Effect of Learning to Use a Mobility Aid on Gait and Cognitive Demands in People with Mild to Moderate Alzheimer’s Disease: Part I – Cane

Examining gait aid use and user safety by older people with dementia: Perspectives of informal carers to inform practice

PURPOSE

To determine gait aid use and decision-making related to usage in people with dementia, and examine factors influencing (1) gait aid use or not; and (2) falls in past year.

MATERIALS AND METHODS

A survey of informal carers of older people with dementia in the community. Closed questions on gait aid use, falls, timing and sources of gait aid acquisition, and advice received to support use were used. Chi-squared tests (Fisher's Exact) compared: (1) gait aid users vs non-users and carers' report of (i) unsteadiness in walking/turning, (ii) dementia severity, (iii) falls in past year, and (2) fallers vs non-fallers and (i) timing of gait aid commencement relative to dementia diagnosis, (ii) whether health professional advice was received regarding use, and iii) regularity of use.

RESULTS

Forty-seven completed surveys, 63.8% of care recipients used a gait aid; 56.9% had ≥2 falls in past year; 66.7% commenced use after dementia diagnosis; 25% acquired their aids from non-health professionals; and 37% did not receive advice regarding use. Gait aid users and non-users differed on carer ratings of unsteadiness in walking/turning (p = 0.02).

CONCLUSION

Carers reported important aspects regarding gait aid acquisition, safe gait aid use and benefits which warrant further investigation.IMPLICATIONS FOR REHABILITATIONIn our small sample, use of gait aids by people with dementia was related to the level of unsteadiness in walking and/or turning, and not associated with falling in the past year.People with dementia do not routinely receive professional advice about how to use gait aids, highlighting the potential value of maximizing health professional involvement in gait aid prescription and training.Deterioration in the ability of gait aid use after the diagnosis of dementia indicates a need for re-assessment or re-training of gait aid use over time.Clinical guidelines to facilitate decision-making regarding under what conditions gait aids are beneficial, what duration and aspects require instruction to ensure effective use by people with dementia are needed.

The Potential for Effect of a Six-Week Training Program for Gait Aid Use in Older People with Dementia with Unsteadiness of Gait: A Pilot Study

This study examined the potential for effect of a six-week gait aid training program for people with dementia on spatiotemporal gait outcomes, perception of use, and falls with gait aid use. The program utilised four 30-min physiotherapy home visits, scheduled at weeks 1/2/3/6, and was enhanced by carer-supervised practice. Falls and the physiotherapist's clinical judgement of participants achieving safe gait aid use during and after the program were described. Perception ratings at each visit were measured using Likert scales which, along with the spatiotemporal outcomes using the gait aid (Time-Up-and-Go-Test, 4-m-walk-test, Figure-of-8-Walk-Test with/without a cognitive task) at weeks 1 and 6, and at weeks 6 and 12 (6-week post-program), were examined with ordinal logistic regression analyses. Twenty-four community-dwelling older people with dementia and their carers participated. Twenty-one (87.5%) older people achieved safe gait aid use. Twenty falls occurred, and only one faller was using their gait aid when they fell. Walking speed, step length, and cadence significantly improved when walking with the gait aid at week 6 compared with week 1. No significant improvements in spatiotemporal outcomes were retained at week 12. Physiotherapists were more likely to agree that gait aid use had improved walking safety among older people with dementia with subsequent training visits. Larger studies of the gait aid training program are needed for this clinical group.

Effects of cane use on the kinematic and kinetic of lower-extremity joints in inexperienced users

The cane is commonly prescribed for the elderly to maintain balance and enhance independent mobility. However, improper use of cane can increase the risk of falling. Understanding the characteristics of cane gait is critical for better establishing proper cane usage norms. The paper aimed to investigate effects of cane use on kinematics and kinetics of lower extremities in the elderly and the young to guide the development of adaptive cane gait. Twenty participants (10 elder and 10 young) were recruited and walked at a self-comfortable speed or with a cane in a two-point gait. The spatiotemporal gait parameters, hip/knee/ankle joint angles and ground reaction force (GRF) were statistically analyzed using MANOVAs to assess the effects of age and cane. Using the cane significantly decreased step length, cadence and speed and increased step time in both age groups. Age and cane had significant effects on ankle plantarflexion angle in initial swing phase (APA-ISw). In cane gait, the peaks of vertical GRF(V-GRF) and anterior-posterior GRF (AP-GRF) in bilateral lower extremities significantly decreased, and the troughs of right V-GRF significantly increased for both groups. These results suggest that using a cane does interfere with the natural gait of the user and insufficient ankle plantarflexion in initial swing phase (ISw) and reduced AP-GRF may be two key risk factors contributing to cane gait instability. Therefore, the users should consider actively increasing ankle plantarflexion in ISw to avoid deteriorating gait performance due to over-reliance on the cane.

The effect of first-time 4-wheeled walker use on the gait of younger and older adults

INTRODUCTION

The 4-wheeled walker is intended to enhance balance and gait for older adults. Yet, some research suggests that walking aids increase falls risk. An understanding of the influence of age with walker use on gait performance is required.

OBJECTIVE

To examine the effect of initial 4-wheeled walker use on spatiotemporal gait parameters between younger and older adults.

DESIGN

Cross-sectional, repeated-measures.

SETTING

Community-dwelling.

PARTICIPANTS

Twenty-five younger (age: 26.5 ± 4.1 years) and 24 older (age: 68.5 ± 10.5 years) adults participated. Younger adults were aged 18 to 35 years, whereas older adults were 50 years or older. Included were people not requiring the use of a walking aid, and those able to converse in English.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Gait velocity and stride time variability were recorded using accelerometers. Gait was examined under three conditions: unassisted walking; walking with a 4-wheeled walker; and walking with a 4-wheeled walker while completing a secondary task. Conditions were performed across two walking paths: straight and figure-of-8 Walk Test. Separate mixed-methods analyses of variance (ANOVAs; within-subject: condition/path; between-subject: group) were used for statistical analyses.

RESULTS

Velocity was lower when walking using a walker while completing a cognitive task (p < .001), in the figure-of-8 Walk Test (p < .001), and in older adults (p = .001). Stride time variability increased with walking path and condition difficulty (p < .001) for the straight path versus the figure-of-8 Walk Test.

CONCLUSIONS

Using a 4-wheeled walker resulted in a slower and more inconsistent gait pattern across both age groups. Walking more complex configurations resulted in the prioritization of gait over the cognitive task while performing the dual-task conditions. No evidence of an age-related difference in the effect of initial walker use on gait was observed. Nonetheless, walkers are cognitively demanding and their introduction should warrant a clinical follow-up.

The Effects on Gait of 4-Wheeled Walker Use in People with Alzheimer’s Disease Dementia and Gait Impairment: A Pilot Study

In people with dementia, provision of mobility aids is standard treatment for those with impaired gait. However, mobility aid use is independently associated with increased falls risk. In this short communication, gait velocity and stride time variability were recorded in eleven adults with Alzheimer’s disease dementia. Three conditions were tested: single-task (no aid), walking with a walker, and dual-task (walker use and counting backwards) under both a straight path and Figure-of-8 walking configuration. Gait velocity increased when using a walker compared to no aid in the Figure-of-8 walking configuration. Walker use improved gait in simple walking, but benefits diminished upon dual-task.

Rehabilitation in Dementia

Dementia is an eurodegenerative disorder, which causes significant disability, especially among the elderly population worldwide. The affected person shows a progressive cognitive decline, which interferes with the independence in performing the activities of daily living. Other than the cognitive domain, the patient tends to have neuropsychiatric, behavioral, sensorimotor, speech, and language-related issues. It is expected that the global burden of the disease will rise with more people entering the geriatric age group. By 2050 close, to 140 million people will be living with one or the other type of dementia. Alzheimer's disease contributes to more than 60% of cases worldwide, followed by vascular dementia. Pharmacotherapy has a limited role to play in the treatment, and at present, no drug is available, which can halt or reverse the progress of the disease. World Health Organization has mandated rehabilitation as a core recommendation in the global action plan on the public health response to dementia. Rehabilitation services are widely recognized as a practical framework to maximize independence and community participation in dementia care. The rehabilitation program is customized to achieve the desired goals, as each person has different experiences, preferences, motivations, strengths, and requirements based on type, course, and severity of the illness. It is an interdisciplinary-team approach with the involvement of several health care professionals. This article reviews the existing literature and outlines the effective rehabilitation strategies concisely in dementia care.

Effectiveness of gait aid prescription for improving spatiotemporal gait parameters and associated outcomes in community-dwelling older people: a systematic review

PURPOSE

To integrate the evidence of gait aid prescription for improving spatiotemporal gait parameters, balance, safety, adherence to gait aid use, and reducing falls in community-dwelling older people.

METHODS

Seven health databases were searched to June 2021. Experimental studies investigating gait aid prescription (provision and instruction for use) for older people, reporting gait parameters, balance, falls, and safety of or adherence to gait aid use was included. Mean differences with 95% confidence intervals of gait and balance outcomes in participants at the program's last follow-up were analyzed. The safety of and adherence to gait aid use were described.

RESULTS

Eight studies were included (N = 555 older people). No meta-analyses could be performed. Five studies used a single gait aid instruction session. Gait aid prescription had inconsistent effects on gait velocity, and no reported benefits in reducing gait variability in older people with mobility problems or fall risks, including Parkinson's or Alzheimer's disease. No study investigated gait aid prescription on falls and balance performance. Effects on safety and adherence to gait aid use were unclear.

CONCLUSION

Research is needed to investigate the benefits of extensive gait aid training in older people with mobility problems, including those with dementia or high falls risk.IMPLICATIONS FOR REHABILITATIONThere is little evidence currently addressing the benefits of gait aid prescription on gait and associated outcomes in older people with mobility problems or fall risks.Gait aid prescription yielded inconsistent effects on increasing gait velocity and did not appear to reduce gait variability in older people with mobility problems or fall risks, nor in those with Parkinson's disease or Alzheimer's disease.Clinicians may consider using a more extensive gait aid training approach to optimize learning of safe gait patterns and gait aid use, which may produce better outcomes.

The Differential Effect of First-Time Single-Point Cane Use between Healthy Young and Older Adults

BACKGROUND

Walking aids are often introduced to older adults to enable independent mobility. Single-point canes are the most common device used. Benefits are tempered by research suggesting that walking aids increase fall risk. A better understanding of the effect of walking aid use on gait performance is required.

OBJECTIVE

To evaluate differences in the effect of initial single-point cane use on gait between younger (YAs) and older adults (OAs).

DESIGN

Cross-sectional.

SETTING

Community-dwelling.

PARTICIPANTS

Twenty-six YAs (mean age ± standard deviation [SD]: 23.7 ± 2.8 years) and 25 OAs (mean age ± SD: 70.8 ± 14.1 years) participated. Inclusion criteria were 18 to 35 years of age for YAs or ≥50 years for OAs, be able to ambulate unassisted, and without any condition affecting mobility.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Gait velocity and stride time variability under different walking path configurations (straight path, Groningen Meander Walking Test, Figure-of-8 Walk Test) and conditions (unassisted walking, walking with a single-point cane, and walking with a single-point cane while completing a cognitive task) were recorded in a laboratory. The arithmetic task of subtracting 1s from 100 was used as the secondary cognitive task. Data analysis included separate three-way mixed analyses of variance (ANOVAs; path/condition/group).

RESULTS

There was a statistically significant two-way interaction between walking path and condition for velocity (P < .001, ω²  = 0.03) and stride time variability (P = .032, ω²  = 0.02). In addition, a significant main effect of group was also observed (velocity: P = .004, ω²  = 0.07; stride time variability: P = .001, ω²  = 0.09).

CONCLUSIONS

Using a single-point cane decreased velocity and increased stride time variability in both YAs and OAs. However, the cognitive load and effect on gait of initial cane use was not different between age groups. Standardized guidelines aimed at facilitating a client's transition toward the safe use of a walking aid are needed. Future research should evaluate if training can mitigate some of the adverse changes to gait stability observed with initial walking aid use.

The patients' perspective on the perceived difficulties of dual-tasking: development and validation of the Dual-task Impact on Daily-living Activities Questionnaire (DIDA-Q)

BACKGROUND

Everyday-life activities often require performing dual tasks (DT), with consequent possible occurrence of motor-cognitive or motor-motor interference. This could reduce quality of life, in particular in people with neurological diseases. However, there is lack of validated tools to assess the patients' perspective on DT difficulties in this population. Therefore, we developed the Dual-task Impact on Daily-living Activities-Questionnaire (DIDA-Q) and tested its psychometric properties in people with multiple sclerosis (PwMS).

METHODS

Items were generated based on existing scales, DT paradigms used in previous studies and the opinion of a multi-stakeholder group, including both experts and PwMS. Twenty DT constituted the preliminary version of the DIDA-Q which was administered to 230 PwMS. The psychometric properties of the scale were evaluated including internal consistency, validity and reliability.

RESULTS

Nineteen items survived after exploratory factor analysis, showing a three-factor solution which identifies the components mostly contributing to DT perceived difficulty (i.e., balance and mobility, cognition and upper-limb ability). The DIDA-Q appropriately fits the graded response model, with first evaluations supporting internal consistency (Cronbach's alpha=0.95), validity (70% of the hypotheses for convergent and discriminant constructs confirmed) and reliability (intraclass correlation coefficients=0.95) of this tool.

CONCLUSION

The DIDA-Q could be used in research and clinical settings to discriminate individuals with low vs. high cognitive-motor or motor-motor interference, and to develop and evaluate the efficacy of personalized DT rehabilitative treatments in PwMS.

Development, reliability and validity of the Safe Use of Mobility Aids Checklist (SUMAC) for 4-wheeled walker use in people living with dementia

BACKGROUND

Balance and gait problems are common and progressive in dementia. Use of a mobility aid provides physical support and confidence. Yet, mobility aid use in people with dementia increases falls three-fold. An assessment tool of mobility aid safety in people with dementia does not currently exist. The objectives of this study were: 1) to develop a tool for the evaluation of physical function and safe use of a 4-wheeled walker in people with dementia, and 2) to evaluate its construct and criterion validity, inter-rater and test-retest reliability and minimal detectable change.

METHODS

Healthcare professionals (HCP) experienced in rehabilitation of people with dementia participated in focus groups for item generation of the new tool, The Safe Use of Mobility Aid Checklist (SUMAC). The SUMAC evaluates physical function (PF) and safe use of the equipment (EQ) on nine tasks of daily life. Reliability was evaluated by HCP (n = 5) scored participant videos of people with dementia (n = 10) using a 4-wheeled walker performing the SUMAC. Inter-rater and test-retest reliability was assessed using intra-class correlation coefficients (ICC). Construct validity evaluated scores of the HCPs to a consensus HCP panel using Spearman's rank-order correlations. Criterion validity evaluated SUMAC-PF to the Performance-Oriented Mobility Assessment (POMA) gait subscale using Spearman's rank-order correlations.

RESULTS

Three focus groups (n = 17) generated a tool comprised of nine tasks and the components within each task for physical function and safe use. Inter-rater reliability was statistically significant for SUMAC-PF (ICC = 0.92, 95%CI (0.81, 0.98), p < 0.001) and SUMAC-EQ. (ICC = 0.82, 95%CI (0.54, 0.95), p < 0.001). Test-retest reliability was statistically significant for SUMAC-PF (ICC = 0.89, 95%CI (0.81, 0.94), p < 0.001) and SUMAC-EQ. (ICC = 0.88, 95%CI (0.79, 0.93), p < 0.001). As hypothesized, the POMA gait subscale correlated strongly with the SUMAC-PF (r_s = 0.84), but not EQ (r_s = 0.39).

CONCLUSIONS

The focus groups and research team developed a tool of nine tasks with evaluation on physical function and safe use of a 4-wheeled walker for people with dementia. The SUMAC tool has demonstrated content validity for the whole scale and good construct and criterion validity for the SUMAC-PF and SUMAC-EQ. The subscores of the SUMAC demonstrated excellent to good inter-rater and test-retest reliability.

Effect of Learning to Use a Mobility Aid on Gait and Cognitive Demands in People with Mild to Moderate Alzheimer's Disease: Part II - 4-Wheeled Walker

BACKGROUND

Cognitive deficits and gait problems are common and progressive in Alzheimer's disease (AD). Prescription of a 4-wheeled walker is a common intervention to improve stability and independence, yet can be associated with an increased falls risk.

OBJECTIVES

1) To examine changes in spatial-temporal gait parameters while using a 4-wheeled walker under different walking conditions, and 2) to determine the cognitive and gait task costs of walking with the aid in adults with AD and healthy older adults.

METHODS

Twenty participants with AD (age 79.1±7.1 years) and 22 controls (age 68.5±10.7 years) walked using a 4-wheeled walker in a straight (6 m) and Figure of 8 path under three task conditions: single-task (no aid), dual-task (walking with aid), and multi-task (walking with aid while counting backwards by ones).

RESULTS

Gait velocity was statistically slower in adults with AD than the controls across all conditions (all p values <0.025). Stride time variability was significantly different between groups for straight path single task (p = 0.045), straight path multi-task (p = 0.031), and Figure of 8 multi-task (0.036). Gait and cognitive task costs increased while multi-tasking, with performance decrement greater for people with AD. None of the people with AD self-prioritized gait over the cognitive task while walking in a straight path, yet 75% were able to shift prioritization to gait in the complex walking path.

CONCLUSION

Learning to use a 4-wheeled walker is cognitively demanding and any additional tasks increases the demands, further adversely affecting gait. The increased cognitive demands result in a decrease in gait velocity that is greatest in adults with AD. Future research needs to investigate the effects of mobility aid training on gait performance.

The experiences of people with Alzheimer's dementia and their caregivers in acquiring and using a mobility aid: a qualitative study

PURPOSE

Cognitive deficits and gait and balance problems are progressive in people with Alzheimer's dementia. Yet, mobility aids are associated with an increased falls risk in people with dementia. Our objectives were to identify the perceptions of people living with mild-to-moderate Alzheimer's dementia, and their caregivers, on the use of mobility aids.

METHODS

A qualitative study using semi-structured, face-to-face interviews was conducted. Community-dwelling older adults with dementia attending a day hospital program were recruited. Thematic analysis was conducted and the text was coded into broad themes aligned with the research questions. The coded text was examined for patterns and similarities, and grouped to form inductive themes.

RESULTS

Twenty-four people (12 living with dementia and their 12 caregivers) participated. Five themes were identified: (1) acknowledgement of need; (2) protecting a sense of self; (3) caregiver oversight and relief of burden; (4) healthcare professional involvement; (5) environment and design of aids.

CONCLUSIONS

The findings suggest that people with Alzheimer's dementia and their caregivers regard mobility aid use as increasing independence. There is a role for healthcare professionals to be involved in the prescription, provision and training for use of mobility aids among people living with dementia to ensure uptake and safety.IMPLICATIONS FOR REHABILITATIONMobility aid use is regarded as increasing independence by people with Alzheimer's disease and their caregivers.Falls risk associated with mobility aid use was not well known and caregivers perceived mobility aids as a means to reduce falls.Most people do not see a healthcare professional when they acquire a mobility aid and there is a role for healthcare professionals to be involved in the prescription, provision and training of people living with dementia in the use of mobility aids in order to increase the uptake of aids and their safe use.

Associations with rates of falls among home care clients in Ontario, Canada: a population-based, cross-sectional study

BACKGROUND

Accidental falls among older adults are a leading cause of injury-related hospitalizations. Reducing falls is an ongoing quality improvement priority for home care, given that many home care clients experience falls. In this study, we identify factors associated with the rate of falls among home care clients.

METHODS

We conducted a population-based, cross-sectional study using secondary data from the Hamilton, Niagara, Haldimand, and Brant health region of Ontario, Canada from January 1 - March 31, 2018. We captured person-level characteristics with falls from the Resident Assessment Instrument - Home Care (RAI-HC). Negative binomial regression was used to model the rate of falls.

RESULTS

Functional characteristics of home care clients had strong, statistically significant associations with the rate of falls. Declines in activities of daily living, assistive device use for locomotion indoors, polypharmacy, and health conditions, such as dizziness or lightheadedness, and parkinsonism, were associated with a higher rate of falls. Males who used assistive devices had a higher rate of falls compared to females; however, males with neurological and cardiovascular health conditions had a decrease in the rate of falls compared to females. Home care clients with parkinsonism who used a cane and took eight or more drugs had stronger associations with an increased rate of falls compared to those who do not have parkinsonism.

CONCLUSIONS

Functional characteristics, polypharmacy, and health conditions are associated with increased rates of falls among home care clients. Home care clients who are at a greater risk of falls may require environmental adjustments in their home to reduce or eliminate the possibility of falling.