SPECIAL PROBLEMS IN GERIATRIC POPULATIONS

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SPECIAL PROBLEMS IN GERIATRIC POPULATIONS
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Balance Disturbance
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Objectives

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Contents

• I. Balance
• II. Assessment of Balance
• 1- Berg Balance Scale (BBS
• 2-Functional Reach Test (FRT)
• 3- Reach in Four Direction Test .
• 4- Get-Up and Go (GUG) .
• 5- Modified Romberg Test.
• IV. The Balance Control Process
• V. Balance Disorders.
• III. Balance Disorders and Falls in Elderly
• VI. Risk factors of fall.
• VII. Complications of falling

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Balance
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• Definition The term balance refers to the
  ability to maintain the bodys center of mass
  over the base of support in order to retain
  stability.
• It is the ability to react to destabilizing
  forces quickly and efficiently so as to regain
  stability.
• Alternatively, balance while standing and
  walking is the ability to maintain the bodys
  center of gravity over the base of support
  against the destabilizing effects of gravity and
  external disturbances.

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• Balance is a complex activity requiring input
  from many sensory systems integration of this
  information at many levels of the nervous system,
  and a musculoskeletal system to implement the
  commands from the central nervous system.
• The vestibular, visual, and proprioceptive
  systems are the primary sensory systems.
• However, hearing and autonomic systems also play
  a role to transmit the information to the
  musculoskeletal system to stimulate the eyes,
  head, trunk, and limbs to produce coordinated eye
  movements, posture, stance and locomotion.

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• Sensory organs including vestibular, visual,
  proprioceptive, hearing, and autonomic systems,
  all bring sensory information to many levels of
  the nervous system.
• The central nervous system can adjust body sway
  and posture by integrating this information, and
  by controlling skeletal muscles to generate joint
  torque and adjust joint angles.
• Impairment in any component of the postural
  control system can lead to instability and falls
  in elder subjects.

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• It has been reported that proximal muscles
  (hip/trunk) are the primary contributors to
  balance control, while the distal group of
  muscles (leg/thigh) are important in
  compensating for a gait disturbance.
• Posture activity from bilateral leg and thigh
  muscles, and the coordination between the two
  lower extremities are the key to reactive balance
  control, and contribute to balance within one
  gait cycle.

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Assessment of Balance
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• The most commonly used tools for the
  measurement of balance disorders are the Berg
  Balance Scale (BBS), Functional Reach Test (FRT),
  Reach in Four Direction Test, and the Timed
  Get-Up-Go Test (GUG).

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Berg Balance Scale (BBS)

• The BBS was developed to measure balance
  disorders in elderly people and those with
  neurological disorders.
• It consists of 14 tasks which are scored from 0
  to 4, where 0 indicates an inability to perform
  the task and 4 indicates the task was performed
  correctly and independently, i.e. normal
  performance.
• The possible score on this test ranges from 0
  (severely impaired balance) to 56 (excellent
  balance). Scores below 45 indicate that the
  subjects balance is impaired, with an increased
  risk of falls .

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Berg Balance Scale Test.
Item Description
1 Sitting to standing
2 Standing unsupported
3 Sitting unsupported
4 Standing to sitting
5 Transfer
6 Standing with eyes closed
7 Standing with feet together
8 Reach forward with an outstretched arm
9 Retrieving object from floor
10 Turning to back behind
11 Turning 360 degrees
12 Placing alternate foot on stool
13 Standing with one foot in front of the other foot
14 Standing on one foot
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Functional Reach Test (FRT)

• The functional reach test (FRT) was designed to
  test the ability to control movement of the
  center of gravity over a fixed base of support.
• It is used as a dynamic measure of balance to
  measure the limit of stability in the anterior
  direction.
• It is based on measuring as the maximal distance
  that subjects could reach forward horizontally
  beyond arms length while maintaining a fixed base
  of support in the standing position .

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• The distance is measured in centimeters on a
  tape measure fixed to wall.
• The patient, standing with one shoulder close to
  a wall, is asked to extend the fist along the
  wall directly frontward.
• The subject then leans forward, fist extended in
  front as far as possible without taking a step or
  losing stability.
• The patient should be able to move the fist
  forward a distance of at least six inches lesser
  distances indicate a significant risk for falling.

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Reach in Four Direction Test (RFDT)

• Reach in Four Direction Test (RFDT) is a
  modification of the FRT, to obtain a better
  measure of the limits of stability, or how far
  the individual can move without taking a step,
  reaching in all four directions, namely forward,
  right, left and backward.

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Get-Up and Go (GUG) and Timed Up and Go tests

• The Get-Up and Go (GUG) and Timed Up and Go
  tests were designed as a quick measure of basic
  balance skill in elderly people.
• The subject is seated in a straight-backed
  high-seat chair.
• Then measure, in seconds, the time taken to
  stand up from a chair with a 48-cm seat height,
  without using the armrests if possible, stand
  still momentarily ,walk a distance of three
  meters to a line on the floor, adjust the center
  of gravity continuously over a moving base of
  support, turn, walk back to the chair, and sit
  down again.
• Sitting balance and transfers from sitting to
  standing are noted.

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Modified Romberg TestA test for gait/ambulation

• The standing patient performs tasks of
  increasing difficulty by observing the response
  to positional stress loss of visual input and
  displacement.
• The patient assumes different standing
  positions, first with eyes open, then with eyes
  closed.
• With each successive maneuver, stability is
  observed and the patient is asked, "Do you feel
  steady?"
• A light nudge to the sternum can be helpful in
  assessing the response to displacement.
• This allows a rough estimate of balance and can
  help identify causative factors (e.g.,
  osteoarthritis, peripheral neuropathy, foot
  problems, atherosclerosis, weakness, stroke, pain
  or contractures).

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• 1-Feet comfortably apart .
• 2- Feet together.

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• 3-Feet semi-tandem (heel-to-instep)
• 4- Feet tandem (heel-to-toe).

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The Balance Control Process

• Balance is a critical component of mobility.
• The ability to maintain balance is a complex
  process that depends on three major components
• (1) The sensory system for accurate information
  about the body position relative to the
  environment
• (2) The brain's ability to process this
  information and
• (3) The muscles and joints for coordinating the
  movements required to maintain balance.

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• For example, one depends on the feet and joints
  to tell us if the surface we are standing on is
  stable or moving.
• We depend on our eyes to tell us if the
  environment around us is moving or still.
  Additionally, we rely on our inner ears to tell
  us if we are upright or leaning, or standing
  still or moving .

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Balance Disorders

• A number of diseases and impairments have been
  associated with balance disorders. The most
  commonly reported of these conditions are the
  following
• 1- Dizziness is a frequently reported reason for
  falls.
• 2- Systemic dysfunction, as hypertension,
  vascular occlusions, vision and hearing losses,
  small vessel ischemic disease, arthritis,
  osteoporosis, and diabetes mellitus.
• 3- Proprioceptive / somato-sensory losses from
  peripheral neuropathy

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• 4- Decreased motor coordination due to age
• 5- Cerebral changes associated with poor balance
  among older people.
• 6-Peripheral arterial disease with intermittent
  claudication (is a clinical diagnosis given for
  muscle pain (ache, cramp, numbness or sense of
  fatigue).
• 7-Foot problems, particularly foot pain and
  deformities, impair balance and functional
  ability
• 8-Visual disturbances, as cataract.
• 9-Postural hypotension and metabolic disorders.

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Balance Disorders and Falls in Elderly

• 1- The functions of the integrating component of
  balance system decline with aging, leading to
  decrease in the ability of subjects to interact
  with their daily living activities, and increase
  of risk factors to fall as a result of balance
  disturbances.

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• 2- Defects or impairments in the balance system,
  such as diminished vision, atrophy of the
  cerebral cortex, cerebro-vascular accidents,
  vestibular system dysfunction, peripheral
  neuropathy as in diabetic patients,
  musculo-skeletal disease usually involving
  multiple neuro-sensory impairments, will also
  lead to balance disturbance and disorders.
• 3- Aging also is associated with decline
  of physical capacity, and the development of many
  chronic diseases, which can lead to decline in
  muscle strength and in physical endurance.

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• 4-Moreover, impaired balance abilities occur
  with advancing age, along with changes in
  posture
• The trunk is frequently bent forward, and the
  head fixed to the trunk or flexed at the neck.
  Such a stance limits the visual field, and
  places the body center of gravity at the
  periphery of the limits of the stability.
• Limitation of the visual field impairs
  orientation, and diminishes the ability to
  accurately determine the COG position.
• With the center of gravity at the forward
  periphery of the limits of stability the
  righting reflexes are often inadequate to
  maintain equilibrium during propulsion .

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Risk factors of fall

• Risk factors associated with falls can be
  classified as either intrinsic (host) or
  extrinsic (enviromental) .
• Host factors include symptoms such as dizzness ,
  weakness, difficulty walking, or confusion.
• Enviromental factors include conditions such
  as slippery surface, loose rug, poor lighting,
  and obstacles .

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Complications of falling

• Falls may result in injury, including fractures.
  Up to 2 of falls result in fracture hip. Other
  fractures, e.g. in the humerus, wrist, and
  pelvis, can occur in up to 5 of falls. Serious
  injuries, such as head and internal injuries and
  lacerations can occur in up to 10 of falls.
• Over 50 of falls among elderly persons result
  in at least some minor injury.

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• Quality of life may deteriorate drastically
  after a fall at least 50 of elderly persons who
  were ambulatory before fracturing a hip do not
  recover their pre-fracture level of mobility.
• If elderly persons remain on the floor for a
  time after a fall dehydration, pressure sores,
  and pneumonia may result.
• Falls are the most prevalent cause of injuries,
  and the sixth leading cause of death in the
  elderly population .