Patient Script – Mr. R.
You are an 86-year-old Caucasian male being seen by a doctor for a “bump on the head” after falling last night on your way to the bathroom. You are about six feet tall, thin, clean-shaven, and dressed in a flannel shirt with grease stains on the front and in jeans that are a little dirty. You wear thick glasses and a hearing aid. You walk slightly stooped over and are a little unsteady on your feet. You are also somewhat short of breath.
Your wife is with you at the doctor’s appointment. She is pleasant, neat in appearance, and very quiet.
As the role-play opens, you and your wife are walking down the hall to the examining room with the health care professional. You will then be seated and asked a series of questions by the health care professional.
Answer only questions directly asked and offer little extra information, especially in regard to your alcohol consumption. Simulate your hearing loss and unsteady gait. If questioned about your fall respond that you don’t remember much about it except getting up to go to the bathroom and feeling dizzy prior to falling.
The bump on your head is probably from hitting the nightstand when you fell, but since you lost consciousness you aren’t aware of this. Shortly after the fall, you were able to sit up at your wife’s prompting, but were not able to get to your feet for about a half hour.
You haven’t been feeling well lately, kind of achy, maybe feverish. Your appetite has been off, and you had only a little dinner and a few drinks last evening. You took your blood pressure medicine as usual and some aspirin for a headache.
If asked directly about your symptoms you can reply:
§ Your head hurts a little
§ You ache all over
§ You feel weak, tired, and maybe a little dizzy
§ You have been diagnosed with leg perfusion and take atenolol 50 mg bid
§ You consume at least 2-3 alcoholic beverages per day
Spouse Script – Mrs. R.
You are an 84-year-old Caucasian female married for 60 years to your 86-year-old husband. You are with him at the doctor, because he fell last night and seemed to lose consciousness. The two of you have been living in the same house for the past 55 years, and you have always prided yourself on your home. You have two sons and one daughter in the area, but not all of them are in close contact with you. Your husband and oldest son had a falling-out some years ago, and your second son has health problems. Your daughter visits as often as she can but lives in a distant suburb and is busy with her job and family.
Lately you have been bothered by arthritis and are not as able to keep up the house as you once did. Your house was always a source of pride to you, and you are reluctant to admit this or ask for help.
You are a quiet person but are clearly quite upset about your husband’s fall. You are not sure why he fell but are afraid that he may have tripped over the dust mop that you left out.
Your husband is a Caucasian male being seen by a doctor for a “bump on the head” after falling last night on his way to the bathroom. He is about six feet tall, thin, clean-shaven and dressed in a flannel shirt with grease stains on the front and in jeans that are a little dirty. He wears thick glasses and a hearing aid, walks slightly stooped over, and is a little unsteady on his feet.
As the role-play opens, you and your husband are walking down the hall to the examining room with the health care professional. You will then be seated and asked a series of questions by the health care professional.
Answer only questions directly asked and offer little extra information, especially in regard to your husband’s alcohol consumption. Indicate your arthritis pain, but don’t mention it unless asked.
Since your husband lost consciousness after the fall, you may be asked to describe what happened. It appears he was on his way to the bathroom when he fell, and you hurried to his side and prompted him to sit up. You wanted to call an ambulance, but he refused and after some time you were able to get him back to bed.
Prior to the fall you both had been feeling poorly lately, achy, and feverish or cold.
Health Care Professional Script
You meet Mr. and Mrs. R. in the hallway and accompany them to the examining room. Using the History Form provided, interview the couple to determine the cause of Mr. R.’s fall and assess any injuries sustained. Since you are not doing a real hands-on exam, you will have to inquire verbally about injuries. Evaluate Mr. R. using the History Form and the Tinetti Balance and Gait Evaluation Scale.
History Form
Instructions: Assess the following areas paying special attention to their possible connection to a fall.
Pulmonary SystemCardiovascular / Circulatory
Neurological / Cognitive
GI / Elimination
Nutrition
GU / Elimination
Musculoskeletal
Skin
EENT / Vision
Pain
Allergy
Communication
Emotional / Social
Environmental
Treatment History
Tinetti Balance and Gait Evaluation Scale
Assess balance and gait using the following criteria to score the patient’s ability to perform the tasks. Add the scores of #1-9 for the balance score and #10-16 for the gait score. Total both scores for the final score.
BALANCE
1. Sitting balance Score = ____
a. Leans or slides in chair = 0
b. Steady, safe = 1
2. Arises Score = ____
a. Unable without help = 0
b. Able, uses arms to help = 1
c. Able, without using arms = 2
3. Attempts to arise Score = ____
a. Unable without help = 0
b. Able, requires more than 1 attempt = 1
c. Able, 1 attempt = 2
4. Immediate standing balance (first 5 seconds) Score = ____
a. Unsteady (swaggers, moves feet, trunk sways) = 0
b. Steady but uses cane or other support = 1
c. Steady without walker or other support = 2
5. Standing balance Score = ____
a. Unsteady = 0
b. Steady but wide stance (medial heels more than
4 inches apart) and uses cane or other support = 1
c. Narrow stance without support = 2
6. Nudges (subject at max position with feet Score = ____
as close as possible, examiner pushes with
palm on subject’s sternum)
a. Begins to fall = 0
b. Staggers, grabs, catches self = 1
c. Steady = 2
7. Eyes closed (same position as for #6) Score = ____
a. Unsteady = 0
b. Steady = 1
8. Turning 360 degrees Score = ____
a. Discontinuous steps = 0
b. Continuous steps = 1
c. Unsteady (grabs, staggers) = 0
d. Uses arms or motion not smooth = 1
9. Sitting down Score = ____
a. Unsafe (misjudged distance, fell into chair) = 0
b. Uses arms or motion not smooth = 1
c. Safe, smooth motion = 2
BALANCE SCORE SUB-TOTAL (add 1 – 9) Score = ____ / 16
GAIT
11. Initiation of gait (immediate initiation) Score = ____
a. Any hesitancy or multiple attempts to start = 0
b. No hesitancy = 1
12. Step length and height
a. Right swing foot Score = ____
i. Does not pass left stance foot with step = 0
ii. Passes left stance foot = 1
iii. Right foot does not clear floor = 0
iv. Right foot completely clears floor = 1
b. Left swing foot Score = ____
i. Does not pass right stance foot with step = 0
ii. Passes right stance foot = 1
iii. Left foot does not clear floor = 0
iv. Left foot completely clears floor = 1
13. Step symmetry Score = ____
a. Right and left step length not equal (estimate) = 0
b. Right and left step length appear equal = 1
14. Step continuity Score = ____
a. Stopping or discontinuity between steps = 0
b. Steps appear continuous = 1
15. Path (estimate 12 inch floor tiles over 10 feet) Score = ____
a. Marked deviation = 0
b. Mild / moderate deviation or uses walking aid = 1
c. Straight without walking aid = 2
16. Trunk Score = ____
a. Marked sway or uses walking aid = 0
b. No sway, but flexion of knees or back
or spreads arms = 1
c. No sway, no flexion, no use of arms or aid = 2
17. Walking time Score = ____
a. Heels apart = 0
b. Heels almost touching while walking = 1
GAIT SCORE SUB-TOTAL (add 10 – 16) Score = ____ / 12
TOTAL SCORE (add 1 – 16) Score = ____ / 28
Fall Profile Form
Possible causes of fall / 1.
2.
3.
4.
Rationale
Further investigation
Care plan
Patient preference determination
Falls Role Play