9. Mobility and Safety

Question 1

Risk Factors

Answer 1

Behavioural:

• dementia
• delirium
• medications
• polypharmacy
• substance use
• hx of falls
• fear of falling
• footwear
• poor nutrition/hydration
• lack of PA
• not using equipment
• taking risky actions

Socioeconomic:

• living alone
• lack of social support
• housing condition
• income level
• communication and language barriers
• limited access to services and transportation
• cultural factors
• costs of equipment, med, treatments

Environmental:

• weather
• clutter
• stairs
• tripping hazard
• slippery surfaces
• poor lighting
• use of restraints
• lack of hand railing/safety equipment
• poor building design

Question 2

Risk Factors

Answer 2

Behavioural:

• dementia
• delirium
• medications
• polypharmacy
• substance use
• hx of falls
• fear of falling
• footwear
• poor nutrition/hydration
• lack of PA
• not using equipment
• taking risky actions

Socioeconomic:

• living alone
• lack of social support
• housing condition
• income level
• communication and language barriers
• limited access to services and transportation
• cultural factors
• costs of equipment, med, treatments

Environmental:

• weather
• clutter
• stairs
• tripping hazard
• slippery surfaces
• poor lighting
• use of restraints
• lack of hand railing/safety equipment
• poor building design

Biological:

• osteoarthritis
• orthostatic hypotension
• balance impairment
• diabetes
• vision/hearing impairment
• age and gender
• health conditions ex. CV, resp, neuro, musculoskeletal, continence…

Question 3

4 Pathologic conditions

affecting mobility

Answer 3

1. Gait disorders
   -ataxia:disorganized gait, staggering, side steps
   -Parkinson’s disease: stooped posture, short, rushing, shuffling steps, uncontrollable propulsion, body ahead of feet
   “frail senior”: stooped, hip and knee flexion, stiffness in turning, no arm swing
   -hemiplegia: poor arm and leg swing, affected limb does not bend, leg swings in wide circle, foot drag
   -osteomalacia: softening of bones dt vit D deficiency: skeletal pain on weight bearing, unstable waddling gait
2. Osteoporosis
   -SILENT disease
   -osteoblasts decrease
   -osteoclasts. increase
   -results in pain, loss of function, suffering, mortality
   -high risk of bone fracture
   -hip fracture will not live beyond 1 year
   Risk factors:
   (Non-modifiable)
   -female
   -white
   -age
   -family hx of it
   -previous fragility and 40+ yrs
   (Modifiable)
   -low body weight of below 132 lbs
   -low calcium intake
   -vit D deficiency
   -estrogen deficiency
   -low testosterone
   -low PA
   -Excess caffeine or alcohol
   -smoking
   -arthritis
   -use of steroids or anticonvulsants(anti-seizure meds)
   Prevention and Management
   -encourage PA
   -eat foods with calcium or take it D
   -smoking cessation
   -drink alcohol in moderation
   -education that steroids deplete calcium stores
3. Parkinson’s disease
   -progressive neurodegenerative disorder of the central nervous system where ell death in a region of the midbrain causes not enough dopamine to be present
   -signs and symptoms are dt deficiency of dopamine which causes an imbalance in acetylcholine to dopamine
   -acetylcholine stimulates skeletal, smooth, and cardiac muscle contraction
   -more common in men
   -onset at 60 yrs, but can occur throughout lifespan
   -characterized by progressive motor dysfunction
   Symptoms:
   -tremor
   -rigidity, stooped posture
   -bradykinesia (sloe movement)
   -hypophonia- lowered voice volume
   -micrographia- small, cramped writing
   -pain
   -depression and dementia are common comorbidities
   Wearing Off Effect
   -aka “end of dose”
   -can be sudden
   -causes anxiety and results in falls
   -cause: early in PD, still some intact neurons
   Therapy:
   -no cure
   -physiotherapy
   -exercise
   -Deep brain stimulation DBS
   (pharm)
   -dopamine agonists
   -supportive drugs (laxatives, antidepressants, anti-anxiety, sleep-inducing…)
4. Arthritic conditions x2
5. Osteoarthritis
   -degenerative joint wear and tear =damage over time = loss of cartilage = rough joints rub =pain, swelling, stiffness
   -most common arthritis
   -onset is gradual., begins in 40’s
   -more women are affected
   -leads to loss of independence
   Treatment:
   (non-pharm)
   -weight loss
   -PA, stretching
   physical therapy
   -local ice/heat
   -stress reduction
   -sleep
   -joint unloading with aids
   (pharm)
   -acetaminophen
   -NSAID’s
   -steroids
   -cortisone injections
   -surgical joint replacement
6. Rheumatoid arthritis
   -a chronic progressive, systemic disease of the immune system (auto-immune disorder)
   -osteoarthritis is not systemic
   -the immune system attacks joint tissues=WBC releases cytokines to attack cells of synovial membrane= membrane forms new blood vessels = inflammations= fluid buildup= joint space decreases = joint ankylosis (aka scar formation) = calcification of fibrous tissue loss of joint mobility
   Cause unknown, could be:
   -infection,
   -autoimmunity
   -genetics
   -environmental factors
   -hormonal factors
   -more common in women
   -symptoms worsen in AM
   or after no PA, lasts months

Osteo Vs Rheumatoid
-osteo: later in life, asymmetrical, weight-bearing joints, stiffness worse in PM, lasts. less than 1 hour
-rheum: can happen at any age, rapid (week-months), symmetrical, small joints of hand and feet, immune disorder
Treatment:
-same as osteo
-DMARDs - anti-rheumatics and immunity suppressants
-antacid - to protect the stomach from NSAIDs
-antibiotics if a joint is septic

Question 4

Assessment

Answer 4

Arthritis and Parkinson’s disease:

• assess pain, mobility, hx of falls, psychological changes
• assess medication management and side effects
• assess need for transport aids
• assess psychological function that are base line for individual pts within the stages of the disease

Question 5

Interventions

Answer 5

• pain management (pharm, non-pharm)
• pt consult and rehab
• ADL aids
• medication management
• ongoing assessment for risk of falls, safe movement and effective ambulatory aids
• possible ROM and massage
• QOL assessment
• identify ways of reducing risks to self and others while promoting autonomy and independence

Question 6

Universal Falls Risk

SAFE

Answer 6

S
safe environment
-bottom rails down
-brakes on
-pathways free of hazards
-lights on prn

A
assist with mobility
-mobilize at least 2x/day
-safe and regular toileting
(q2-3h)
-transfer/mobility status documented and visible
-glasses, hearing, and mobility devices within reach

F
fall and injury risk reduction
-call bell and personal items within reach
-bed lowered
-footwear
-hip protectors prn

E
engage pt and family
-discuss avoidable/ongoing risk factors
-discuss how, why, and when to use interventions
-mutual falls risk reductions plan developed