Assessment of the Geriatric Patient: Gait and Balance

Mark E. Williams, MD; Angela Gentili, MD

Disclosures

November 16, 2009

In This Article

Balance and Gait Assessment After a Fall

Falls are a major health hazard. Seventy percent of fall-related deaths occur in old people. The annual prevalence for people over age 65 years is 30% to 60% in the community (4.5% of falls will result in serious injury), 150% in hospitals (1500/1000), and 165% in long-term care.[3,4] Functional deterioration after a fall is common

Factors Associated With Falling

Risk factors for falling are increasing age, having previous falls, muscle wasting, poor overall health, being on multiple medications, and having lower-extremity arthritis. Factors NOT associated with falls include alcohol ingestion, past vigorous physical activity, blood pressure (or postural) changes, the number of environmental hazards, living alone, or education level.[4] Although it intuitively seems as if factors such as alcohol ingestion, postural changes related to blood pressure, and number of environmental hazards would be associated with increased risk for falling, there are no data to support increased risk. This may be because elderly individuals adapt to these conditions.

Predisposing factors account for about 40% of falls. These factors include accidents (slips and trips) and environmental hazards such as walking surface, lighting, and obstacles.

Precipitating factors for falls are sentinels of illness. Conditions that can precipitate falls include acute illness; weakness, balance, and gait disorders; syncope and drop attacks; dizziness and vertigo; visual disturbances; and orthostatic hypotension.

The Table includes data from a number of studies related to injurious fall risks for both elderly people living in the community and for those living in institutions.

Table. Significant Risk Factors for Injurious Falls in Community Living and Institutionalized Older People

Risk Factors Community OR/RR
OR (confidence interval)
Institutionalized OR/RR
OR (confidence interval)
     
Demographic factors    
Increasing age   3.8 (P < .01) [5]
Female sex 2.1 (1.0-4.4) [6]
2.0 (0.6-6.6) [7]
1.8 (1.1-2.9) [8]
1.7 (1.4-2.1) [9]
 
Race (white) 18.4 for major injury [7]  
  2.0 for minor injury [7,8,9]  
     
History of maternal hip fracture 1.8 (1.2-2.7) [10]  
     
History of falling 6.7 [7]
1.4 (1.0-2.1) [10]
1.2 (1.07-1.33) [11]
6.8 (P < .005) [5]
     
Mental status    
Cognitive impairment 2.8 (1.7-4.1) [6]
2.2 (1.5-3.2) [8]
1.8 (1.2-2.8) [7]
7.5 [5]
     
Medications    
Psychoactive drugs 23.1 (2.9-182.2) [12]  
Anticonvulsants 2.0 (0.8-4.9) [10]  
Sedative/hypnotics 36.8 (P < .005) [5]  
Long-acting hypnotics and anxiolytics 1.9 (1.4-2.7) [13] 1.35 (1.09-1.68) [14]
Long-acting benzodiazepines 2.2 (0.9-5.38) [15]
1.6 (1.1-2.4) [10]
 
Tricyclic antidepressants 2.0 (1.1-3.4) [13]  
Antidepressants 2.2 (1.6-3.0) [13]
1.5 (1.03-2.1) [16]
 
Antipsychotics 1.9 (1.3-2.7) [13] 2.2 (1.6-3.0) [16]
1.31 (1.06-1.61) [14]
Nonsteroidal anti-inflammatory drugs 15.8 (P < .05) [5]  
Antihypertensives   4.0 (1.2-13.3) [5]
Digitalis 2.2 (0.87-5.67) [15]  
Calcium channel blockers 2.4 (1.3-4.47) [15]  
Vasodilators 5.0 (P = .05) [5]  
     
Functional Characteristics    
Being ambulatory   4.0 (P < .005) [5]
Activity limitation days 1.8 [17]  
>10 activities per week 2.0 [17]  
Slow hand reaction time 1.8 [7]  
Decreased grip strength 1.5 [7]  
Inability to rise from chair 1.7 (1.1-2.7) [10]  
Impaired balance and gait 3.5 (1.40-8.77) [15]
1.8 (1.3-2.7) [8]
1.4 [17]
 
Path deviation 2.3 (1.15-4.78) [15]  
Short step length 32.1 (2.35-43.8) [15]  
Slow walking speed   P = .0063 [5,16]
Use of assistive devices 15.8 (1.9-130.9) [18] 2.04 (1.04-3.0) [18]
1.7 (1.01-2.81) [5]
Absent quadriceps reflex 4.8 (1.15-19.6) [15]  
Reduced quadriceps strength   5.9 (1.15-30.7) [5,16]
Reduced iliopsoas strength 1.8 (0.96-3.32) [15]  
     
Coexisting Health Problems    
>/= 2 chronic conditions 2.0 (1.4-2.9) [8]  
> 1 fall risk factor   1.7-51.9 depending on combination [5]
Low body mass 1.8 (1.2-2.9) [6]
1.8 (1.2-2.5) [8]
 
Visual impairment 2.7 (1.1-7.0) [7]
2.17 (1.24-3.8) [19]
6.7 (1.33-33.4) [16]
4.5 (P < .05) [5]
Dizziness 2.0 [17] 1.7(1.07-2.57) [16]
Stroke 2.4 (1.3-4.5) [17]  
     
Environmental Factors    
Falling on stairs 2.0 (1.1-3.5) [6]  
Displacing activities 1.8 (1.0-3.0) [6]  
Place of residence   5.8 (1.4-23.8) [9]
0.6 (0.2-1.6) [20]

Sequelae of Falls

Often the impact of falling is minimal, as most falls do not result in injury. However, a major concern is the subsequent loss of confidence or fear of falling. A vicious cycle can be established beginning with loss of confidence, increased anxiety, limited excursions, social isolation, deconditioning, depression, further loss of confidence, increased unsteadiness, and so on

A major concern is sustaining a fall-related injury such as a soft tissue injury or a fracture. Approximately 3% to 6% of falls result in a fracture. Hip fractures are common. The hip fracture rate is 0.5% for individuals aged 65-69 years and 10% for those over age 85.[4] Arm fractures constitute roughly one third of fractures, rib fractures account for 20%, and vertebral, pelvic, and facial fractures comprise about 5% each.

Decreased bone density is a significant factor in fall-related injury. Bone mass is reduced by 25% to 30% in women over the life span and by 15% to 20% in men.[21] The formula for determining fracture likelihood is:

traumatic intensity x frequency / bone strength

Fracture Implications

For the clinician: The fall was probably severe, so look for other injuries.

For the patient: More than 50% of injured fallers are discharged to long-term care and more than 50% of these will remain there for the remainder of their lives.

Evaluation of the Elderly Person at the Site of a Fall: Key Issues

If you are called to see an elderly person who has just fallen, you have 2 fundamental questions that must be addressed: (1) Has the patient had a catastrophic event? (2) Has the patient sustained an injury? Search carefully for any evidence of myocardial infarction, pulmonary embolus, stroke, arrhythmia, hemorrhage, or any other acute catastrophe. Next, evaluate the extent of any injuries, such as fracture, internal injury, or soft tissue injury.

Basic observations:

  • Pay careful attention to the patient's level of consciousness, vital signs (especially respiratory rate, pulse and postural blood pressure, fever (or hypothermia), pallor, or ecchymoses. The cardiac evaluation may show arrhythmia, a new murmur, signs of aortic stenosis, or cardiac ischemia.

  • The extremities may show bony deformity, swelling or ecchymosis, pain on use or weight-bearing, and decreased range of motion.

  • If there is hip pain, inspect the leg. If it is foreshortened and externally rotated, consider fracture of the femoral neck (intertrochanteric fracture). If the leg is externally rotated but not foreshortened, consider fracture of the femoral shaft. If the thigh is externally rotated, flexed, and abducted, consider anterior dislocation. If the thigh is internally rotated and adducted with a very prominent greater trochanter, consider posterior dislocation.

Check for osteophony (bone sound) (Hueter's sign). Place the diaphragm of your stethoscope on the pubic symphysis. Gently percuss each kneecap with your forefinger. An intact bone will produce a clear, bright tapping sound. A hip fracture will give a muffled, distant sound. Other approaches include using a tuning fork on the patella or listening over each iliac crest as opposed to the pubic symphysis. Checking for osteophony is extremely helpful when evaluating patients during home visits or in the nursing home.

  • For any possible fracture, stabilize the extremity and check the neurovascular bundle distal to the probable fracture site.

  • Now perform a careful neurologic evaluation. Again, note the level of consciousness, mental function, focal neurologic signs, muscle strength, tone, adventitious movements, and cerebellar findings.

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