Mobility Issues

Definition

Mobility issues refer to difficulties that seniors have with getting around physically, whether indoors or outdoors. The English words mobility and mobile come from a Latin word that means “capable of movement.” Other words that are used in connection with mobility issues are ambulatory, which means that a person is able to walk about, as compared to one who is confined to bed; and gait, which refers to an individual's characteristic manner of walking. Abnormalities of gait are part of a medical evaluation for mobility issues.

Description

Mobility issues are not the inevitable result of aging itself; rather, they usually reflect the overall effects of other conditions that become more common and severe as a person gets older. They include a number of different problems that older adults may have with walking or otherwise getting around, such as weakness in the legs, knees, or ankles; difficulty with balance or coordination; pain in the joints or muscles that make walking difficult; loss of visual acuity or proprioception (internal awareness of the body's position in space); and difficulty with breathing.

Activities of daily living

Mobility issues can threaten a senior's independence because they interfere with both activities of daily living (ADLs), which are basic activities necessary for adequate self-care; and instrumental activities of daily living (IADLs), which are necessary to maintaining one's independence within a neighborhood or community. ADLs include:

• bathing or showering
• dressing and undressing
• eating (feeding oneself)
• transferring oneself from bed to chair and back
• maintaining bowel and bladder continence
• using the toilet

IADLs include:

• ability to use telephone
• shopping (for other items as well as groceries)
• food preparation
• housekeeping (cleaning house, making beds, washing dishes, etc.)
• doing laundry
• using transportation (driving own car or using public transportation)
• proper use of medications
• money management

It is not difficult to see how inability to walk (or walk comfortably or safely) can keep a senior from maintaining adequate personal hygiene , using the toilet when necessary, cooking and cleaning, and carrying out all the other activities that are part of independent living.

Other considerations

In addition to interfering with activities of daily living, mobility issues can compromise a senior's quality of life in several other respects. First, impaired mobility increases the risk of falls , which can lead to increased mortality as well as a number of health problems beyond bone fractures and joint damage. Second, impaired mobility interferes with pleasurable activities (traveling, participation in sports, hobbies, etc.) and social life, including visits with friends and family. This loss helps to explain why seniors with mobility issues are at increased risk of depression and other mood disorders. Last, inactivity tends to worsen such chronic conditions as diabetes, insomnia , chronic constipation , and some types of arthritis.

Demographics

Mobility problems and falls are widespread among older adults. Between 30 and 40 percent of older adults living in the community suffer a fall in any given year. Falls are the leading cause of accidental death in people over 65. At least 20 percent of seniors living in the community have gait problems or some difficulty in walking; this figure increases to 50 percent in those over 85. Researchers studying a large group of community-living persons 75 years of age and older found that 10 percent needed help in walking across a room; 20 percent could not climb a flight of stairs without help, and 40 percent were unable to walk a half-mile.

Causes and symptoms

Mobility problems may have a range of different and intersecting causes. In many cases, a senior may suffer from more than one disorder that affects movement, in addition to coping with the side effects of medications given to treat the disorders:

• Diseases that affect the bones and joints: osteoarthritis, fibromyalgia, rheumatoid arthritis, osteoporosis.
• Diseases that affect the central nervous system: Parkinson's disease, late-stage syphilis, meningitis, seizure disorders, stroke.
• Diseases that affect breathing and endurance: asthma, emphysema, pneumonia, lung cancer.
• Infectious diseases that cause fever: influenza, pneumonia, common cold, urinary tract infection.
• Eye disorders and changes in vision due to aging. These include declining visual acuity, difficulty seeing the contrast between light and dark, and loss of depth perception.
• Disorders that affect the sense of balance: Ménière's disease, infections of the inner ear, loss of nerve endings related to hearing.
• Medication side effects. Many seniors take several different drugs, a condition known as polypharmacy. The more drugs a person takes, the higher the risk that one or more will affect alertness and balance.
• Alcohol or substance abuse.
• Malnutrition. A senior who is not eating adequately will eventually suffer from wasting of muscle tissue. In addition, a deficiency of vitamin B12 increases an older adult's risk of cardiovascular disease as well as such mood disorders as depression.
• Deconditioning. An older adult who is confined to bed by an illness or following surgery loses muscular strength and endurance.
• Environmental factors. These include a house or apartment with stairs that are difficult to manage, poor lighting, slippery or uneven floors, and other features that may increase the risk of falls. In addition, living in an unsafe neighborhood may discourage an older adult from going outside for fear of being attacked.

The symptoms of mobility issues range from falls and injuries associated with falls to pain when trying to walk; gait disorders (dragging the feet, limping, waddling, lifting the feet high because the knee cannot bend normally, tottering, or taking irregular steps); fear of falling; and avoidance of walking.

Diagnosis

History-taking and physical examination

Because there are so many different possible causes of mobility problems, the senior's doctor will take a careful medical history, including past medical problems, medication history, acute illnesses, family history, and other issues that might affect the senior's stability, strength, coordination, or posture. The physical examination will look for possible problems with hearing or vision as well as checking blood pressure , temperature, pulse rate, breathing, reflexes, spinal curvature, and muscle tone. The doctor may also give the senior a mini mental status examination or similar screening test for dementia.

A common test for mobility disorders that can be carried out in the doctor's office is the Get-Up-and Go Test. In this test, the doctor watches while the patient gets up from a standard armchair, walks a fixed distance in a straight line, turns, walks back to the chair, and sits down again. This test allows the doctor to check for weakness in the legs, knees or ankles; loss of balance while standing or sitting; or an unsteady or abnormal gait.

Laboratory tests and imaging studies

The doctor may order a blood test to check for anemia or thyroid disorders, a urine test to check for a urinary tract infection , or X-rays to check for fractures or arthritis. A bone density test may be given to check for osteoporosis . If a brain disorder is suspected, the doctor may order a CT scan or MRI. In some cases, the patient may be referred to a neurologist for tests of the nerves in the lower leg.

Questioning the patient about falls and mobility problems

Since the early 2000s, it has become recommended practice for primary care doctors to ask older adults about any falls within the past year. This precaution is necessary because many seniors are afraid to report falls for fear of being institutionalized, or because they were not seriously hurt and do not think the fall was important. If the senior reports having fallen, the doctor will ask how many times they fell; what they were doing at the time; where they were when they fell; whether they were dizzy or had trouble breathing before the fall; whether they lost consciousness; whether they were able to get up within a few minutes or had trouble getting back up; what medications they were taking at the time; and whether they had severe pain afterward.

Treatment

Specific treatments depend on the underlying causes of the senior's mobility problems. Although therapy does not always mean that the senior will walk again as well as they did when they were younger, relief from pain and improvement in function is possible in most cases.

Medications

Medications may be prescribed to bring down fever, treat infections, or reduce the pain of arthritis and other muscle or joint disorders. Vitamin therapy may be prescribed if the senior's diet is deficient in folic acid or vitamin B ₁₂.

Exercise and physical therapy

Therapeutic exercise and physical therapy are frequently prescribed for mobility issues. Therapeutic exercise is aimed at improving the strength of the lower body, increasing endurance, improving balance, and increasing the flexibility and range of motion of the joints. The doctor may refer the senior to a physical therapist for a personalized program of therapeutic exercise that targets the senior's specific areas of weakness.

The physical therapist may also use ultrasound or various types of electrical stimulation to strengthen the senior's muscles, relieve muscle spasms, and promote tissue healing. Other treatments that are helpful are hydrotherapy and the application of heat to the sore joint or muscle.

Surgery

Many seniors with severe arthritis in the hips and knees are helped considerably by total joint replacement. Surgery may also be used simply to remove torn cartilage or bone spurs from an arthritic joint. If the senior's mobility problems are caused by eye disorders, surgery may be recommended. Cataract removal is an increasingly common and highly successful procedure to improve sight, as is surgery to correct glaucoma .

Assistive devices and environmental changes

The doctor may recommend a cane or walker in order to encourage the senior to stay as active as possible. Physical therapists can usually help in selecting the right size for the patient and teaching him or her to use it correctly. Orthotic shoe inserts, leg or ankle braces, or shoes with special supports may also be prescribed in order to increase the patient's stability and balance when walking.

The doctor will usually recommend checking the senior's home for safety hazards (inadequate lighting, loose rugs, slippery floors, lack of railings on stairwells, etc.) and other environmental concerns. Many times furniture rearrangement, closet and storage reorganization, and the installation of grab bars on the toilet and in the shower can help to prevent falls.

QUESTIONS TO ASK YOUR DOCTOR

• Would I benefit from a therapeutic exercise program?
• What can I do to minimize my risk of falls?
• Am I a candidate for knee or hip surgery?

Nutrition/Dietetic concerns

Nutritional concerns are relevant to mobility issues insofar as a healthful diet is important to maintaining muscle strength and bone density. In addition, seniors who are depressed because of mobility difficulties should be assessed to make sure they are getting enough to eat. Last, seniors whose mobility issues are related to overweight should consider weight reduction through a reduced-calorie diet as well as exercise.

Therapy

Therapy for mobility issues may consist of one or more of the following: regular moderate exercise for overall fitness or weight reduction; therapeutic exercise to improve balance, flexibility, strength, or endurance; physical therapy; joint replacement surgery; other surgical procedures to strengthen or improve range of motion in joints or repair damaged muscles; medication to reduce inflammation in sore joints and muscles; and assistive devices to improve mobility.

Prognosis

The prognosis for mobility issues depends on the senior's age; the underlying disease(s) or disorders; the number of other factors that may be contributing to weakness or loss of balance; the number of falls the senior may have had in the past; and the type of therapy recommended.

Prevention

Some factors that contribute to mobility issues in later life are genetic (such as a family history of osteoarthritis or osteoporosis) and cannot be prevented.

Older adults can, however, lower their risk of mobility problems by:

• Quitting smoking.
• Using alcohol and other substances that affect balance and coordination carefully and in moderation.
• Reporting any falls to the doctor promptly even if there is no apparent injury.
• Keeping one's weight at a healthful level.
• Getting regular exercise for overall fitness and flexibility.
• Asking the doctor about possible benefits from a therapeutic exercise program.
• Keeping such chronic conditions as high blood pressure, heart problems, or diabetes under control.
• Checking the house or apartment for safety hazards and correcting them.
• Wearing properly fitted sturdy low-heeled shoes with nonslip soles.
• Moving to a safer neighborhood if necessary.

KEY TERMS

Activities of daily living (ADLs) —Activities considered necessary for adequate self-care.

Ambulatory —Able to get up and walk around.

Deconditioning —Loss of physical fitness due to illness or inactivity.

Functional independence —The ability to carry out or perform actions or activities necessary for everyday life without assistance.

Gait —A person's characteristic manner of walking. Abnormalities of gait are part of assessing an older adult for mobility problems.

Instrumental activities of daily living (IADLs) —Activities necessary for independent living within one's community.

Polypharmacy —Taking five or more drugs at the same time.

Proprioception —Internal perception of the position of the body and limbs in space that does not depend on visual information.

Rehabilitation —The process of restoring a patient to a condition of health or useful and constructive activity.

Sedentary —Not physically active.

Caregiver concerns

The senior's caregiver should:

• Check the senior's living situation for safety hazards periodically.
• Make sure that the senior is not abusing alcohol or sleeping medications, and is taking all other prescription medications correctly.
• Check the senior's shoes for proper fit, and replace them when needed.
• Encourage the senior to keep walking as much as possible, and to continue their therapeutic exercise program if one has been recommended.
• Report any falls to the doctor at once, along with a brief description of where the accident occurred, what the senior was doing, and any other relevant information. Reporting the fall is particularly critical if the senior lost consciousness or could not get up for several hours.
• Observe the senior from time to time in order to see whether there are any changes in gait or signs of weakness in the legs or feet.
• Make sure that the senior is eating a nutritious diet.

Resources

books

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 20, “Falls.” Whitehouse Station, NJ: Merck, 2005.

Houts, Peter S., ed. Eldercare at Home, 2nd ed., Chapter 21, “Mobility Problems.” New York: American Geriatrics Society Foundation for Health in Aging, 2007.

Silber, Irwin. A Patient's Guide to Knee and Hip Replacement. New York: Simon and Schuster, 1999.

periodicals

Hakim, R. M., A. Roginski, and J. Walker. “Comparison of Fall Risk Education Methods for Primary Prevention with Community-Dwelling Older Adults in a Senior Center Setting.” Journal of Geriatric Physical Therapy 30 (February 2007): 60–68.

Newstead, A. H., J. G. Walden, and A. J. Gitter. “Gait Variables Differentiating Fallers from Nonfallers.” Journal of Geriatric Physical Therapy 30 (March 2007): 93–101.

Rand, Scott E., et al. “The Physical Therapy Prescription.” American Family Physician 76 (December 1, 2007):1661–1666.

Rubenstein, Laurence, Christopher Powers, and Catherine MacLean. “Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders.” Annals of Internal Medicine 135 (October 16, 2001): 686–693.

Unsworth, C. A., Y. Wells, C. Browning, et al. “To Continue, Modify or Relinquish Driving: Findings from a Longitudinal Study of Healthy Ageing.” Gerontology 53 (November 21, 2007): 423–431.

other

Katz ADL Scale and Lawton IADL Scale. Available online in PDF format at http://son.uth.tmc.edu/coa/FDGN_1/RESOURCES/ADLandIADL.pdf [cited February 19, 2008].

National Institute on Aging (NIA). Exercise: A Guide from the National Institute on Aging. NIH Publication No. 01-4258. Bethesda, MD: NIA, 2007. Available online in PDF format at http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A508-94CA4E537D4C/0/Exercise_Guide907.pdf [cited March 24, 2008].

National Institute on Aging (NIA) Age Page. Falls and Fractures. Bethesda, MD: NIA, 2007. Available online at http://www.nia.nih.gov/HealthInformation/Publications/falls.htm [cited March 24, 2008].

organizations

American Geriatrics Society (AGS), Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY, 10118, (212) 308-1414, (212) 832-8646, [email protected], http://www.americangeriatrics.org/index.shtml.

American Physical Therapy Association (APTA), 1111 North Fairfax Street, Alexandria, VA, 22314, (703) 684-APTA (2782), (800) 999-2782, (703) 684-7343, http://www.apta.org/.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 1 AMS Circle, Bethesda, MD, 20892, (301) 495-4484, (877) 22-NIAMS, (301) 718-6366, [email protected], http://www.niams.nih.gov/.

National Institute on Aging (NIA) Information Center, P.O. Box 8057, Gaithersburg, MD, 20898, (800) 222-2225, www.nia.nih.gov.

Rebecca J. Frey Ph.D.