Neil B. Alexander

Background: Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity. Methods: Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team. Results: Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually “gave up” trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC. Conclusions: Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study. Trial registration: ClinicalTrials.gov NCT 04045054 05/08/2019.

Background Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity.Methods Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team.Results Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually “gave up” trying to connect; computer literacy issues and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC.Conclusion Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study.ClinicalTrials.gov NCT 04045054 05/08/2019

Background: Near-falls such as a trip, slip, stumble, or misstep involve a loss of balance (LOB) that does not result in a fall, occur more frequently than actual falls, and are associated with an increased fall risk. To date, studies have largely involved detection of simulated laboratory LOBs using wearable devices in young adults. Data on the detection of and kinematics of naturally occurring LOBs in people at high risk of falling are lacking. This may provide a new way to identify older adults at high risk for falls. We aimed to explore key body kinematics underlying real-world trips in at-fall risk community dwelling older adults wearing inertial measurement units (IMU). Methods: Five community-dwelling older adults with a history of falls who reported trips during the study period participated. They wore a voice recorder and 4 IMUs mounted on feet, lower back and wrist for two consecutive weeks to provide a record of the context and timing of LOB events. Sensor data prior to time-stamped voice recording of a trip were processed in order to visually identify unusual foot trajectories and lower back and arm orientations. Then, data of feet, lower back and wrist position and orientation were combined to create a three-dimensional animation representing the estimated body motion during the noted time segments in order to corroborate the occurrence of a trip. Events reported as a trip by the participant and identified as a trip by a researcher, blinded to voice recordings description, were included in the final analysis. Results: A total of 18 trips obtained from five participants were analyzed. Twelve trips occurred at home, three outside and for three the location was not reported. Trips were identified in the sensor data by observing (1) additional peaks to the typical foot velocity signal during swing phase; (2) increased velocity of the contralateral foot and (3) sharp changes in lower back pitch angles. Conclusions: Our approach demonstrates the feasibility of identifying and studying the mechanisms and context underlying trip-related LOBs in at-fall risk older adults during real world activities.

THE link between cognition, gait, and the potential for falls is being increasingly recognized. In this special section of the Journal, a number of experts present new data that further explore the mechanisms underlying this link.

OBJECTIVES: To compare the effect of two 10‐week balance training programs, Combined Balance and Step Training (CBST) versus tai chi (TC), on balance and stepping measures. DESIGN: Prospective intervention trial. SETTING: Local senior centers and congregate housing facilities. PARTICIPANTS: Aged 65 and older with at least mild impairment in the ability to perform unipedal stance and tandem walk. INTERVENTION: Participants were allocated to TC (n= 107, mean age 78) or CBST, an intervention focused on improving dynamic balance and stepping (n=106, mean age 78). MEASUREMENTS: At baseline and 10 weeks, participants were tested in their static balance (Unipedal Stance and Tandem Stance (TS)), stepping (Maximum Step Length, Rapid Step Test), and Timed Up and Go (TUG). RESULTS: Performance improved more with CBST than TC, ranging from 5% to 10% for the stepping tests (Maximum Step Length and Rapid Step Test) and 9% for TUG. The improvement in TUG represented an improvement of more than 1 second. Greater improvements were also seen in static balance ability (in TS) with CBST than TC. CONCLUSION: Of the two training programs, in which variants of each program have been proven to reduce falls, CBST results in modest improvements in balance, stepping, and functional mobility versus TC over a 10‐week period. Future research should include a prospective comparison of fall rates in response to these two balance training programs.

Problems with ambulation and mobility are frequent problems in older adults. Each year, about one in 100 older adults develops new severe mobility disability. Assessment of abnormal gait constitutes a major component of clinical practice and may lead to fall reduction. Clinicians can benefit from simple gait and mobility assessment tools to be used in busy clinical settings. This review focuses on gait and stepping performance measures that can be used by the busy clinician to assess gait, mobility performance, balance, and falls risk in the older adult.

Gait disorders predict functional decline in older adults. They are often the result of multiple causes, so a full assessment should consider different sensorimotor levels and should include a focused physical examination and evaluation of functional performance. Exercise and medical and surgical interventions are effective and can reduce the degree of gait disorder, but usually not without some residual impairment. Orthoses and mobility aids are also important interventions to consider.

Objectives: To determine the relationships between two tests of stepping ability (the maximal step length (MSL) and rapid step test (RST)) and standard tests of standing balance, gait, mobility, and functional impairment in a group of at‐risk older adults. Design: Cross‐sectional study. Setting: University‐based laboratory. Participants: One hundred sixty‐seven mildly balance‐impaired older adults recruited for a balance‐training and fall‐reduction program (mean age 78, range 65–90). Measurements: Measures of stepping maximally (MSL, the ability to maximally step out and return to the initial position) and rapidly (RST, the time taken to step out and return in multiple directions as fast as possible); standard measures of balance, gait, and mobility including timed tandem stance (TS), tandem walk (TW, both timing and errors), timed unipedal stance (US), timed up and go (TUG), performance oriented mobility assessment (POMA), and 6‐minute walk (SMW); measures of leg strength (peak knee and ankle torque and power at slow and fast speeds); self‐report measures of frequent falls (>2 per 12 months), disability (Established Population for Epidemiologic Studies of the Elderly (EPESE) physical function), and confidence to avoid falls (Activity‐specific Balance Confidence (ABC) Scale). Spearman and Pearson correlation, intraclass correlation coefficient, logistic regression, and linear regression were used for data analysis. Results: MSL consistently predicted a number of self‐report and performance measures at least as well as other standard balance measures. MSL correlations with EPESE physical function, ABC, TUG, and POMA scores; SMW; and peak maximum knee and ankle torque and power were at least as high as those correlations seen with TS, TW, or US. MSL score was associated with the risk of being a frequent faller. In addition, the six MSL directions were highly correlated (up to 0.96), and any one of the leg directions yielded similar relationships with functional measures and a history of falls. Relationships between RST and these measures were relatively modest. Conclusion: MSL is as good a predictor of mobility performance, frequent falls, self‐reported function, and balance confidence as standard stance tests such as US. MSL simplified to one direction may be a useful clinical indicator of mobility, balance, and fall risk in older adults.

Background. Difficulty in rising from a chair is common in older adults and may be assessed by examining the biomechanics of the rise. The purposes of this study were (i) to analyze the biomechanics of rise performance during chair-rise tasks with varying task demand in older adults with varying rise ability and (ii) to determine whether a strength-training program might improve chair-rise success and alter chair-rise biomechanics, particularly under situations of increased task demand. Methods. A training group (n = 16; mean age, 82 years) completed a 12-week strength-training regimen while a control group (n = 14; mean age, 84 years) participated in a seated flexibility program. Outcomes included the ability to complete seven chair-rise tasks, and, if the chair-rise tasks were successful, the biomechanics of these rises. Chair-rise task demand was increased by lowering the seat height, restricting the use of hands, increasing rise speed, and limiting foot support. Results. At baseline, increased chair-rise task demand generally required increased task completion time, increased anterior center of pressure (COP) placement, increased momentum, increased hip flexion, and increased hip and knee torque output. Those unable to rise at 100% knee height without the use of their hands (task NH-100), compared with those able to rise during task NH-100, followed this pattern in requiring increased time, more anterior placement of the COP, and increased hip flexion to rise in the least demanding tasks allowing the use of hands. However, the unable subjects generated less momentum and knee torque in these tasks. At 12 weeks, and compared with baseline and controls, the training group demonstrated changes in chair-rise biomechanics but no significant changes in rise success. The training subjects, as compared with the controls, maintained a more posterior COP, increased their vertical and horizontal momentum, maintained their knees in greater extension, and maintained their knee-torque output. Conclusions. These data demonstrate that subtle yet significant changes can be demonstrated in chair-rise performance as a result of a controlled resistance-training program. These biomechanical changes may represent a shift away from impairment in chair-rise ability, and, although the changes are small, they represent how training may reduce rise difficulty.

Difficulty in transferring, the ability to rise in and out of a bed and chair, is a common problem in older adults, particularly those residing in skilled nursing facilities. Focusing on one aspect of transferring, rising from supine to sitting position, we devised a set of bed mobility tasks to test key arm, leg, and trunk movements that likely contribute to successful rising from bed. Healthy young controls (YC, n=22, mean age 23), and older adults (aged 60 and over) either residing independently in congregate housing (CH, n=29, mean age 84) or undergoing rehabilitation in a skilled nursing facility (SNF, mean age 77) were assessed in the time to rise from supine to sitting and in the ability or inability to perform 16 other bed mobility tasks. Trunk function-related tasks, specifically those requiring trunk elevation and trunk balance, were most difficult for the SNF, followed by CH, and then YC. Tasks focusing on trunk flexion strength (sit up arms crossed, bilateral heel raise) and lateral trunk strength/balance were the most difficult for both SNF and CH, although there was minimal difference in the percent unable to complete each task. The major CH-SNF differences occurred in trunk elevation tasks where the upper limb was important in facilitating trunk elevation (sit up with head of bed elevation with use of arms, sit up with the use of a trapeze, or sit up with use of arms from a flat bed position). These findings suggest that to improve frail older adult performance on bed mobility tasks, and specifically in rising from supine to sitting, training should move beyond improving trunk function (i.e., trunk strength). There should be an additional focus, either through therapy or bed design modifications, on how upper limb movements and positioning can be used to assist in trunk elevation.