GAIT DISTURBANCES AND FALLS IN OLDER ADULTS Suggestions for Lecturer -1-hour to 1½-hour lecture -Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS and Geriatrics at Your Fingertips for further content. -Supplement lecture with handouts, eg, “Recommendations from the AGS Guidelines for the Prevention of Falls” and various assessment tools, eg, Romberg, Dix-Hallpike, Mini-Cog, and POMA. -See GRS7 questions 3, 28, 103, 123, 125, and 146 for additional case vignettes on gait disturbances and falls.

OBJECTIVES Know and understand: How to perform a diagnostic evaluation of gait dysfunction How to conduct a gait assessment of the older adult The importance of falls by older persons How to assess and treat falls by an older person Slide 2

TOPICS COVERED Gait Disorders Gait Assessment Epidemiology of Falls Causes of Falls Evaluation and Treatment of Falls Clinical Guidelines for Preventing Falls Slide 3

GAIT IMPAIRMENT Gait disorders are common and a predictor of functional decline Certain gait-related mobility disorders progress with age and are associated with morbidity and mortality Community-dwelling older adults with gait disorders, particularly neurologically abnormal gaits, are at higher risk of institutionalization and death Slide 4

GLOSSARY OF GAIT ABNORMALITIES (1 of 2) Term Description Antalgic gait Pain-induced limp with shortened phase of gait on painful side Circumduction Outward swing of leg in semicircle from the hip Equinovarus Excessive plantar flexion and inversion of the ankle Festination Acceleration of gait Foot drop Loss of ankle dorsiflexion secondary to weakness of ankle dorsiflexors Foot slap Early, frequent audible foot-floor contact with steppage gait compensation Genu recurvatum Hyperextension of knee Topic Slide 5

GLOSSARY OF GAIT ABNORMALITIES (2 of 2) Term Description Propulsion Tendency to fall forward Retropulsion Tendency to fall backward Scissoring Hip adduction such that the knees cross in front of each other with each step Steppage gait Exaggerated hip flexion, knee extension, and foot lifting, usually accompanied by foot drop Trendelenburg gait Shift of the trunk over the affected hip, which drops because of hip abductor weakness Turn en bloc Moving the whole body while turning Topic Slide 6

CONDITIONS CONTRIBUTING TO GAIT DISORDERS IN PRIMARY CARE SETTINGS Degenerative joint disease Acquired musculoskeletal deformities Intermittent claudication Impairments following orthopedic surgery Impairments following stroke Postural hypotension Dementia Fear of falling Usually multifactorial Slide 7

CLASSIFICATION OF GAIT DISORDERS May classify by abnormal sensorimotor level: low, middle, and high These levels may overlap when certain disorders involve multiple levels, eg, Parkinson’s disease involving high (cortical) and middle (subcortical) structures Slide 8

LOW SENSORIMOTOR LEVEL GAIT DISORDERS Peripheral sensory dysfunction Proprioceptive, neuropathic (unsteady, uncoordinated) Vestibular (unsteady, weaving) Visual (tentative, uncertain) Peripheral motor dysfunction Arthritic (antalgic, joint deformity) Myopathic and neuropathic (weakness) Slide 9

MIDDLE SENSORIMOTOR LEVEL GAIT DISORDERS Hemiplegia, hemiparesis (leg circumduction, loss of arm swing) Paraplegia, paraparesis (bilateral circumduction, possibly scissoring) Parkinsonism (small shuffling steps, hesitation, festination, propulsion, retropulsion, turning en block, absent arm swing) Cerebellar ataxia (wide-based gait with increased trunk sway, irregular stepping) Slide 10

HIGH SENSORIMOTOR LEVEL GAIT DISORDERS Dementia (cautious gait, fear of falling) Frontal-related gait disorders (spectrum, from gait ignition failure to frontal gait disorder to frontal disequilibrium) Cerebrovascular Normal-pressure hydrocephalus Slide 11

GAIT ASSESSMENT: KEY POINTS Careful medical history and physical exam can elucidate contributing factors Use a gait assessment tool (eg, timed Get Up and Go test) Establish person’s comfortable gait speed; use as both assessment and outcome measure Remember that most gait disorders are associated with underlying disease A brief systemic evaluation for evidence of subacute metabolic disease (eg, thyroid disorders), acute cardiopulmonary disorders (eg, myocardial infarction), or other acute illness (eg, sepsis) is warranted because an acute gait disorder may be the presenting feature of acute systemic decompensation in older adults. The physical examination should include an attempt to identify motion-related factors, eg, by provoking both vestibular and orthostatic responses. The Dix- Hallpike test can be performed to test for vestibular dysfunction. Blood pressure should be measured with the patient both supine and standing to exclude orthostatic hypotension. Vision screening, at least for acuity, is essential. The neck, spine, extremities, and feet should be evaluated for pain, deformities, and limitations in range of motion, particularly regarding subtle hip or knee contractures. Leg-length discrepancies such as can occur with a hip prosthesis and either as an antecedent or subsequent to lower back pain can be measured simply as the distance from the anterior superior iliac spine to the medial malleolus. A formal neurologic assessment is critical and should include assessment of strength and tone, sensation (including proprioception), coordination (including cerebellar function), station, and gait. The Romberg test screens for simple postural control and whether the proprioceptive and vestibular systems are functional. Given the importance of cognition as a risk factor, assessing cognitive function is also indicated. Slide 12

COMFORTABLE GAIT SPEED Measure as part of a timed walk For a short distance (eg, 10 feet) or As a distance walked over time (eg, 6 min) Predicts disease activity (eg, arthritis), cardiac and pulmonary function, mobility and ADL disability, institutionalization, and mortality ADL = activities of daily living Slide 13

THE TIMED GET UP AND GO TEST (1 of 2) Record the time it takes a person to: Rise from a hard-backed chair with arms Walk 10 feet (3 meters) Turn Return to the chair Sit down Slide 14

THE TIMED GET UP AND GO TEST (2 of 2) Most adults can complete in 10 sec Most frail elderly adults can complete in 11 to 20 sec ≥14 sec =  falls risk >20 sec  comprehensive evaluation Results are strongly associated with functional independence in ADLs Slide 15

FALLS Definition: coming to rest inadvertently on the ground or at a lower level One of the most common geriatric syndromes Most falls are not associated with syncope Falls literature usually excludes falls associated with loss of consciousness Slide 16

EPIDEMIOLOGY OF FALLS Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term- care facilities, experience falls Slide 17

EPIDEMIOLOGY OF FALLS Annual incidence of falls is close to 60% among those with history of falls Complications of falls are the leading cause of death from injury in persons aged ≥65 Slide 18

MORBIDITY AND MORTALITY Most falls by older adults result in some injury 10%–15% of falls by older adults result in fracture or other serious injury The death rate attributable to falls increases with age Mortality highest in white men aged ≥85: 180 deaths/100,000 population Slide 19

SEQUELAE OF FALLS Associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling Half of those who fall are unable to get up without help (“long lie”) A “long lie” predicts lasting decline in functional status Slide 20

COSTS OF FALLS  Emergency department visits  Hospitalizations Indirect cost from fall-related injuries like hip fractures is substantial Slide 21

CAUSES OF FALLS BY OLDER ADULTS Rarely due to a single cause May be due to the accumulated effect of impairments in multiple domains (such as other geriatric syndromes) Complex interaction of: Intrinsic factors (eg, chronic disease) Challenges to postural control (eg, changing position) Mediating factors (eg, risk taking, underlying mobility level) Slide 22

CAUSES: INTRINSIC Age-related decline Chronic disease Acute illness Changes in visual function Proprioceptive system, vestibular system Chronic disease Parkinson’s disease Osteoarthritis Cognitive impairment Acute illness Medication use (see next slide) Slide 23

CAUSES: MEDICATION USE Specific classes, eg: Benzodiazepines Antidepressants Antipsychotic drugs Cardiac medications Hypoglycemic agents Recent medication dosage adjustments Total number of medications Slide 24

FALLS ASSESSMENT (1 of 2) Ask all older adults about falls in past year Single fall: check for balance or gait disturbance Recurrent falls or gait or balance disturbance: (1) Obtain relevant medical history, physical exam, cognitive and functional assessment Slide 25

FALLS ASSESSMENT (2 of 2) (2) Determine multifactorial falls risk: History of falls Medications Visual acuity Gait, balance, and mobility Muscle strength (2) Determine multifactorial falls risk: Neurologic impairments Heart rate and rhythm Postural hypotension Feet and foot wear Environmental hazards Slide 26

PHYSICAL EXAMINATION Blood pressure and pulse, both supine and standing Vision screening Cardiovascular exam Musculoskeletal exam Neurologic exam See GRS7 Falls chapter for further content. Slide 27

GAIT AND BALANCE EVALUATION Romberg test One-legged stance for 30 seconds, eyes open Tandem gait task for 10 feet Dix-Hallpike test (motion-induced imbalance) Mental status exam (eg, Mini-Cog) Timed Up and Go test Berg Balance Test Performance Oriented Mobility Assessment (POMA) Functional reach Appropriateness of footwear A useful test of integrated strength and balance is the Timed Up and Go test, which can be performed with or without timing. It consists of observation of an individual standing up from a chair without using the arms to push against the chair, walking across a room, turning around, walking back, and sitting down without using the arms. This test can demonstrate muscle weakness, balance problems, and gait abnormalities. A test of integrated musculoskeletal function is the Berg Balance Test. The Berg test includes 14 items of balance, including timed tandem stance, semitandem stance, and the ability of a person to retrieve an object from the floor. Berg scores <40 have been associated with an increased risk of falls. The Performance-Oriented Mobility Assessment (POMA) tests balance and gait through a number of items, including ability to sit and stand from an armless chair, ability to maintain standing balance when pulled by an examiner, and the ability to walk normally and maneuver obstacles. A reliable cut-point score for predicting falls with the POMA has yet to be established. These and related tests are discussed in GRS7 and Geriatrics At Your Fingertips. Slide 28

LABORATORY AND DIAGNOSTIC TESTING Tests and procedures should be guided by the history & physical exam: echocardiography, brain imaging, radiographic studies of spine Hemoglobin, serum urea nitrogen, creatinine, glucose: can exclude anemia, dehydration, or hyperglycemia Holter monitoring: no proven value for routine evaluation Carotid sinus massage with continuous heart rate and BP monitoring: can uncover carotid sinus hypersensitivity These and related tests are discussed in GRS7 and Geriatrics At Your Fingertips. Slide 29

TREATMENT Most favorable results with health screening followed by targeted interventions Aim to reduce intrinsic and environmental risk factors Interdisciplinary approach to falls prevention is most efficacious A Cochrane collaboration systematic review of interventions to reduce the incidence of falling in older adults was performed. Because of the large numbers of fall intervention trials and because interventions may be more effective in certain settings, systematic reviews of fall interventions were divided into two groups: fall prevention interventions among community dwellers and fall prevention interventions among institutionalized persons. The April 2009 update of the Cochrane systematic review of fall interventions among community dwellers included 111 individual trials. As of January 2008, a systematic review of falls interventions in acute and chronic hospital settings included 8 trials. Slide 30

AGS FALLS PREVENTION GUIDELINES Recommendations include: Assessment of all older adults Assessment of anyone with history of falls Multifactorial interventions including: Minimize medications Initiate individually tailored exercise program Treat vision impairment Manage postural hypotension, heart rate and rhythm abnormalities Supplement vitamin D Manage foot and footwear problems Modify the house environment Cosponsored by the American Geriatrics Society and the British Geriatrics Society. Systematic reviews have concluded that there is no evidence that hip protectors are effective in reducing hip fractures in studies that randomized individual patients within an institution or among older adults living at home. However, adherence to the use of hip protectors was low in these studies, which many argue could explain the lack of efficacy. At least a dozen types of hip protectors are commercially available. Many of these hip protectors have not been tested in either the laboratory or in clinical trials. Despite the lack of evidence to date to support the use of hip protectors, it is not unreasonable to consider their use in patients at high risk of hip fractures who are willing to use them. Slide 31

SUMMARY Gait disorders are associated with many diseases and syndromes, including falls Falls by older adults are common and usually multifactorial Falls predict functional decline Screening and targeted preventive interventions are most effective AGS falls prevention guidelines are available and recommend multifactorial interventions Slide 32

CASE 1 (1 of 3) An 88-yr-old man comes to the office because he has been feeling more tired than usual, and yesterday he fell in his bedroom. He was hospitalized with pneumonia 2 months ago; he received daily physical and occupational therapy in a nursing facility for 4 weeks and was then discharged home at maximal function. He has a history of Parkinson’s disease, hypertension, and osteoarthritis. Medications include carbidopa/ levodopa, hydrochlorothiazide, metoprolol, and acetaminophen. Slide 33

CASE 1 (2 of 3) Which of the following is most likely to yield additional information useful for reducing his risk of falling? (A) Serum electrolytes (B) Vitamin D level (C) Postural blood pressure (D) Timed Up and Go test Slide 34

CASE 1 (3 of 3) Which of the following is most likely to yield additional information useful for reducing his risk of falling? (A) Serum electrolytes (B) Vitamin D level (C) Postural blood pressure (D) Timed Up and Go test ANSWER: C Up to 70% of patients with Parkinson’s disease fall in a given year. This patient’s recent fall and his fatigue may be related to the orthostasis associated both with Parkinson’s disease and with carbidopa/levodopa. He should be evaluated for postural hypotension. Furthermore, he has had several recent transitions—from the hospital to a nursing facility to home. Changes in medication regimen are a common cause of complications in transition of care, raising the possibility that the patient’s hypertension is being overtreated. Both hydrochlorothiazide and metoprolol may be lowering his blood pressure excessively. Serum electrolytes should be checked because of the patient’s fatigue and because he takes hydrochlorothiazide. Low sodium or potassium concentrations could cause the patient’s symptoms, but orthostasis remains the primary consideration in this case. Inadequate levels of vitamin D are common in older adults, and supplementation with vitamin D3 can decrease fall risk. Checking the vitamin D level is appropriate in the overall management of fall risk but is a secondary consideration in this situation. The Timed Up and Go test is a good screen for functional balance, strength, and gait but would not yield specific useful information in this situation. Because the patient has recently undergone intensive rehabilitation, results of the Timed Up and Go test are not likely to lead to further interventions to improve his physical function. Slide 35

CASE 2 (1 of 2) Which of the following should be undertaken first in an initial evaluation to determine if a new patient is at risk of falls? (A) Check vision. (B) Ask about previous falls. (C) Examine feet. (D) Check for arrhythmia. (E) Perform a mental status examination. Slide 36

CASE 2 (2 of 2) Which of the following should be undertaken first in an initial evaluation to determine if a new patient is at risk of falls? (A) Check vision. (B) Ask about previous falls. (C) Examine feet. (D) Check for arrhythmia. (E) Perform a mental status examination. ANSWER: B Fall prevention is important to incorporate in the care of all older adults. Risk assessment and management reduce the incidence of falls, and in the primary care setting, can reduce the incidence of emergency treatment for fall injuries. The first step in assessing risk is to ask about previous falls. Patients who have fallen previously are at risk of future falls, especially if they have impaired mobility. Older adults often will not mention previous falls unless specifically asked about them. According to published guidelines, if a patient has fallen more than once in the past year, or has fallen once and has impaired gait or balance, fall risk should be fully assessed. The evaluation should identify factors that can be modified or eliminated to reduce fall risk.Modifiable factors include problems with balance and gait, use of more than four medications, postural hypotension, and home environmental hazards. Additional factors are sensory deficits, especially vision, and problems with feet and unsupportive footwear. Cardiac examination, including checking for arrhythmia, is indicated, especially if there are symptoms of lightheadedness or a history of syncope. Patients with dementia are at increased risk of falls, and a mental status screening test is an important part of the evaluation. Slide 37

CASE 3 (1 of 4) A 90-year-old woman comes to the office because she has had increasing difficulty walking. Her gait is slower, and she feels as if she might fall backward at times. She has hypertension, hypothyroidism, and osteoarthritis, and she had CABG 10 years ago, with no recurrence of angina. She has moderate dorsal kyphosis and arthritic changes in her fingers and knees. Slide 38

CASE 3 (2 of 4) Strength and reflexes are symmetric. The patient has some increased muscle tone. She uses her arms to push up from the chair; once standing, she has difficulty starting to walk. Her gait is symmetric, with a normal base, but her foot clearance and stride length are both decreased. She turns slowly and carefully, with an increased number of steps. Slide 39 39

CASE 3 (3 of 4) Which of the following is the most likely cause of the patient’s gait abnormality? (A) Osteoarthritis (B) Proprioceptive deficits Cerebrovascular disease Parkinson’s disease Cautious gait Slide 40

CASE 3 (4 of 4) Which of the following is the most likely cause of the patient’s gait abnormality? (A) Osteoarthritis (B) Proprioceptive deficits Cerebrovascular disease Parkinson’s disease Cautious gait ANSWER: C This older patient has known vascular disease. The difficulty starting to walk, the slow gait with decreased foot clearance, and the tendency to fall backward suggest subclinical cerebrovascular disease. Her advanced age and history of hypertension place her at risk of microvascular disease affecting cerebral white matter and of lacunar infarcts. More advanced cerebrovascular disease can result in vascular parkinsonism, with poor standing balance, rigidity, masked face, parkinsonian gait, and cognitive impairment. The patient has osteoarthritis, yet she does not have evidence of pain on walking and does not complain of her legs “giving way.” Her gait is symmetric, whereas with painful osteoarthritis, there is usually some gait asymmetry. Proprioceptive deficits, with loss of position sense, lead to a wide-based, steppage gait, which this patient does not have. The typical gait of Parkinson’s disease involves initial hesitation, then small, shuffling steps with no arm swing and difficulty with balance. Associated findings would include tremor, masked face, and cogwheel rigidity. Fear of falling can lead to a slow, cautious gait, with decreased step length. Although this patient is probably being cautious because she fears falling, she has objective abnormalities, including difficulty rising from a chair, difficulty with starting to walk, and decreased foot clearance. Slide 41 41

Copyright © 2010 American Geriatrics Society ACKNOWLEDGMENTS Editor: Annette Medina-Walpole, MD GRS7 Chapter Authors: Neil B. Alexander, MD Sarah D. Berry, MD, MPH Douglas P. Kiel, MD, MPH GRS7 Question Writer: Mary B. King, MD Pharmacotherapy Editor: Judith L. Beizer, PharmD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2010 American Geriatrics Society Slide 42