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

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. Perform Timed Up & Go test
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 – seconds
Age 70 – seconds

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

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