Gait, Balance, and Osteoporosis
Treatment in Seniors
Regina Harrell, MD, CMD
Geriatrician
University of Alabama
“You can tell a man’s health by what he
takes two at a time: pills or stairs.”
Objectives
• Know how to assess gait and balance in an older
population.
• Learn interventions to minimize fall risks.
• Know the differences between gait assistance
devices.
• Know the risk factors and how to reduce them for
osteoporosis.
• Learn health benefits of exercise in addition to
osteoporosis risk reduction.
• Learn the basics of osteoporosis treatment.
• Learn how the treatment of osteoporosis changes
with age and comorbidity.
Normal Gait
• Get Up and Go Test
– Start sitting in a chair.
– Stand without using hands to push upwards.
– Walk 10 feet.
– Turn around and walk back to chair.
– Sit down.
• Normal <10 seconds.
• Abnormal > 20 seconds.
• Simple, sensitive screen for ALs.
Tinetti Gait and Balance Test
• 10-15 minutes to complete
• Most often done by a therapist.
• Scoring is done on a three point scale with a
range of 0 to 2. 0 represents the most
impairment, while a 2 represents
independence of the patient.
• Gait and balance are assessed separately and
the scores are then totalled.
Tinetti Gait and Balance Test
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The maximum score for gait is 12.
The maximum score for balance is 16.
The maximum total score is 28 points.
In general, a score below 19 is a high risk for
falls.
• Too sensitive, not specific enough for ALs.
• http://www.sgim.org/workshop01/pdf/hando
ut16TinettiAssessmentTool1.pdf
There is more to walking than walking.
• Medications
• Vision
– “I leave my glasses next to my bed.”
– Cataracts, macular degeneration
• Postural blood pressure
– 20mmHg drop in systolic pressure
– 10mmHg drop in diastolic pressure
• Neurological diseases
• Cardiovascular diseases
• Musculoskeletal problems
Medications
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Benzodiazepines
Sedative/hypnotics
Antihypertensives
Antidepressants
Neuroleptics
Alcohol
Illegal drugs
Comorbid diseases
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Increase risk of injury from fall as well
Osteoporosis
Steroid-thinned skin
Anticoagulants
Arthritis
Dementia
Pain
Acute infection
Interventions to Decrease Risk
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Not all falls are preventable.
If a risk is fixable, fix it.
If a risk is not fixable, minimize it.
Plan of care documentation
Interventions to Decrease Risk
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Gait training
Tai Chi
Dancing
Exercise
Footwear
Restraints
Hip protectors
Hip Protectors
• Decrease risk of fall injury
• Do not decrease risk of fall
• Very effective, difficult to consistently use
Gait Assistance Devices--Cane
• Widens base of support
• Single-tip cane
– Offset
– Crook-neck
Gait Assistance Devices--Walkers
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5-inch wheels for ease of movement
15-30 degree elbow bend
Handles at greater trochanters
4-wheel walker
– Light support
• No-wheel walker
– Large amount of weight-bearing support
– Extreme fear of falling
– Too heavy for severe CHF, deconditioning, osteoporosis
Gait Assistance Devices--Walkers
• 3-wheel walker
– Not for weight-bearing
– Pretty colors
– Keeps up with the Joneses
– Convenient for groceries
Gait Assistance Devices--Walkers
• Merry Walker
– Patients with dementia
– Can’t remember they are unsteady
– Generally for facility use
Osteoporosis: Definition
• Not enough bone in your bones
• DEXA bone mineral density scan
– Osteopenia= thin bones, some risk
– Osteoporosis= thinner bones, higher risk
• T-score -2.5 or less
Why is osteoporosis bad?
• Half of women over 50 will have an
osteoporosis-related fracture
• Hip fracture after one year
– 1/3 recover completely
– 1/3 cannot walk independently
– 1/3 die
• Broken bones hurt
– Spine fractures notorious for pain problems
• Independence
Osteoporosis: Demographics
• Affects 10 million Americans
• 34 million Americans have low bone density
and are at risk
• 80% women
• Causes 1.5 million fractures a year at a cost of
$18 billion a year
Osteoporosis: Risk factors
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White or Asian race
Smoking, alcohol
Petite size
Family history
Estrogen, testosterone
Some medications
Diet
Osteoporosis: Risk reduction
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Stop smoking
Avoid excessive alcohol
Adequate calcium and vitamin D
Pick good parents
Exercise
Exercise
Exercise
Exercise
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Reduces fall risk
Increases bone density
Improves joint mobility
Improves heart and circulatory function
Increases independence
Improves balance
Exercise
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Boring
Causes pain
Inconvenient
Requires special clothing and equipment
Expensive
Takes too much time
Boring
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Get a partner (misery loves company)
Vary exercise type
Vary exercise location
For stationary exercises, talk on the phone,
read a book, watch television, listen to music
Inconvenient
Cost
• Wear clothes that are comfortable and easy to
move in
• Use bags of rice or cans of soup as one pound
hand weights
• Put food cans inside an old purse to put
around ankles for weights
• Walk in the mall, a large store, or church gym
instead of a treadmill
Pain
• No pain, no gain
• Not true
Exercise: Where to start?
• Start where you are comfortable
• 3 goals:
– Range of motion
– Aerobic training
– Strength
• Work with a doctor, therapist, or personal
trainer if you have serious health problems.
Range of Motion: Where to start?
Move your joints in all the directions they are
supposed to move, gently and slowly.
Increase time spent moving joints and the total
angle moved.
Depending on underlying disease, major
improvements may take a month or more.
Aerobic Training: Where to start?
• Walk one minute a day.
• Increase by one minute a day each week.
• Goal is 25 minutes at least 4 times a week.
Strength: Where to start?
• Once range of motion is comfortable, add a
small weight in each hand and around each
ankle for range of motion movements.
• Increase the number of repetitions weekly.
• Once 2 sets of 10 repetitions can be done,
increase weight again.
• Goal is 25 minutes of strength training at least
3 times a week.
Exercise as an Activity
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Create competitions
Pedometers
Add music
Let residents make suggestions
Certificates, flowers, massage rewards
No candy bars as rewards
Back to Osteoporosis
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You are exercising
You get enough calcium and vitamin D
You quit your bad habits
Your bones are still thin
What next?
Osteoporosis Medications
• Calcium 1200 mg per day
• Vitamin D 400 IU per day
• All other medicines require adequate calcium
(building blocks) to be effective
Bisphosphonates
• Increase bone density by slowing down the
cells that break down bone
• Pills: Alendronate (Fosamax), ibandronate
(Boniva), risedronate (Actonel)
• IV: pamidronate (Aredia), zoledronic acid
(Zometa or Reclast)
• Decrease fracture risk
• Increase bone density
Bisphosphonates
• FLEX trial showed some women can stop
treatment after 5 years
– Improved bone density while on treatment
– No fractures
– T score > -3.5
• Stomach side effects
• Weight bearing exercise required
Selective Estrogen Receptor Modulator
• Raloxifene (Evista) daily pill
• Also reduces breast cancer risk
• Increases venous thrombosis blood clot risk
Parathyroid Hormone
• Teriparatide (Forteo)
• Daily injection for up to 2 years
• For severe osteoporosis only
Other Osteoporosis Medicines
• Calcitonin (Miacalcin) daily nose spray
– Mostly used for pain related to vertebral fractures
• Estrogen
– Side effects controversial
Osteoporosis Treatment Considerations
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Other concurrent illnesses
Life expectancy
Ability to swallow pills
Side effects
Cost
Ability to exercise
References
• Tinetti, Mary. Preventing Falls in Elderly Persons.
NEJM 2003;348(1): 42-49.
• Vu MQ, Weintraub N, Rubenstein LZ. Falls in the
Nursing Home: Are They Preventable? J Am Med
Dir Assoc 2004; 5:401-406.
• Nied RJ, Franklin B. Promoting and prescribing
exercise in the elderly. Am Fam Physician
2002;65(3):419-26,427-8.
• www.nof.org National Osteoporosis Foundation
• Fracture Intervention Trial Long-Term Extension,
JAMA, December 2006