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Gait, Balance and Osteoporosis Treatment in Seniors

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    Gait, Balance and Osteoporosis Treatment in Seniors Gait, Balance and Osteoporosis Treatment in Seniors Presentation Transcript

    • 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
      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