Gait, Balance, and Osteoporosis Treatment in Seniors

Regina Harrell, MD, CMDGeriatrician

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

• 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/

handout16TinettiAssessmentTool1.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

• Benzodiazepines• Sedative/hypnotics• Antihypertensives• Antidepressants• Neuroleptics• Alcohol• Illegal drugs

Comorbid diseases

• Increase risk of injury from fall as well• Osteoporosis• Steroid-thinned skin• Anticoagulants• Arthritis• Dementia• Pain• Acute infection

Interventions to Decrease Risk

• 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

• 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

• 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

• White or Asian race• Smoking, alcohol• Petite size• Family history• Estrogen, testosterone• Some medications• Diet

Osteoporosis: Risk reduction

• Stop smoking• Avoid excessive alcohol• Adequate calcium and vitamin D• Pick good parents• Exercise• Exercise• Exercise

Exercise

• Reduces fall risk• Increases bone density• Improves joint mobility• Improves heart and circulatory function• Increases independence• Improves balance

Exercise

• Boring• Causes pain• Inconvenient• Requires special clothing and equipment• Expensive• Takes too much time

Boring

• 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

• Create competitions• Pedometers• Add music• Let residents make suggestions• Certificates, flowers, massage rewards• No candy bars as rewards

Back to Osteoporosis

• 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

• 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