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Did you assess gait as part of the geriatric evaluation? [Margaret (Meega) Wells, PhD, RN, NP]

Nurse practitioners in the primary care setting in both rural and urban areas are in ideal positions to provide quality care to older adult patients to help them maintain independence and function. According to the U.S. Census bureau (2010),it is estimated that 13% of the U.S. population is 65 years and older. Most of these older adults reside in the community and receive healthcare in outpatient settings. Older adult patients are often complicated to manage and nurse practitioners must be systematic and thorough in providing care to this group. A comprehensive geriatric assessment (CGA) should be performed once a year along with periodic focused assessments for management of chronic illnesses. Ideally, performing a CGA on a regular basis will allow the nurse practitioner to detect subtle changes in older adults and intervene before major problems occur. Components of the comprehensive geriatric assessment should include medical, psychosocial, cognitive, and functional assessments. Assessing functional assessment of older adults using physical performance measures will be the focus of this article.

Functional Component

The functional assessment should include self-reported measures as well as an objective physical performance measure. First, it is necessary to ask patients if they have any difficulties with activities of daily living (ADL). ADL include eating, dressing, ambulating, and toileting. Next, patients should be asked about their ability to perform instrumental activities of daily living (IADL). IADL include shopping, managing finances, housekeeping, taking medications, using the telephone, and driving or using public transportation and this requires higher executive functioning. Inability to perform IAD is also associated with cognitive impairment. (Reppermund et al., 2011)

It is important that nurse practitioners watch their patients’ walk and this is often omitted from the geriatric assessment. Patients are usually put in the exam room and assisted to the exam table prior to the nurse practitioner’s arrival to the room. Nurse practitioners may not have the opportunity to observe patients walk unless they incorporate it in to the physical exam. There are several physical performance measures that can be used to objectively measure physical function. Gait speed and Timed Up and Go (TUG) are two measures that will be discussed in this article and both of these measures include observation of gait.

In many cohort studies,gait speed, or the rate in which one walks, has been found to be associated with survival in older adults. (Cesari et al., 2005; Cesari et al., 2009; Ostir, Kuo, Berges, Markides, & Ottenbacher, 2007; Rolland et al., 2006; Rosano et al., 2008) Walking requires energy, movement control, and support, which put demand on multiple organ systems, and this is why gait speed is thought to predict survival. (Abellan van Kan et al., 2009) Gait speed is usually calculated using time in seconds to walk 4 meters and is reported in meters per second. Gait speeds of 1 m/s or faster suggest healthier aging, while gait speeds of 0.6 m/s or slower increase the likelihood of poor health and function. (Viccaro, Perera, & Studenski, 2011)

In a systematic review of 9 cohort studies for a total of 34,485 community-dwelling older adults who had gait speed measured at baseline, and survival monitored for at least 5 years, the overall 5-year survival rate for participants was 84% and the 10-year survival rate was 59.7%. (Abellan van Kan et al., 2009) The mean gait speed of the participants was 0.92 meters per second (m/s) and it was associated with survival in all studies using hazard ratios. Survival increased as gait speed increased in 0.1 m/s increments.

Gait speed measurement has a place in the clinical setting because it may help identify older adults who have a high probability of living for 5 or 10 years and would benefit from more intensive preventative interventions. Further, gait speed may be used to help stratify risks of the patient for surgery or chemotherapy. Gait speed is relatively easy to measure and only requires a stopwatch and a 4-meter course. Patients are instructed to walk at usual pace, as if walking down the street, with no further encouragement or instructions. A gait speed less than 1 m/s or a declining gait speed over time may indicate a new health problem that requires evaluation. A physical therapy referral may be needed at this time. A recent systematic review of frail older adults found that an exercise intervention improved gait speed and performance on ADLs; however, the type of exercise was not specified nor was the effect on mortality. (Chou, Hwang, & Wu, 2012) Hardy and colleagues found that improved gait speed significantly reduced mortality in a sample of community-dwelling adults 65 years and older. (Hardy, Perera, Roumani, Chandler, & Studenski, 2007)

The TUG test can also be used to assess balance and gait. The TUG measures some aspects of balance such as rising, walking, turning, and sitting and is correlated with functional mobility. (Podsiadlo & Richardson, 1991) The TUG is quick, requires no special equipment, and can be done in about 1-2 minutes during an office visit. The TUG is the time it takes a patient to rise from a standard height chair with arms, walk 10 feet (3 meters), turn around, walk back to the chair and sit down. Patients may use their arms or an assistive device when rising from the chair; however, another person may not assist them. This screening test is timed and using assistive devices or the arms of the chair to rise may slow down the time it takes to complete the task. An independently mobile adult should be able to complete the TUG in less than 10 seconds. A TUG time of 15 seconds or greater requires further evaluation to determine the cause of the mobility impairment. If a musculoskeletal problem is found to be the problem, a referral to physical therapy may be appropriate.

Gait speed and TUG both were found to predict health decline, ADL difficulty, and falls in older adults living the community. (Viccaro et al., 2011) However, both tests were found to be more useful in predicting recurrent falls rather than first-time falls. (Viccaro et al., 2011)According to the Panel on Prevention of Falls in Older Persons, TUG is recommended to evaluate gait and balance in patients with a positive fall screen or those at risk for falling. (Panel on Prevention of Falls in Older Persons,American Geriatrics Society and British Geriatrics Society, 2011) Evidence exists that supports using gait speed or the TUG to screen for mobility impairment; however, more research is needed is support interventions that can improve or maintain physical function.

Summary

It is essential that nurse practitioners perform a comprehensive geriatric assessment as least once a year on all older adult patients. The four components of this evaluation include medical, psychosocial, cognitive, and functional assessments. In the primary care setting, many nurse practitioners do not always objectively evaluate the physical functional ability of patients. Either gait speed or TUG can be used to measure functional ability in older adults. Both are easy to perform and do not require special equipment other than a chair, a measured distance, and a stopwatch. Both tests require patients to follow direction to carry out the task. The nurse practitioner can obtain much information from watching the patient perform these tasks. Maintaining independence is important to older adults and detecting subtle changes in functional ability can help nurse practitioners to manage the care older adult patients more effectively. The nurse practitioner should perform a comprehensive geriatric assessment that includes either gait speed or the TUG. If either is found to be slow or declined from the previous year, careful evaluation of the patient is needed and an intervention such as physical therapy or an individualized exercise program may be an appropriate addition to the treatment plan prescribed by the nurse practitioner.

References

Abellan van Kan, G., Rolland, Y., Andrieu, S., Bauer, J., Beauchet, O., Bonnefoy, M., et al. (2009). Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an international academy on nutrition and aging (IANA) task force. Journal of Nutrition, Health & Aging, 13(10), 881-889.

Cesari, M., Kritchevsky, S. B., Penninx, B. W., Nicklas, B. J., Simonsick, E. M., Newman, A. B., et al. (2005). Prognostic value of usual gait speed in well-functioning older people–results from the health, aging and body composition study. Journal of the American Geriatrics Society, 53(10), 1675-1680.

Cesari, M., Pahor, M., Marzetti, E., Zamboni, V., Colloca, G., Tosato, M., et al. (2009). Self-assessed health status, walking speed and mortality in older mexican-americans. Gerontology, 55(2), 194-201.

Chou, C., Hwang, C., & Wu, Y. (2012). Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: A meta-analysis. Archives of Physical Medicine and Rehabilitation, 93(2), 237-244.

Hardy, S. E., Perera, S., Roumani, Y. F., Chandler, J. M., & Studenski, S. A. (2007). Improvement in usual gait speed predicts better survival in older adults. Journal of the American Geriatrics Society, 55(11), 1727-1734.

Ostir, G. V., Kuo, Y. F., Berges, I. M., Markides, K. S., & Ottenbacher, K. J. (2007). Measures of lower body function and risk of mortality over 7 years of follow-up. American Journal of Epidemiology, 166(5), 599-605.

Panel on Prevention of Falls in Older Persons,American Geriatrics Society and British Geriatrics Society. (2011). Summary of the updated american geriatrics society/british geriatrics society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157.

Podsiadlo, D., & Richardson, S. (1991). The timed “up & go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.

Reppermund, S., Sachdev, P. S., Crawford, J., Kochan, N. A., Slavin, M. J., Kang, K., et al. (2011). The relationship of neuropsychological function to instrumental activities of daily living in mild cognitive impairment. International Journal of Geriatric Psychiatry, 26(8), 843-852.

Rolland, Y., Lauwers-Cances, V., Cesari, M., Vellas, B., Pahor, M., & Grandjean, H. (2006). Physical performance measures as predictors of mortality in a cohort of community-dwelling older french women. European Journal of Epidemiology, 21(2), 113-122.

Rosano, C., Aizenstein, H., Brach, J., Longenberger, A., Studenski, S., & Newman, A. B. (2008). Special article: Gait measures indicate underlying focal gray matter atrophy in the brain of older adults. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 63(12), 1380-1388.

U.S, C. B. (2010). USA QuickFacts. Retrieved December 29, 2011, from http://quickfacts.census.gov/qfd/states/00000.html

Viccaro, L. J., Perera, S., & Studenski, S. A. (2011). Is timed up and go better than gait speed in predicting health, function, and falls in older adults?. Journal of the American Geriatrics Society, 59(5), 887-892.

 

Rural Veterans: What Rural Nurses Need to Know. [Angeline Bushy, PhD, RN, FAAN ,U.S. Army, Col. (Retired)]

Since the founding of our country, rural Americans have always responded when our

Nation has gone to war. In the American Revolution, rural Americans left their homes and their families to fight the threat of loss to their families and their lands. During the American Civil War, rural Americans again responded to fight the threat of loss to their way of life, and to protect their families. However, during the Civil War the United States government instituted the first-ever military draft. Again, motivated by tradition and values, rural Americans responded.

According to an Issue Paper published by the National Rural Health Association Rural (2007) people respond to such needs because they maintain value structures that are reflective of service to others and service to their country, volunteerism, care of home, and a sense of place. They also respond for economic concerns and certainly through patriotism. Whether motivated by their values, patriotism, and/or economic concerns, the picture has not changed much in 200 years. More than 44 percent of U.S. military recruits come from rural areas, Pentagon figures show. In contrast, 14 percent come from major cities. Youths living in the most sparsely populated Zip Codes are 22 percent more likely to join the Army, with an opposite trend in cities. Regionally, most enlistees come from the South (40 percent) and West (24 percent) (NRHA, 2007).

In the last two decades the United States has been involved with a number of military conflicts predominately in the Mideast (US Department of Veterans Affairs (VA), 2013), resulting in the deployment of numerous military personnel. Moreover, it is not unusual for a soldier to be deployed multiple times within a 3 year period. Since the U.S. has an all-volunteer military (army, air force, navy, marines) the majority are in the reserve component or the National Guard. Again, a disproportionate number of returning veterans have rural origins, and are returning to their home communities having physical and emotional health care needs.

Compared to urban veterans, rural veterans have higher prevalence of physical illness, lower health-related quality of life, and greater health care needs. Despite their greater need, rural veterans are less likely than urban veterans to use VA or private sector health care services. The disparity in use of health care may be due in part to longer driving distances to VA medical facilities experienced by many rural veterans, relative to their urban counterparts. VA primary care is available within a 30-minute drive for 91% of urban veterans, 38% of rural veterans, and 22% of highly rural veterans. Fewer than half (49%) of highly rural veterans live within 60 minutes of VA primary care.

The Department of Veterans Affairs (VA) is statutorily required to provide VA-enrolled veteran with access to timely and quality medical care. It does so through the nation’s largest integrated health care delivery system, with more than 150 VA medical centers (VAMCs), 800 community-based outpatient clinics (CBOCs), and a range of other types of facilities (e.g., nursing homes) that provide care to more than 5.5 million patients. Despite this, Congress remains concerned that veterans, in particular rural veterans, may not be able to access VA health services. Among veterans enrolled in VA health care, 41% reside in rural or highly rural areas. Rural-enrolled veterans share certain characteristics that influence access to and the need for care.

Congress has demonstrated continuing interest in modifying VA delivery of care to expand access for rural veterans. Such interest has been demonstrated through report language, statutory mandates, appropriation of funds, and authorization of demonstration projects. In particular, Congress has encouraged the VA to collaborate with federally qualified health centers (FQHCs)—facilities that receive federal grants and are required to be located in areas where there are few providers, particularly rural areas. The VA is generally a provider—rather than a financer—of health care services; however, the VA has statutory authority to reimburse non-VA providers for services that are not readily available within the VA’s integrated health care delivery system. VA facilities may consider contracting with outside providers to provide services to rural veterans.

One type of facility that the VA has contracted with in the past are FQHCs. Although FQHCs are one type of facility that the VA can collaborate with, FQHCs may be candidates for VA collaboration because, as a condition of receiving a federal grant, they must meet certain requirements that include providing specific types of services, maintaining certain records, and meeting certain quality standards. These requirements, and the leverage that the federal government may have as a funding source, may facilitate VA-FQHC collaboration to provide care to veterans in rural areas. Some considerations that may arise during attempts to increase VA-FQHC collaboration include the costs of care to an FQHC, the VA, and veterans; the capacity of an FQHC to serve veterans in addition to its existing patients; and the compatibility of the VA and an FQHC in terms of the services available, quality initiatives, accreditation, and use of electronic health records. To address these considerations and encourage VA-FQHC collaboration, there are a number of policy levers that Congress might use. These include oversight, an incentive fund, directed spending, statutory mandates, and watchful waiting. Congress may also consider a combination of these levers.

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Table I: VA-Enrolled Veterans *

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Not all veterans are eligible to enroll in the VA. In general, eligibility for enrollment in VA health care operates through a system of eight priority groups, based on veteran status, presence of service-connected disabilities or exposures, income, and/or other factors, such as status as a former prisoner of war or receipt of a Purple Heart. Once enrolled in the VA health care system, a veteran remains enrolled and does not have to reapply, even if the veteran’s priority group changes (due, for example, to a change in income).Veteran status is established by active-duty status in the U.S. Armed Forces and an honorable discharge or release from active military service. Generally, persons enlisting in one of the armed forces after September 7, 1980, and officers commissioned after October 16, 1981, must have completed two years of active duty or the full period of their initial service obligation to be eligible for VA health care benefits. Service members discharged at any time because of service-connected disabilities are not held to this requirement. Veterans returning from combat operations are eligible to enroll for five years from the date of discharge without having to satisfy a means test or demonstrate a service-connected disability. A service connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities and, for those with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability (38 C.F.R. §§4.1-4.31). Veterans who are eligible on the basis of exposure include those veterans who may have been exposed to Agent Orange during the Vietnam War or veterans who may have diseases potentially related to service in the Gulf War.

*Source: CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Erin Bagalman.

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References:

Congressional Research Service. (2013, April 3).Health Care for Rural Veterans: The Example of Federally Qualified Health Centers. Accessed on May 21, 2013 from http://www.himss.org/files/HIMSSorg/Content/files/20130418-CRS-RptHealthCareRuralVeterans.pdf

National Rural Health Association Issue Paper. (2007). Rural Veterans: A special Concern for Rural Health Advocates. Accessed May 21, 2013 from: http://www.ruralhealthweb.org/go/rural-health-topics/veterans-health

US Department of Veterans Affairs Website, Accessed on May 21, 2013 from: http://www.va.gov

US Department of Veterans Affairs (2013). Rural Health Exchange Information. Accessed on May 21, 2013 from: http://www.va.gov/health/NewsFeatures/20110421a.asp