olivier beauchet why does my...why does my patient have gait instability … and fall? olivier...

WHY DOES MY

PATIENT HAVE GAIT

INSTABILITY

… AND FALL?

Olivier BEAUCHETMD, PhD

Full Professor of Geriatrics

Holder of the Dr. Joseph Kaufmann

Chair in Geriatric Medicine - Faculty

of Medicine, McGill University

Department of Medicine, Division of

Geriatric Medicine, Sir Mortimer B.

Davis Jewish General Hospital

Director, Centre of Excellence on

Longevity, RUIS McGill

[email protected]

MONTREAL, APRIL 2018

_PRESENTER DISCLOSURES

PRESENTER: OLIVIER BEAUCHET

Relationship with financial sponsors: None

Discussion of Off-Label, Investigational, or Experimental Drug Use: No

This program has received financial support from None

This program has received in-kind support from None

Potential for conflict of interest Chair of the CGS Scientific

Planning Committee

Yes

WHY DOES MY PATIENT HAVE GAIT INSTABILITY… AND FALL?

TO IMPROVE KNOWLEDGE (i.e.; DIAGNOSIS AND

TREATMENT) ON THE IDENTIFICATION OF OLDER

PATIENT WITH GAIT INSTABILITY

_

> Know definitions

> Understand the mechanism

> Have an overview the epidemiology

> Be able to diagnose and treat

> Apply: To make the right assessment and therapeutic

choice, to the right patient, at the right time…

_ OBJECTIVES


Medical term to describe human locomotion

PHYSIOLOGICAL APPROACH

> Depends on closely integrated

actions of the bones, muscles and

nervous system

> Degree of integration determines

gait patterns (i.e.; the patterns of

trunk & limbs movements)

> Any defect leads to gait instability

BIOMECHANICAL APPROACH

> Form of bipedal locomotion as there

is an alternating movements between

upper & lower extremities

> Legs:

One is in touch with the ground for

support and propulsion

The other is in swing phase for

creating a new step forward

Dynamic balance condition

Series of rhythmic, alternated

and coordinated movements

of legs… arms & trunk resulting

in forward progression of body

_ DEFINITION OF GAIT


_ DEFINITION OF GAIT


Balance stability: Ability to

assume a stable upright

posture and maintain it

Locomotion: Ability to

initiate and maintain

rhythmic stepping…

Navigation: Ability of

displacement

Musculoskeletal integrity:

Normal joints & bones,

spine and muscles

Neurological control: Receive

& send messages to tell the

body how to move (visual,

vestibular, auditory, sensori-

motor inputs)

_ WHAT IS NEEDED FOR A SAFE GAIT?


PARADOXICAL MOTOR BEHAVIOR

Simple execution Complex biomechanics (dynamic balance)

« Hard » motor behavior:

Automatic = Propulsion / Balance

« Flexible » motor behavior:

Adaptation = Navigation

LEVELS AND TYPES OF CONTROL

CORTICAL LEVEL

Initiation and adaptation of gait

SUBCORTICAL LEVEL

Modulation of automatic

movements

At steady walking, without

stimulation and straight

(gait propulsion condition):

involvement of cortical level

in gait control

SPINAL LEVEL

Gait patterns generation

of automatic, regular and

rhythmic movements

_ GAIT CONTROL COMPONENTS


− SLR: Subthalamic locomotor region

− MLR: Mesencephalic locomotor region

− CLR: Cerebellar locomotor region

− PMRF: Pontine and medullary reticular

formations

− CPG: Central pattern generators

> Gait instability is a major health issue in older patients

> Gait is a distinctive attribute of an individual that:

Changes (i.e., decline in performance) over the life span

due to aging and accumulation of diseases

These changes lead to GAIT INSTABILITY… and FALLS.

> Prevalence of gait instability ≥ 65 years:

High: 20-80%!

Variation related to:

No consensual definition (from subjective clinical

examination to objective assessment)

Advance in age (disease-related accumulation)

_ WHY IT’S IMPORTANT TO FOCUS

YOUR ATTENTION ON GAIT INSTABILITY


> Main adverse outcomes:

High mortality

Hospitalization and institutionalization

Disability (low level of function)

Falls and related consequences

> A predictor of cognitive impairment…

Snijders AH et al. Lancet Neurol 2007;6:63-74

_ WHY IT’S IMPORTANT TO FOCUS

YOUR ATTENTION ON GAIT INSTABILITY


> Main clinical hallmark of dementia: Cognitive impairment… and decline

> Motor disorders:

Not prominent but commonly described at late stages:

bradykinesia, extrapyramidal rigidity, resting tremor and gait

disorders

Related to basal ganglia, cerebellum

and primary motor areas lesions

(neurodegenerative ± ischemia)

… BUT

Gait disorders also described at

early stage of cognitive decline

Beauchet O et al. Neuropsychiatr Dis Treat. 2008;4:155-160

_ MOTOR DISORDERS = HALLMARK OF DEMENTIA


PREVALENCE OF GAIT DISORDERS:

90%: PDD

80%: VaD

75%: DLB

Mild: 40

Moderate: 87

Severe: 100

25%: AD

Mild: 0

Moderate: 33

Severe: 50

7%: Control

Rela

tio

nship

with

th

e s

tag

es o

f d

em

en

tia

Allan LM et al. J Am Geriatr Soc. 2005;53:1681-1687

_ GAIT DISORDERS ARE ASSOCIATED WITH DEMENTIA


Beauchet O et al. J Am Med Dir Assoc. 2016; 17:482-490

WORSE GAIT PERFORMANCE

(SLOW GAIT SPEED +++)

PREDICTS DEMENTIA

_ GAIT DISORDERS PREDICT DEMENTIA


Figure 1. Forest plot of pooled estimated

hazard ratio for risk of incident dementia

Square box area proportional to the sample

size of each study; horizontal lines

corresponding to the 95% confidence interval;

diamond representing the summary value;

vertical line corresponding to a hazard ratio

combined with relative risk of 1.00, equivalent

to no difference

Verghese J et al. J Gerontol A Biol Sci Med Sci. 2013;68:412-418 / Verghese J et al. Neurology. 2014 Aug 19;83:718-726.

MCR SYNDROME: COGNITIVE COMPLAINT + SLOW GAIT SPEED (-1SD ADJUSTED ON AGE AND SEX)

_ MOTORIC COGNITIVE SYNDROME


> Past decade characterized by increased interest

in identifying and validating biomarkers for early

diagnosis of AD and other forms of dementia

> Emergence of biomarkers has contributed

extensively to the early diagnosis of dementia, but

the use of biomarkers has limitations:

Time consuming

Technical support

High cost

_ PERSPECTIVES


> Need to optimize and increase accessibility of clinical

dementia risk assessments in community-dwelling

population, in order to initiate preventive measures

> Gait performance impairment (like slow gait speed)

could allow to screen individuals at risk in general

population… But need to better understand the

relationship with early stages of dementia


_ PERSPECTIVES

> A 87-year-old woman walks into your office unaided. She

came to see you for a prescription renewal accompanied by

her daughter.

> She reports that she has gait difficulties with fear of falling

since two consecutive falls during the past three weeks.

> Her medication list includes Amlodipine 5mg QD, Metformin

500mg BID, Aspirin 80mg QD, Atorvastatin 10mg QD,

Donepezil 5mg QD and Temazepam as needed for sleep.

> Her body mass index is 18 kg/m2. The daughter gives you an

X-ray report indicating that the patient has severe osteoporosis,

moderate spinal (cervical and lumbar) osteoarthritis with dorsal

kyphosis.

_ PATIENT SCENARIO


> A 87-year-old woman…



> All adults ≥ 65 yo should be examined for gait instability:

Systematically, at least once a year

Report gait instability and/or falls

Or in case of an acute medical condition

_ WHO SHOULD BE SCREENED FOR GAIT INSTABILITY?


> An 87-year-old woman…



> All adults ≥ 65 yo should be examined for gait instability:

Systematically, at least once a year

Report gait instability and/or falls

Or in case of an acute medical condition

_ WHO SHOULD BE SCREENED FOR GAIT INSTABILITY?


> Usually multifactorial origin

> Requirement of a comprehensive assessment to

determine contributing factors and targeted interventions

Intrinsic factors

(i.e., individual-related; health condition)

Behavioral factors

(physical activity)

Environmental factors

(place of living)

_ WHAT ARE THE CAUSES OF GAIT INSTABILITY?


> There are 2 categories of factors which cause gait instability:

1 - Predisposing factors:

• Individual-related

• Physiological aging of the sensorimotor system +

chronic medical conditions

2 - Precipitating factors related to:

• Acute medical conditions

• Physical activity inducing gait instability

> Complex synergic interactions between factors, explaining why

gait instability may fluctuate with time



SINGLE TASK DUAL TASK

Decline in spatio-temporal gait performance with a greater instability…

_ DUAL-TASKING


> Fact: Limited capacity of the brain (cognition +++)

> Consequence: Combination of two cognitive-demanding tasks

(walking + an explicit cognitive task) overloads the brain

capacity, leading to share cognitive resources between tasks

> Result: Changes in performance while dual tasking interpreted

as an interference due to competing demands for cognitive

resources needed for both tasks

Pashle

rH

. P

sycholB

ull.

1994;1

16:

220-4

4

LEVEL OF ATTENTION WHILE:

WALKINGEXPLICIT

COGNITIVE TASK Dual tasking

SHARING OF

COGNITIVE

RESOURCES

Single taskingSingle tasking

_ DUAL-TASKING


Results showed that:

− Gait was not only an automatic rhythmic

motor task

− Gait assessment while dual-tasking

underlined:

1) Involvement of cognitive resources

(attention +++)

2) Highest gait control level: cortical

(too high in older adults with

neuropsychiatric disorders)

3) An apparent good predictive tool

for risk of fall!

_ DUAL-TASKING


Log rank test: P < 0.001

Zwergal A et al. Neurobiol Aging. 2012;33:1073-84

– INVOLVEMENT OF CORTICAL LEVEL IN GAIT

CONTROL WHILE USUAL WALKING

– NO AGE-RELATED CHANGE IN LOCOMOTOR

BRAIN NETWORK (PREMOTOR CORTEX, BASAL

GANGLIA, MIDLINE CEREBELLUM,

PONTOMESENCEPHALIC TEGMENTUM)

_ FUNCTIONAL BRAIN IMAGING OF GAIT


Zwergal A et al. Neurobiol Aging. 2012;33:1073-84

MORE CORTICAL ACTIVATION

WITH AGING

LESS CORTICAL DEACTIVATION WITH AGING

INCREASE AND DECREASE IN CORTICAL

ACTIVITY: A COMPENSATORY MECHANISM

DUE TO AGE-RELATED SENSORIMOTOR

DECLINE

_ FUNCTIONAL BRAIN IMAGING OF GAIT


> Main chronic medical conditions:

• Visual impairment with abnormal distance vision including low visual

acuity and low contrast sensitivity

• Lower limb poor muscle mass, strength and power

• Lower limb joint deformity, podiatric abnormalities and back deformity

(e.g.; kyphosis, scoliosis) related to arthritis and osteoporosis

• Malnutrition: obesity or malnutrition

• Lower limb proprioception impairment

• Myelopathy

• Normal-pressure hydrocephalus

• Parkinson disease

• Cerebellar dysfunction or degeneration

• Vascular brain disease

• Vestibular disorders

• Cognitive impairment: from mild cognitive impairment to severe

dementia

• Depression

• Fear of falling

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s_ WHAT ARE THE CAUSES OF GAIT INSTABILITY?


> Defined as a subjective lack of self-confidence that activities

of daily living may be performed without falling (based or not on

objective evidence of gait and/or balance disorders)

> Common in older adults: high prevalence ≈ 20%

> Evaluation from a single question (are you afraid of falling?) to

complex scales (activities-specific Balance Confidence [ABC]

Scale)

> … A complex interplay with gait instability

_ FEAR OF FALLING


> Associations:

1 : Constant

1-2-3: Classical (peripheral and/or CNS disorders)

3-1-2: Less known (impairment in cortical level of gait

control)

Gait instability

FOF

Falls

1

2.a

2.b

3


_ FEAR OF FALLING

> Any acute medical condition may: Increase gait instability rapidly (within hours)

Lead to a motor deconditioning (i.e.; loss of body postural reflexes

and inability to stand up and/or walk without assistance), in older

individuals with predisposing factors to gait instability

> Do not forget medications: Polypharmacy (i.e.; ≥ 5 therapeutic classes/day):

Interaction

Low compliance (50%)

Marker of multimorbidity

Psychoactive drugs:

Antidepressants

Benzodiazepines

Neuroleptics

1) New prescription (≤ 2 weeks)

2) Long term actions

3) ≥ 2 therapeutic classes



Indirect effect:

Marker of health status

Direct effects:

Specific effect

Side effect

DRUG

GAIT

INSTABILITY/FALLS

– Therapeutic class

– Posology

– Duration

– Interaction

– Modification

Co

nfo

un

de

rs

_ GAIT INSTABILITY AND MEDICATION?


Intrinsic factors

(i.e., individual-related;

health condition)

CHRONIC conditions

predisposing factors

ACUTE

conditions

Non-specific

diseases

− Gait Instability =

Atypical symptom

− Precipitating

factors

Specific

diseases

- Gait instability =

Typical symptom

- Causing factors

Infections (UTI, pneumonia),

CHF, CKF, Etc…

Most of the time:

Association of

predisposing,

precipitating or

causing factors

CVA, Arrhythmia, Etc…



> An 87-year-old woman walks into your office unaided. She came to

see you for a prescription renewal accompanied by her daughter.

> She reports that she has gait difficulties with fear of falling since two

consecutive falls during the past three weeks.

> Her medication list includes Amlodipine 5mg QD, Metformin 500mg

BID, Aspirin 80mg QD, Atorvastatin 10mg QD, Donepezil 5mg QD

and Temazepam as needed for sleep.

> Her body mass index is 18 kg/m2. The daughter hands you an X-ray

report indicating that the patient has severe osteoporosis, moderate

spinal (cervical and lumbar) osteoarthritis with dorsal kyphosis.

_ PATIENT SCENARIO


_ WHAT CONSEQUENCES TO GAIT INSTABILITY?


> Coming to rest, involuntary, on a lower level compared to

starting condition

> Key points:

1. Involuntary

2. Lower level… Not necessary the ground!

> Recurrence: ≥ 2 falls over a 12-month period

> Paradox: Simple criteria / Difficult to identify in clinic because of

memory deficit, common event, fear of institutionalization

> Diagnosis based on:

Interview (patient and caregivers – criteria of definition) +++

Physical examination (consequences: skin hematoma…)

_ FALL DEFINITION


> Falls are a daily issue:

High prevalence and incidence increase with

age: 35% ≥ 65 years and 50% ≥ 85 years

Greater prevalence in institution (i.e.,

residence and hospital) compared to home

> Fallers are “repeat offenders”:

50% of fallers are recurrent fallers

_ FALL EPIDEMIOLOGY


Numerous physical and psychological traumas related to falls:

Prevalence (%)

Traumas

Physical (soft tissues>>fractures) 50/5

Psychological (fear of falling) 40

Dependence 50

Emergency visit and/or admission in wards 20

Institutionalization

Death

40

5

_ FALL-RELATED INJURIES


Bone fracture is a serious event: the example of hip





Prevalence (%)

Traumas

Physical (soft tissues/fractures) 50/5


Dependence 50



Death

40

5



The second leading cause of accidental death

Older adults ≥ 65 have the greatest number of fatal falls

Prevalence (%)

Traumas

Physical (soft tissue/fractures) 50/5


Dependence 50



Death

40

5



> Fall-related adverse consequences are not only limited to fallers…

> Healthcare teams:

Anxiety and guilt

Caused by fallers and/or their families complaints

A legal event when occurring in institution

> Health system:

Increased health expenditures

High number of non-fatal fall-related traumas in

individuals ≥ 65 years old (USA, 2011) = 2.4 millions

with a direct cost of US$30 billions... In 2020: Estimated

direct and indirect costs = US$68 billions

_ OTHER CONSEQUENCES OF FALLS


> For clinicians:

Paradoxical situation: quality of prediction is poor while

intervention (usually based on physical activity) is efficient

(magnitude of fall reduction ≈ 20%).

Physical activity is good for health but has a price when

considering the growing older population (and not an

individual) at risk of falls and thus should be prescribed

only among the subgroup at high risk.

> For researchers:

Paradoxical situation... too

Increase in understanding of fall mechanism but no tool

with a good prognostic value (sensibility and specificity

under 70%)!

_ FALL PARADOX


Older adults ≥ 65 years

FALL?

GAIT / BALANCE INSTABILITY (USE AID)?

NoYes

SEVERE?

No Yes

Yes

ASSESSMENT

Physical EXERCICES

Physical ACTIVITY

No

NUMBER OF FALLS?

1 ≥2

_ THE RIGHT QUESTION

FOR THE BEST PRACTICE


Visual observation of gait :

Retropulsion

Lateral deviation

Increase steps width

Decrease arms/legs swing

Slow gait speed

> Specific syndromes:

> Use of walking aid

> If yes, type?

> Usual condition self-pace

> Stress conditions

_ CLINICAL GAIT ASSESSMENT




Clinical objective measures of gait performance:

Get-Up & Go Timed Up & Go

Principe − Stand up from a chair

− Walk 3 meters

− Turn and go back to sit on the chair

Analysis – Qualitative

– Observation

− Quantitative

− Time measure

Score − 1 to 5

− Cotation: 2-4!

− Score = Risque

− Time in seconds

− > 20: Abnormal

Evaluation Fall risk Gait instability

Objective measures

of gait performance:

Gait speed



> The role of laboratory testing for diagnostic has not been well

studied.

> There is no systematic investigation recommended.

But the following complementary investigations are

recommended:

Bone radiography in the event of acute pain, joint

deformation and/or functional disability

Standard 12-lead ECG in case of dizziness

Blood glucose level in patients with diabetes

Serum 25OHD concentration if there is no vitamin D

supplementation

> Cerebral imaging in the absence of specific indication based upon

the clinical examination may not be necessary

_ COMPLEMENTARY INVESTIGATION: WHO? WHAT?


> It is recommended to suggest, irrespective of the place of living,

an intervention combining several of the following domains:

Review of the medications (fall-related drugs and/or the

number of drugs is ≥ 5)

Correction of predisposing or modifiable precipitating

factors (including environmental risk factors)

Wearing shoes with broad, low heels (2 to 3cm), and firm,

thin soles with a high upper

Regular practice of walking and/or any other physical activity

Use of an adapted walking aid

Correction of a potential vitamin D deficiency by a daily

dose of at least 800 IU

_ WHAT INTERVENTIONS?


> It is recommended to prescribe physiotherapy, including:

Working on static and dynamic postural balance

Increasing the strength and muscular power of the

lower limbs

> Other techniques, including stimulation of sensory afferents

or learning to stand up from the ground may also be

proposed.

> Such interventions may involve rehabilitation professionals.

_ WHAT INTERVENTIONS?


> Gait instability related to:

Polypharmacy & psychoactive drugs

Lower limb diabetic polyneuropathy causing proprioceptive

impairment

Abnormal static posture due to spinal osteoarthritis and

osteoporosis deformity

Poor muscle mass and strength (BMI score 18 kg/m2)

Cognitive impairment (dementia)

You can propose:

To discontinue Temazepam

To continue anti-osteoporotic treatment and vitamin D

supplementation

A regular practice of walking and specific physical exercises

focusing on gait control and muscles (power & strength)

_ PATIENT SCENARIO RESOLUTION


THANKS FOR

YOUR ATTENTION

MONTREAL, APRIL 2018

[email protected]

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