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
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
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
Perform Timed Up & Go test
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
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
•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
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
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
•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
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
•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
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