Geriatrik Popülasyonda Düşme, Yürüyüş ve Denge Bozuklukları
Özet
Bu bölüm, yaşlı bireylerde yürüyüş ve denge bozukluklarının düşme riski üzerindeki etkilerini, altta yatan mekanizmaları, değerlendirme yöntemlerini ve güncel rehabilitasyon yaklaşımlarını ele almaktadır. Yaşlanmayla birlikte görsel, vestibüler, somatosensoriyel ve nöromüsküler sistemlerde meydana gelen değişiklikler, denge kontrolünü ve yürüme performansını olumsuz etkileyerek düşme riskini artırmaktadır. Düşmeler; yaralanma, fonksiyon kaybı, bağımsızlığın azalması ve mortalite artışı gibi ciddi sonuçlara yol açabilmektedir. Bölümde yürüyüş ve denge bozukluklarının nörolojik ve nörolojik olmayan nedenleri açıklanmakta, yaşlanmanın yürüme biyomekaniği üzerindeki etkileri güncel literatür ışığında değerlendirilmektedir. Ayrıca öykü alma, fizik muayene, fonksiyonel denge testleri, bilgisayarlı dinamik postürografi, vestibüler fonksiyon testleri ve üç boyutlu yürüyüş analizi gibi klinik değerlendirme yöntemleri ayrıntılı olarak sunulmaktadır. Son bölümde ise egzersiz temelli rehabilitasyon, vestibüler rehabilitasyon, sanal gerçeklik uygulamaları, oyunlaştırılmış tedavi yaklaşımları ve çevresel düzenlemeler gibi güncel müdahale stratejileri ele alınmaktadır. Erken tanı, kapsamlı değerlendirme ve bireyselleştirilmiş rehabilitasyon programlarının yaşlı bireylerde düşmelerin önlenmesi ve fonksiyonel bağımsızlığın korunmasında kritik öneme sahip olduğu vurgulanmaktadır.
This chapter addresses the effects of gait and balance disorders on fall risk in older individuals, the underlying mechanisms, assessment methods, and current rehabilitation approaches. Changes in the visual, vestibular, somatosensory, and neuromuscular systems that occur with aging negatively affect balance control and gait performance, increasing the risk of falls. Falls can lead to serious consequences such as injury, loss of function, decreased independence, and increased mortality. The chapter explains the neurological and non-neurological causes of gait and balance disorders and evaluates the effects of aging on gait biomechanics in light of current literature. Clinical assessment methods such as history taking, physical examination, functional balance tests, computerized dynamic posturography, vestibular function tests, and three-dimensional gait analysis are also presented in detail. The final section discusses current intervention strategies such as exercise-based rehabilitation, vestibular rehabilitation, virtual reality applications, gamified treatment approaches, and environmental modifications. It emphasizes that early diagnosis, comprehensive assessment, and individualized rehabilitation programs are critical for preventing falls and maintaining functional independence in older individuals.
Referanslar
Bergland A, Wyller TB. Risk factors for serious fall related injury in elderly women living at home. Injury prevention. 2004;10(5):308–13.
Tinetti ME, Speechley M. Prevention of falls among the elderly. New England journal of medi- cine. 1989;320(16):1055–9.
Cumming RG. Epidemiology of medication-related falls and fractures in the elderly. Drugs & Aging. 1998;12(1):43–53. doi: 10.2165/00002512-199812010-00005. PubMed PMID: 9467686.
Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010;21(5):658–68. doi: 10.1097/ EDE.0b013e3181e89905. PubMed PMID: 20585256.
Weel Cv, Vermeulen H, van den Bosch W. Falls, a community care perspective. Lancet.
1995;345(8964):1549–51. doi: 10.1016/s0140-6736(95)91091-3. PubMed PMID: 7791442.
Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. New England journal of medicine. 1997;337(18):1279–84.
Salvà A, Bolíbar I, Pera G, et al. Incidence and consequences of falls among elderly people living in the community. Medicina clinica. 2004;122(5):172–6.
Kannus P, Sievänen H, Palvanen M, et al. Prevention of falls and consequent injuries in elderly people. The Lancet. 2005;366(9500):1885–93. doi: 10.1016/S0140-6736(05)67604-0. PubMed PMID: 16310556.
LeBlanc ES, Hillier TA, Pedula KL, et al. Hip fracture and increased short-term but not long- term mortality in healthy older women. Archives of internal medicine. 2011;171(20):1831–7. Epub 20110926. doi: 10.1001/archinternmed.2011.447. PubMed PMID: 21949033; PubMed Central PMCID: PMC3576923.
Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evi- dence show? Medical Clinics. 2006;90(5):807–24.
Prudham D, Evans JG. Factors associated with falls in the elderly: a community study. Age and ageing. 1981;10(3):141–6. doi: 10.1093/ageing/10.3.141. PubMed PMID: 7270321.
Mahlknecht P, Kiechl S, Bloem BR, et al. Prevalence and burden of gait disorders in elderly men and women aged 60–97 years: a population-based study. PloS one. 2013;8(7):e69627. Epub 20130724. doi: 10.1371/journal.pone.0069627. PubMed PMID: 23894511; PubMed Central PMCID: PMC3722115.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. New England journal of medicine. 1988;319(26):1701–7.
Verghese J, Holtzer R, Lipton RB, et al. Quantitative gait markers and incident fall risk in older adults. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences. 2009;64(8):896–901. Epub 20090406. doi: 10.1093/gerona/glp033. PubMed PMID: 19349593; PubMed Central PMCID: PMC2709543.
Agrawal Y, Carey JP, Della Santina CC, et al. Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004. Arc- hives of internal medicine. 2009;169(10):938–44. doi: 10.1001/archinternmed.2009.66. PubMed PMID: 19468085.
Verghese J, Annweiler C, Ayers E, et al. Motoric cognitive risk syndrome: multicountry pre- valence and dementia risk. Neurology. 2014;83(8):718–26. Epub 20140716. doi: 10.1212/ WNL.0000000000000717. PubMed PMID: 25031288; PubMed Central PMCID: PMC4150127.
Salzman B. Gait and balance disorders in older adults. Americanfamilyphysician. 2010;82(1):61– 8.
Thompson TL, Amedee R. Vertigo: a review of common peripheral and central vestibular di- sorders. Ochsner Journal. 2009;9(1):20–6. PubMed PMID: 21603405; PubMed Central PMCID: PMC3096243.
Sturnieks DL, St George R, Lord SR. Balance disorders in the elderly. Neurophysiologie Cli- nique/Clinical Neurophysiology. 2008;38(6):467–78. Epub 20081007. doi: 10.1016/j.neuc- li.2008.09.001. PubMed PMID: 19026966.
P. Di Fabio AE, John F. Greany, Saurav Paul, et al. Suppression of the vertical vestibulo-ocular reflex in older persons at risk of falling. Acta oto-laryngologica. 2001;121(6):707–14.
Pothula V, Chew F, Lesser T, et al. Falls and vestibular impairment. Clinical Otolaryngology & Allied Sciences. 2004;29(2):179–82. doi: 10.1111/j.0307-7772.2004.00785.x. PubMed PMID: 15113307.
Karatas M. Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. The neurologist. 2008;14(6):355–64. doi: 10.1097/NRL.0b013e31817533a3. PubMed PMID: 19008741.
Hausdorff JM, Nelson ME, Kaliton D, et al. Etiology and modification of gait instability in older adults: a randomized controlled trial of exercise. Journal of Applied Physiology. 2001;90(6):2117– 29. doi: 10.1152/jappl.2001.90.6.2117. PubMed PMID: 11356774.
Grace Gaerlan M, Alpert PT, et al. Postural balance in young adults: the role of visual, ves- tibular and somatosensory systems. Journal of the American Academy of Nurse Practitioners. 2012;24(6):375–81. Epub 20120329. doi: 10.1111/j.1745-7599.2012.00699.x. PubMed PMID: 22672489.
Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age and Ageing. 2006;35(suppl_2):ii7–ii11.
Chaudhry H, Findley T, Quigley KS, et al. Measures of postural stability. Journal of rehabili- tation research and development. 2004;41(5):713–20. doi: 10.1682/jrrd.2003.09.0140. PubMed PMID: 15558401.
Angelaki DE, Cullen KE. Vestibular system: the many facets of a multimodal sense. Annual Review of Neuroscience. 2008;31(1):125–50. doi: 10.1146/annurev.neuro.31.060407.125555. Pu- bMed PMID: 18338968.
Lord SR, Clark RD, et al. Visual acuity and contrast sensitivity in relation to falls in an elderly population. Age and ageing. 1991;20(3):175–81. doi: 10.1093/ageing/20.3.175. PubMed PMID: 1853790.
Aboutorabi A, Arazpour M, Bahramizadeh M, et al. The effect of aging on gait parameters in able-bodied older subjects: a literature review. Aging clinical and experimental resear- ch. 2016;28(3):393–405. Epub 20150726. doi: 10.1007/s40520-015-0420-6. PubMed PMID: 26210370.
Callisaya ML, Beare R, Phan TG, et al. Brain structural change and gait decline: a longitudinal population‐based study. Journal of the American Geriatrics Society. 2013;61(7):1074–9. Epub 20130624. doi: 10.1111/jgs.12331. PubMed PMID: 23796055.
Perry MC, Carville SF, Smith ICH, et al. Strength, power output and symmetry of leg muscles: effect of age and history of falling. European journal of applied physiology. 2007;100(5):553–61. Epub 20060718. doi: 10.1007/s00421-006-0247-0. PubMed PMID: 16847676.
Kirkwood RN, de Souza Moreira B, Vallone ML, et al. Step length appears to be a strong disc- riminant gait parameter for elderly females highly concerned about falls: a cross-sectional ob- servational study. Physiotherapy. 2011;97(2):126–31.
Polcyn AF, Lipsitz LA, Kerrigan DC, et al. Age-related changes in the initiation of gait: degrada- tion of central mechanisms for momentum generation. Archives of physical medicine and reha- bilitation. 1998;79(12):1582–9. doi: 10.1016/s0003-9993(98)90425-7. PubMed PMID: 9862305.
DeVita P, Hortobagyi T. Age causes a redistribution of joint torques and powers during gait. Journal of applied physiology. 2000;88(5):1804–11. doi: 10.1152/jappl.2000.88.5.1804. PubMed PMID: 10797145.
Prince F, Corriveau H, Hébert R, et al. Gait in the elderly. Gait & posture. 1997;5(2):128–35.
Samson MM, Crowe A, De Vreede P, et al. Differences in gait parameters at a preferred walking speed in healthy subjects due to age, height and body weight. Aging clinical and experimental research. 2001;13(1):16–21.
Menz HB, Lord SR, Fitzpatrick RC. Age‐related differences in walking stability. Age and ageing.
2003;32(2):137–42.
Kobayashi H, Kakihana W, Kimura T. Combined effects of age and gender on gait symmetry and regularity assessed by autocorrelation of trunk acceleration. Journal of neuroengineering and rehabilitation. 2014;11(1):109. Epub 20140704. doi: 10.1186/1743-0003-11-109. PubMed PMID: 24993146; PubMed Central PMCID: PMC4105560.
Fukagawa NK, Brown M, Sinacore DR, et al. The relationship of strength to function in the older adult. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1995;50(Special_Issue):55–9.
Begg R, Sparrow W. Ageing effects on knee and ankle joint angles at key events and phases of the gait cycle. Journal of medical engineering & technology. 2006;30(6):382–9.
Peterson DS, Martin PE. Effects of age and walking speed on coactivation and cost of wal- king in healthy adults. Gait & posture. 2010;31(3):355–9. Epub 20100127. doi: 10.1016/j.gait- post.2009.12.005. PubMed PMID: 20106666.
Borel L, Alescio-Lautier B. Posture and cognition in the elderly: interaction and contribution to the rehabilitation strategies. Neurophysiologie Clinique/Clinical Neurophysiology. 2014;44(1):95– 107. Epub 20131031. doi: 10.1016/j.neucli.2013.10.129. PubMed PMID: 24502910.
Ji L, Zhai S. Aging and the peripheral vestibular system. Journal of Otology. 2018;13(4):138–40. Epub 20181116. doi: 10.1016/j.joto.2018.11.006. PubMed PMID: 30671091; PubMed Central PMCID: PMC6335476.
Shaffer SW, Harrison AL. Aging of the somatosensory system: a translational perspective. Phy- sical therapy. 2007;87(2):193–207. Epub 20070123. doi: 10.2522/ptj.20060083. PubMed PMID: 17244695.
Axer H, Axer M, Sauer H, et al. Falls and gait disorders in geriatric neurology. Clinical neurology and neurosurgery. 2010;112(4):265–74. Epub 20100120. doi: 10.1016/j.clineuro.2009.12.015. PubMed PMID: 20089351.
Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? Jama. 2007;297(1):77–86. doi: 10.1001/ jama.297.1.77. PubMed PMID: 17200478.
Society AG, Society G, Of AA, et al. Guideline for the prevention of falls in older persons. Jour- nal of the American Geriatrics Society. 2001;49(5):664–72.
Baker JM. Gait disorders. The American journal of medicine. 2018;131(6):602–7. Epub 20171227. doi: 10.1016/j.amjmed.2017.11.051. PubMed PMID: 29288631.
Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50–8.
Takakusaki K. Functional neuroanatomy for posture and gait control. Journal of Movement Disorders. 2017;10(1):1–17.
Lusardi MM, Fritz S, Middleton A, et al. Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability. Journal of Geriatric Physical Therapy. 2017;40(1):1–36.
Berg KO, Wood-Dauphinee SL, Williams JI, et al. Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health. 1992;83(Suppl 2):S7–S11.
Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society. 1991;39(2):142–8.
Weiner DK, Duncan PW, Chandler J, et al. Functional reach: a marker of physical frailty. Jour- nal of the American Geriatrics Society. 1992;40(3):203–7.
Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society. 1986;34(2):119–26.
Shumway-Cook A, Gruber W, Baldwin M, et al. The effect of multidimensional exercises on balance, mobility, and fall risk in community-dwelling older adults. Physical Therapy. 1997;77(1):46–57.
Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Physical Therapy. 2009;89(5):484–98.
Peterka RJ. Sensorimotor integration in human postural control. Journal of Neurophysiology.
2002;88(2):1097–118.
Bugnariu N, Fung J. Aging and selective sensorimotor strategies in the regulation of upright balance. Journal of Neuroengineering and Rehabilitation. 2007;4(1):19.
Visser JE, Carpenter MG, van der Kooij H, et al. The clinical utility of posturography. Clinical Neurophysiology. 2008;119(11):2424–36.
Maki BE, McIlroy WE. Control of rapid limb movements for balance recovery: age-related changes and implications for fall prevention. Age and Ageing. 2006;35(suppl_2):ii12–ii8.
Fife TD, Tusa RJ, Furman JM, et al. Assessment: vestibular testing techniques in adults and children. Neurology. 2000;55(10):1431–41.
MacDougall HG, Weber KP, McGarvie LA, et al. The video head impulse test: diagnostic accu- racy in peripheral vestibulopathy. Neurology. 2009;73(14):1134–41.
Goncalves DU, Felipe L, Lima TM. Interpretation and clinical significance of caloric testing.
Brazilian Journal of Otorhinolaryngology. 2008;74(3):440–6.
Arriaga MA, Chen DA, Cenci KA. Rotational chair (ROTO) instead of electronystagmography (ENG) as the primary vestibular test. Otolaryngology–Head and Neck Surgery. 2005;133(3):330– 3.
Curthoys IS. The interpretation of clinical tests of peripheral vestibular function. Laryngoscope. 2012;122(4):734–47.
Herdman SJ. Vestibular rehabilitation. 4th ed: F.A. Davis; 2013.
Baker R. Gait analysis methods in rehabilitation. Journal of Neuroengineering and Rehabilitati- on. 2006;3(1):4.
Montesinos L, Castaldo R, Pecchia L. Wearable Inertial Sensors for Fall Risk Assessment and Prediction in Older Adults: A Systematic Review and Meta-Analysis. IEEE Trans Neural Syst Rehabil Eng. 2018;26(3):573–82. doi: 10.1109/tnsre.2017.2771383. PubMed PMID: 29522401.
Kidziński Ł, Yang B, Hicks JL, et al. Deep neural networks enable quantitative movement analy- sis using single-camera videos. Nat Commun. 2020;11(1):4054. Epub 20200813. doi: 10.1038/ s41467-020-17807-z. PubMed PMID: 32792511; PubMed Central PMCID: PMC7426855.
United Nations DoE, Social Affairs PD. World Population Ageing 2019. 2019.
Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2019(1).
Seidler RD, Bernard JA, Burutolu TB, et al. Motor control and aging: links to age-related brain structural, functional, and biochemical effects. Neuroscience & Biobehavioral Reviews. 2010;34(5):721–33.
Horak FB, Shupert CL, Mirka A. Components of postural dyscontrol in the elderly: a review.
Neurobiology of Aging. 1989;10(6):727–38.
Pijnappels M, Reeves ND, Maganaris CN, et al. Tripping without falling; lower limb strength, a limitation for balance recovery and a target for training in the elderly. Journal of Electromyog- raphy and Kinesiology. 2008;18(2):188–96.
Li F, Harmer P, Fisher KJ, et al. Tai Chi and fall reductions in older adults: a randomized cont- rolled trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2005;60(2):187–94.
Mirelman A, Rochester L, Maidan I, et al. Addition of a non-immersive virtual reality compo- nent to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial. The Lancet. 2016;388(10050):1170–82.
Keshner EA. Virtual reality and physical rehabilitation: a new toy or a new research and reha- bilitation tool? Journal of Neuroengineering and Rehabilitation. 2004;1(1):8.
Suarez H, Suarez A, Lavinsky L. Postural adaptation in elderly patients with instability and risk of falling after balance training using a virtual-reality system. International Tinnitus Journal. 2006;12(1):41–4.
Goble DJ, Cone BL, Fling BW. Using the Wii Fit as a tool for balance assessment and neuroreha- bilitation: the first half decade of “Wii-search”. Journal of Neuroengineering and Rehabilitation. 2014;11(1):12.
Pai YC, Bhatt T, Yang F, et al. Perturbation training can reduce community-dwelling older adults’ annual fall-risk: a randomized controlled trial. The Journals of Gerontology: Series A. 2014;69(12):1586–94.
Lord SR, Dayhew J, Howland A. Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. Journal of the American Geriatrics So- ciety. 2002;50(11):1760–6.
Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hy- pofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. Journal of Neurologic Physical Therapy. 2021;45(4):1–35.
Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. Journal of Clinical Neurology. 2011;7(4):184–96.
Schubert MC, Migliaccio AA, Clendaniel RA, et al. Mechanism of dynamic visual acu- ity recovery with vestibular rehabilitation. Archives of Physical Medicine and Rehabilitation. 2008;89(3):500–7.
Lacour M, Helmchen C, Vidal PP. Vestibular compensation: the neuro-otologist’s best friend.
Journal of Neurology. 2016;263(1):54–64.
Pavlou M. The use of optokinetic stimulation in vestibular rehabilitation. Journal of Neurologic Physical Therapy. 2010;34(2):105–10.
McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibu- lar dysfunction. Cochrane Database Syst Rev. 2015;1(1):Cd005397. Epub 20150113. doi: 10.1002/14651858.CD005397.pub4. PubMed PMID: 25581507; PubMed Central PMCID: PMC11259236.
Whitney SL, Wrisley DM, Marchetti GF, et al. The effect of age on vestibular rehabilitation out- comes. The Laryngoscope. 2002;112(10):1785–90.
Korda A, Zamaro E, Wagner F, et al. Impact of Otolith Dysfunction on the Rehabilitation of Patients with Unilateral Vestibular Hypofunction. Frontiers in Neurology. 2020;11:587356.
