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

• 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 fallsRisk factor Adjusted OR 95% CI Use of sedatives 28.3 3.4-239.4 Cognitive impairment 5.0 1.8-13.7 Lower ext disability 3.8 2.2-6.7 Palmomental reflex 3.0 1.5-6.1 Foot problems 1.8 1.0-3.1 Balance/gait abnormal

0-2 1.0 3-5 1.4 0.7-2.8 6-7 1.9 1.0-3.7

From: Tinetti 1988

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 sitePrimary diagnosis Neurology Primary CareFrontal gait disorder

NPH, Multiinfarct20-28 0

Sensory imbalancePeriph neurop

4-18 9

Myelopathy 16-24 0Parkinsonism 10-12 9Cerebellar atrophy 8 0Toxic encephalopathy 2-6 0Other 14-16 80

DJD, Gout 4 44Orthostasis 2 9Senile gait 6-14 3

Single Dx-Combined Dx 56-28 NA-75

Gait disorder classificationSensorimotor 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 (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

Subclincaldisablity

2.0 0.9 335 7.2 2.5 Household, 1/4mile walk

Subclinicaldisability

2.5 1.15 414 5.75 3.0 Carry bag, liteyard work

Usualhealthy

3-3.5 1.4-1.6 500-580 4.0-4.75 4.0 Mod-heavyhousework,carry loads,multiple stairs

Fit 4.0 1.8+ 660+ 3.5 >4.0 Heavy work,sports

(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

Measure Positive Outcome Negative Outcome

Number of falls in last 6 months

One fall or less in last 6 months

2 falls=> Do full eval

Romberg (Eyes open or closed)

EC, sensory (vestib/position OK)

EC: sensory prob EO: lots problem

One leg stance >30 sec no balance problem

<5 sec balance problem

Gait inspection Looks normal Looks abnormal=> Do full eval

TUG <12 sec fast pace= community normal

14s, esp >20s=> Do full eval

Screening

Follow-up, exercise, and rehabilitation outcomesTUG, Gait speed, 6MW, POMA? BBS? SPPB?

Divided Attention Test Predicts Falls

Verghese 2002

Test

Result Sensitivity Specificity +PV OR (CI) p

Tinetti

Bal ≤10

62 70 36 3.5 (1.01-13) 0.06

WTW

≥ 20 s

38 85 42 4.3 (1.05-18) 0.06

WTW-S

≥ 20 s

46 89 55 7.02 (1.7-29) 0.01

WTW-C

≥ 33 s

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)

Cognitive Predictors of Obstacle Avoidance in Healthy Older Adults

Test Factor Tested Coeff P value

WI Card Sort Perseveration

Decisions Flexibility

-0.54 <0.004

Stroop Interference

Attention Inhibit responses

0.41 <0.008

Test Anxiety Anxiety during experiment

0.38 <0.01

TOVA Variability

Attention consistency

-0.35 <0.02

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

20

40

60

80

100

120

140

160

180

200

WT-NS WT-A WT-B

Co

mp

leti

on

Tim

e

NC MCI- MCI+ AD

* Mean ±SEM covaried for age and usual gait speed (in Persad et al 2006)

Executive Control

Affect and SelfEfficacy

(e.g. depression)

Basic CognitiveFunction

(e.g. memory)

Physiological Capacities

(e.g. balance)

Balance and gait + increasedcognitive demand

Figure 1. Proposed model of balance and gait under conditions ofIncreased cognitive demand

Lab workup: as directed by H+P

Test Suspected disorderBloods (Chemistries,

CBC)Fluid, electrolyte and

glucose disorders,anemia, sepsis

EKG, 24-hour cardiacmonitor, echo,cardiac enzymes

Arrhythmia, valvulardisease, ischemia

Spine x-ray, MRI MyelopathyHead CT, MRI Infarct, space-

occupying lesion

Interventions: medical, therapy

Factor Intervention Consult Balance/gait

disorder, weakness, joint pain

PT: exercise, modalities, assistive device use and training

Neuro Rheum Ortho

Dizziness PT: habituation ENT Cognitive loss Eval for reversible

causes, provide supervision

Neurol, Neuropsych

Foot problem Podiatry Footwear Eval support, sole

‘

*Treat underlying diseases *

Interventions: medical, therapy (2)

Factor Intervention Consult Vision Lens correction, low

vision aids, d/c bi or tri focals

Ophthy

Osteoporosis Calcium, Vit D, other meds, exercise

Low BMI Wt loss eval (incl depression), supplements

Dietician

Medications Eliminate, lower dose, short acting

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 referralsFortinsky, 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 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 nalexand@umich.edu

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

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

78

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)

DependentVariable

RegressionCoefficient (SE)

Corresponding ratioCBST 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