What is the best management approach for an 80-year-old patient with gait instability due to osteoarthritis of the hip?

Management of Gait Instability in Late 80s Patient with Hip Osteoarthritis

For an 80-year-old patient with gait instability from hip osteoarthritis, immediately prescribe a cane for the affected side, initiate a supervised exercise program combining strength and balance training, and refer for multidisciplinary assessment including physical therapy and fall risk evaluation. 1

Immediate Interventions for Gait Stability

Assistive Device Prescription

• Prescribe a cane immediately for patients whose hip OA causes sufficient impact on ambulation, joint stability, or pain to warrant assistive device use 1
• The cane should be used on the contralateral side to the affected hip to reduce joint loading and improve stability 1
• Ensure proper fitting: the cane handle should align with the wrist crease when the arm hangs naturally at the side 1

Pain Management

• Initiate multimodal analgesia to prevent immobility-related complications (pneumonia, pressure ulcers, deconditioning) 1
• Start with scheduled acetaminophen as first-line for mild-to-moderate pain 2
• Add topical NSAIDs if acetaminophen insufficient, particularly given advanced age and likely comorbidities 1
• Avoid opioids as first-line due to dramatically increased risk of falls, delirium, and mortality in elderly patients 1

Core Non-Pharmacological Management

Exercise Therapy (Highest Priority)

• Prescribe supervised exercise therapy as this is more effective than unsupervised home programs 1
• The program must include three components:
  • Strength training: Focus on hip abductors, extensors, and quadriceps to improve joint stability 1
  • Balance exercises: Essential for fall prevention in elderly with gait instability 1
  • Aerobic exercise: Walking or aquatic exercise to maintain cardiovascular fitness 1
• Adequate dosage requires sessions 2-3 times weekly with progression tailored to functional capacity 1
• Tai chi is strongly recommended as it specifically addresses strength, balance, fall prevention, and self-efficacy in hip OA 1

Self-Management and Education

• Enroll in a structured self-management program combining skill-building (goal-setting, problem-solving), disease education, joint protection, and exercise goals 1
• These programs should occur 2-3 times weekly and can be delivered in-person or online 1
• Reinforce education at every subsequent clinical encounter 1

Weight Management (If Applicable)

• If the patient is overweight or obese, target ≥5% body weight loss as this produces clinically meaningful improvements in pain and function 1
• Weight loss efficacy increases with concurrent exercise programs 1
• Benefits continue to increase with 10-20% weight loss 1

Fall Prevention and Home Safety

Environmental Modifications

• Conduct home safety assessment focusing on:
  • Remove throw rugs and tripping hazards (as illustrated in the AAOS case example) 1
  • Install grab bars in bathroom and along hallways 1
  • Ensure adequate lighting, especially for nighttime bathroom access 1
  • Consider raised toilet seat and shower chair 1

Footwear Assessment

• Recommend appropriate footwear with non-slip soles, adequate support, and proper fit 1
• Avoid slippers without back support or smooth-soled shoes 1

Multidisciplinary Assessment

Comprehensive Geriatric Evaluation

• Refer for orthogeriatric assessment to evaluate:
  • Cognitive function baseline (important for fall risk and treatment adherence) 1
  • Complete medication review to identify fall-risk medications 1
  • Nutritional status and vitamin D levels 1
  • Comorbidities affecting mobility (cardiovascular, pulmonary, neurological) 1, 3
  • Frailty assessment 3

Physical Therapy Referral

• Request comprehensive PT assessment using ICF core set for OA 4
• PT should evaluate gait pattern abnormalities including step length asymmetry, weight-bearing asymmetry, and dynamic range of motion 5, 6
• Establish baseline function using validated measures: Six Minute Walk Test, Timed Up and Go test 6, 4

Monitoring and Follow-Up

Regular Reassessment

• Schedule follow-up every 4-6 weeks initially to monitor:
  • Pain levels using Numeric Pain Rating Scale 4
  • Functional improvement using Hip Disability and Osteoarthritis Outcome Score 4
  • Exercise adherence and progression 1
  • Fall incidents or near-falls 1

Red Flags Requiring Urgent Evaluation

• Sudden worsening of pain or inability to bear weight (possible fracture) 4
• New neurological symptoms (possible nerve compression) 4
• Signs of infection if previous joint injection 4

Common Pitfalls to Avoid

• Do not delay assistive device prescription waiting for physical therapy—prescribe the cane at the initial visit 1
• Do not prescribe unsupervised home exercise alone in elderly with gait instability—supervised programs are significantly more effective 1
• Do not overlook cognitive assessment—undiagnosed cognitive impairment increases fall risk and affects treatment adherence 1
• Do not use opioids for chronic OA pain management in this age group due to fall risk 1
• Do not focus solely on the hip—assess for concurrent knee OA, spinal stenosis, or peripheral neuropathy that may contribute to gait instability 3, 4

Consideration for Surgical Referral

• If conservative management fails after 3-6 months of optimal non-pharmacological therapy, consider orthopedic surgery referral for total hip arthroplasty evaluation 1
• Age alone is not a contraindication—functional status, comorbidities, and patient goals determine surgical candidacy 1
• If surgery pursued, ensure orthogeriatric comanagement to reduce mortality, complications, and length of stay 1