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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Gait

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment


Related Issues:

Mobility, ambulation, transportation, neuropathy

Why Gait is Important:

  • 30% of people over 65 years of age living in the community fall each year and the fall rate increases with age (CDC, 2011Gillespie et al., 2012)
  • Many people who fall, even if they are not injured, develop fear of falling; this fear may cause them to limit their activities, leading to reduced mobility and loss of physical fitness, which in turn increases their actual risk of falling (CDC, 2011)
  • 20-30% of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas; these injuries threaten and impact independence (CDC, 2011)
  • Among those age 65 and older, falls are the leading cause of injury-related death (CDC, 2011)

Normal Age-Related Changes:

  • Sarcopenia (decreased muscle mass and strength)
  • Slower motor response time
  • Increased risk of postural hypotension
  • Decreased bone density (osteoporosis risk)

Older adults are at increased risk if they have any of the following:

Falls Specific Risk Factors (Shanthi, 2005; Capone, et al, 2012Costa & de Jesus, 2015Bloch et al, 2010)

  • Female
  • Poor balance
  • Vertigo and syncopal episodes
  • History of falls
  • Cognitive impairment
  • Mobility impairment
  • Dizziness/orthostatic hypotension
  • Sensory deficits (visual, audio, impairment, peripheral neuropathy)
  • Use of psychotropics, anti-convulsants, sedatives, diuretics, or pain medicine
  • Fear of falling
  • Use of assistive devices
  • Prior stroke
  • Bladder/bowel incontinence
  • Motor deficits (gait imbalance, right or left sided weakness, lower extremity weakness)
  • Needs help transferring


  • Peripheral neuropathy
  • Peripheral edema in lower extremity
  • Peripheral vascular disease
  • Vertigo
  • Syncope
  • Imbalance secondary to vision impairment and inner ear disorder
  • Neurological movement disorders
  • Dementia
  • Severe Pain
  • Metastatic disease

Behavioral Risk Factors

  • Alcohol overuse or abuse
  • Non-Adherence to prescribed treatment or medication regimens

Medication-Related Risk Factors

  • Psychotropics (sleep medicines, hypnotics, sedatives, anxiolytics)
  • Anti-convulsants
  • Diuretics
  • Opiods
  • Steroid-induced myopathy

Chemotherapy-Related Risk Factors

  • Peripheral Neuropathy
  • Taxanes (paclitaxel [taxol], docetaxel [taxotere])
  • Epothilones (ixabepilone)
  • Vinca alkaloids (vincristine, vinblastine)
  • Platinum-based (oxaliplatin, cisplatin, carboplatin)
  • Others: thalidomide, bortezomib, lenalidomide, interferon, ipilimumab
  • Mobility or Cerebral Dysfunction
  • Ara-c (cytarabine), high-dose bolus 5fu, chloramabucil
  • Bone Density
  • anastrozole (Arimidex), exemestane (Aromosin), letrozole (Femara), leuprolide (Lupron, Viadur, Eligard), goserelin (Zoladex), triptorelin (Trelstar), histrelin (Vantas), degarelix (Firmagon), flutamide (Eulexin), bicalutamide (Castodex), nilutamide (Nilandron)

Surgery-Related Risk Factors

  • Orthopedic procedures
  • Neurologic procedures

Radiation Risk Factors

  • Radiation to cerebellum (brain)
  • Radiation to spine
  • Radiation to lower extremities

Cancer Diagnoses

  • Central nervous system malignancies
  • Lower extremity bone lesions


1. Screening Questions​

  • Do you have difficulty transferring from positions (standing from a seated or lying position)?
  • Do you have difficulty getting around your home (to the bathroom, kitchen, bedroom, or using stairs)?
  • Do you have numbness, tingling, pain, or swelling in your lower extremities?
  • Are you fearful of falling?

2. Observations

  • Is the person steady and balanced when walking or sitting upright?
  • Is there step symmetry, with the steps equal in length and regular?
  • Is the patient able to sit safely and judge distance correctly?
  • What type of shoes is the patient wearing? (Ideally, shoes should be flat and rubber-soled with laces)

3. Screening Tests and Measurements

  • Timed Get-Up-and-Go Test (preferred tool)

This is performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with arm rests

On the word "go", the patient is asked to do the following:

  1. Stand up from the arm chair
  2. Walk 3 meters (in a line)
  3. Turn
  4. Walk back to the chair
  5. Sit down

Time the second effort

Observe patient for postural stability, steppage, stride length, and sway


  • Normal: completes task in <10 seconds
  • Abnormal: completes task in >20 seconds

Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls

  • Turn 180 Test

Number of steps taken to turn 180 degrees is counted; more than four steps indicates increased risk of falls (Simpson, Worsfold, Reilly, Nve, 2002)

4. Physical Assessment: Standard examination with special focus on

  • Strength
  • Test strength by having the patient move against your resistance
  • Always compare one side to the other
  • Grade strength on a scale from 0 to 5 "out of five":

Grading Motor Strength




No muscle movement


Visible muscle movement, but no movement at the joint


Movement at the joint, but not against gravity


Movement against gravity, but not against added resistance


Movement against resistance, but less than normal


Normal strength

  • Presence of peripheral edema
  • Romberg's Test (tests proprioception, sensation, and vision)

Assess patient standing still with their heels together; ask the patient to remain still and close their eyes; if the patient loses their balance, the test is positive

  • Monofilament Test

Using monofilament (a piece of plastic fiber) test patients feeling of sensation on feet using varying degrees of pressure

  • Tandem Walk (to test for truncal ataxia)

Assess patient walking heel to toe, placing the toes of the back foot against the heel of the front foot

  • Heel Walk (to test dorsiflexion)

Assess patient walking on heels only

  • Toe Walk (to test plantarflexion)

Assess patient walking on toes only



Nursing Intervention:

  • Assist in determining underlying etiology of altered gait and reverse if possible
  • Patient education RE: personal falls risk
  • Implement standard safety interventions for all patients
  • Environmental Safety
  • Remove excess safety equipment/supplies/furniture from rooms and hallways to minimize clutter; special attention should be paid to path between bed/chair/exam table and bathroom/commode
  • Secure excess electrical and telephone wires
  • Maintain equipment in good working order through routine and prn maintenance
  • Secure locks on all beds, stretchers, exam tables, treatment chairs, and wheelchairs; keep exam tables in lowest position possible
  • Clean all spills in patient room or hallway immediately to ensure safe and dry passageways; signs should be utilized to indicate wet floor hazard
  • Ensure adequate environmental lighting
  • Orient ambulatory patients to clinical environment, including bathroom, use of bed, chair, exam table, and location of call light
  • Keep call bells, frequently used items, assistive devices, and patient belongings within patient reach
  • Assess safety of home (VNS RN referral): non-skid rugs, grab bars and mats in bathroom and shower, shower chair, even level of pavement and ground, ramp if needed
  • Physical therapy referral for gait training, strength, endurance, balance, and coordination
  • Obtain assistive devices
  • Arrange care giver assistance (HHA)
  • Elevate lower extremities for peripheral edema
  • Compression stockings for peripheral edema


Bloch, F., Thibaud, M., Dugue, B., Rigard, A.S. & Kemoun, G. (2010). Episodes of falling among elderly people: a systematic review and meta-analysis of social and demographic pre-disposing characteristics. Clinics (Sao Paulo), 65(9), 895-903.
Capone, L.J., Albert, N.M., Bena, J.F. & Tang, A.S. (2012). Predictors of a fall event in hospitalized patients with cancer. Oncology Nursing Forum, 39(5), e407-15.

Centers for Disease Control and Prevention. Falls among older adults: an overview. Retrieved March 16, 2011, from
Costa dos Reis, K.M. & de Jesus, C.A.C. (2015). Cohort study of institutionalized elderly people: fall risk factors from the nursing diagnosis. Rev Lat Am Enfermagem, 23(6), 1130-1138.
Gewandter, J.S., Fan, L. Magnuson, A., Mustian, K., Peppone, L., Heckler, C., Hopkins, J., Tejani, M., Morrow, G.R. & Mohile, S.G. (2013). Falls and functional impairments in cancer survivors with chemotherapy-induced peripheral neuropathy (CIPN): A University of Rochester CCOP Study. Support Care Cancer, 21(7), 2059-2066.
Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M., & Lamb, S.E. (2012) Interventions for preventing falls in older people living in the community. Cochrane Database for Systematic Reviews,  9, CD007146.
Shanthi, G.S. & Krishnawamy, G. (2005). Risk factors for falls in elderly. Journal of The Indian Academy of Geriatrics, 1(2), 57-60.
Simpson, J.M., Worsfold, C., Reilly, E., & Nve, N. (2002). A standard procedure for using TURN180: testing dynamic postural stability among elderly people. Physiotherapy88(6), 342-53.