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ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 88-92

Predicting the probability of falls in geriatrics using traditional timed up and go test and dual-task constraint timed up and go test: An observational study


Department of Physiotherapy in Neuroscience, Dr. Vithalrao Vikhe Patil Foundation's College of Physiotherapy, Ahmednagar, Maharashtra, India

Date of Web Publication18-May-2017

Correspondence Address:
Hitav Pankaj Someshwar
Someshwar,417/2 Vasant Niwas, Bhaudaji Road No. 10, Matunga, Mumbai - 400 019, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_175_16

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  Abstract 

BACKGROUND: It is unclear how older adults modulate dual-task mobility under changing postural challenges.
AIMS: The aim of this study is to compare traditional timed up and go test (TUG) and dual-task TUG for identifying geriatric population who are at risk of falling.
METHODS: An observational study was performed at PDVVPF's Hospital, Ahmednagar. Sixty patients in the age group of 60–80 years who could walk independently and had a mini-mental state examination score >24 were selected after ethical clearance, inform consent was obtained from the patients, and the patient performed traditional TUG. The patient performed TUG with a motor constraint, i.e., typing from 1 to 9 on a calculator, and later with a cognitive constraint, i.e., answer simple questions. Time was recorded for all three tests and analyzed.
RESULTS: For TUG (traditional), mean time was 20.96 s in fallers and 12.95 s in nonfallers; for TUG (manual), mean time was 25.12 s in fallers and 14.96 s in nonfallers to complete the test; and for TUG (cognitive), fallers group took 26.02 s and nonfallers group took 15.61 s to complete the test. The cutoff value to determine fallers for the traditional TUG is 15.95 s, for the motor TUG is 18.81 s, and for the cognitive TUG is 19.92 s, for determining geriatric population at a risk of falls. The traditional TUG had 90% sensitivity and 96.6% specificity, dual-task TUG motor 93.33% sensitivity and 93.33% specificity, and dual-task TUG cognitive 96.6% sensitivity and 93.33% specificity.
CONCLUSION: TUG performed under cognitive constraint was a better indicator of falls.

Keywords: Falls, geriatrics, normative value, sensitivity, specificity, timed up and go test


How to cite this article:
Someshwar HP, Kunde C, Ganvir SS. Predicting the probability of falls in geriatrics using traditional timed up and go test and dual-task constraint timed up and go test: An observational study. Int J Health Allied Sci 2017;6:88-92

How to cite this URL:
Someshwar HP, Kunde C, Ganvir SS. Predicting the probability of falls in geriatrics using traditional timed up and go test and dual-task constraint timed up and go test: An observational study. Int J Health Allied Sci [serial online] 2017 [cited 2024 Mar 28];6:88-92. Available from: https://www.ijhas.in/text.asp?2017/6/2/88/206421


  Introduction Top


Aging is a dynamic, progressive, and physiological process accompanied by functional, morphological, biochemical, and psychological change.[1] India as the second most populous country in the world has 76.6 million people at or over the age of 60, constituting above 7.7% of total population.[2] Falls are the leading cause of accidental deaths among older adults, thus understanding mobility and fall risk may reduce this burden.[3] According to the WHO, falls are defined as inadvertently coming to rest on the ground, floor, or other lower level excluding intentional change in the position of rest.[4] Gait and balance problems are responsible for up to a quarter of falls in the elderly. The prevalence of falls in India is 37.8% for the population above 60 years of age.[5] The timed up and go test (TUG) is a simple test used to assess a person's mobility and requires both static and dynamic balance. The TUG measures the time it takes a person to stand up from an arm chair, walk a distance of 3 m, turn, walk back to the chair, and sit down. It was developed originally as a clinical measure of balance in elderly people and was scored on an ordinal scale of 1–5 based on an observer's perception of the performer's risk of falling during the test.[6] Podsiadlo and Richardson modified the original test by timing the task (rather than scoring it qualitatively) and proposed its use as a short test of basic mobility skills for frail community-dwelling elderly.[6]

Moderate to high correlations have been observed with scores on Berg Balance Scale, gait speed, stair climbing, and the Barthel Index of Activities of Daily Living Scale.[7],[8] Inter-rater reliability is high with a same day, three-rater intraclass correlation coefficient (ICC) of 0.992.[7],[9],[10] The ICC was 0.97 in another study of inter-rater reliability among three physiotherapists.[8],[11] The inter-rater reliability was an ICC of 0.99 for a physical therapist, physician, and patient attendant on consecutive visits, and the consecutive intra-rater reliability was an ICC of 0.99.

Dual-task assessment has become increasingly popular in recent years because they examine the relationship between cognitive function and attentional limitations, that is, individual's ability to divide attention.[12],[13] Divided attention while walking manifests as subtle changes in posture, balance, or gait; it is these changes which provide potentially clinically significant correlations.[3],[14] Research on dual-task gait is largely based on studies examining straight-ahead walking, yet most daily activities require transition movements such as turns and sit-to-stand.[11] Mechanics of turning deteriorate with age wherein a simplified turning pattern can predict recurrent falls in the elderly.[15] Gait in older adults is compromised during dual-task conditions, such that speed and stride length are reduced, and stride time and its variability are increased. Dual-task-related gait decrements can lead to instability and increased fall risk.[4]

Recent research has suggested that assessment of balance under multitask conditions may be a more sensitive indicator of balance problems and falls than an assessment of balance in a single-task context. Researchers using laboratory tests of balance under dual-task conditions have found that the ability to maintain stability can be affected by the performance of concurrent cognitive tasks and this effect is enhanced in older adults with balance impairments and a recent history of falls.[16] It is unclear whether dual-task assessments, which have become increasingly popular in recent years, have any added benefit over single-task assessments in predicting falls.

Shumway-Cook et al. in September 2000 in their study concluded that older adults who take longer than 14 s to complete the TUG have a high risk for falls. In addition, difference scores (e.g., TUG manual − TUG) did not increase the ability to identify community-dwelling older adults who are prone to falls. Franchino S. Porciuncula et al. found that there is a decrement in phases of the test when subjected to dual tasks and the time taken is longer and the study of Chen et al. stated that the three TUGs combined are an important test used to assess the patient at risk of falls.

Very few studies provide information about prediction of risk for fall using dual-task constraint TUG in Indian population. Hence, the purpose of this study is to identify the better predictor of fall risk in geriatric population using traditional TUG and dual-task constraint TUG in Ahmednagar district.


  Methods Top


An observational study took place at our hospital and physiotherapy outpatient department for 1 year, sixty patients were chosen through purposive sampling, and sample size was calculated using the formula N = 4Za2S2/w2 where Za is standard normal deviates and a confidence level of 95%, desired total width of confidence interval being 5 and standard deviation being 10. After ethical clearance was obtained from the Institutional Ethical Committee, participants were selected based on the inclusion and exclusion criteria, and the individuals willing to participate in the age group 60–80 years of both genders were included in the study. Those who could walk independently and had mini-mental state examination (MMSE) score of >24 were included in the study, while individuals with any severe musculoskeletal or neurological abnormalities or had a history of falls in the last 1 year were excluded from the study. Individuals with a history of falls in the past 6 months were considered. The participants were explained about the study and informed consent was obtained from all the participants those who were willing to participate. The demographic data and history of falls, hypertension, and diabetes, and MMSE score were obtained. The following materials required were chair without arm support, stopwatch, calculator, and measuring tape. TUG, motor constraint TUG, and cognitive constraint TUG were the outcome measures of our study.

The participants were then explained the procedure of the test and asked to perform TUG under three conditions; performance of TUG alone, performance of TUG with an addition of cognitive task (TUGcognitive), and performance of TUG with an addition of an upper extremity motor task (TUGmanual); the tasks were presented in a random order; while performing the TUG, upon cue, the participant would stand up from the chair without hand support, walk straight 3 m, turn around, walk back to the chair, and sit down, and the time required to complete the test would be recorded [Figure 1] shows the illustration of the timed up and go test. In TUGcognitive, the participant performed the TUG with different questions being asked while walking, and while performing TUGmanual, the individual would perform the same test with a motor constraint of typing the number 1–9 on the calculator while performing the TUG. The participants performed all the tests three times and the mean of the three would be recorded.
Figure 1: Illustration of timed up and go test

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A multivariate analysis of variance (MANOVA) was performed to determine whether group differences existed on the transformed time variable and was used to reanalyze the TUG data using age and gender as a covariate. A logistic regression procedure was used to determine the cutoff value for each timed test and also test the specificity and sensitivity of the three variants of TUG. These analyses were performed using SPSS 8.0 software and GraphPad InStat 3 software (Chicago, USA).


  Results Top


In this study, sixty participants took part, which consisted of 32 males and 28 females. The mean age and mean body mass index for males were 66.56 years and 23.12 kg/m 2 and for females were 67.16 years and 23.48 kg/m 2. The difference in ages was considered statistically nonsignificant (P > 0.5). The participants were in the age group of 60–65 (n = 28), 66–70 (n = 16), 71–75 (n = 13), and 76–80 years (n = 5). [Table 1] shows the baseline parameters of the participants of this study.
Table 1: Demographic data of the participants taking part in the study

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[Table 2],[Table 3],[Table 4] show results that the time taken by fallers and nonfallers to complete the TUG in three variants; for TUG (traditional), mean time was 20.96 s in fallers and 12.95 s in nonfallers; for TUG (manual), mean time was 25.12 s in fallers and 14.96 s in nonfallers to complete the test; and for TUC (cognitive), fallers group took 26.02 s, and nonfallers group took 15.61 s to complete the test. It shows a statistically significant relationship (P < 0.0001) on MANOVA tests; it indicates that the participants with a history of falls have taken a longer time to complete the test under all three conditions as compared to participants without a history of falls. The time taken to complete the test in fallers when an additional motor task was given increased by 19.21% as compared to nonfallers who had 15.51% increase and when an additional cognitive task was given increased by 24.14% as compared to nonfallers who had 20.05% increase. [Figure 2] and [Figure 3] show the time taken by fallers and nonfallers to complete the three variants of TUG, respectively.
Table 2: Time taken by fallers and nonfallers to complete the three variants of timed up and go test

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Table 3: Difference between the dual.task and single.task timed up and go test in both the groups shows that the time taken to complete timed up and go test with an additional cognitive task is more as compared to the motor task in both fallers and nonfallers

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Table 4: Time taken to complete the three variants of timed up and go test in fallers and nonfallers according to gender shows that the time take to complete three variants of timed up and go test in males and females

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Figure 2: Time taken by nonfallers to complete the three variants of timed up and go test

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Figure 3: Time taken by fallers to complete three variants of timed up and go test

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The cutoff value to determine fallers for the traditional TUG is 15.95 s, for the motor TUG is 18.81 s, and for the cognitive TUG is 19.92 s, for determining geriatric population at a risk of falls. [Table 5] shows the specificity and sensitivity of three variants of TUG. Discriminate analysis indicated that the three variants (traditional TUG, motor TUG, and cognitive TUG) were equivalent with respect to classifying fallers and nonfallers. The traditional TUG correctly classified 27/30 fallers (90% sensitivity) and 29/30 nonfallers (96.6% specificity) and an overall prediction of 93.33%. When comparing the dual task Motor TUG with the traditional TUG, the former was able to classify 28 out of 30 participants as fallers (93.33% sensitivity) and 28 out of 30 participants as non fallers (93.33% specificity) and an overall prediction of falls was 93.33%. when comparing Dual task cognitive TUG with traditional TUG, the former was able to classify 29 out of 30 participants as fallers (96.6% sensitivity), and 28 out of 30 participants as non fallers (93.33% specificity), and an overall prediction of falls being 94.83%. Using the difference of dual-task time and single-task time to determine probability for falls resulted in lower prediction rates than when the actual test scores were used.
Table 5: The specificity and sensitivity of three variants of timed up and go test

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  Discussion Top


In this study, we found that the specificity and sensitivity of three variants of TUG, i.e., traditional TUG, TUGcognitive, and TUGmanual. The result of this study indicates that traditional TUG with an additional cognitive task is a sensitive and specific predictor of fall in geriatrics.

The difference between the TUGcognitive and traditional TUG was found to be 3.97 s and between TUGmanual and traditional TUG was found to be 2.86 s; according to the study of Lundin-Olsson et al., the difference for manual and traditional TUG was 3.12 s and that for cognitive and traditional TUG was 4 s.[17] This result could be explained by the following reasons: cognitive functions, particularly attention, are necessary during gait; hence, gait decrements during dual tasks can be explained by the limited capacity of attention processing, or due to competition for cognitive resources. Cognitive tasks may impact gait, just as gait may perturb cognitive performance. Motor task may also impact gait as attention is diverted from the single task to the new task and thus may lead to fall.[4],[7],[9]

Our study states that the time taken by the participants with a history of falls is more as compared to the participants without a history of falls in all the three variants of TUG; this findings goes in favor with the study of Shumway-Cook et al. and of Podsiadlo et al.[6],[16] This may be due to these participants have developed fear of falls due to previous experience of fall.

The cutoff value to determine risk of fall is >15.95. In the previous study done by Shumway-Cook et al., a cutoff value was 14 s in Seattle geriatric population; and in the study of Allain et al., a cutoff value was 16 s in the Korean elder population which determined the risk of falls in geriatrics.[16],[18] Another study by Podsiadlo et al. where geriatrics of Chicago were assessed a cutoff value of >30 s and study done by Abhay B. ManeT Sanjana, Prabhakar R. Patil and T. Sriniwas. had a cutoff value >27 indicating a better predictor of falls, this may be due to the reason that both studies included participants with assistive device subject variance.[6],[11] However, in our study, we have included participants who could walk independently and without any neurological problems.

The finding of our study states that there was not any significant difference in the genderwise value for three variants of TUG. The study of Pondal et al. had shown that female gender take more time in completing the TUG; this may be due to the inclusion of patients living in institutionalized environment and also the large sample size of 1448 participants in an age group of 71–99 years.[19]

Our study also states that the dual-task constraint TUG is a better predictor of falls when compared to the traditional TUG; this result is supported by the study of Franchino S. Porciuncula et al., who found that there is a decrement in phases of the test when subjected to dual tasks and the time taken is longer, and the study of Lord SR, Menz HB, Tiedemann A. et al., who stated that the three TUGs combined are an important test used to assess patient at risk of falls.[13] It is contradictory to the study of Shumway-Cooket al., who state only tradition TUG is a better predictor of falls in geriatrics; this finding may be due to the inclusion of participants who use assistive devices for locomotion.[16]


  Conclusion Top


We can conclude that the TUG with an additional cognitive task is a better indicator of falls TUG as compared to the TUG alone. The cutoff value to determine fallers for the traditional TUG is 15.95 s, for the motor TUG is 18.81 s, and for the cognitive TUG is 19.92 s, for determining geriatric population at a risk of falls. Since the incidence and consequences of falls among geriatrics is high, in this study, TUG with an additional cognitive constraint is a simple method, which is a specific and sensitive indicator to measure the probability of falls. Hence, the addition of cognitive training in interventions designed to improve balance and decrease the risk of falls in geriatrics will have added benefits.

Acknowledgment

I would like to thank Dr. Vithalrao Vikhe Patil foundations management for their continuous support during the research.

Hitav P. Someshwar.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Pondal M, Del Ser T. Normative data and determinants for the timed “up and go” test in a population-based sample of elderly individuals without gait disturbances. J Gerontol A Biol Sci Med Sci 1997;52:M232-40.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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