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Landon Center on Aging
Landon Center on Aging  :  Geriatric Education & Training

Mobility Gait Falls

Instructor: Mary McDonald, MD
Reviewed by: Doug Woolley, MD, MPH

 

Specific Learning Objectives:

A. Introduction

Before reviewing the learning objectives and content, please take the following Pre-Test. You must do this before you can proceed with the module. The answers are given in the Post-Test that complete the module.

Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.

B. Attitudes

The student will appreciate the influence of mobility limitations and instability on the ability of older adults to remain independent and to carry out normal functions in the community and in the home. They will understand the role of the physician in identifying and managing these conditions as well as the physician's role in engaging use of rehabilitation and home health services and environmental modifications.

C. Knowledge:

  1. Impact and Prevalence of Falls
  2. Postural Control Theory
  3. Risk Factors
  4. Clinical Approach to Gait Instability and Falls
  5. Post-Fall Assessment
  6. Management Approach
  7. Assistive Technology and Protective Attire

D. Readings

Required Readings:

  • Vu, MQ, Weintraub, N, Rubenstein, LZ. Falls in the nursing home: Are they preventable? J Am Med Dir Assoc 2005 May-Jun; 6(3 suppl):S82.7.
  • Bateni, H, Maki, BE. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med Rehabil. 2005 Jan;86(1):134-45.

Recommended Readings:

  • Daal, JO, van Lieshout, JJ. Falls and medications in the elderly. Neth J Med. 2005 Mar;63(3):91-6.
  • Redford, JB: Assistive Devices. Prevention/Rehabilitation in Geriatric Practice. In Practice of Geriatrics (3rd ed). EH Duthie & PR Katz, WB Saunders Co: Philadelphia, PA. 1998;17(3):173-186.
  • Studenski S, Wolter, L: Instability and Falls. Syndromes in Geriatric Practice. In Practice of Geriatrics (3rd ed). EH Duthie & PR Katz, WB Saunders Co: Philadelphia, PA. 1998; 19(4):199-206.

E. Skills - Students will be able to:

  1. Perform screening assessment of mobility status.
  2. Perform and interpret a test of the righting reflex.

F. Cases

 

1. IMPACT AND PREVALENCE OF FALLS

  • Impact of Impaired Mobility, Gait, and Falls
    • Significant cause of injury, loss of function and mortality
    • A marker for functional decline and morbidity
    • Increased risk for greater all-cause health care costs

  • Prevalence and Consequences of Falls
    • One-third of community dwelling elders and one-half of nursing home residents fall each year
    • Falls are the leading cause of accidental death in older persons
    • Although most falls do not result in injury 1% of those who fall fracture a hip, 5% sustain another fracture, 5% incur a serious soft tissue injury, and 2% are hospitalized

  • Epidemiology of Hip Fractures
    • Hip fracture is a leading cause of morbidity and mortality
    • 200,000 hip fractures occur each year
    • About 20% of hip fracture victims die within 6 months
    • Another 20% are admitted to nursing homes
    • Hip fracture results in a 10-15% decrease in life expectancy
    • Hip fracture costs are higher than $1 billion annually

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2. POSTURAL CONTROL THEORY

  • Balance
    • Static vs. Dynamic postural control
      • Static Postural Control: the ability to remain upright standing
      • Dynamic Postural Control: the ability to remain upright in motion. This is achieved by continually controlling the displacement of the body’s center-of-mass over a moving base of support.
      • The mass is usually a tall narrow column in the upright human
      • The base-of-support is often the area between the two feet
      • This biomechanical task adapts to constantly changing conditions (standing vs. walking)

  • Postural Control System (physiologic: intrinsic factors)
    • System organization
      • organizes the biomechanical tasks of standing and walking (sometimes called "controlled falling")
      • uses multiple sensory inputs to continually determine the body's position and movement
      • uses a central nervous system to integrate the sensory information and organized rapid responses
      • uses effector systems such as muscles and joints to carry out the instructions from the central nervous system

  • Postural Control System Components
    • Three Sensory Systems
      • Vision
      • Somatosensation
      • Vestibular function
    • Central Nervous System
      • Global level of consciousness/cerebral perfusion
      • Attention/response time
      • Automatic postural response (long loop reflex)
    • Effector Components
      • Strength
      • Joint flexibility
      • Endurance

  • Failures of Postural Control
    • The postural control system has redundancies and back-up adaptive mechanisms
    • Failure of postural control may occur when:
      • the demands of the biomechanical task overwhelm the system
      • a critical element of the system fails
      • the adaptive back-up systems are gradually depleted through multiple accumulating deficits
    • Balance problems and falls almost always lead to fear of falling and a cycle of reduced activity, deconditioning and muscle weakness
    • Deconditioning has been proven to be remarkably reversible even in very old people who can increase their strength and endurance with targeted activity programs
      • This makes the effector system the most commonly affected and treatable factor in falls
      • A physical therapy program including lower extremity strengthening is almost always useful.

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3. RISK FACTORS

  • FEAT: A Structured Approach to Falls

    1. Functional abilities:
      The individual's capacity for specific movement or tasks

      • Frail people meet criteria for "disordered walking"
        • Use an assistive device, or
        • Take steps that are shorter than twice the length of the foot
        • Have the highest risk for falls, and more likely to have falls indoors
        • Instability may result in fear of falling, social isolation, dependency

      • Vigorous persons
        • Can walk heel-to-toe
        • Descend steps step-over-step
        • Are least likely to fall, but impact force of a fall is more likely higher

      • Transitional people function midway between Vigorous and Frail people
        • Often have difficulty rising from chairs
        • Often users of canes and walkers
        • Highest risk for falls and reduced functional abilities
        • Mobility assessment tests:
          • "Get Up and Go" test
          • Tinetti Scale
          • Berg Scale

    2. Environmental context (extrinsic factors)
      • Assesses the interaction between an organism and the environment
        (extrinsic factors)

      Rugs

      Distant bathroom, bed, or telephone

      Worn rugs

      Low or unstable furniture

      Loose cords

      Ill-fitting shoes

      Clutter

      Slippery surfaces

      Poor lighting

      Stair treads

      Uneven stairs

      Pets

      Cracked sidewalks

    3. Acute Toxic and Metabolic Stressors
      • Generally not found in people with a longstanding problem with falls
      • Feeling "weak and dizzy" may be the result of:
        • Infection
        • Dehydration
        • Blood loss
        • Electrolyte imbalance
        • Hypoxemia
        • Other acute illness

    4. Threats to Postural Control
      • Sensory
        • Visual Visual deficits (acuity, depth perception, visual fields, dark adaptation)
        • Proprioception
        • Vestibular deficits
          • Semicircular canals (sensations of acceleration)
          • Utricle and saccule (gravitational sensation that determines the vertical upright position)
        • Peripheral sensory deficits (Peripheral Neuropathy)
          • Very common, may be asymptomatic, and often not assessed on medical exam
          • Leads to difficulty in determining the position of the foot and ankle
          • Limits detection of irregularities in the terrain
          • Reduces the ability to detect sway
        • Multiple sensory deficits
          • Especially likely to produce a disequilibrium syndrome

      • Central Processing
        • Coordinates movements smoothly and efficiently
        • Organization and speed of postural responses can be impaired by:
          • Parkinson's disease
          • Cerebrovascular disease
          • Cerebellar syndromes
          • Normal pressure hydrocephalus
          • Spinal cord lesions
          • Dementias (impaired judgment and attention, deconditioning)
          • Medications (sedation, delayed response time, orthostasis, extrapyramidal side effects)
          • Reduced cerebral perfusion (arrhythmias, valvular lesions)

      • Effector
        • Effector components include:
          • Muscle strength
          • Joint flexibility
          • Endurance
        • Effectors may be impaired by:
          • Aging
          • Disease
          • Disuse
          • Foot problems (bunions, hammertoes, elongated nails, improper footwear)

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4. CLINICAL APPROACH TO GAIT INSTABILITY AND FALLS

  • General Considerations
    • The older adult with instability or falls may not actively bring these problems to the physician's attention
    • All health care providers should consider screening their older patients briefly and periodically for both falls and instability

  • Screening
    • Falls, Gait Instability, and Fear of Falling
      • Inquire about falls, gait instability, and fear of falling
        • Identify if falling is new, has changed recently (within weeks to months), or is of long standing
        • In the absence of falling, ask about fear of falling, or restrictions of activity due to lack of confidence
        • Acquire a general feeling for the functional level of the individual while watching the older adult enter the examination room or move from the chair to the examination table

    • Environmental Context
      • Inquire about the environmental context - Falls history should be task and environment specific and in the context of balance competency
        • For patients who have fallen, identify the setting and activity at the time of the fall
        • In the absence of falls, inquire about the kinds of environments the person avoids or enters only with the assistance of another person or device
        • Match the functional capacity with the environmental context
        • Falls in a person with vigorous function and minimal environmental challenge indicate the presence of transient medical events or perhaps psychological issues
        • Similarly, a vigorous individual who restricts activity and avoids environments unnecessarily may benefit from reassurance

    • Change in Pattern of Falls/Gait Instability
      • Seek whether there is a recent onset or a change in the patter of falls/gait instability - Higher risk of toxic or metabolic causes
        • Complete a physical examination to identify more acute medical problems
          • Dehydration
          • Infection
          • Cardiopulmonary abnormalities
          • Neuromuscular abnormalities
        • Consider brief screening tests for toxic and metabolic stressors
          • Electrolyte imbalance
          • Hypoxia

  • Assess All Components of Postural Control
    • Sensory Elements

    Identify threats to sensory elements of postural control

    History Physical Examination
    1. Vision
    • Eye wear
    • Peripheral vision
    • Visual acuity
    • Dark adaptation
    		1.  Vision
    • Visual acuity, distance testing
    • Peripheral vision, field cuts
    • Depth perception
    • Dark adaptation
    2. Somatosensation
    • Numbness
    • Disequilibrium syndrome
    		2. Somatosensation
    • Peripheral sensory testing
    • Rhomberg & vibratory testing
    3. Vestibular function
    • Vertigo
    		3. Vestibular function
    • Nystagmus
    • Hallpike maneuver
    • Marching in place
    • Benign positional vertigo
    • Meniere's disease
    • Chronic vestibular
    • Central Processing

    Identify threats to central processing of postural control

    • Global level of consciousness/cerebral perfusion
    • Attention/response time
    • Autonomic postural response
    • Central postural responses can be tested directly in the clinical setting by performing a righting test
    • Further neurological examination is needed to detect specific conditions associated with poor postural responses such as:
      • Parkinson's disease
      • Dementia (Alzheimer's, multi infarct syndromes)
      • Normal pressure hydrocephalus
      • Spinal cord syndromes (cervical and lumbar stenosis)
      • Medications (delayed reaction time, sedation, decreased cerebral perfusion, or extrapyramidal effects)
      • Cardiovascular causes (decreased cerebral perfusion, orthostasis, arrhythmias, valvular lesions)
    • Effector Components
      • Assess:
        • Muscle strength
        • Joints flexibility, alignment, and symmetry
        • Endurance

  • Assessment of Physical Function/Balance Competency
    • Basic Level
      • Step length at least twice foot length
      • Walks without assistive device
      • Rises from chair without using arms
    • High Level
      • Tandem walks at least four to five steps
      • Descends stairs step over step
    • Categories
      • Frail: Fails basic level
      • Transitional: Passes basic level, fails high level
      • Vigorous: Passes basic and high level

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5. POST FALL ASSESSMENT

  1. History
  • Peri-fall symptoms
  • Predisposing and environmental risk factors for falls
  • Medical conditions, prior falls
  • Medications, especially new and high risk medications
  1. General Approach: Physical Exam
  • Vital signs: temperature, orthostatic blood pressure, pulse
  • Visual loss, visual fields
  • Cardiovascular: Arrhythmia, murmur
  • Neurologic: dementia, focal deficits, weakness, gait, rigidity, cerebellar signs, peripheral neuropathy, tremor
  • Muscoloskeletal: injuries, arthritic changes, flexibility, range of motion, feet and shoes
  1. Specific Testing
  • Somatosensation
    • Vibratory sensation and Rhomberg must be tested
    • Muscle Spindle more sensitive than Joint Receptors
    • Light Touch and Pressure Sensation on Plantar Aspect of feet must be tested

  • Vestibular Function
    • Vertigo
    • Nystagmus

  • Central Nervous System
    • Perfusion - Assess for orthostasis and presyncope/syncope and their possible causes. Cardiac causes common.
    • Slowed Responses - May have no signs or symptoms. Assess for deceased alertness through deceased foot tapping, mental tasks, and/or righting reflex. Medications that cause sedation or slowed reactions, i.e., benzodiazepines or anticholinergics

  • Effector
    • Muscle Strength - test lower extremity strength through screening; i.e., getting up from a chair without use of their upper extremities or rising to their toes
  1. Diagnostic Testing

    Because falls have a heterogeneous origin, both diagnostic tests and management plans must be individually tailored based on the clinical information obtained. It should be noted that up to 95% of all fall diagnoses are determined from the history and physical examination alone.

  2. Laboratory Studies
  • Should be guided by the results of the history and physical exam
  • Consider:
    • Chemistry profile, complete blood count, oxygen saturation
    • Urinalysis
  • In selected patients:
    • Electrocardiogram, chest radiograph
    • Drug levels
    • Holter monitor, event monitor, echocardiogram
    • An imaging study or EMG may be helpful if there are focal neurological findings
    • A home evaluation to assess the environmental hazards and directly observe the patient's performance of ADLs and IADLs can be quite revealing

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  1. Environmental Modifications and Home Safety Checklist to Reduce Fall Risk
  • Flooring
    • Secure rugs (nonskid backing) and carpets (tack down, no tears)
    • Remove clutter and obstacles from stairs, hallways
    • Keep cords out of traffic areas
    • Use nonskid wax

  • Access
    • Store frequently used items within reach
    • Repair unstable railings and other handholds
    • Provide handrails the full length of the stairway

  • Proper footwear
    • Shoes with firm nonskid soles and low heels
    • Avoid footies and slippers

  • Lighting
    • Ensure adequate lighting, especially on stairways
    • Check for light switches near doorways, bed
    • Provide night lights for bathroom, stairway, etc.

  • Bathroom
    • Install grab bars for tub, toilet
    • Place rubber mat or decals in tub or shower
    • A bedside commode or urinal may decrease risk for patients with nocturia or significantly impaired gait/balance.

  • Outdoors
    • Be sure sidewalks and driveway are free of cracks or breaks
    • Examine lawn and garden for holes, rocks, loose boards, etc.
    • Keep walkways free of leaves, snow, ice, etc.

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6. MANAGEMENT APPROACH

  1. Individualized Multidisciplinary Modifications

    Given the multifactorial causes of falls, management strategies must be multifaceted and comprehensive, yet individualized. The goal is to maximize function and independence while minimizing injury. A multidisciplinary approach engages various personnel to address the disability. This may involve treating reversible disease, modifying impairments, and adapting to fixed disabilities.

  2. Specific Identifications and Treatments
  • Reverse: Toxic or metabolic factors. Rare to have single treatable condition.
  • Adapt
    • Friendly Environment
    • Human help
    • Assistive devices
      • Increasing the base of support of the assistive device increases stability
        • Increases inconvenience and problems with maneuverability
  • Modify
    • Vision: deficits may be helped with corrective lenses/ prisms
    • Vestibular disorders: medications (meclizine) and rehabilitation (desensitization training)
    • Central disorders ( ie , Parkinson’s disease ): medications and rehabilitation
    • Effector : rehabilitation and exercise
  1. Additional Interventions to Reduce Fall Risk
  • Medications
    • Eliminate unnecessary medications
    • Eliminate or reduce high risk medications where possible
    • Consider contribution of over-the-counter medications, ETOH
    • Treat untreated or uncontrolled medical conditions
  • Physical Therapy
    • Mobility, strengthening, gait training, endurance , balance, low impact resistive exercises, tai chi, water exercises, formal weight training, Theraband
    • Assistive devices, hip protectors

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7. ASSISTIVE TECHNOLOGY AND PROTECTIVE ATTIRE

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F. CASES

Case Study #1
Mr. R., age 78

Mrs. R is a 78 year old female who comes to the clinic with complaint of falls.  She has had 4 falls in the last month.  Other than some bruising, she has not been injured by these falls.  She lives in her own home by herself and does not socialize with family or neighbors as she feels judged by them.  She knows that her family is distressed about the current state of clutter in her home and that she takes in many stray animals.  She states that her falls typically occur during the night or early in the morning when she gets up to use the bathroom.  She denies any loss of consciousness or palpitations related to these falls although she sometimes feels dizzy upon standing.  Due to fear of falling, Mrs. H has become increasingly sedentary over the last month.

Gait exam

Medications:

  • nitroglycerin patch 0.4 mg TD qd for coronary artery disease
  • KCl 20 mEq daily for replacement
  • Lasix 40 mg daily as her “water pill”
  • Multivitamin daily
  • Tylenol PM every night to help her sleep
  • HCTZ 25 mg daily for hypertension
  • Hydrocodone/Acetaminophen 5/500 1-2 ever 6 hours as needed for arthritis pain
  • Glipizide 5mg daily for diabetes
  • Gabapentin 200mg three times daily for neuropathic pain in feet
  • Colace daily

PMH
DM II
CHF
CAD
Insomnia
Neuropathic pain in feet
Osteoarthritis of knees and hips.
Bilateral cataracts

Review of Systems:

  • Gen: No fevers, night sweats, chills, weight loss, malaise
  • Sensory: Loss of sensation and stabbing pains in feet, decreased vision, hearing intact
  • Cardiovascular: No chest pains, palpitations, orthopnea, PND or leg swelling
  • Pulm: No cough or dyspnea on exertion
  • GI: No heartburn, dyspepsia, constipation, dysphagia
  • GU: Some urinary urgency, +nocturia 2-3 times a night, No dysuria or gross hematuria
  • Psych: Denies any depressive symptoms
  • Endocrine: No heat or cold intolerance, +frequent urination

Questions:

  1. List at least 10 possible contributing factors related to Mrs. R’s falls
  2. Describe modifications that can be initiated to help reduce the risk of falls for Mrs. R based on your list above.


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Case Study #2
Mr. M., age 78

Mr. M is a 78 year old retired married petroleum engineer who lives in a retirement community with his ailing wife for whom he provides supervision and assistance. He describes four falls in the last few months. All occur suddenly and unexpectedly. He never loses consciousness or feels dizzy and can tell when he is starting to fall but can't stop himself. All falls have occurred on level ground without any obstacles. He says he just suddenly "goes over". In three of the four falls, he fell backwards. He has had no injuries. He has otherwise been quite well and takes only one aspirin a day.

Physical exam reveals a quiet gentleman with little facial expression. His blood pressure is 120/80 sitting, 96/60 standing, pulse 72. His vision is excellent with his current correction and his hearing is good. His cardiac and pulmonary exams are unremarkable. Folstein is 30/30. His cranial nerve exam shows loss of upward gaze. Strength is 5/5 through out. Sensory exam is normal. Deep tendon reflexes are two plus and symmetric including ankle jerks. Tone shows subtle cog wheeling accentuated by contra lateral motor activity. There is no resting tremor. Romberg is negative. Righting reflex is absent. Gait shows step length twice foot length with a width under 6 inches, and symmetric steps. There is no arm swing and neck and head appear forward flexed. He cannot tandem walk or stand on one foot for ten seconds. He is able to rise from a chair without using his arms.

Questions:

  1. Is his overall mobility level high, transitional or frail?
  2. Review the components of postural control and describe abnormalities shown in this case.
  3. What can you tell about his static and dynamic balance?
  4. What diagnostic and therapeutic options should you consider?


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Case Study #3
Mrs. H., age 88

Mrs. H is an 88 year old, widowed, retired English teacher, who lives alone in her own home. She no longer drives because of low vision but is managing to get by with the help of neighbors and friends. She comes to clinic complaining of "feeling unsteady". She is not able to garden or go for walks because she feels "unsure of herself". She has had no falls. She has been having trouble sleeping because of burning in her feet especially at night.

She has a history of non insulin requiring diabetes for the last 10 years managed with glipizide 10 mg. daily. She also has history of coronary artery disease and uses a nitropatch at 0.4 mg/hour.

On physical exam her blood pressure is 110/70, pulse is 84 and regular. Her vision is very compromised by central scotoma from macular degeneration; she can read large print words in her peripheral vision and must swing her head to see faces and the environment. Her lungs are clear and her cardiac exam is unremarkable. Pulses are normal at the carotids and radials. They are absent in the feet. There are no carotid bruits but there are bilateral femoral bruits. Cranial nerves are normal except for vision, there is no nystagmus. Deep tendon reflexes are two plus and symmetric at the biceps, triceps and knees. Ankle jerks are absent and plantar responses are down going. Sensory exam shows loss of vibration sense to the knees. Strength is 4 plus out of five throughout. Romberg is positive. She says she feels a little dizzy when she first stands up but things don't spin around. Righting reflexes shows multiple small steps to displacement. Finger to nose and rapid alternating movements are brisk and symmetric. Tone is normal, gait is slow and hesitant with step length about one foot length and step width is about one foot. Steps are symmetric. Her 180 degree turn is slow and stable, taking 6 steps. She is not able to rise from a chair without using her arms.

Questions:

  1. Is her overall mobility level high, transitional or frail?
  2. Review the components of postural control and describe abnormalities shown in this case. There are a few important pieces of information missing; what are they?
  3. What can you tell about her static and dynamic balance?

She is prescribed amitriptyline 50 mg q hs for peripheral neuropathy and insomnia.

She is seen in the emergency room 24 hours later for a wrist fracture associated with a fall. She has been very dizzy when she gets up and has been feeling very fuzzy headed. She fell down the front steps of her home going out for the mail this afternoon. She did not lose consciousness.

  1. What are the mechanisms by which amitriptyline could affect balance?
  2. What are some alternative approaches that could have been offered for her complaints?

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