Mobility and Gait – Evaluation and Management M. Kathy Wiley, MD, MS Cathryn Caton, MD, MS

Objectives Understand morbidity and mortality factors associated with falls in elders. Identify fall risk factors. Evaluate medications that may increase fall risk. Demonstrate the evaluation of gait & mobility in elderly patients. Implement appropriate referral and self- management education

Incidence of Falls >1/3 of ambulatory elderly fall each year For patients with no risk factors, fall risk is 8% For patients with 4 or more risk factors, fall risk is 78% In 2005 1.8 million older adults fell Approximately 15,800 died from their injuries In South Carolina, over a 6 year period (1996 – 2002) 26,298 hip fractures ~ 4400 per year

Cost of Falls In 2002 direct costs for In South Carolina Fatal falls totaled $0.2B Non-fatal fall-related injuries totaled $19B In South Carolina An average charge of $21,398 is associated with hospitalization per hip fracture repair

Consequences of Falls Physical – Fall-related injuries 5 – 15% of falls result in fractures or serious soft tissue injuries Account for ~ 10% of ED visits and 6% of urgent hospitalizations Loss of function or immobility Death Social – impacts quality of life Psychological – Fall-related fear & loss of self- efficacy

Self-Efficacy Beliefs in one’s capabilities to organize and execute the courses of action required to produce a given attainment Influenced by Having relevant skills Past experiences Observation of the experiences of others Social persuasion including provider influence

Case 79 y/o woman presents for f/u CHF, arthritis, depression, difficulty sleeping Medications: antidepressant, diuretic, ACE-I, Beta-Blocker. Also takes OTC sleep and allergy meds Chronic conditions appear stable Daughter reports 2 falls in the past 6 months

Perform Timed Up & Go test Algorithm Brief Fall History Circumstances Medications Chronic conditions Mobility ETOH intake Do Falls Assessment Vitals – Orthostatics if indicated Visual assessment Lower extremity strength Targeted neuro exam Timed Up & Go test Cardiac eval if symptoms suggest syncope Perform Timed Up & Go test Consider recommending exercise program Intervention Options Gait, balance & exercise programs Medication modification Postural hypotension treatment Environmental hazard modification Cardiovascular disorder treatment Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007. Single fall with no injury 2 or more falls, 1 fall with injury Fall reported in last year ABNORMAL NORMAL

Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury Brief Fall History Circumstances Medications Chronic conditions Mobility ETOH intake Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

History Ask all patients about falls in past year Establish if recurrent vs. single episode Determine circumstances of fall- “true fall vs. syncope” Evaluate associated symptoms – dizziness, lightheadedness, vision disturbance, LOC, gait or balance problems Determine whether injury occurred Review medications – number of medications (4 or more increases fall risk) recent changes, sedating drugs, narcotics (Beers’ List)

Perform Timed Up & Go test Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury Brief Fall History Circumstances Medications Chronic conditions Mobility ETOH intake Perform Timed Up & Go test Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

Timed Up & Go Test Patient can use arms or assistive device – must document if either is used Explain the test to the patient Demonstrate the test Do practice trial Perform timed evaluation

Timed Up & Go Test Patient starts from a seated position Time starts when the patient initiates movement The patient walks 10ft across the room and circles around a marker Time stops when the patient returns and is seated in the chair

Timed Up & Go Test Average results are as follows Age 60 – 69 7.24 seconds Age 70 – 79 8.54 seconds

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Perform Timed Up & Go test Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury Brief Fall History Circumstances Medications Chronic conditions Mobility ETOH intake Do Falls Assessment Vitals – Orthostatics if indicated Visual assessment Lower extremity strength Targeted neuro exam Timed Up & Go test Cardiac eval if symptoms suggest syncope Perform Timed Up & Go test ABNORMAL NORMAL Consider recommending exercise program Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

Physical Exam Check vitals –orthostatics if indicated Visual assessment Test for lower extremity strength Perform targeted neuro exam – proprioception, sensation Perform Timed Up & Go Test – establishes gait and balance abnormalities, normal <10 seconds Do cardiovascular work-up if falls history suggests syncopal event

Perform Timed Up & Go test Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury Brief Fall History Circumstances Medications Chronic conditions Mobility ETOH intake Do Falls Assessment Vitals – Orthostatics if indicated Visual assessment Lower extremity strength Targeted neuro exam Timed Up & Go test Cardiac eval if symptoms suggest syncope Perform Timed Up & Go test ABNORMAL NORMAL Intervention Options Gait, balance & exercise programs Medication modification Postural hypotension treatment Environmental hazard modification Cardiovascular disorder treatment Consider recommending exercise program Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

Intervention May require more than one intervention Gait, balance and exercise programs (PT referral, Tai Chi) Medication modification Postural hypotension treatment Environmental hazard modification Cardiovascular disorder treatment if cardiac source is identified as cause of fall

Gait, balance & exercise programs Physical Therapy referral MMSE Geriatric Depression Scale ROM Muscle Performance Quality of gait Ability of patients to multitask – balance while talking on phone, walk and talk Use of assistive devices Aging in place

Medication Adjustment Reduction of sedating and narcotic medications – consider Beers’ List Taper to lowest effective dose or stop Be able to justify the addition of a new medication

Postural Hypotension Reduce medications that contribute Teach patients to change position slowly Consider liberalizing salt intake Encourage adequate hydration

Environmental Hazard Modification This may be done as part of the Physical Therapy referral or as a separate Home Health Evaluation Aging in place Hazards include Clutter Electric cords Slippery throw rugs and loose carpet Poor lighting Lack of stair rails Lack of shower rails / grab bars Proper shoes

Perform Timed Up & Go test Algorithm Brief Fall History Circumstances Medications Chronic conditions Mobility ETOH intake Do Falls Assessment Vitals – Orthostatics if indicated Visual assessment Lower extremity strength Targeted neuro exam Timed Up & Go test Cardiac eval if symptoms suggest syncope Perform Timed Up & Go test Consider recommending exercise program Intervention Options Gait, balance & exercise programs Medication modification Postural hypotension treatment Environmental hazard modification Cardiovascular disorder treatment Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007. Single fall with no injury 2 or more falls, 1 fall with injury Fall reported in last year ABNORMAL NORMAL

Case 79 y/o woman presents for f/u CHF, arthritis, depression, difficulty sleeping Medications: antidepressant, diuretic, ACE-I, Beta-Blocker. Also takes OTC sleep and allergy meds Chronic conditions appear stable Daughter reports 2 falls in the past 6 months

Fall Risk Factors Based on findings of two or more observational studies Arthritis Depressive symptoms Orthostasis Use of four or more medications Parkinson’s Disease

Fall Risk Factors Impairment in Cognition Vision Balance and gait Muscle strength

Fall Risk Factors Medication Classes shown to have strongest link to an increased risk of falling Serotonin-reuptake inhibitors Tricyclic antidepressants Neuroleptic agents Benzodiazepines Anticonvulsants Class IA anti-arrhythmics

Summary We reviewed Morbidity and mortality factors associated with falls in vulnerable elders Fall risk factors Medications that may increase fall risk Evaluation of gait and mobility in elderly patients Implement appropriate referral and self- management education