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Balance and Mobility - Frailty And Atypical Illness Presentations

age aging clinical falls journal adults tinetti

Falls are common in older adults; approximately 50 percent of community-dwelling seniors fall each year, and 10 percent of these suffer an important injury, such as a fracture, bleeding around the brain (subdural hematoma), or skin laceration. Falls and immobility are rarely caused by a single deficit, but rather the interaction of multiple acute and chronic abnormalities. A common mistake in the care of older adults is to search for the cause of a fall, rather than addressing the multiple deficits. The presence of a stroke, orthostatic hypotension (one's blood pressure falls when one stands up), or weakness of a particular muscle group, for example, would be an unusual cause of a fall without other predisposing factors.

Falls and immobility in older adults are generally manifestations of frailty. Frailty can be thought of as the interaction among many strengths and weaknesses of an individual, giving rise to current abilities and vulnerability to further loss. Many of these weaknesses may not be detrimental by themselves, and not readily apparent—what Dr. Linda Fried calls "subclinical disability"—but when they are mixed together, they are important. For example, mild and individually unimportant impairments in vision, strength, proprioception, and reaction time can combine together to produce frequent falls.

If such an individual develops a urinary tract infection, which is relatively harmless in healthy adults, he or she may find the mobility deficit greatly exacerbated. This phenomenon of atypical illness presentations leads to the common illness behavior in older adults of "taking to bed." A senior who exhibits a change in mobility most certainly has a new illness, though not necessarily one involving the neuromuscular system. These atypical illness presentations involve symptoms and signs not expected on the basis of the underlying disease. For example, a patient with pneumonia would be expected to present with cough, fever, and shortness of breath, and to have abnormal findings on examination of the lungs. A frail older adult will commonly present with delirium, functional decline, falls, or other atypical presentations, without necessarily having symptoms or signs associated with the lungs. The atypical illness presentations are also known as "Geriatric Giants," a term coined by the British geriatrician Bernard Isaacs.

The treatment of immobility and falls involves addressing both the new problem (if one is present) and the frailty. This requires a multifactorial approach. M. E. Tinetti demonstrated that a multidisciplinary team—a nurse addressing potentially harmful medications and orthostatic hypotension, a physiotherapist supervising exercise, and an occupational therapist making the home safer—reduced the incidence of falls in community-dwelling seniors. An approach aimed at a single component of the problem, such as weakness only, will likely prove unsuccessful.




BRONSTEIN, A. M.; BRANDT, T.; and WOOLLACOTT, M. Clinical Disorders of Balance, Posture, and Gait. London: Arnold, 1996.

FRIED, L. P.; HERDMAN, S. J.; KUHN, K. E.; RUBIN, G.; and TURANO, K. "Preclinical Disability: Hypotheses About the Bottom of the Iceberg." Journal of Aging and Health 3 (1991): 285–300.

GURALNIK, J. M.; FERRUCCI, L.; SIMONSICK, E. M.; SALIVE, M. E.; and WALLACE, R. B. "Lower-Extremity Function in Persons Over the Age of 70 Years as a Predictor of Subsequent Disability." New England Journal of Medicine 332 (1995): 556–561.

MACKNIGHT, C., and ROCKWOOD, K. "Assessing Mobility in Elderly People. A Review of Performance-Based Measures of Balance, Gait and Mobility for Bedside Use." Reviews in Clinical Gerontology 5 (1995a): 464–486.

MACKNIGHT, C., and ROCKWOOD, K. "A Hierarchical Assessment of Balance and Mobility." Age and Ageing 24 (1995b): 126–130.

TINETTI, M. E., and GINTER, S. F. "Identifying Mobility Dysfunctions in Elderly Patients: Standard Neuromuscular Examination or Direct Assessment?" Journal of the American Medical Association 259 (1988): 1190–1193.

TINETTI, M. E.; BAKER, D. I.; MCAVAY, G.; CLAUS, E. B.; GARRETT, P.; GOTTSCHALK, M.; KOCH, M. L.; TRAINOR, K.; and HORWITZ, R. I. "A Multifactorial Intervention to Reduce the Risk of Falling Among Elderly People Living in the Community." New England Journal of Medicine 331 (1994): 821–827.

TINETTI, M. E.; INOUYE, S. K.; GILL, T. H.; and DOUCETTE, J. T. "Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes." Journal of the American Medical Association 273 (1995): 1348–1353.

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