The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Gait

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, 2011; Gillespie 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, 2012; Costa & de Jesus, 2015; Bloch 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

Conditions

• 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

Assessment:

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

Scoring:

• 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
Grade	Description
0/5	No muscle movement
1/5	Visible muscle movement, but no movement at the joint
2/5	Movement at the joint, but not against gravity
3/5	Movement against gravity, but not against added resistance
4/5	Movement against resistance, but less than normal
5/5	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 http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html.
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. Physiotherapy, 88(6), 342-53.