How to screen for gait instability and fall risk in geriatric patients

Screening for Gait Instability and Fall Risk in Geriatric Patients

All older adults aged 65 and over should be screened annually for falls by asking about fall history in the past year, followed by standardized gait and balance assessment for those reporting falls or demonstrating unsteadiness. 1, 2

Initial Screening Algorithm

Step 1: Annual Fall History Screening

• Ask all older adults at least once a year: "Have you fallen in the past 6-12 months?" 1, 2
• Document the number of falls and any associated injuries 1
• A single fall in the past year warrants further evaluation 1

Step 2: Basic Mobility Assessment

• Perform the "Get Up and Go Test" for all patients reporting falls or at risk 1
  • Have the patient rise from an armchair without using arms
  • Walk 3 meters (10 feet)
  • Turn around
  • Walk back to the chair and sit down 1
  • Normal time is less than 10 seconds for healthy adults over 60 1
• Those demonstrating difficulty or unsteadiness require comprehensive assessment 1

Comprehensive Fall Risk Assessment

For patients who:

• Report recurrent falls in the past year
• Present after a fall
• Demonstrate abnormalities in gait or balance during screening 1, 2

Components of Assessment:

1. Detailed Fall History

   • Circumstances of falls (including witness accounts when available)
   • Time and place of falls
   • Activity during fall
   • Symptoms before fall (dizziness, palpitations, etc.) 1, 2

2. Medication Review

   • Focus on psychoactive medications
   • Polypharmacy (four or more medications)
   • Cardiovascular medications 2

3. Physical Examination

   • Vision assessment
   • Lower extremity joint function
   • Basic neurological examination (proprioception, strength, reflexes)
   • Cardiovascular assessment (including postural blood pressure) 1, 2

4. Functional Assessment

   • Standardized balance and gait tests:
     • Tinetti Performance-Oriented Mobility Assessment (POMA) 3
     • Berg Balance Scale (BBS) 3
     • Timed Up and Go (TUG) - most useful for nursing home residents 3
   • Assessment of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) 1

5. Environmental Assessment

   • Home hazard evaluation (if feasible)
   • Footwear assessment 1, 2

Advanced Gait Assessment Considerations

For specialized settings or high-risk patients, consider more detailed gait analysis:

• Gait variability measures (temporal parameters of swing and stance) have shown highest sensitivity in distinguishing fallers from non-fallers 4
• Key gait properties to assess include 'pace', 'variability', and 'coordination' 5
• Local dynamic stability measures can help identify fall-prone elderly adults 6

Common Pitfalls to Avoid

• Relying solely on fall risk screening without implementing targeted interventions 2
• Overlooking medication review, especially psychotropic medications 2
• Failing to assess multiple risk factors in high-risk individuals 2
• Not performing at least two different standardized tests for more precise assessment 3
• Neglecting to follow up with patients who have fallen previously, as recurrence rates increase over time 2

Intervention Planning Based on Assessment

• Exercise programs with balance training for those with gait instability 2
• Medication review and modification, particularly psychotropic drugs 2
• Treatment of postural hypotension if identified 2
• Home hazard modification for environmental risks 2
• Gait training and advice on appropriate assistive devices 2

By following this structured approach to screening and assessment, clinicians can effectively identify older adults at risk for falls and implement appropriate interventions to reduce fall risk and associated morbidity and mortality 1, 2.