Transcript Mobility and Gait - Medical Center Intranet

Mobility and Gait –
Evaluation and Management
M. Kathy Wiley, MD, MS
Cathryn Caton, MD, MS
Objectives
Understand 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 selfmanagement education

Incidence 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%
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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 Falls

In 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 Falls

Physical – 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
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Psychological – Fall-related fear & loss of selfefficacy
Self-Efficacy
Beliefs in one’s capabilities to organize
and execute the courses of action
required to produce a given attainment
 Influenced by
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Having relevant skills
Past experiences
Observation of the experiences of others
Social persuasion including provider influence
Case
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79 y/o woman presents for f/u
CHF, arthritis, depression, difficulty sleeping
Medications: antidepressant, diuretic, ACE-I,
Beta-Blocker. Also takes OTC sleep and
allergy meds
Chronic conditions appear stable
Daughter reports 2 falls in the past 6
months
Algorithm
Fall
reported in
last year
Single fall with
no injury
Brief Fall History
•Circumstances
•Medications
•Chronic conditions
•Mobility
•ETOH intake
Perform Timed Up & Go
test
ABNORMAL
2 or more falls,
1 fall with
injury
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
NORMAL
Consider recommending
exercise program
Intervention Options
Reference
Chang, T.T. and David A. Ganz. Quality
Indicators for Falls and Mobility
Problems in Vulnerable Elders. JAGS 55S327-S334, 2007.
•Gait, balance & exercise programs
•Medication modification
•Postural hypotension treatment
•Environmental hazard modification
•Cardiovascular disorder treatment
Fall
reported in
last year
Single fall with
no injury
Brief Fall History
•Circumstances
•Medications
•Chronic conditions
•Mobility
•ETOH intake
Reference
Chang, T.T. and David A. Ganz. Quality
Indicators for Falls and Mobility
Problems in Vulnerable Elders. JAGS 55S327-S334, 2007.
2 or more falls,
1 fall with
injury
History
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Ask all patients about falls in past year
Establish if recurrent vs. single episode
Determine circumstances of fall- “true fall vs.
syncope”
Evaluate associated symptoms – dizziness,
lightheadedness, vision disturbance, LOC, gait or
balance problems
Determine whether injury occurred
Review medications – number of medications (4
or more increases fall risk) recent changes,
sedating drugs, narcotics (Beers’ List)
Fall
reported in
last year
Single fall with
no injury
Brief Fall History
•Circumstances
•Medications
•Chronic conditions
•Mobility
•ETOH intake
Perform Timed Up & Go
test
Reference
Chang, T.T. and David A. Ganz. Quality
Indicators for Falls and Mobility
Problems in Vulnerable Elders. JAGS 55S327-S334, 2007.
2 or more falls,
1 fall with
injury
Timed Up & Go Test
Patient can use arms or assistive device –
must document if either is used
 Explain the test to the patient
 Demonstrate the test
 Do practice trial
 Perform timed evaluation

Timed Up & Go Test
Patient starts from a seated position
 Time starts when the patient initiates
movement
 The patient walks 10ft across the room
and circles around a marker
 Time stops when the patient returns and
is seated in the chair

Timed 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
Fall
reported in
last year
Single fall with
no injury
Brief Fall History
•Circumstances
•Medications
•Chronic conditions
•Mobility
•ETOH intake
Perform Timed Up & Go
test
ABNORMAL
NORMAL
Consider recommending
exercise program
Reference
Chang, T.T. and David A. Ganz. Quality
Indicators for Falls and Mobility
Problems in Vulnerable Elders. JAGS 55S327-S334, 2007.
2 or more falls,
1 fall with
injury
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
Physical Exam
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Check vitals –orthostatics if indicated
Visual assessment
Test for lower extremity strength
Perform targeted neuro exam –
proprioception, sensation
Perform Timed Up & Go Test – establishes
gait and balance abnormalities, normal <10
seconds
Do cardiovascular work-up if falls history
suggests syncopal event
Fall
reported in
last year
Single fall with
no injury
Brief Fall History
•Circumstances
•Medications
•Chronic conditions
•Mobility
•ETOH intake
Perform Timed Up & Go
test
ABNORMAL
2 or more falls,
1 fall with
injury
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
NORMAL
Consider recommending
exercise program
Intervention Options
Reference
Chang, T.T. and David A. Ganz. Quality
Indicators for Falls and Mobility
Problems in Vulnerable Elders. JAGS 55S327-S334, 2007.
•Gait, balance & exercise programs
•Medication modification
•Postural hypotension treatment
•Environmental hazard modification
•Cardiovascular disorder treatment
Intervention
May require more than one intervention
 Gait, balance and exercise programs (PT
referral, Tai Chi)
 Medication modification
 Postural hypotension treatment
 Environmental hazard modification
 Cardiovascular disorder treatment

 if cardiac source is identified as cause of fall
Gait, balance & exercise programs
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Physical Therapy referral
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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 Adjustment
Reduction 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 Hypotension
Reduce medications that contribute
 Teach patients to change position slowly
 Consider liberalizing salt intake
 Encourage adequate hydration
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Environmental Hazard Modification
This may be done as part of the Physical Therapy
referral or as a separate Home Health Evaluation
 Aging in place
 Hazards include
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Clutter
Electric cords
Slippery throw rugs and loose carpet
Poor lighting
Lack of stair rails
Lack of shower rails / grab bars
Proper shoes
Algorithm
Fall
reported in
last year
Single fall with
no injury
Brief Fall History
•Circumstances
•Medications
•Chronic conditions
•Mobility
•ETOH intake
Perform Timed Up & Go
test
ABNORMAL
2 or more falls,
1 fall with
injury
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
NORMAL
Consider recommending
exercise program
Intervention Options
Reference
Chang, T.T. and David A. Ganz. Quality
Indicators for Falls and Mobility
Problems in Vulnerable Elders. JAGS 55S327-S334, 2007.
•Gait, balance & exercise programs
•Medication modification
•Postural hypotension treatment
•Environmental hazard modification
•Cardiovascular disorder treatment
Case
79 y/o woman presents for f/u
 CHF, arthritis, depression, difficulty
sleeping
 Medications: antidepressant, diuretic,
ACE-I, Beta-Blocker. Also takes OTC
sleep and allergy meds
 Chronic conditions appear stable
 Daughter reports 2 falls in the past 6
months

Fall Risk Factors
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Based on findings of two or more
observational studies
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Arthritis
Depressive symptoms
Orthostasis
Use of four or more medications
Parkinson’s Disease
Fall Risk Factors
 Impairment
in
◦ Cognition
◦ Vision
◦ Balance and gait
◦ Muscle strength
Fall Risk Factors

Medication Classes shown to have
strongest link to an increased risk of
falling
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Serotonin-reuptake inhibitors
Tricyclic antidepressants
Neuroleptic agents
Benzodiazepines
Anticonvulsants
Class IA anti-arrhythmics
Summary

We 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 selfmanagement education