of Timed Up and Go and other static assessments, when providers rely on TUG alone for fall risk assessment, they fall short of one of their paramount duties: to prevent falls and keep residents as safe as is reasonably possible. That does not mean that senior living providers should abandon TUG – instead, that they should move beyond using TUG alone. Assessments by physicians should be performed periodically and, ideally, supplemented with ambient monitoring in the resident’s living space.

This allows providers to keep residents safer by having a full sense of their risk of falling in the period after admission, but also after the residents have settled in and begun to make themselves home in the community.

A holistic approach to fall risk assessment, which supplements Timed Up and Go with a professional’s expert judgment and technical solutions, can drastically reduce the frequency of falls in senior living facilities.

What steps are you taking to overcome the limitations of Timed Up and Go?

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