presence of pathology, many of these gait deviations are a result of slower self-selected gait speed, as well as reduced fast gait speed and maximal gait speed (Harwood & Conroy, 2009). Gait speed has been studied extensively and is directly correlated with functional status and balance confidence, both of which are important for fall prevention. In an important study by Studenski and colleagues (2011), gait speed was examined in a systematic review of nine studies with more than 34,000 total combined participants, various age groups, both sexes, minority groups, and community-dwelling older adults. A key point of this systematic review was that gait speed predicted survival rates in all nine studies, with 0.8 m/s (2.62 ft/s) gait speed equaling the average life expectancy at most ages for both sexes. In other words, as gait speed increases, survival rates increase and older adults live longer. If an older adult can walk at 1 m/s (3.3 ft/s) or faster, then they would exceed survival rates expected for their age category and sex. Adults who walk slower than 0.6 m/s (or 1.97 ft/s) show increased risk for mortality, poor health, and poor function. Gait speed also has been linked to function, hospitalization, and need for rehabilitation in another key study by Fritz and Lusardi (2009). Table 3, adapted from the Fritz article, summarizes their findings and is a great educational tool for patients. Table 3: Gait Speed and Links to Function Walking Speed Functional Result
fall history, gait speed, socioeconomic status, endurance, and physical activity. Identifying reliable determinants for frailty is an important need for future researchers, but for now, the most commonly used model is the Fried model (Fried et al., 2001). The Fried research model defines frailty as three of the five following factors: 1. Unintentional weight loss of more than 10 pounds in past year. 2. Grip strength loss. 3. Gait speed decline to less than 0.60 m/s. 4. Reported exhaustion. 5. Decrease in physical activity via kcal per week; less than 1,000 with exercise activities. The incidence of frailty varies depending on which definition is used to describe it, but generally accepted statistics for adults 65 years of age and older are 3% to 7%, whereas the incidence for adults 80 years of age and older is 25% to 40%. Women experience frailty twice as often as men. It is unclear whether frailty is more prevalent in whites than in blacks or other ethnic groups (Op het Veld et al., 2015). The cumulative effects of frailty render an older adult vulnerable to situational challenges, including falls, increased mortality, disability, and loss of independence. In addition to physical factors, many frail older adults also experience dementia (51–73%) and/or depressive symptoms (22%; Vaughan, Corbin, & Goveas, 2015). When considering fall risk in older adults, it is important to screen for the presence of frailty. Regardless of the model used, older adults of more advanced age or with multiple comorbidities should be screened for presence of frailty. Lewis and Dring (2016) proposed a frailty screening with three criteria: age over 81 years, TUG score over 15 seconds, and taking more than four medications, based on an article by Abizanda, Romero, and Sanchez-Jurado (2012). Age-related changes in gait The adult gait pattern stays fairly stable overall until advanced age or pathology sets in. Gait parameters that remain stable include vertical displacement of the center of gravity, gait phasing and timing (60% stance and 40% swing), stride rate, time for recovering leg swing, and time for single- and double- limb support (Hamacher, Singh, Van Dieen, Heller, & Taylor, 2011). Several gait parameters are affected by the aging process, in particular, step length shortens, toe out increases, ankle plantar flexion is reduced, pelvic rotation is reduced, and base of support widens, especially in those who fall. Without the
Normal SSWS in meters: 1.2-1.4 m/s (3.3-3.9 ft/s).
Independent community ambulation.
Decline in speed: 0.70 – 1.01 m/s (2.3 – 3.3 ft/s.
Decline in function.
Decline in speed: < 0.61m/s ( 2 ft /s).
Risk for hospitalization, dependent in ADLs.
MCIDa for SSWS older adults in meters: 0.05 m/s (0.33 ft/s). MCID for impaired older adults: 0.1 m/s (0.33 ft/s). ADL = activities of daily living; MCID = minimal clinically important difference; SSWS = self-selected walking speed. a Specific to population age, sex, and diagnoses; amount needed to increase in speed to result in a functionally important difference. Note . From Western Schools, 2019.
ASSESSMENT OF FALL RISK
which was then endorsed by the American Physical Therapy Association. The STEADI tool kit (CDC/STEADI, 2017), available for free online at the CDC website (www.cdc.gov/steadi/index. html), includes fall risk assessment tools, educational information on fall risk for health practitioners and consumers, and helpful guidelines for assessing fall risk in a primary care or in the community setting. Fall risk assessment is a two-step process. First, all older adults should be screened for fall risk. Those who are found to be at risk for falls in the screening process should undergo a full multifactorial assessment by a physical therapist or other qualified healthcare professional in order to design interventions to reduce this risk. In contrast to the quick and simplistic nature of screens, assessments provide a deeper understanding of impairments to help develop targeted rehabilitation strategies. These processes are described in the following sections, beginning with descriptions of screening recommendations.
With so many factors influencing fall risk in older adults, accurate assessment can be complicated and cumbersome. To address the crucial need for practical, effective fall risk screening and more individualized fall risk assessment, several healthcare agencies and organizations have developed guidelines in this area. Four of the more comprehensive approaches will be discussed in this section, including approaches from the National Council on Aging (NCOA), the Centers for Disease Control and Prevention (CDC), Academy of Geriatric Physical Therapy clinical guidance statement (CGS), and the American Geriatrics Society and British Geriatrics Society (AGS/BGS) guidelines. In 2011, the CDC formed a fall prevention task force composed of physicians, nurse practitioners, physician assistants, and nurses. A review of the literature on fall prevention by the task force exposed a large need for healthcare provider education. In 2012, the task force released its product, STEADI, which stands for “Stopping Elderly Accidents, Deaths, and Injuries,” General screening recommendations Fall prevention begins with an accurate and reliable screening process to identify older adults at risk for falls. Many screening processes are designed to be accurately performed by either nonskilled personnel or by a skilled healthcare provider.
Screening results may indicate the need for a more in-depth assessment, which should be performed by a clinician with knowledge of fall risk assessments.
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