Transcript Training Mobility-Impaired Older Adults to Rise from the Floor

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
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 lines
Most 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 falls
Risk factor
Adjusted OR
Use of sedatives
28.3
Cognitive impairment
5.0
Lower ext disability
3.8
Palmomental reflex
3.0
Foot problems
1.8
Balance/gait abnormal
0-2
1.0
3-5
1.4
6-7
1.9
From: Tinetti 1988
95% CI
3.4-239.4
1.8-13.7
2.2-6.7
1.5-6.1
1.0-3.1
0.7-2.8
1.0-3.7
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 site
Primary diagnosis
Frontal gait disorder
NPH, Multiinfarct
Sensory imbalance
Periph neurop
Myelopathy
Parkinsonism
Cerebellar atrophy
Toxic encephalopathy
Other
DJD, Gout
Orthostasis
Senile gait
Single Dx-Combined Dx
Neurology
20-28
4-18
16-24
10-12
8
2-6
14-16
4
2
6-14
56-28
Primary Care
0
9
0
9
0
0
80
44
9
3
NA-75
Gait disorder classification
Sensorimotor 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 (RosowBreslau, 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
Highest
Studenski 2003
Percent of VA and Medicare HMO group
1-year outcomes according to gait speed
Gait Speed
(m/s)
<0.6
Decline in
Global Hlth
(incl SF-36)
36%
New BADL
Difficulty
69%
Hospitalization
(HMO group
only)
41%
0.6-1.0
11%
28%
24%
>1.0
6%
12%
11%
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
Functional
4 m walk 6 min
status
MPH (m/s)
walk (m)
400 m
Typical hx
walk (min) METs fatigue w/---
Overt
disability
165-250
9.5-14.5
<2
Self care, short
walks
335
7.2
2.5
Household, 1/4
mile walk
Subclinical 2.5
1.15
disability
Usual
3-3.5 1.4-1.6
healthy
414
5.75
3.0
500-580
4.0-4.75
4.0
Fit
660+
3.5
>4.0
Carry bag, lite
yard work
Mod-heavy
housework,
carry loads,
multiple stairs
Heavy work,
sports
1-1.5 0.5-0.7
Subclincal 2.0
disablity
4.0
0.9
1.8+
(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
Screening
Measure
Positive Outcome
Number of falls in
last 6 months
Romberg (Eyes
open or closed)
One leg stance
One fall or less in
last 6 months
EC, sensory
(vestib/position OK)
>30 sec no balance
problem
Looks normal
Gait inspection
TUG
Negative Outcome
2 falls=>
Do full eval
EC: sensory prob
EO: lots problem
<5 sec balance
problem
Looks abnormal=>
Do full eval
<12 sec fast pace= 14s, esp >20s=>
community normal Do full eval
Follow-up, exercise, and rehabilitation outcomes
TUG, Gait speed, 6MW, POMA? BBS? SPPB?
Divided Attention Test Predicts Falls
Test
Result
Tinetti
Bal ≤10
WTW
≥ 20 s
WTW-S
≥ 20 s
WTW-C
≥ 33 s
Sensitivity Specificity +PV
OR (CI)
p
62
70
36
3.5 (1.01-13)
0.06
38
85
42
4.3 (1.05-18)
0.06
46
89
55
7.02 (1.7-29)
0.01
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)
Verghese 2002
Cognitive Predictors of Obstacle
Avoidance in Healthy Older Adults
Test
Factor Tested
Coeff
P value
WI Card Sort
Perseveration
Stroop
Interference
Test Anxiety
Decisions
Flexibility
Attention
Inhibit responses
Anxiety during
experiment
Attention
consistency
-0.54
<0.004
0.41
<0.008
0.38
<0.01
-0.35
<0.02
TOVA
Variability
Overall model R2=0.73 (p<0.008)
Persad, 1995
Stepping Accuracy with Increasing Cognitive and
Visual Demand: A Trails Stepping Test
Estimated marginal means* for the walkway tasks after
controlling for age and simple walking speed
200
180
Completion Time
160
140
120
100
80
60
40
20
WT-NS
NC
WT-A
MCI-
WT-B
MCI+
AD
* Mean ±SEM covaried for age and usual gait speed (in Persad et al 2006)
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
Lab workup: as directed by H+P
Test
Bloods (Chemistries,
CBC)
EKG, 24-hour cardiac
monitor, echo,
cardiac enzymes
Spine x-ray, MRI
Head CT, MRI
Suspected disorder
Fluid, electrolyte and
glucose disorders,
anemia, sepsis
Arrhythmia, valvular
disease, ischemia
Myelopathy
Infarct, spaceoccupying lesion
Interventions: medical, therapy
*Treat underlying diseases *
Factor
Balance/gait
disorder,
weakness,
joint pain
Dizziness
Cognitive loss
Foot problem
Footwear
‘
Intervention
PT: exercise,
modalities,
assistive device
use and training
PT: habituation
Eval for reversible
causes, provide
supervision
Consult
Neuro
Rheum
Ortho
ENT
Neurol,
Neuropsych
Podiatry
Eval support, sole
Interventions: medical, therapy (2)
Factor
Vision
Intervention
Lens correction, low
vision aids, d/c bi or
tri focals
Osteoporosis Calcium, Vit D, other
meds, exercise
Low BMI
Wt loss eval (incl
depression),
supplements
Medications Eliminate, lower
dose, short acting
Consult
Ophthy
Dietician
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 referrals
Fortinsky, 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 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)
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
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 balance
lose balance
<40%= RED light; 40-80%= YELLOW; >80%= GREEN light
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 balance
lose 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
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 onto
furniture, less clutter
Rise/walk strategy 62
Daily habits
54
Mindful of balance 78
challenge situation
Less hurry, more
careful, get up slowly
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)
Testing Protocol:
Maximum Step Length
(Medell J Gerontol 2000; Cho JAGS 2004)
Testing Protocol:
Maximum Step Length
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)
Dependent Regression
Variable
Coefficient
(SE)
Corresponding
ratio
CBST 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