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Balance and Gait Disordersin Older AdultsNeil Alexander MDUniversity of MichiganVA Ann Arbor Health Care System GRECC Mobility Research Center (MRC), Geriatrics Center and Division of Geriatric Medicine, University of Michigan Biomechanics Research Laboratory (BRL), Department of Mechanical Engineering and Applied Mechanics, University of Michigan Acknowledgments: National Institute on Aging, VA Office of Research and Development (Rehab R&D and Medical Research Services), AARP-Andrus Foundation, Hartford Foundation/AFAR
Gait Disorders in Community-Dwelling Older Adults: Subsequent Risk of Institutionalization and Death (Verghese et al JAGS 2006)
Gait abnormalities in non-demented older adults predict development of vascular dementia Notes: Kaplan-Meier curves w/95% CI lines Most common abnl= unsteady, frontal, hemiparetic (Verghese et al NEJM 2002)
Falls in older adults: epidemiology Leading cause of death from unintentional injuries (5th leading cause of all deaths in older adults) Annual falls: 35-40% of community-dwelling 1/2 of nursing home residents (1.5 falls/bed) 10-25% result in fx, laceration, hospital care Repeat fallers: At increased risk for hospitalization, decreased ADL/IADL, institutionalization, death Fall-related injuries account for 6% of all medical expenditures for aged 65.
AGE Central processing Vision Vestibular Systemic Musculoskeletal Neurological AGE-ASSOCIATED DISEASES Central processing Dementia Vision Cataracts, ARMD, Glaucoma Vestibular Previous labyrinthitis, BPPV Systemic Disease Musculoskeletal Arthritis Neurological Parkinson’s, myelopathy, stroke, PN Intrinsic factors: falls and gait disorders
Medications affecting fall risk, balance, and gait • Reduce alertness or retard central processing Analgesics (esp. narcotics) Psychotropics (esp. benzodiazepines, phenothiazines, tricyclics, SSRI’s?) • Impair cerebral perfusion Antihypertensives, Diuretics, Antiarhythmics? • Direct vestibular toxicity Aminoglycosides, high dose loop diuretics • Extrapyramidal effects
Risk factors associated with falls From: Tinetti 1988
Falls and gait evaluation: history • Rising from a lying or sitting position [orthostatic BP change or Benign Paroxysmal Vertigo (BPV)] • Trip or a slip [gait, balance, or vision disturbance AS WELL AS environmental demand] • Post-cough or urination, recent meal [hypotension] • Looking up or sideways [Post TIA, cervical DJD?, carotid hypersensitivity?] • Leg catch, gave out, unstable [DJD, pain] • Dizziness: a new geriatrics syndrome (Tinetti 2000)? • Vertigo: BPV, Posterior CVA/TIA, Cervical • Presyncope: Orthostatic, Dysrythmia, Anemia • Other: Sensory loss (PN, Viz), Anxiety/depression
Falls and gait evaluation: exam • Mental status • Orthostatic BP and pulse (1 min, up to 3 min) • Hallpike-Dix, Barany maneuver • Vision screen • Cardiac auscultation, Carotid massage? • Joint and foot deformities, limited ROM (neck, spine, extremities) • Neurological exam • Strength and tone • Sensation (particularly proprioception) • Station and gait: Romberg, Usual gait Timed unipedal stance: <5 s => risk for fall injury
Walking Self-reported Difficulty or Disability • Need help from person or equipment walking across room in last 12 months (ADL) • Note: time referent, type of device • Able to walk 1/2 mile without help (Rosow-Breslau, EPESE) • Alternatives: 1/4 mile, one block • Able to walk up and down stairs to the second floor without help (Rosow-Breslau, EPESE) • Assistive device use (type, terrain) • Modification to walking: “Slowed down”, limit duration or terrain?
Performance-based Measures • Scoring: How abnormal, timing, inability to perform • How important is slow if still able? • Goal is safety without undue fatigue • Burden: Minimal equipment, testing time • Simple measures powerful but provide little insight into mechanisms of dysfunction • Reliability: OK in small published samples • Short term fluctuation in diseased population • Difficult to perform in cognitive impaired
Walk Speed/Distance Measures • Predict: Disease activity (e.g. arthritis) Cardiopulmonary function (e.g. CHF, COPD) Mobility- and ADL-disability Institutionalization Mortality • Affected by: Disease Leg length and function (e.g. strength) Other factors (e.g. FOF, falls, physical activity)
Walk Speed/Distance Measures • Usual speed: e.g. 1 m start-up, 4 m walk • Should also have 1 m decel portion • Primary clinic sample, risk for hosp, functional decl Studenski 2003
Gait Speed (m/s) Decline in Global Hlth (incl SF-36) New BADL Difficulty Hospitalization(HMO group only) <0.6 36% 69% 41% 0.6-1.0 11% 28% 24% >1.0 6% 12% 11% Percent of VA and Medicare HMO group 1-year outcomes according to gait speed all p<0.001, in Studenski 2003
Walk Speed/Distance Measures • Six minute walk • May have small improvement in test-retest • May “pace” themselves instead of trying to cover as much distance as possible • May approach peak VO2 in impaired (e.g. CHF) • Estimates: <300m impaired, >500m unimpaired • Long distance corridor walk (400 m) • Goal of distance, not time, so less “pacing” • Low functioning older adults cannot complete • Estimates: ?< 5 min unimpaired (~7 min~1 m/s)
The meaning of gait speed (Studenski 2005)
Sets of multiple tasks • Timed up and go Widely used, proposed as screening Community dwelling (<12 s fast pace), Fall risk (14 s nl pace), ADL dependency (>20 s nl pace) • Modest reliability in cognitively impaired, or unable to complete due to immobility, safety concerns, or refusal • Performance-oriented mobility assessment (POMA, also Tinetti Balance and Gait Scale) Less widely used, predicts falls Risk: High <19, Increased 19-23, Low >23 • Ceiling effect (other fall causes not in test)
Suggested clinical use of balance and gait measures Screening Follow-up, exercise, and rehabilitation outcomes TUG, Gait speed, 6MW, POMA? BBS? SPPB?
Divided Attention Test Predicts Falls WTW=20 ft walk-turn-20 ft walk; WTW-S= + recite alphabet; WTW-C= + recite alternate letters (i.e. a,c,e) Verghese 2002
Cognitive Predictors of Obstacle Avoidance in Healthy Older Adults Overall model R2=0.73 (p<0.008) Persad, 1995
Stepping Accuracy with Increasing Cognitive and Visual Demand: A Trails Stepping Test
Estimated marginal means* for the walkway tasks after controlling for age and simple walking speed 200 180 160 140 120 Completion Time 100 80 60 40 20 WT-NS WT-A WT-B NC MCI- MCI+ AD * Mean ±SEM covaried for age and usual gait speed (in Persad et al 2006)
Balance and gait + increased cognitive demand Executive Control Basic Cognitive Function (e.g. memory) Affect and Self Efficacy (e.g. depression) Physiological Capacities (e.g. balance) Figure 1. Proposed model of balance and gait under conditions of Increased cognitive demand
Interventions: medical, therapy *Treat underlying diseases *
Specific interventions for gait disorders • Medications (e.g. Vitamin def, PD, OA pain relief) • Physical therapy • Traditional gait/assistive device use training • Disease or task specific training (e.g. body weight support/treadmill, sensory cues for PD) • Group exercise • Behavioral and environmental modifications (includes lighting, clutter removal, “furniture surf”) • Orthoses/braces • Surgery (esp. for cervical and lumbar stenosis, NPH, joint replacement): outcomes depend on underlying disease process and comorbidities, not a “perfect cure”
Interventions to prevent community older adult falls (Cochrane) 1. Multidisciplinary, multifactorial, health + environmental risk factor, screening+intervention RR 0.73 (0.63-0.85 95%CI) RR 0.86 (0.76-0.98 95%CI) w/hx falls, known risk RR 0.60 (0.50-0.73 95%CI) residential care 2. Muscle strengthening + balance, individual prescription, by trained health professional RR 0.80 (0.66-0.98 95%CI) 3. Home hazard assessment and modification, individual professional prescription, w/hx falls RR 0.66 (0.54-0.81 95%CI)
Challenges in Applying Multifactorial Models to Community • Physicians underdetect falls and fail to provide interventions when a fall is detectedRubenstein, JAGS, 2004 • Remaining barriers: • patient frailty/comorbidity • patient fear of admitting to falling • patient adherence hinders interventions • fragmented health care system and reimbursement limitations hinder referrals Fortinsky, JAGS, 2004 • Physical therapy practice may be variable • ER may be key time
Multifactorial Intervention, Group Model, Behavioral + (Clemson, JAGS, 2004) Age 70+, fall in last yr or concern about falling 7 weekly classes + 1 home OT visit + 1 booster to improve self-efficacy, encourage behavioral change, reduce falls Focus on balance and strength exercises, improving home and community environmental and behavioral safety, encouraging vision screen and med review Included balance exercise as direct part of intervention 31% reduction in falls; RR = 0.69 (0.5 to 0.96 95% CI)
IMPLEMENTATION OF A FALL-RISK REDUCTION PROJECT FOR OLDER ADULT CONGREGATE HOUSING RESIDENTSN. B. Alexander1,2,3, D. Strasburg1, L. Nyquist2 , L. Blumberg4 1Mobility Research Center, Geriatrics Center, Division of Geriatric Medicine, Department of Internal Medicine; 2Institute of Gerontology; University of Michigan. 3VA Ann Arbor Health Care System GRECC. Ann Arbor, MI USA. 4Commission on Jewish Eldercare Services, Jewish Federation of Metropolitan Detroit, West Bloomfield MI, USA firstname.lastname@example.org Supported by the New Jewish Fund and the Jewish Federation of Metropolitan Detroit
Overview of program • Purpose • Reduce fall risk in community-dwelling older adults through increased understanding of personal risk factors and targeted risk factor remediation • Objectives • Recognize fall risk factors, interaction • Optimize health • Increase physical activity • Enhance safe daily mobility • Increase personal control and self-efficacy • Develop personal action plan
Module 6: Moving Mindfully Concern with falls restricts activity Using balance confidence scale identifies specific activity that is restricted (e.g. ADL, social activity outside home) 0%REDYELLOWGREEN 100% Likely to(Main focus) Very unlikely to lose balancelose balance <40%= RED light; 40-80%= YELLOW; >80%= GREEN light
Module 6: Moving Mindfully Concern with falls restricts activity Using balance confidence scale identifies specific activity that is restricted (e.g. ADL, social activity outside home) 0% RED YELLOW GREEN 100% Likely to(Main focus) Very unlikely to lose balancelose balance <40%= RED light; 40-80%= YELLOW; >80%= GREEN light Risk factor: Walking on stairs=YELLOW light Action Plan: WHEN: not fatigued; HOW: walk step to step, use railings; WHERE: well-lit, + edge contrast
Group Exercise Model • Include standing exercises that challenged balance • Stepping, Tai Chi, change of direction • Complexity and speed of exercises increases • Classes held 1-2 times per week, typically also with home exercises • Long duration: 15 weeks to 1 year • Exercises are individualized as needed
Hypotheses Compared to baseline and compared to participants in Tai Chi (TC) training, participants in Combined Balance and Stepping Training (CBST) will show greater improvement at 10 weeks in: 1) Measures of stepping 2) Timed Up-and-Go (TUG)
Testing Protocol:Maximum Step Length (Medell J Gerontol 2000; Cho JAGS 2004)
Combined Balance and Stepping Training in Balance-Impaired Elders • Phase I • Increase limits of stability and step length • Speed up step initiation and weight shifting • Phase II • Develop step responses in functional situations • Curbs, steps (improve step height) • Narrow support (beam) • Uneven terrain • Simultaneous tasks (esp upper extremity)
Table 2. Extent of Improvement in CBST Compared to TC: Timed Up and Go,Maximum Step Length, Rapid Step Test (CBST n=106, TC n=107) Nnodim et al, JAGS, 2006