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
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Balance and Gait Disorders in Older Adults Neil Alexander MD University of Michigan VA Ann Arbor Health Care System GRECC Mobility Research Center (MRC),
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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
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
• 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
– 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
• 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
– 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
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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