1. Tiffany Shubert, MPT Graduate Student, HMSC August 14, 2006
Physical Performance Testing in Clinic: Assessing function in patients with dementia
My name is Tiffany Shubert and I am a physical therapist in the geriatric evaluation clinic. So I use these tools every Monday. I also am a graduate student in the human movement science program. I am using all the tests we are talking about today in my dissertation research.
Tiffany Shubert, MPT
Graduate Student, HMSC
August 14, 2006

2. Older Patients: What do you want to know?
How long will they live? OR
How well will they live?
As a clinician, you want a way to gaze into the crystal ball to determine if your patient is currently at risk of a fall, or morbidity and mortality. It also would be helpful to be able to predict of they are at future risk of the geriatric conditions like hip fractures, dementia, ulcers, pneumonia, etc. so, what are you going to do about it? If you walked into a clinic today, what tools would you use to assess your geriatric patient? Oh, and remember you have 15 minutes for a visit.

3. The G-Scope A not so high tech test:
Gait Speed: How fast do they walk?
Chair Rise: Can they get up from a chair? Without using arms? How many times?
Balance
Timed up and go
This is a tool that was coined by John Morley, the former editor of the Journals of Gerontology. He was lamenting the fact that reimbusement was so poor for these simple practical tests. The g scope includes the following. We will review and demonstrate each of these tests today, as we discuss each assessment, I would like you to think of potential problems that may occur when working with a demented patient.

4. Gait Speed: What it tells us
If your patient walks slower than m/s, she is at risk of:
Loss of ADL (Guralnik, 2000)
Decline in health status (Studenski, 2003)
Increased risk of nursing home admission, morbidity and mortality (Guralnik, 1994)
Gait Changes with Aging:
Older adults tend to increase double stance time, have increased variability in step length and cadence, and lose the rhythmic nature of movement.
Slower speeds due to loss of motor units, increased co-contraction, decreased proprioception, as well as many other factors, all resulting in decreased efficiency and reflective of decline in function.
Studenski did a study where she compared gait speed to a physician’s prediction on future function and found gait speed to be a more accurate predictor of function.

5. Gait Speed: How does it tell us?
Mark off a 10 meter walkway
Patients walk at usual pace
Convert to m/s
Demonstrate Gait Speed.
Open discussion for working with a demented patient. Make sure to talk about
Uninhibited gait – could signify a falls risk, or could be quite safe. No fear of falling.
Easily distracted
Falls risk
Uncooperative patient
One of the safest assessments as you can walk up to an individual with dementia and ask them to go for a walk with you.

6. Chair Rise: What it tells us
Indicator of leg strength and dynamic balance (Scarborough et al., 1999; Schenkman et al., 1996)
Associated with endurance (Hughes et al., 1996)
Time > 15 s = increased risk of nursing home admission, morbidity and mortality (Guralnik, 1994)
Demonstrate Chair Rise
Older adults have selective atrophy and loss of function in lower extremities faster than upper extremities due to disuse and motor unit loss.
Issues with demented patients:
Uninhibited
Can not understand instructions
Will not cooperate
Do not understand time frame to do activity
Alternatives?

7. Chair Rise: How does it tell us
Use a standard height chair with a firm seat
Ask patient to rise once without using their arms
If successful, time performing 5 repetitions – start on “go” and stop on 5th stand
Instructions for working with a patient with dementia

8. Balance Assessments: Static Balance – What does it tell us?
Tandem Stance Test
Increased falls risk (Lord, 1999)
Performance of a novel task (Tabbarah, 2002)
Drawback: physiologically challenging for some patients
Unique position – not done every day.
Requires hip abductor strength, ankle stability, proprioception, reaction time.
Also involves motor planning and coordination.

9. Balance Assessments: Tandem Stance –How does it tell us?
Can person maintain semi-tandem stance for 10 seconds?
Can person maintain full tandem stance for 10 seconds?
Demonstrate Sequence
This assessment is focused more on strength then balance in my view.
Would you use this assessment with patients who have dementia?
Potential problems
Falls
Unable to understand directions
If there is an injury or they have had a surgery and don’t remember (ie hip fracture)
What information are you going to get from it?

10. Balance Assessments: Dynamic Balance–What does it tell us?
Timed 360º Turn
Taking >4 sec = increased risk of falls and disability
Observation of function
Turning is a necessary skill, and highly related to mobility
Demonstrate Turning
Turning is a necessary part of one’s daily routine.
One must be able to maintain balance and move in a way that challenges vestibular function.
This test provides information regarding dynamic balance abilities.
Issues with a demented patient
Pretty easy to follow directions
Make sure you are guarding – disinhibited
Can provide valuable insight as to how they are negotiating their world.

11. Balance Assessments: Timed 360º Turn –How does it tell us?
Ask patient to turn in the direction of their choice
Start timing on “go” and stop when both feet are facing you. Instruct to turn only one time
Record total time to do task.

12. Balance Assessments: Timed Up and Go: What does it tell us?
Screening tool: Sensitive (.87) and specific (.87) for falls risk and decline (Shumway-Cook 2000, Chiu 2003)
Discriminates frequent fallers from 1 time fallers
Has not been studied in relationship to ADL decline and mortality
This test integrates sit to stand, gait, and turning abilities.
Insight on muscle strength, balance, endurance.
Best screen for falls risk at this time.

13. Balance Assessments: TUG: How does it tell us?
Start sitting in a chair
Tell the patient to stand, walk 3 meters, turn 180◦, and return to the chair and sit
Timing stops when patient sits
Use of assistive device is allowed, subjects instructed to walk at normal pace
≥ 13.5 seconds has sensitivity of 80% to predict fallers, and 100% to predict non-fallers.
Demonstrate:
Issues with a demented patient?
Following instructions
May go slower or faster than usual speed
Learn by watching movements

14. Summary WATCH YOUR PATIENTS MOVE!!
Efficient, non-invasive, reliable and valid measure of health status for all older adults
Key Numbers Gait : < 1.0 m/second
Sit-Stand: should do 1 time
Tandem: hold semi-position
360 Turn: > 4 seconds
Timed Up and Go: > 13.5 seconds
Many of these numbers do go out the window with the demented patient, however the tests themselves give you a unique opportunity to watch your patients move and navigate their environment. You can also get a sense of how they can follow directions, and their level of implusivity.