Gait and balance

Gait often slows by age 80, but disordered gait is not an inevitable consequence of aging. The increased prevalence of gait problems among the elderly reflects the higher frequency and severity of age-associated diseases, which can be classified according to the sensorimotor level that is affected.² As you observe the patient walking, look for slow gait speed—a risk factor for falls. Also note stride length and height, smoothness of gait, balance, and arm movement. Does the patient turn spasmodically or favor one side? Can the patient maintain his or her balance while standing and walking? Are knee or hip flexion contractures present? Does the patient shuffle or have poor posture? Parkinson's disease, marked by cogwheel rigidity, tremor, a masklike face, and shuffling gait, is an important cause of immobility in older people. Dizziness is also common, and since it may be caused by a variety of conditions, the patient should be referred to a neurologist if the etiology is not readily apparent.³

Neurologic

Loss of dopamine neurons (part of the natural aging process) can induce a Parkinson's-type gait—slow, stooped, and shuffling. Disorientation and impulsivity stemming from a frontal lobe disorder may cause falls directly or limit motor ability, which leads to falls. A fall or mobility evaluation in older patients should include the Mini-Mental State Examination.

Orthopedic

Footwear and foot conditions frequently implicated in falls include shoes with pointed toes, high-heeled shoes, long toenails, bunions, calluses, tendonitis, bursitis, deformities, foot pain, and impaired ankle flexibility.⁴ Appropriate footwear depends on the patient's foot structure, as well as the activities in which the patient engages. All toes should be flat on the ground when the patient steps down. Orthopedic shoes may be necessary for people whose feet are pronated or supinated.

Vision and hearing

Annual vision and hearing checks are vital to preventing falls in older people. Removal of cataracts and adjustment of an eyeglass prescription may be all that is needed to reduce risk. Be alert for vestibular impairments, such as Meniere's disease, that impair balance. Loss of hearing, medications that affect the inner ear, or even a benign inner ear infection may also cause falls.

Benign paroxysmal positioned vertigo (BPPV) is common but treatable in older adults. It is identified through careful history-taking and the Dix-Hallpike maneuver. Physical therapists who specialize in balance and vestibular rehabilitation routinely perform this test if the history is indicative of BPPV.

Aging eyes do not adapt quickly to changes in lighting. In addition, diminished contrast sensitivity may develop, rendering older patients unable to distinguish different patterns, on rugs for example, or to locate the edge of stairs or curbs. Concomitant disease, such as diabetes, may also affect vision. Balance training, as well as widening the base of support with orthopedic shoes, a single point cane, or a walker may benefit vision-impaired patients. Patients with diminished contrast sensitivity should be advised to put brightly colored tape on the edges of any steps in their home and night lights in hallways and the bathroom.

INTERVENTIONS TO PREVENT FALLS

Strategies proven to reduce the risk of falls in older adults include treating underlying diseases and risk factors associated with falls and establishing an exercise program to improve strength, balance, gait, and flexibility. All medications should be reviewed and their use minimized when possible. Psychotropic agents, antianxiolytics, antidepressants, class IA an-tiarrhythmics, digoxin (Digitek, Lanoxicaps, Lanoxin), and diuretics are some of the medications that increase the risk of falls.

The American Geriatric Society guidelines suggest educating patients about the appropriate use of assistive devices, treating postural hypotension and cardiovascular disorders, and advising patients to modify their surroundings at home so they are less likely to fall.¹ When it has been determined that a patient is at high risk for falls, a physician, visiting nurse, or physical therapist should also assess the patient's home for hazards, such as poor lighting, cluttered rooms, sliding rugs, and exposed electrical cords. Alternatively, you can provide the patient with the CDC's home safety checklist (available at http://www.cdc.gov/ncipc/falls/) to be completed at home and returned on a follow-up visit.

Exercise: "Start low and go slow"

With their vulnerability to chronic disease and deconditioning, no segment of the population can benefit from exercise more than elderly adults. Exercise delays disability, ameliorates diseases, and fortifies strength, balance, flexibility, and endurance in older patients who are frail or have conditions such as osteoarthritis.^5-8 An ideal program should target strength, balance, and flexibility, unless specific activities are contraindicated. Training with a physical therapist is recommended for patients with overt risk factors for falls.

Before an older patient starts an unmonitored exercise program, all cardiac contraindications should be ruled out.⁹ These include: MI within 6 months, angina, physical signs and symptoms of congestive heart failure, a resting systolic BP (SBP) of 200 mm Hg or higher, or diastolic BP (DBP) of 110 mm Hg or higher.

In patients who have a sedentary lifestyle or severe neuromuscular problems, the program should begin with low-intensity activities and gradually intensify. Since aging is associated with increased muscle stiffness and reduced connective tissue elasticity, patients must warm up before exercise and cool down afterwards (5-10 minutes of slow stretching for each) to reduce the risk of injury.¹⁰

The goal is to perform at least 3 sets of 8 to 12 repetitions with a 1- to 2-minute rest between sets, preferably at a load that is 70% to 80% of a 1-minute maximum (the heaviest load a person can lift through a full ROM once).¹¹ Patients who are exercising on their own should be instructed in proper techniques and, depending on the type of exercise, should be supervised by you, your staff, or a physical therapist occasionally.

Aerobic training Aerobic exercise has been shown to improve overall health and diminish the pain and disability associated with knee osteoarthritis in older adults.^8,11 However, conditions that are common in the frail elderly, including severe gait disorders, arthritis, and visual impairment, may make even walking impossible. Therefore, muscle strength, joint stability, and balance must be improved before aerobic conditioning is attempted.¹²

Balance training Optimal balance exercises incorporate activities that are designed to improve the multiple systems that contribute to balance and functional mobility. Dynamic balance activities that incorporate standing weight shifts, walking with directional changes, circle turns, and standing on heels, toes, or in tandem, improve overall motor coordination. When people with vision impairment perform these activities on a variety of firm and altered surfaces, they can reduce their reliance on vision for balance. Training and supervision are mandatory for safety and progress in balance training.¹²

A large, controlled trial sponsored by the National Institute of Aging showed a substantial reduction in falls among patients aged 70 and older who practiced tai chi chuan, a martial arts form emphasizing slow, fluid, and precise movements.¹³ This cost-effective activity is also believed to reduce BP, improve balance and strength, and reduce pain and debility. Tai chi chuan has no adverse effects, so it is an ideal discipline for patients with osteoarthritis or rheumatoid arthritis who risk swollen joints or further bone deterioration from other forms of exercise.

Endurance training Patients without cardiovascular disease who are unable to walk for 15 minutes are more likely to lack endurance than the biomechanical strength to move their legs. Instruct patients who are deconditioned and need to improve their walking distance to repeatedly perform partial or full stands from a sitting position until they feel fatigued. This exercise works well in older adults who are starting to have some mobility limitations. After this exercise is mastered, strength building can begin. Partial stands are recommended for patients with severe lower body weakness and imbalance. Marching in place for 1 to 2 minutes while holding onto a chair for support is another alternative for patients with moderate balance problems.

Resistance training Weakness and loss of muscle mass are prominent deficits in older people. Improved muscle strength can enhance the performance of activities such as climbing stairs, carrying packages, and even walking. People with a severe impairment such as paralysis of a limb, spinal cord injury, or a broken hip that never healed properly may always lack sufficient threshold strength to perform certain tasks. Weight-bearing exercises are beneficial, however, in patients with lower body weakness, slow gait, or the onset of osteoporosis. Muscles can be overloaded with elastic tubing, light ankle weights, or weighted vests.⁹ Most patients will see a dramatic improvement in pain-free ROM, muscle strength and mass, and bone density after a few months of resistance training.

Before the patient moves on to a program of moderate intensity, monitor BP and heart rate. Poor candidates for a moderate exercise program include older patients who have an abnormal cardiac response (decrease in SBP of 20 mm Hg or more; increase in SBP to 250 mm Hg or higher or in DBP to 120 mm Hg or higher; or repeated increases in heart rate of 90% or higher of age-specific maximum).⁹ If possible, increase the amount of weight lifted every 2 to 3 weeks as strength increases.

When pain and stiffness interfere

Pain and stiffness can be caused by an injury, an overly intense regimen, or an underlying disease. Most patients who are about to embark on an exercise program should be prepared for muscle aches that will subside as the body becomes acclimated to the routine. If the aches do not resolve, however, determine the cause. You may need to decrease the intensity of the program but encourage as much exercise as possible within a nonpainful range of movement. Or the patient may need to discontinue the exercise, rest the affected joint, and see a physical therapist. Water therapy is another approach. The patient can continue resistance activities but with less stress on the joints. It also allows the patient to practice techniques, such as reaching forward, that may lead to falls on land.

Some people have chronic pain due to their underlying disease. Intense exercise is not recommended in patients with severe pain from advanced osteoarthritis. However, sometimes simply wrapping the knee with an elastic bandage may substantially decrease the pain of osteoarthritis by stimulating the nerve fibers around the knee, thereby increasing proprioception. If the patient has fluid in the knee, aspirate it. Injecting cortisone is a controversial treatment because it merely masks symptoms while allowing for greater movement and thus, faster joint destruction.

Motivating older patients to exercise

Addressing patients' concerns about exercise is the first step toward motivating them to engage in physical activity. Do they think it will be too painful? Is their neighborhood unsafe? Do they feel incapable of exercise? Starting slowly with low-intensity exercise a couple of days per week is an attainable goal. Gradually increase the patient's exercise regimen in frequency and intensity to at least 30 minutes of moderate physical activity each day.

Pedometers may also be useful motivational devices, because patients can see how many steps they accumulate during their daily activities. A minimum of 10,000 steps per day meets the guidelines set by the American College of Sports Medicine and the CDC.¹⁴

If the neighborhood is unsafe, encourage the patient to find a nearby shopping mall, many of which open early to accommodate walkers. A number of exercises can also be performed at home, without expensive equipment. Sometimes, writing a prescription for exercise emphasizes its importance and therapeutic value.

Increasing patients' awareness of their sedentary behavior may motivate them to exercise, as well. Patients are often surprised at how much time they spend sitting or lying down. Decreasing sedentary activities sometimes increases physical activity.

Discussing a variety of exercises may help determine what the patient enjoys and thus, what he or she is most likely to adhere to in the long-term. Some patients may prefer exercise with an element of socialization, such as a tai chi chuan class. Others may like to exercise outdoors. Patients who enjoy solitude are more inclined to work out at home, with either exercise equipment such as a bike or treadmill, or an aerobics videotape.

Any exercise is better than none, as long as it is properly executed and unlikely to cause further deterioration to preexisting injuries and conditions. Minor lifestyle modifications such as taking the stairs instead of the elevator offer patients easy ways to improve their health and should be praised. The power of the physician's encouragement should not be underestimated.

This article was written by Stacy DiLoreto and reviewed by Dr Alexander.

Dr Alexander discloses that he has no financial relationship with any manufacturer in this area of medicine.

REFERENCES

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