Mobility and Gait – Evaluation and Management

1. Mobility and Gait – Evaluation and Management M. Kathy Wiley, MD, MS Cathryn Caton, MD, MS I’ve fallen and I can’t get up!

2. 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 self-management education

3. 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% • 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

4. 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

5. 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 • Psychological – Fall-related fear & loss of self-efficacy

6. Self-Efficacy • Beliefs in one’s capabilities to organize and execute the courses of action required to produce a given attainment • Influenced by • Having relevant skills • Past experiences • Observation of the experiences of others • Social persuasion including provider influence

7. 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

8. Algorithm Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury • Brief Fall History • Circumstances • Medications • Chronic conditions • Mobility • ETOH intake • 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 Perform Timed Up & Go test ABNORMAL NORMAL • Intervention Options • Gait, balance & exercise programs • Medication modification • Postural hypotension treatment • Environmental hazard modification • Cardiovascular disorder treatment Consider recommending exercise program Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

9. Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with 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 55-S327-S334, 2007.

10. History • 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)

11. Beers’ List

12. Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with 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 55-S327-S334, 2007.

13. 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

14. 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

15. Timed Up & Go Test • Average results are as follows • Age 60 – 69 7.24 seconds • Age 70 – 79 8.54 seconds

16. http://webituponline.com/aging/5.htm

17. Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury • Brief Fall History • Circumstances • Medications • Chronic conditions • Mobility • ETOH intake • 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 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 55-S327-S334, 2007.

18. Physical Exam • 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

19. Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury • Brief Fall History • Circumstances • Medications • Chronic conditions • Mobility • ETOH intake • 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 Perform Timed Up & Go test ABNORMAL NORMAL • Intervention Options • Gait, balance & exercise programs • Medication modification • Postural hypotension treatment • Environmental hazard modification • Cardiovascular disorder treatment Consider recommending exercise program Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

20. 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

21. Gait, balance & exercise programs • Physical Therapy referral • 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

22. 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

23. Postural Hypotension • Reduce medications that contribute • Teach patients to change position slowly • Consider liberalizing salt intake • Encourage adequate hydration

24. 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 • Clutter • Electric cords • Slippery throw rugs and loose carpet • Poor lighting • Lack of stair rails • Lack of shower rails / grab bars • Proper shoes

25. Algorithm Fall reported in last year Single fall with no injury 2 or more falls, 1 fall with injury • Brief Fall History • Circumstances • Medications • Chronic conditions • Mobility • ETOH intake • 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 Perform Timed Up & Go test ABNORMAL NORMAL • Intervention Options • Gait, balance & exercise programs • Medication modification • Postural hypotension treatment • Environmental hazard modification • Cardiovascular disorder treatment Consider recommending exercise program Reference Chang, T.T. and David A. Ganz. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS 55-S327-S334, 2007.

26. 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

27. Fall Risk Factors • Based on findings of two or more observational studies • Arthritis • Depressive symptoms • Orthostasis • Use of four or more medications • Parkinson’s Disease

28. Fall Risk Factors • Impairment in • Cognition • Vision • Balance and gait • Muscle strength

29. Fall Risk Factors • Medication Classes shown to have strongest link to an increased risk of falling • Serotonin-reuptake inhibitors • Tricyclic antidepressants • Neuroleptic agents • Benzodiazepines • Anticonvulsants • Class IA anti-arrhythmics

30. 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 self-management education