What’s New in the Patient Safety World
November 2011
Another Use for
the Timed Up-and-Go Test
One of our pet
peeves in primary care is that physicians readily order bone densitometry tests
and prescribe drugs for osteoporosis yet almost never do fall risk assessments
on those patients. CMS even uses ordering the bone densitometry test or
prescribing the drugs in their quality measures yet also does not assess
whether fall risk assessments were done. In that population, our real goal is
to prevent fractures so why would you just look for osteoporosis and skip the
fall risk assessment?
There are obviously
many factors that predispose patients to falls (drugs, orthostatic hypotension,
neuropathies with loss of proprioception, other neurological diseases, and
multiple sensory deficits, among others) and there are numerous fall risk
assessment tools out there.
But a recent paper
noted the value of the time up-and-go test (yes, the same one we just described
earlier in this month’s What’s New in the Patient Safety World column “Timed
Up-and-Go Test and Surgical Outcomes”). Zhu and colleagues (Zhu 2011)
looked at bone densitometry and the timed up-and-go test (“TUG”) in a cohort of
women aged 70-85 who were followed for 5 years in a randomized clinical trial
of calcium supplementation to prevent fractures. They found that the TUG (using
a cutoff of 10.2 seconds) was an independent predictor of nonvertebral
fracture.
The TUG is a measure incorporated into several frailty indices. For those of you unfamiliar with the TUG, you simply time a patient standing up from a chair, walking 10 feet, returning to the chair and sitting down.
The TUG costs
nothing and takes almost no time to complete so it can be easily integrated
into almost any practice setting.
The editorial
accompanying the Zhu article (Bauer 2011)
notes that some good existing algorithms to predict fracture, such as WHO’s FRAX, also lack inputs that assess fall
risk and could be significantly improved by inclusion of such a variable. He
notes that such a variable should be easy to measure, reproducible, and
strongly predictive of fracture independent of bone density and other factors
and notes that the timed up-and-go test has many of those attributes. Though
advocating further studies to formally assess that combination, he suggests
that adding the TUG to the FRAX tool may prove to be very useful.
Sometimes it’s
remarkable how we overlook useful things that are right in front of us!
References:
Zhu K, Devine A, Lewis JR, et al. "'Timed Up and Go' Test and Bone Mineral Density Measurement for Fracture Prediction. Arch Intern Med. 2011; 171(18): 1655-1661
http://archinte.ama-assn.org/cgi/content/abstract/171/18/1655
Bauer DC. FRAX, Falls, and Fracture Prediction: Predicting the Future: Comment on " ‘Timed Up and Go’ Test and Bone Mineral Density Measurement for Fracture Prediction". Arch Intern Med. 2011;171(18):1661-1662
http://archinte.ama-assn.org/cgi/content/extract/171/18/1661
WHO’s FRAX algorhithm and scoring tool
http://www.patientsafetysolutions.com/
What’s New in the Patient Safety World Archive