Best Practices for Improving Patient Outcomes in Older Patient Population - Episode 3
Stephanie Chow, MD, MPH: Another M for the 5Ms of geriatrics is mobility, and gait assessment and fall risk are very important aspects of the comprehensive geriatric assessment. Having a nice walk area for the individual to demonstrate their gait is very important. Looking at their speed, looking at their posture, their arm swing, their footsteps, and how they turn and stand up and sit down—all the things we take for granted are things that a geriatrician will really scrutinize. If they need to use something for walking, looking at the durable medical equipment—a cane, a rollator, a walker—these are things that are actual tools for walking, and these are things that are going to prevent the individual from walking.
Looking at the height, the angle of the arm, how they’re holding themselves—this is something that is very important. How fast the gait speed of an individual is and their function are good predictors of their functional status and their prognosis. This is an important aspect. Their ability to transfer from positions is very important. The Timed Up & Go test is a great way to evaluate the patient in the clinic room. There are different functional reach tests. There are different tests to also assess.
Stressing the importance of balance exercises, resistance training—a simple 30 minutes a day or 20 minutes a day of walking, or walking for 150 minutes a week—are good ways to remind patients that while they have physical therapy for perhaps 6 weeks of their life, even when that physical therapy ends, they’re expected to continue with these exercises. They should be walking every day, and they should also know that that specific exercise is a form of physical activity that gets your heart moving and racing, so you’re breathing a little faster. It’s not simply walking to the mailbox. If that’s something that’s a piece of cake for you, that’s not considered your exercise.
The mobility piece is extremely important. This is often the piece that a patient might first realize is declining and may also lead to more social isolation and a reduction in their activities. It’s important to identify this up front, as something to help with, if you notice that there are some challenges.
It’s very important to assess for fall risk. There’s a greater likeliness of frail, older individuals falling and having a hip fracture and ending up in an acute rehab nursing home facility after hospitalization, as opposed to returning home. And so to prevent these complications and to prevent this more likely undesirable—nobody wants to go into a rehab facility when they could go home.
A patient should work on maintaining the safest possible structure at home. That may include having positional grab bars in various places—perhaps the bathroom, around the toilet seat, the bathtub, or maybe having a railing on the side of their bed. It may also include making sure that their chairs are sturdy and stable. Rocking chairs for somebody who has some balance impairment or challenges with balance are not advised, for example. Removing rugs and fluffy floor coverings from the apartment or house is important, and making sure that the stairs, for example, have a good floor grip. In addition, it is important to look at whatever the individual is wearing on their feet. They should wear good walking shoes.
It’s important to do this kind of home-safety assessment. If a geriatrician or a primary care provider is able to go into the home and do a home-safety evaluation, that’s even better. Other times, if you’re not able to do that—for time purposes or just restriction of the practice—physical therapists are able to do this. It’s important for the geriatrician, if needed, to communicate with the therapist to discuss what needs to be assessed and what needs to be done.
Transcript edited for clarity.