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Balance and Gait Disordersin Older Adults
Neil Alexander MDUniversity of Michigan
VA 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 linesMost 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.
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
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 fallsRisk factor Adjusted OR 95% CI Use of sedatives 28.3 3.4-239.4 Cognitive impairment 5.0 1.8-13.7 Lower ext disability 3.8 2.2-6.7 Palmomental reflex 3.0 1.5-6.1 Foot problems 1.8 1.0-3.1 Balance/gait abnormal
0-2 1.0 3-5 1.4 0.7-2.8 6-7 1.9 1.0-3.7
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
Percent of Dx by referral sitePrimary diagnosis Neurology Primary CareFrontal gait disorder
NPH, Multiinfarct20-28 0
Sensory imbalancePeriph neurop
4-18 9
Myelopathy 16-24 0Parkinsonism 10-12 9Cerebellar atrophy 8 0Toxic encephalopathy 2-6 0Other 14-16 80
DJD, Gout 4 44Orthostasis 2 9Senile gait 6-14 3
Single Dx-Combined Dx 56-28 NA-75
Gait disorder classificationSensorimotor level Disorders
High Cautious gait (fear of falling) Frontal or white matter lesions (includes cerebrovascular, NPH) Drug, Metabolic
Medium Spastic (hemiplegic, paraplegic) Cerebellar ataxia Parkinsonian Choreic gait, dystonic gait
Low Peripheral motor: arthritis (antalgia, joint/leg deformity) Peripheral motor: muscle weakness (myopathy, periph neuropathy) Peripheral sensory (post column, PN, vestib, visual)
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
Group Speed (m/s) Risk
Extremely fit >1.3 Low
Fast 1.0-1.3 Low
Intermediate 0.6-1.0 Higher
Slow 0.2-0.6 High
Very impaired <0.2 HighestStudenski 2003
Percent of VA and Medicare HMO group 1-year outcomes according to gait speed
11%12%6%>1.0
24%28%11%0.6-1.0
41%69%36%<0.6
Hospitalization(HMO group only)
New BADL Difficulty
Decline in Global Hlth (incl SF-36)
Gait Speed (m/s)
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 Functionalstatus MPH
4 m walk(m/s)
6 minwalk (m)
400 mwalk (min) METs
Typical hxfatigue w/---
Overtdisability
1-1.5 0.5-0.7 165-250 9.5-14.5 <2 Self care, shortwalks
Subclincaldisablity
2.0 0.9 335 7.2 2.5 Household, 1/4mile walk
Subclinicaldisability
2.5 1.15 414 5.75 3.0 Carry bag, liteyard work
Usualhealthy
3-3.5 1.4-1.6 500-580 4.0-4.75 4.0 Mod-heavyhousework,carry loads,multiple stairs
Fit 4.0 1.8+ 660+ 3.5 >4.0 Heavy work,sports
(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
Measure Positive Outcome Negative Outcome
Number of falls in last 6 months
One fall or less in last 6 months
2 falls=> Do full eval
Romberg (Eyes open or closed)
EC, sensory (vestib/position OK)
EC: sensory prob EO: lots problem
One leg stance >30 sec no balance problem
<5 sec balance problem
Gait inspection Looks normal Looks abnormal=> Do full eval
TUG <12 sec fast pace= community normal
14s, esp >20s=> Do full eval
Screening
Follow-up, exercise, and rehabilitation outcomesTUG, Gait speed, 6MW, POMA? BBS? SPPB?
Divided Attention Test Predicts Falls
Verghese 2002
Test
Result Sensitivity Specificity +PV OR (CI) p
Tinetti
Bal ≤10
62 70 36 3.5 (1.01-13) 0.06
WTW
≥ 20 s
38 85 42 4.3 (1.05-18) 0.06
WTW-S
≥ 20 s
46 89 55 7.02 (1.7-29) 0.01
WTW-C
≥ 33 s
39 96 71 13.7 (2.3-84) <0.01
WTW=20 ft walk-turn-20 ft walk; WTW-S= + recite alphabet;WTW-C= + recite alternate letters (i.e. a,c,e)
Cognitive Predictors of Obstacle Avoidance in Healthy Older Adults
Test Factor Tested Coeff P value
WI Card Sort Perseveration
Decisions Flexibility
-0.54 <0.004
Stroop Interference
Attention Inhibit responses
0.41 <0.008
Test Anxiety Anxiety during experiment
0.38 <0.01
TOVA Variability
Attention consistency
-0.35 <0.02
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
20
40
60
80
100
120
140
160
180
200
WT-NS WT-A WT-B
Co
mp
leti
on
Tim
e
NC MCI- MCI+ AD
* Mean ±SEM covaried for age and usual gait speed (in Persad et al 2006)
Executive Control
Affect and SelfEfficacy
(e.g. depression)
Basic CognitiveFunction
(e.g. memory)
Physiological Capacities
(e.g. balance)
Balance and gait + increasedcognitive demand
Figure 1. Proposed model of balance and gait under conditions ofIncreased cognitive demand
Lab workup: as directed by H+P
Test Suspected disorderBloods (Chemistries,
CBC)Fluid, electrolyte and
glucose disorders,anemia, sepsis
EKG, 24-hour cardiacmonitor, echo,cardiac enzymes
Arrhythmia, valvulardisease, ischemia
Spine x-ray, MRI MyelopathyHead CT, MRI Infarct, space-
occupying lesion
Interventions: medical, therapy
Factor Intervention Consult Balance/gait
disorder, weakness, joint pain
PT: exercise, modalities, assistive device use and training
Neuro Rheum Ortho
Dizziness PT: habituation ENT Cognitive loss Eval for reversible
causes, provide supervision
Neurol, Neuropsych
Foot problem Podiatry Footwear Eval support, sole
‘
*Treat underlying diseases *
Interventions: medical, therapy (2)
Factor Intervention Consult Vision Lens correction, low
vision aids, d/c bi or tri focals
Ophthy
Osteoporosis Calcium, Vit D, other meds, exercise
Low BMI Wt loss eval (incl depression), supplements
Dietician
Medications Eliminate, lower dose, short acting
Pharmacy
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 detected Rubenstein, 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 referralsFortinsky, 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 falling7 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 RESIDENTS
N. 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 [email protected]
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
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 balance lose balance<40%= RED light; 40-80%= YELLOW; >80%= GREEN light
Concern with falls restricts activity
Module 6: Moving Mindfully
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 balance lose balance<40%= RED light; 40-80%= YELLOW; >80%= GREEN light
Concern with falls restricts activity
Risk factor: Walking on stairs=YELLOW lightAction Plan: WHEN: not fatigued; HOW: walk step to step, use railings; WHERE: well-lit, + edge contrast
Post-Project Report of Behavior Change (n=39)
Behavior Change % Example
Health 50 Use cane/walker more
Physical activity 60 Exercise more
Home hazards 32 Increase light, hold ontofurniture, less clutter
Rise/walk strategy 62
Daily habits 54 Less hurry, morecareful, get up slowly
Mindful of balancechallenge situation
78
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)
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)
DependentVariable
RegressionCoefficient (SE)
Corresponding ratioCBST vs TC(95% CI)
P value Percent improvement CBST versus TC
TUG (sec) 0.0899 (0.03)
1.094 (1.041, 1.149)
0.001 9.4
MSL 0.0294 (0.01)
N/A* 0.0003 9.8
RST (sec) 0.0522 (0.02)
1.054 (1.003, 1.106)
0.02 5.4
Nnodim et al, JAGS, 2006