Florida State University Libraries Faculty Publications

Department of Geriatrics

2013

Competency in Gait and Falls Risk Evaluation Workshop Lisa Granville, Zaldy S. (Zaldy Sy) Tan, and Hal Atkinson

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Zaldy S. Tan, M.D., M.P.H. Division of Geriatric Medicine David Geffen School of Medicine University of California at Los Angeles

Financial Disclosures: None

Disclosure of Financial Relationships Zaldy Tan, MD

Has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Falls in the Elderly 

COMMON:  Yearly

rates:

Community-dwelling elderly: 30%  Nursing home residents: 50% 



EXPENSIVE:  Falls-related



fracture: $17billion (2005)

PREVENTABLE:  Multiple

causes and risk factors

2010 AGS/BGS Clinical Practice Guideline:

Prevention of Falls in Older Persons 

Screening and Assessment  Focused

history & physical examination  Functional assessment & Environmental Assessment 

Interventions  Older

persons living in the community  Older persons living in long-term care facilities  Older persons with cognitive impairment http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

Strength of Recommendation 

Grade A

Strongly recommended

 Good evidence of improvement in health outcome  Benefit substantially outweighs the harms



Grade B

Recommended

 Fair evidence of improvement in health outcome  Benefit outweighs the harms



Grade C

No recommendation

 Balance of benefits and harms too close to justify general recommendation http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

Strength of Recommendation 

Grade D

Not recommended

 Fair evidence that intervention is ineffective or that harms outweigh benefits



Grade I

Insufficient Evidence  Evidence of efficacy is lacking, or poor quality, or conflicting

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

AAMC Minimum Geriatric Competencies Cognitive and behavioral disorders  Medication management  Self-care capacity  Falls, balance, gait disorders  Atypical presentation of disease  Palliative care  Hospital care for elders  Health care planning and promotion 

AAMC Minimum Geriatric Competencies Cognitive and behavioral disorders  Medication management  Self-care capacity  Falls, balance, gait disorders  Atypical presentation of disease  Palliative care  Hospital care for elders  Health care planning and promotion 

Minimum Geriatric Competencies for IM/FM Residents Transitions of Care  Hospital Patient Safety  Cognitive, Affective, and Behavioral Health  Complex or Chronic Illnesses  Medication Management  Ambulatory Care  Palliative and End of Life Care 

Minimum Geriatric Competencies for IM/FM Residents  

   

Transitions of Care Hospital Patient Safety Cognitive, Affective, and Behavioral Health Complex or Chronic Illnesses Medication Management Ambulatory Care  Gait



evaluation; Falls screening and prevention

Palliative and End of Life Care

Outpatient Clinic:

75 y.o. F with CC: “Falls”

What is expected of me?  What questions should I ask?  How do I evaluate?  How do I intervene? 

Outpatient Clinic:

75 y.o. F with CC: “Falls”

What is expected of me?  What questions should I ask?  How do I evaluate?  How do I intervene? 

Gait Competency Expectations • •

AAMC (Medical Students): "Ask all patients greater than 65 years old or their caregivers, about fall in the last year, watch the patient rise from a chair and walk, then record and interpret the findings, and in a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical exam, functional assessment."

•

Minimum Geriatrics Competencies for Internal Medicine and Family Medicine Residents:

•

“Yearly screen all ambulatory elders for falls or fear of falling. If positive assess gait and balance instability, evaluate for potential precipitating causes (medications, neuromuscular conditions, and medical illness) and implement interventions to decrease risk of falling."

Outpatient Clinic:

75 y.o. F with CC: “Falls”

What is expected of me?  What questions should I ask?  How do I evaluate?  How do I intervene? 

Falls Screening/History Questions 1: Ask if the patient is experiencing difficulties with walking or balance.  2: Ask the patient whether he/she has fallen in the past year.  3: If the patient reports a fall, ask about the frequency and circumstances of the fall(s). 

Falls Screening/History Questions 1: “What difficulties have you had with walking or balance?”  2: “How many times have you fallen in the past year?”  3: “What are the circumstances of the falls?” 

Outpatient Clinic:

75 y.o. F with CC: “Falls”

What is expected of me?  What questions should I ask?  How do I evaluate?  How do I intervene? 

Risk factors for Falls (PMHx & ROS)    

 

Age Cognitive impairment Past history of a fall Lower extremity weakness Balance problems Urinary incontinence

   

 



Psychotropic drug use Arthritis Osteoporosis History of stroke Orthostatic hypotension Dizziness Anemia

Chronic Diseases •

Osteoarthritis – –

Mobility Ability to maneuver and step over objects – Postural stability: avoidance of weight bearing on a painful joint

•

Diabetes – –

•

Peripheral neuropathy and increase fall risk Ensure adequate blood sugar control but avoid hypoglycemia with too tight a control

Parkinson disease – –

Rigidity of the lower extremity musculature Inability to correct sway trajectory due to slowness in initiating movement – Hypotensive drug effects – Cognitive impairment

Functional/Environmental Assessment Activities of Daily Living  Use of adaptive equipment & mobility aids  Perceived functional ability 

 Fear



of falling

Environmental assessment

Medications and Falls 

Greater numbers of any type, and recent changes in the dose medications — neuroleptics, benzodiazepines, opioids, antiepileptics and antidepressants (tricyclics and SSRIs)  Antihypertensives and cardiovascular medications — vasodilators diuretics, nitrates, digoxin, and anticholinergic drugs  Psychoactive

Medications and Falls 

Psychotropics (any): 1.73 (1.52 – 1.97) 1.48 (1.23 – 1.77)  Neuroleptics: 1.50 (1.25 –1.79)  Sedative/Hypnotics: 1.54 (1.40 – 1.70)  Antidepressants: 1.66 (1.40 – 1.95)  Benzodiazepines:

Diuretics: 1.08 (1.02 – 1.16)  Anti-arrhythmics (Ia): 1.59 (1.02 – 2.48)  Digoxin: 1.22 (1.05 – Leipzig 1.42et) al. JAGS 1999; 47(1) 

Medications and Falls Meta-analysis of 22 articles  English language, published 1996 – 2007  Age > 60  79,081 participants 

Woolcott, J. C. et al. Arch Intern Med 2009;169

Medications and Falls

Woolcott, J. C. et al. Arch Intern Med 2009;169

Get up and Go Test Assesses the ability to stand up from a standard arm chair*, walk a distance of 10 feet, turn, walk back to the chair, and sit down • Wears regular footwear and uses their customary walking aid (none, cane, walker) • No physical assistance is given • Back against chair, arms resting on the armrests, and their walking aid at onhand. *Approximate seat height of 46 cm [18in], arm height 65 cm [25.6 in]. No wheels chair. •

“our e: Podsiadlo D, Ri hardso “. The ti ed up a d go : a test of asi fu tio al JAGS 1991; 39: 142-148;

o ility for frail elderly perso s.

Get up and Go Test 

“When I say ‘go’ I want you to stand up (if you can without pushing off with your arms), turn and then walk back to the chair and sit down again. Walk at your normal pace.”



Take note of/document the following:  Used

arms to get up from chair?  Unstable on turning?  Walking aid used? Type of aid: __________

Gait Observation •

Rise from chair – – –

•

•

– –

•

•

Normal Unstable

•

– – –

Normal (Upright) Stooped Kyphotic

•

Normal Decreased Exaggerated

Speed – –

Posture

Normal (>2x foot length) Short-stepped

Step height – – –

Normal Widened/Broad-based

Normal Decreased Asymmetric

Stride length – –

Balance – –

•

•

Normal Hesitant start

Stance

Arm swing – – –

Stable, without using arms Stable, needed to use arms Unstable

Initiation – –

•

Normal Slow

Turn – – –

Stable Unstable En-bloc

Sensory System •

• •

Vision – Decrease in visual acuity, depth perception, contrast sensitivity, and dark adaptation – Multifocal lenses – Vision correction: adjustment period Proprioceptive sensitivity loss – Control blood sugar and other vascular risk factors Balance – Loss of labyrinthine hair cells, vestibular ganglion cells, and nerve fibers – Loss of neurons and depletion of neurotransmitters like dopamine in the basal ganglia.

Footwear Low-heeled shoes are advisable  Avoid going barefoot and/or ambulating with only socks on  No type of shoe has been shown conclusively to be better in preventing falls than others 

Outpatient Clinic:

75 y.o. F with CC: “Falls”

What is expected of me?  What questions should I ask?  How do I evaluate?  How do I intervene? 

Falls Prevention • •

111 trials (55, 303 participants) Significant Factor Group exercise Tai chi Home exercise Falls assessment/intervention Psychotropic med withdrawal Pacemakers First cataract Sx

Rate Ratio 0.78 0.63 0.66 0.75 0.34 0.42 0.66

Cochrane Intervention Review 2009

Environmental Hazards Home hazard assessment  Information on hazard reduction  Modification/adaptation of home  Installation of safety devices 

Muscle Factors Decreased muscle cross-sectional area and increased muscle adiposity  Less efficient muscle activation with change in posture  Strengthening and balance exercises to mitigate the muscular factors 

Sarcopenia 

Related to:  Inactivity  Underlying

medical conditions  Poor nutritional status  Hormonal changes  Neuronal Changes  Aging  Inflammation Mohamed et al. Phys Med Rehabil Clin N Am 2005;16

Resistance Exercises 

  

Improves protein (myosin) synthesis and muscle strength Improved torque due to decreased antagonist muscle co-activation Improved oxidative capacity, mitochondrial volume density and muscle size Suppressed levels of TNF

Mohamed et al. Phys Med Rehabil Clin N Am 2005;16

Exercise Categories Gait and balance training  Strength training  Flexibility  Movement (such as Tai Chi or dance)  General physical activity  Endurance 

Vitamin D and Falls

Bischoff-Ferrari, H.A. et al. BMJ 2009;339

Vitamin D and Falls

Bischoff-Ferrari, H.A. et al. BMJ 2009;339

Vitamin D and falls in the elderly Proposed mechanism: higher vitamin D levels are associated with improved muscle function  Assessing vitamin D levels in patients with high fall risk and supplementing with at least 800 IU daily should be a part of any fall prevention program 

Summary Gait and falls evaluation skills are expected of all clinicians  Falls = high morbidity, mortality and cost  Falls risk can be reduced by evidencebased interventions 