mobility and gait – evaluation and management

Mobility and Gait – Mobility and Gait – Evaluation and ManagementEvaluation and Management

M. Kathy Wiley, MD, MSCathryn Caton, MD, MS

I’ve fallen and I can’t get up!

ObjectivesObjectivesUnderstand 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 FallsIncidence 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 FallsCost of FallsIn 2002 direct costs for

◦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 FallsConsequences of FallsPhysical – 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-EfficacySelf-EfficacyBeliefs 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

CaseCase79 y/o woman presents for f/uCHF, arthritis, depression, difficulty

sleepingMedications: antidepressant,

diuretic, ACE-I, Beta-Blocker. Also takes OTC sleep

and allergy medsChronic conditions appear stableDaughter reports 2 falls in the past 6

months

AlgorithmAlgorithm

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

ReferenceChang, 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

Brief Fall History

•Circumstances•Medications•Chronic conditions•Mobility•ETOH intake


Elders. JAGS 55-S327-S334, 2007.




HistoryHistoryAsk all patients about falls in past yearEstablish if recurrent vs. single episodeDetermine circumstances of fall- “true fall

vs. syncope”Evaluate associated symptoms – dizziness,

lightheadedness, vision disturbance, LOC, gait or balance problems

Determine whether injury occurredReview medications – number of

medications (4 or more increases fall risk) recent changes, sedating drugs, narcotics (Beers’ List)

Beers’ ListBeers’ List

Brief Fall History

•Circumstances•Medications•Chronic conditions•Mobility•ETOH intake



Elders. JAGS 55-S327-S334, 2007.




Timed Up & Go TestTimed Up & Go TestPatient can use arms or assistive

device – must document if either is used

Explain the test to the patientDemonstrate the testDo practice trialPerform timed evaluation

Timed Up & Go TestTimed Up & Go TestPatient starts from a seated

positionTime starts when the patient

initiates movementThe patient walks 10ft across the

room and circles around a markerTime stops when the patient

returns and is seated in the chair

Timed Up & Go TestTimed Up & Go Test

Average results are as follows

◦Age 60 – 69 7.24 seconds

◦Age 70 – 79 8.54 seconds

http://webituponline.com/aging/5.htm

Brief Fall History





exercise program


Elders. JAGS 55-S327-S334, 2007.




ABNORMAL

NORMAL

Physical ExamPhysical ExamCheck vitals –orthostatics if

indicatedVisual assessmentTest for lower extremity strengthPerform targeted neuro exam –

proprioception, sensationPerform Timed Up & Go Test –

establishes gait and balance abnormalities, normal <10 seconds

Do cardiovascular work-up if falls history suggests syncopal event

Brief Fall History








Elders. JAGS 55-S327-S334, 2007.




ABNORMAL

NORMAL

InterventionInterventionMay require more than one

interventionGait, balance and exercise

programs (PT referral, Tai Chi)Medication modificationPostural hypotension treatmentEnvironmental hazard modificationCardiovascular disorder treatment

if cardiac source is identified as cause of fall

Gait, balance & exercise Gait, balance & exercise programsprogramsPhysical 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 AdjustmentMedication AdjustmentReduction 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 HypotensionPostural Hypotension

Reduce medications that contribute

Teach patients to change position slowly

Consider liberalizing salt intakeEncourage adequate hydration

Environmental Hazard Environmental Hazard ModificationModificationThis 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

AlgorithmAlgorithm

Brief Fall History








Elders. JAGS 55-S327-S334, 2007.




ABNORMAL

NORMAL

CaseCase79 y/o woman presents for f/uCHF, arthritis, depression,

difficulty sleepingMedications: antidepressant,

diuretic, ACE-I, Beta-Blocker. Also takes OTC sleep and allergy meds

Chronic conditions appear stableDaughter reports 2 falls in the

past 6 months

Fall Risk FactorsFall Risk FactorsBased on findings of two or more

observational studies◦Arthritis◦Depressive symptoms◦Orthostasis◦Use of four or more medications◦Parkinson’s Disease

Fall Risk FactorsFall Risk Factors

Impairment in ◦Cognition◦Vision◦Balance and gait◦Muscle strength

Fall Risk FactorsFall Risk FactorsMedication 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

SummarySummaryWe 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

mobility and gait – evaluation and management

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