● Gait speed of ≥0.6 m/s to <1.0 m/s indicates that the person may have difficulty or limited ability to walk in the community and may be at increased risk of falls. ● Gait speed of <0.6 m/s indicates the person is severely impaired. It is likely the person is capable of only limited community or household walking, requires assistance with ADLs, and is at risk for hospitalization (Middleton, Fritz, & Lusardi, 2015). Certain health conditions such as arthritis can make the older adult less active and therefore subject to further deconditioning, which affects other mobility tasks such as transfers. Age-related reductions in muscle strength become accentuated when other comorbidities are apparent. Difficulty with tasks such as standing up after sitting in a chair often require that the older adult make use of the upper extremities. This task is tested specifically in the 5-Minute Sit-to-Stand test, which is also an element in the Modified Physical Performance test. Higher-level tasks such as standing up from the floor are often avoided in the less active older adult because the person may fear being unable to get up. A recent study attempted to use a standing-up-from-the- floor transfer task as a predictor of mortality. Although the results indicated that subjects who avoided this task had more weakness, they failed to establish that the task itself could serve as a predictor of mortality (De Brito et al., 2012). Several outcome tools are appropriate for the patient having activity limitations. The 10-Meter Walk Test (10MWT) is frequently used to assess gait speed (Fritz & Lusardi, 2009; Guralnik et al., 1994). Norms for gait speed are available by gender and age for community-dwelling older adults and for several different diagnoses. An individual’s gait speed can be determined by measuring his or her gait at either a comfortable pace or a fast pace. Usually the subject is given two trials that are then averaged. These values can be compared to normative data for older adults of the same gender and similar ages (Bohannon, 2009). The Berg Balance Scale (BBS) is a 14-item objective measure that was designed to assess static balance and fall risk in older adults. It has been studied with multiple populations and requires between 10 and 30 minutes to complete. Each item is rated 0 to 4, with a maximum score of 56. Researchers have found that older adults with scores lower than the 45 cutoff score are likely to fall (Fabre, Ellis, Kosma, & Wood, 2010). There are diagnosis- specific minimal clinically important differences available. The Dynamic Gait Index (DGI) assesses functional gait while changing the position of the head and stepping over obstacles, and includes eight items in total. The DGI has been studied extensively, especially with patients with vestibular disorders. Each item of the test is scored on a 0 to 3 scale, with a best possible score of 24. Subjects scoring 19 or lower are considered to be at risk for falls. An extension of the DGI, which includes three additional items, is called the Functional Gait Assessment (FGA). Walking in tandem, backward, and forward with eyes closed were added to the FGA, whereas walking around obstacles was eliminated. The scale’s highest score is 30. The FGA has been found to be a predictor of falls in people with scores lower than the cutoff of 22/30 (Wrisley & Kumar, 2010). The Four Square Step Test (4SST) is a test of dynamic balance that clinically assesses the person’s ability to step over objects forward, sideways, and backward (Dite & Temple, 2002). Four canes are placed to form a cross. Subjects can use assistive devices. Each trial is timed in seconds, and objective data are achieved that are responsive to change. Trials that take longer than 15 seconds indicate that the subject has increased falls risk (Dite & Temple, 2002). The Short Physical Performance Battery is available free online, as indicated in Appendix A. It assesses lower extremity functional muscle strength, balance, and gait speed (Guralnik et al., 2000).
● Assessing the correct depth of stairs. Decreases in vision and hearing are correlated to a decline in cognition (Lin, 2011). Auditory and visual sensory changes can be assessed by asking older adults about their hearing and vision. However, physical therapists should use their observation skills to determine the impact of sensory loss on function and safety. While specific auditory and vision testing is outside of the scope of physical therapy practice, physical therapists should be familiar with the specialists needed to measure and treat sensory losses and be prepared to work as a referral team. Changes in activity Changes in activity include balance and falls, gait, high-level mobility, and transfers. Despite its importance in preventing falls, the mechanism of change in balance for older adults is not well understood or as heavily researched as strength and endurance (ACSM et al., 2009). Falls are the leading reason for injury-caused deaths among older adults (National Council on Aging [NCOA], 2014). Balance is the ability to maintain control of the body over its base of support. Having adequate balance is important because it allows individuals to complete the many dynamic anticipated and reactionary movements associated with daily occupations and general participation in life (Sibley, Voth, Munce, Straus, & Jaglal, 2014). Good balance – including intact vision, proprioception, and vestibular functioning – allows individuals to anticipate the changing forces in their bodies while opening a heavy door, for example, or prevents them from falling when encountering an unexpected environmental change (Ceria-Ulep et al., 2010). Age-related decreases in strength, combined with reduced opportunities to challenge balance systems, can result in decreased functional performance for older adults. In addition, clinicians should consider chronic diseases such as hypertension and COPD that put an older adult at higher risk for falls as particular “red flags” for fall risk. The literature shows that older adults on medication for hypertension are more likely to fall, especially when the medication is poorly controlled (Berry & Kiel, 2014). Persons with dyspnea, who are often more concerned with reaching a resting position than with safety, are also more likely to fall (Roig et al., 2011). Further research is needed to consider if and how chronic disease should be incorporated into fall prevention guidelines. Balance-enhancing programs that challenge the older adult’s postural control through a reduced or changing base of support can result in functional gains and reduced fear of falling (Peterson & Clemson, 2008). Although this is most frequently accomplished with older adults through popular exercise programs like Tai Chi, Matter of Balance programs, and Otago, there is growing evidence that positive outcomes can also be achieved through training that involves habitual daily routines (Clemson et al., 2010; Leung, Chan, Tsang, Tsang, & Jones, 2011; National Council on Aging, n.d.). Otago is a home-based exercise program that includes strengthening of lower extremities, balance, stability, and active range of motion (AROM) exercises. This program is based specifically on what the individual older adult needs (Robertson & Campbell, 2003). The Resources section of this course provides more information on this program. Gait speed declines normally as we age. Sartor-Glittenberg and colleagues (2014) found that fast gait speed correlated strongly with reports of increased quality of life. This finding is a strong statement about the role of gait speed in health-related quality of life. Others have considered gait speed to be as good as a full battery of tests in predicting the risk of disability in community- dwelling older adults. Gait speed is often termed the sixth vital sign due to its predictive capabilities. Interpretation of cut off values indicative of corresponding predicted outcomes includes: ● Gait speed of ≥1.0 m/s reaches or exceeds the minimal necessary speed for community walking. Person is capable of walking in the community, less likely to be hospitalized, more independent in self-care, and less likely to have adverse events.
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