What is the best course of action for a patient with an unsteady gait, who is able to stand up from a wheelchair and walk with difficulty, and is requesting a walker for mobility?

Walker Prescription for Patient with Unsteady Gait

This patient should receive a walker prescription immediately, with referral to physical therapy for formal gait assessment, walker fitting, proper training, and comprehensive fall risk evaluation. 1, 2

Immediate Clinical Action

Prescribe a two-wheel rolling walker (not a four-wheel rollator) as the initial device, since this patient demonstrates:

• Ability to stand independently from wheelchair 2
• Capacity to ambulate with support (using walls/furniture) 2
• Unsteady gait requiring stabilization 1, 2

A two-wheel rolling walker provides superior stability compared to a four-wheel rollator while remaining more functional than a standard walker, making it appropriate for patients with balance impairment who retain some ambulatory capacity 2.

Required Physical Therapy Referral

Refer to physical therapy for:

• Formal gait and balance assessment using the Timed Up and Go test (TUG) or 4-Stage Balance Test 1
• Proper walker sizing (top of device should align with wrist crease when arms relaxed at sides) 3
• Training on correct walker use, as most patients receive devices without proper instruction and use them incorrectly 3, 4
• Assessment of upper body strength and coordination needed for safe walker operation 2, 3

Comprehensive Fall Risk Assessment

Evaluate using the P-SCHEME framework 1:

• Pain (axial or lower extremity) 1
• Shoes (suboptimal footwear) 1
• Cognitive impairment 1
• Hypotension (orthostatic or iatrogenic) 1
• Eyesight (vision impairment) 1
• Medications (centrally acting drugs) 1
• Environmental factors 1

Administer the three key screening questions 1:

1. Have you fallen in the past year? 1
2. Do you feel unsteady when standing or walking? 1
3. Are you worried about falling? 1

A "yes" to any question warrants broader fall risk intervention 1.

Medication Review

Review all medications for fall risk, particularly:

• Centrally acting medications that impair balance or cause sedation 1
• Drugs causing orthostatic hypotension 1
• Polypharmacy (≥5 medications) associated with functional decline 1

Exercise and Mobility Maintenance

Counsel on balance and strength exercises including tai chi, walking programs, and resistance training to maintain mobility and reduce fall risk 1.

Critical Safety Considerations

Common pitfalls to avoid:

• Incorrect walker height causes musculoskeletal strain and instability 3
• Lack of proper training leads to incorrect use in 16-29% of walking periods, reducing stability 4
• Environmental constraints (doorways, stairs, slopes) create hazards requiring specific training 4, 5
• Four-wheel rollators are inappropriate for patients with significant balance impairment despite being easier to maneuver 2

When to Consider Wheelchair Instead

Reassess for wheelchair if the patient:

• Lacks sufficient upper body strength for walker operation 6, 2
• Cannot safely ambulate even with walker assistance 6
• Develops pressure ulcer risk requiring specialized seating 7, 6
• Has severely limited walking ability preventing mobility-related ADLs 7, 6

Documentation Requirements

Document in medical record:

• Specific functional limitations (e.g., "unsteady gait with fall risk, requires assistive device for safe ambulation") 6
• Medical justification for walker necessity 6
• Statement that less costly alternatives are insufficient 6