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Balance and Gait Disorders in Older Adults Neil Alexander MD University of Michigan VA Ann Arbor Health Care System GREC PowerPoint Presentation
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Balance and Gait Disorders in Older Adults Neil Alexander MD University of Michigan VA Ann Arbor Health Care System GRECC Mobility Research Center (MRC), Geriatrics Center and Division of Geriatric Medicine, University of Michigan

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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

slide2

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
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

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.

intrinsic factors falls and gait disorders
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
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
falls and gait evaluation history
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
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
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
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
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 measures18
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

percent of va and medicare hmo group 1 year outcomes according to gait speed

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 measures20
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)
sets of multiple tasks
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
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
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
Cognitive Predictors of Obstacle Avoidance in Healthy Older Adults

Overall model R2=0.73 (p<0.008)

Persad, 1995

estimated marginal means for the walkway tasks after controlling for age and simple walking speed
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)

slide29

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
Interventions: medical, therapy

*Treat underlying diseases *

specific interventions for gait disorders
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
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
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
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)

slide37

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 nalexand@umich.edu

Supported by the New Jewish Fund and the Jewish Federation of Metropolitan Detroit

overview of program
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
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 mindfully40
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
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
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
Testing Protocol:Maximum Step Length

(Medell J Gerontol 2000; Cho JAGS 2004)

combined balance and stepping training in balance impaired elders
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)
slide48

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