Gait Disorders and Falls in the Elderly

Effects of tai chi on postural balance and quality of life among the elderly with gait disorders: A systematic review

BACKGROUND

Tai Chi is good for improving the physical fitness of older adults. But few studies have reported the effects of Tai Chi on the postural balance and quality of life of older adults with gait disorders.

OBJECTIVE

This review aimed to assess the influence of tai chi on postural stability and quality of life in older adults with abnormal gait.

METHOD

According to the literature retrieval principles, the works published from the inception date to May 2023 were retrieved, including the following databases: PubMed, Scopus, Web of Science, China National Knowledge Infrastructure, EBSCOhost, and Google Scholar. Subsequently, literature screening and quality assessment were performed.

RESULTS

A total of 16 randomized controlled trials were included in this study, Tai Chi intervention can affect populations with Parkinson's disease (PD), no exercise, mild cognitive impairment (MCI), chronic stroke, sedentary, fear of falling, or history of falling. Postural instability is associated with balance, gait, the Unified Parkinson's Disease Rating Scale Motor Subscale 3 (UPDRS III), mobility, lower body strength, and falls. Only two articles looked at quality of life. The Yang style is the most commonly used in the intervention. Nonetheless, most studies were performed on female participants, hence, more research on older male populations is needed.

CONCLUSION

Tai Chi intervention benefits postural balance in patients with gait disorders. 12 weeks is the most common intervention period for patients with gait disorders. The frequency of intervention is seven articles twice a week, and the intervention time is about 60 minutes. The Tai Chi intervention methods in this study involve Yang Style, Sun Style, Taoist Tai Chi, and Health Qigong Tai Chi, but the Yang Style Tai Chi intervention is the most widely used.

Association between toileting and falls in older adults admitted to the emergency department and hospitalised: a cross-sectional study

OBJECTIVES

This study aimed to explore the potential risk factors associated with toileting-related falls in community-dwelling older adults who presented to the emergency department and were subsequently hospitalised.

DESIGN

This was a cross-sectional study.

SETTING AND PARTICIPANTS

This study was conducted in two teaching hospitals in Shanghai, China between October 2019 and December 2021 among community-dwelling adults aged ≥60 years.

METHODS

In-person interviews, physical assessment and medical record review were performed to collect data on the characteristics and risk factors of falls. Associations of toileting-related falls with demographic characteristics and geriatric syndromes were examined using logistic regression models.

MAIN OUTCOME MEASURES

Potential risk factors for toileting-related falls.

RESULTS

This study included 419 older patients with a mean age of 73.8±9.7 years. Among 60 (14.3%) patients with toileting-related falls (mean age: 78.8±9.2 years), 63.3% of toileting-related falls, mainly occurred between 00:00 and 05:59 hours, compared with 17.3% of non-toileting-related falls, which primarily occurred during the daytime. The rate of recurrent falls (35%) was significantly higher in the toileting-related falls group than in the non-toileting-related falls group (21.2%) (p=0.02). Logistic regression showed that visual impairment (OR 2.7, 95% CI 1.1 to 7.1), cognitive impairment (OR 3.3, 95% CI 1.3 to 8.4), gait instability (OR 3.1, 95% CI 1.1 to 8.8) and urinary incontinence (OR 3.4, 95% CI 1.2 to 9.9) were strongly associated with toileting-related falls. Twenty-three (38.3%) patients in the toileting-related falls group had moderate and severe injuries, compared with 71.7% in the non-toileting-related falls group (p<0.05).

CONCLUSIONS

This study revealed that patients who reported toileting-related falls were more likely to have cognitive impairment, urinary incontinence, gait instability, visual impairment than patients who fell during other activities. Social and healthcare professionals should prioritise the management of toileting activities in older patients and provide targeted interventions to those in the high-risk group.

Is foot clearance influenced by different types of dual task in once-only faller community-dwelling older adults?

BACKGROUND

Tripping is one of the main causes of falls in older adults and has an important association with minimum toe clearance (MTC). MTC variability while performing alternating (ADT) or concurrent (CDT) dual-task activities may be a useful gait parameter to differentiate once-only fallers from non-faller older adults.

RESEARCH QUESTION

Is the MTC variability influenced by ADT and CDT in once-only faller community-dwelling older adults?

METHODS

Twenty-two community-dwelling older adults with a self-report of up to one fall in the last 12 months were allocated to the fallers group and 38 to the non-fallers group. Gait data were collected by two foot-worn inertial sensors (Physilog® 5, GaitUp, Lausanne, Switzerland). MTC mean magnitude and variability, as well as the stride-to-stride variability, stride time and length, lower limb peak angular velocity, and foot forward linear speed at the MTC instant, were calculated across approximately 50 gait cycles for each participant and condition using the GaitUp Analyzer software (GaitUp, Lausanne, Switzerland). The statistical analyzes were performed in the Statistical Package for the Social Sciences (SPSS), v.22.0, using generalized mixed linear models, adopting an alpha of 5%.

RESULTS AND SIGNIFICANCE

No interaction effect was observed; however, faller participants reduced the MTC variability (standard deviation) [(mean difference, MD = -0.099 cm; confidence interval, 95%CI = -0.183 to -0.015)], regardless of the condition. CDT compared to a single task (only gait) reduced the mean magnitude of the foot forward linear speed (MD=-0.264 m/s; 95%CI=-0.462 to -0.067), peak angular velocity (MD = -25.205 degrees/s; 95%CI = -45.507 to -4.904), and gait speed (MD = -0.104 m/s; 95%CI = -0.179 to -0.029), regardless of the group. These results suggest that MTC variability, regardless of condition, may be a promising gait parameter to differentiate once-only faller community-dwelling older adults from non-fallers.

The Role of Cognitive Performance and Physical Functions in the Association between Age and Gait Speed: A Mediation Study

Simple Summary

Age and mobility are interrelated. In this context, cognitive performance (CP) and physical functions (PF) play a mediating role. However, these concepts are multifaceted, and their interrelationships need further investigations. Thus, our study aims (1) to investigate the association between CP and PF with GS and (2) to examine whether CP and PF mediate the association between age and GS in a large sample of older Brazilian adults. The findings show that low levels of CP and PF were associated with a greater chance of the older individual presenting a slow GS. Moreover, the mediation model indicated that CP and PF mediated, by approximately 12% and 98%, respectively, the association between age and GS.

Abstract

Introduction: With vulnerable aging, gait speed (GS) undergoes progressive changes, becoming slower. In this process, cognitive performance (CP) and physical function (PF) both play an important role. This study aims (1) to investigate the association between CP and PF with GS and (2) to examine whether CP and PF mediate the association between age and GS in a large sample of Brazilian older adults. Methods: A cross-sectional study analyzed 697 individuals (mean age 70.35 ± 6.86 years) from the state of Amazonas. The CP was evaluated by the COGTEL test battery, PF by the Senior Fitness Test battery, and GS with the 50-foot Walk Test. Results: Older adults with a lower CP and PF had a 70% and 86% chance of slow GS, respectively. When CP and PF were placed simultaneously as mediators, the direct effect estimated by the model revealed a non-significant relationship between age and GS. Specifically, CP and PF mediated the association between age and GS, at approximately 12% and 98%, respectively. Conclusions: CP and PF show the potential to estimate GS performance among older adults. Moreover, CP and PF indicated a negative and direct association between age and slow GS, especially PF.

Hip Fractures and Visual Impairment: Is There a Cause–Consequence Mechanism?

Background: Numerous studies have pointed out how visual impairment relates to falls in the elderly, causing dangerous consequences, such as fractures. The proximal femur fracture is one of the most frequent fracture types related to poor vision. This study investigates the link between fall-related hip fractures and visual impairment. Methods: The present is an observational monocentric case–control study. We collected the ophthalmologic anamnesis and measured the visual acuity of 88 subjects with femur neck fracture (case group), comparing it with 101 adults without fractures and a recent fall history. Results: The results showed no statistical difference between the two groups regarding visual acuity, with a p-value of 0.08 for the right eye and 0.13 for the left one. One of the major ophthalmologic morbidities found was cataracts, present in 48% of the control group and 30% of the case group. Conclusions: The data obtained suggest that visual impairment might not be crucial in determining falls in the elderly.

Conscious Control of Gait Increases with Task Difficulty and Can Be Mitigated by External Focus Instruction

Objectives: We aimed to address whether increased task difficulty is sufficient to induce heightened conscious control and influence gait performance in older adults through the manipulations of either task difficulty or attentional focus. Method: Fifty older adults, split into high- (HR) and low-reinvestor (LR) groups, performed a walking task on a 7.4 m straight walkway in two conditions: firm level-ground surface (GW) and foam surface (FW). They subsequently performed the same walking task under two attentional focus conditions: Internal focus (IF) and External focus (EF). Electroencephalography (EEG) T3-Fz and T4-Fz coherences were used to indicate real-time conscious motor control and visual-spatial control, respectively. Results: We observed significantly higher T3-Fz and T4-Fz coherences under FW compared to GW. HR reduced their gait speed at a greater extent than LR under FW. Significantly lower T3-Fz coherence and faster gait were demonstrated under EF compared to IF. LR walked slower under IF compared to Baseline while gait speed of HR did not differ. Discussion: Visual-spatial and conscious movement processing increase as a function of task difficulty during gait. Our findings also advocate the use of external focus instructions in clinical settings, with the potential to reduce conscious control and promote movement automaticity, even in relatively complex gait tasks.

Effectiveness of the fall prevention intervention in older adults with arterial hypertension: randomized clinical trial

OBJECTIVE

To evaluate the effectiveness of the nursing intervention Fall Prevention in reducing falls in older adults with arterial hypertension.

METHODS

Pilot clinical trial, with 118 participants with arterial hypertension from a city in the Northeast of Brazil. Participants were allocated by simple randomization into two groups: intervention (n = 58) and control (n = 60). The intervention was carried out at the participants' homes and consisted of guidelines for modifying environmental and behavioral risk factors for falls. A protocol with nursing activities associated with the Fall Prevention intervention proposed in the Nursing Interventions Classification (NIC) taxonomy was used. The outcome was the self-reported occurrence of falls.

RESULTS

There was a significant difference between the groups in the frequency of self-reported falls (p=0.38) with fewer falls occurring in the intervention group. Sixteen participants fell, of which 5.1% attributed the fall to difficulty walking, 6.8% fell in the living room, 3.4% had a sprain, and 6.8% reported to be afraid to fall again.

CONCLUSION

The nursing intervention Fall Prevention was effective in reducing the occurrence of falls in older adults with arterial hypertension. These findings contribute to the advancement of clinical protocols for the prevention of falls in older adults, as the educational intervention investigated is applicable to different sociodemographic and cultural scenarios.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Extraction and selection of gait recognition features using skeleton point detection and improved fuzzy decision

It is of great importance to effectively measure gait features and recognize the signature gait patterns for gait rehabilitation. In this work, we used a skeleton point detection to extract gait features and proposed an improved fuzzy decision to select the most significant features for classifying gait patterns. Thirteen gait recognition features were extracted from the obtained skeleton points data. Taking the extracted features as an input, our improved fuzzy similarity priority decision method has obtained important sequences of all features based on the relatively important scores. Then, the ranked features were delivered in different classifiers by a sequential forward selection strategy to select the optimal feature subset. There were significant differences between groups in each of the thirteen gait recognition features (p < 0.005), indicating that all extracted features are potential influence factors for classifying gait patterns. We also found that the highest classification accuracy of 100% for gait feature subsets included the stride frequency, maximum flexion angle of knee, and toe-out angle, on the all classifiers. The results suggest that the proposed approaches are very useful in searching for the optimal feature subset in present dataset.

Trends in the Characterization of the Proximal Humerus in Biomechanical Studies: A Review

Proximal humerus fractures are becoming more common due to the aging of the population, and more related scientific research is also emerging. Biomechanical studies attempt to optimize treatments, taking into consideration the factors involved, to obtain the best possible treatment scenario. To achieve this, the use of finite element analysis (FEA) is necessary, to experiment with situations that are difficult to replicate, and which are sometimes unethical. Furthermore, low costs and time requirements make FEA the perfect choice for biomechanical studies. Part of the complete process of an FEA involves three-dimensional (3D) bone modeling, mechanical properties assignment, and meshing the bone model to be analyzed. Due to the lack of standardization for bone modeling, properties assignment, and the meshing processes, this article aims to review the most widely used techniques to model the proximal humerus bone, according to its anatomy, for FEA. This study also seeks to understand the knowledge and bias behind mechanical properties assignment for bone, and the similarities/differences in mesh properties used in previous FEA studies of the proximal humerus. The best ways to achieve these processes, according to the evidence, will be analyzed and discussed, seeking to obtain the most accurate results for FEA simulations.

Combining diagnostic memory clinic with rehabilitation follow-up after hip fracture

PURPOSE

Cognitive impairment and dementia are common in older hip fracture patients. We describe new diagnoses of cognitive disorders (NDCDs) and associated factors in a two-year post-hip fracture follow-up including the use of the diagnostic facilities of a memory clinic.

METHODS

Data were collected on admission and at outpatient assessment 4-6 months post-hip fracture. Diagnoses of cognitive disorders followed the evidence-based Finnish national care guideline including internationally accepted criteria. NDCDs up to 2 years post-hip fracture were extracted manually from the patient files. Logistic regression models were computed to examine the associations between the pre-fracture factors and the domains of the outpatient geriatric assessment and NDCDs.

RESULTS

Of the 1165 hip fracture patients aged ≥ 65 years, 831 had no previous diagnosis of cognitive disorder. Of these, NDCD was documented in 23.3%. Alzheimer's disease (AD) with or without vascular cognitive impairment (VCI) was the most common diagnosis. Cognitive disorder was usually at a moderate stage. Age, higher ASA score and poor nutritional status on admission were associated with new cognitive disorders. At the outpatient follow-up, poorer activities of daily living and mobility disability were associated with NDCD. Patients with a NDCD were more likely to suffer greater mobility impairment, poorer nutritional status and to have more supported living arrangements at follow-up than in the pre-fracture situation.

CONCLUSION

NDCDs are common after hip fracture and associated with impaired rehabilitation outcomes and poor nutritional status. A post-hip fracture assessment co-organized in the form of a memory clinic seems to be feasible to detect previously undiagnosed cognitive disorders. Earlier diagnosis of cognitive disorders is warranted.

The role of reinvestment in conservative gait in older adults

Previous research suggests that reinvestment (i.e. conscious control of movements) is associated with inefficient information processing and compromised movement strategies in older adults during walking. We examined whether reinvestment propensity is associated with conservative gait behaviour in older adults. Trait Reinvestment propensity was measured using the Movement Specific Reinvestment Scale (Chinese version) (MSRS-C). Thirty-eight older adults were categorized into 'Low Reinvestor Group' (LRG) (MSRS-C < 27) and another 38 were categorized into 'High Reinvestor Group' (HRG) (MSRS-C > 38). There were no significant differences in physical and cognitive abilities between groups. Participants were asked to walk along a 6-m straight level-ground walkway at a self-selected pace under conditions of no instruction (Baseline), instruction related to self-focus on body movements (BI), and instruction related to the external environment (EI). No significant difference was found in gait behaviour between LRG and HRG at Baseline. However, significant changes, indicative of conservative gait patterns, were found in LRG when given instructions that prompted them to consciously control their body movements. No changes were observed in HRG under external-related instructions that are assumed to reduce conscious motor processing and improve motor performance. Our findings contradict previous views on the association between trait reinvestment propensity and compromised motor performance in older adults, which potentially reduces justification for reducing trait reinvestment propensity in older adults. We also suggest that MSRS is insensitive to reflect the degree of conscious control during gait tasks. Our findings also implicate the potential detrimental effect of applying inward-focus-related instructions in healthcare rehabilitation settings.

Neurologic examination in the elderly

Clinical evaluation of neurologic disorders in the elderly requires seeking a thorough history and performing an age-appropriate neurologic examination with special attention to changes that occur with normal aging. The history should be obtained from the patient as well as collateral sources close to the patient to ensure accuracy and should include contextual elements such as medical history, social, economic, and psychological background, as well as an assessment of current functional state beyond activities of daily living. The safety of the patient, including the presence of physical, psychological, and financial threats, should be addressed during the interview. The neurological examination in older adults may need to be modified to circumvent disabilities such as hearing and visual impairment. Some elements of the neurological examination are expected to be affected by the process of aging, including pupillary reactivity, presbyopia, difficulty with ocular pursuit and up-gaze, reduced or absent distal reflexes, slower motor speed, and reduced ability to tandem walk, among others. In addition to a screening neurological assessment, evaluation of older adults with a particular complaint may require additional interview queries and examination manoeuvres. Common symptoms in the elderly include cognitive difficulties, balance and gait disorders, tremors, and neuropathy. A specialized approach to patients with cognitive difficulties must include assessment of each cognitive domain, including attention, executive function, learning and memory, perceptual-motor function, and social cognition. Balance and gait are essential parts of the neurological examination, and in patients with a history of falls or mobility issues, should become a central part of the evaluation. In patient with tremors, careful observation of the tremor quality (amplitude, frequency, and alleviating/exacerbating factors such as rest, movement, and posture) can aid diagnosis. Evaluation of neuropathy includes determining modality (numbness, tingling, pain, and weakness) and the distribution of symptoms in order to localize the site of nerve injury, which can be supplemented with nerve conduction studies/electromyography, to guide further diagnostic workup and treatment. A combination of detailed history and examination often will suggest a likely underlying neurodegenerative disorder and guide further diagnostic workup to establish a specific diagnosis.