A diminished ability to perform activities of daily living is a major concern of older adults. Being able to walk independently is often a prerequisite for functional independence and the achievement or maintenance of a reasonable quality of life. Gait can therefore be considered as one of the most important physical functions to an older adult and his/her caregivers. Age- or disease-related mobility limitations may seriously complicate activities of daily living and eventually lead to (injurious) falls. Therefore, hampered gait is often the immediate cause for institutionalization of an older individual. As a consequence, a relatively large proportion of older adults living in residential aged care facilities (RACFs) use wheelchairs or walk with aids.
Older adults use walking aids for various reasons. They might be introduced as a therapeutic tool to regain walking skills after acute lower limb problems (eg, joint inflammations, fractures, and with arthroplasties) or neurologic disorders such as strokes. At the end of the rehabilitation period, some older adults keep on using walking aids even if they are no longer essential, rendering a state of learned disuse.1 Giving up the walking aid sometimes seems to be difficult for the individual accustomed to it. Conversely, older adults who (still) need their assistive device may abandon their device too soon. Although some older adults refuse to walk with assistive devices, others experience the benefits of improved walking abilities. It allows them to maintain or regain social activities, gives them feelings of safety and/or improved self-confidence.2 Generalized or local muscle weakness, joint pain, balance disorders, dizziness, and fear of falling may also prompt older adults to start using walking aids. Walking aids can thus be helpful for both physical and mental burdens. However, some specific demands and difficulties might arise when using mobility aids. The older individual must have sufficient strength, balance, coordination, and attentional capacity to master the aid.2–4 Furthermore, the aid should be chosen and adjusted carefully on the basis of the individual's abilities and environmental demands.2,5 Also, the older adult should be instructed and trained to use it correctly.2,3 Using walking aids may make using stairs difficult,2 induce destabilizing biomechanical effects,4,6 cause excessive upper limb stress and pain,4 and is associated with an increased fall risk.4,7,8
The relationship between using walking aids and falling is somewhat inconsistent and poorly understood. A number of studies have identified the use of mobility aids as a risk factor or predictor of future falls4,7,8 and fall-related injuries,9,10 because they can affect gait patterns by inhibiting normal arm swing, affecting posture, reducing gait speed, step length and swing time, and increasing stance time.11 On the contrary, some researchers found that the use of walking aids may have protective effects against falls in older adults living in residential settings,12,13 as walking aids may be helpful when older adults with limited mobility are exposed to environmental threats.12 This prospective study aims to investigate the use of walking aids as a risk factor for future falls among older adults living in RACFs and identify spatiotemporal gait parameters that mediate the former potential relationship.
Forty-three healthy older adults (≥60 years) were recruited from 2 RACFs: “St-Job” in Aalst (Belgium) and “St-Franciscus” in Brakel (Belgium). Residential aged care facilities were contacted through online advertising, and participants were recruited through flyer distribution and by word of mouth. Twenty-two persons (51%) used walking aids for at least 1 year, and 21 (49%) walked without any assistive device or support. Of those using walking aids, 18 used a 4-wheeled walker (“rollator”), 2 used a 2-wheeled walker (“front-wheeled walker”), 1 used a walking frame (“standard walker”), and one used a cane. Reasons for using walking aids were determined by closed-ended questions. Participants used walking aids because of fear of falling (54.5%), feeling of safety (27.3%), and habituation (ie, ever since surgery or injury) (18.2%). Inclusion criteria were (1) aged 60 years and above, (2) living in an RACF, (3) able to understand instructions related to study procedures, (4) able to walk independently with or without walking aids for at least 10 m, (5) absence of stroke, Parkinson disease, or other major neurological conditions, and (6) absence of musculoskeletal disorders impeding them to walk unaided for 10 m (eg, amputations and major rheumatic conditions in lower extremities). The Ethical Committee of the Ghent University Hospital gave approval to this study, and all participants signed an informed consent.
Grip strength (kg) of the dominant hand was recorded by the Jamar® dynamometer (Sammons Preston Rolyan Inc, Bolingbrook, Illinois) while seated in an armless chair with shoulders adducted and neutrally rotated and elbow flexed at 90°, forearms in neutral position, and wrist between 0° and 30° of dorsiflexion.14 Participants were instructed to squeeze the handle as hard as possible.15 The maximal grip score of 3 trials was retained.
Gait velocity (cm/s), cadence (steps/min), step length (cm), step time (s), stance phase (%), and swing phase (%) were captured by the portable electronic GAITRite® walkway system (8.3 m × 0.89 m; CIR Systems Inc, Havertown, Pennsylvania) with proven validity16 and reliability.17 Participants were asked to walk at a self-selected normal walking speed wearing comfortable shoes. They were instructed to start walking 2 m before the GAITRite® mat and keep walking for 2 m beyond the mat to minimize acceleration and deceleration effects, respectively.
The Mini-Mental State Examination (MMSE) was used as a general cognitive screening instrument.18 The Clock Drawing Test (CDT) was done to estimate executive functioning. Four items as proposed by Thalmann et al19 were selected: item 2 (12 numbers are present), item 5 (number “12” correctly placed), item 25 (hands have correct proportions), and item 34 (participant reads time correctly). A validated algorithm to combine results from the MMSE and the CDT was used to estimate executive functioning.19 An MMSE score of 27 or more was coded as 3, and an MMSE score of 26 or less was coded as 0. The 4 CDT items were coded as 0 or 1 for items 2, 25, and 34; and as 0 or 3 for item 5. These recoded scores of the MMSE and the CDT were then combined to a single score (MMSE-CDT) with a maximum of 9, representing a good cognitive function. A cut-off score of less than 7 on the MMSE-CDT was used to classify participants as having reduced cognitive functioning.19
Fall history was recorded by asking the participants whether they fell during the past year. After baseline measurements, falls and fall-related injuries were prospectively monitored during 12 months using monthly fall calendars and phone calls in case a fall occurred. A fall was defined as “an unexpected event in which the person comes to rest on the ground, floor, or lower level.”20 One participant (not using walking aids) was lost to follow-up and not included in statistical analyses. Fear of falling was replaced by the simple question “Are you afraid of falling?” with possible answers: (i) “not at all afraid,” (ii) “slightly afraid,” (iii) “somewhat afraid,” and (iv) “very afraid.” Given the small sample size and to make interpretation easier, more straightforward binary scores were derived for statistical analyses: “(i)” was considered “no” (no fear) and “(ii),” “(iii),” or “(iv)” was considered “yes” (fear).
Independent samples t tests (continuous variables) and Chi-square tests (categorical variables) were performed to compare older adults using walking aids with older adults not using walking aids. Univariate and multivariate logistic regression models were applied to investigate the association between using walking aids and falls, and between covariates (demographic, physical, and cognitive) and falls. Covariates with a univariate statistical significance of P ≤ .15 were then entered in separate logistic regression models to determine how much they reduced the walking aids-falls odds ratio (OR). Data were analyzed using SPSS.21 for Windows (SPSS, Inc, Chicago, IL). For reasons of illness and absence at the time of the test procedure, 2 participants (1 using walking aids and 1 not using walking aids) did not complete gait analysis and 1 (not using walking aids) performed no grip strength measurement.
The mean age of the 43 participants was 83.2 years (standard deviation, 7.1 years) (range, 63-94 years) and 32 participants (74.4%) were female. Participants using walking aids were older than those not using walking aids, with a mean age of 85.9 years (standard deviation, 4.7 years) and 80.4 years (standard deviation, 8.2 years), respectively (Table 1). Table 1 also shows that a significantly greater proportion of the older adults who used walking aids compared with those who did not use walking aids reported fear of falling (86.4% vs 52.4%). Cognitive states did not differ significantly between both groups although it is noteworthy that the older adults using walking aids scored better on the MMSE but worse on the CDT (Table 1). Twenty-two (52.4%) older adults fell at least once during the 12-month follow-up period (“fallers”); 12 (28.6%) fell once (“single fallers”) and 10 (23.8%) fell twice or more (“multiple fallers”). Five (11.9%) participants had injuries that could be attributed to fall events. Fifteen (68.2%) older adults using walking aids reported at least one fall compared with 7 (35.0%) older adults not using walking aids.
Individuals using walking aids showed a significantly different gait pattern compared with individuals not using walking aids. They walked significantly slower with smaller step lengths and greater step times and took a lower number of steps/minute. Mean stance time percentage was higher and mean swing time percentage lower, but these differences failed to reach the significance level of .05 (P = .059 and P = .089, respectively).
Univariate risk factors for falls were using walking aids, taking psychotropic drugs, reporting falls in the previous year, increased age, lower cadence, higher stance percentage, and lower swing percentage (Table 1). After separately entering explanatory variables, previous falls yielded a reduction of the walking aids/falls OR of 5.0% (OR, 3.38; 95% confidence interval [CI], 0.90-12.67). Parameters that caused a substantial reduction in the walking aids/falls relationship, and therefore could be considered mediators, were cadence (34.4%; OR, 2.61; 95% CI, 0.52-13.17), stance percentage (30.2%; OR, 2.78; 95% CI 0.70-10.97), swing percentage (29.4%; OR, 2.81; 95% CI, 0.71-11.08), age (22.4%; OR, 3.09; 95% CI, 0.78-12.17), and psychotropic drug intake (19.0%; OR, 3.22; 95% CI, 0.85-12.23).
The present study confirmed that using an assistive device to walk is a strong risk factor for future falls among older adults living in RACFs. The most common aid was a walker. Fall incidence of older adults using walking aids was nearly double that of older adults not using walking aids. Participants using walking aids were significantly older, had more fear of falling, and showed a significantly different gait pattern compared with participants not using walking aids.
Although some studies found the use of walking aids to be protective against future falls,12,13 the finding that fallers use walking aids more than nonfallers and the identification of using walking aids as a risk factor for falls is generally in accordance with previous research.4,7,8,21–24 The fact that using walking aids, taking psychotropic drugs, having a positive fall history, and the presence of fear of falling were the strongest univariate risk factors for falls for the greater part confirms the findings of the recent systematic review and meta-analysis, considering risk factors for falls in older people in nursing homes and hospitals of Deandrea et al.7 Still, caution is warranted when interpreting the role of using walking aids on future falls. Associating the use of ambulatory devices with future falls does not necessarily mean that using such devices causes falls, as has previously been warned for by Ganz et al.25 The use of a walking aid may indicate a worse general health condition including problems that might be fall risk factors themselves (eg, balance impairment and functional decline). Alternatively, the use of a walking aid itself may increase fall risk by inhibiting compensatory grasping,26 causing tripping or loss of balance because of increased attentional requirements. Wright and Kemp27 have indeed proven that using commonly prescribed walking aids such as walkers is highly attention demanding, even after relatively extensive experience using or teaching how to use the devices. Although no statistical significant differences in cognitive state could be retained between participants walking with or without walking aids, those walking with walking aids tended to have worse executive functioning (lower CDT scores), which might have complicated attentional requirements.
A statistically significantly lower number of steps per minute were taken by participants using walking aids compared with participants not using walking aids. Because the magnitude of the difference clearly exceeds the minimal detectable change value of 8.4 steps/min,28 this change in cadence can be considered clinically meaningful. A lower cadence during aided walking has previously been described elsewhere.27 Besides, this gait parameter has repeatedly been associated with (future) falls,29–31 which might explain its large mediating effect of the walking aids/falls relationship (34.4% reduction of OR). Spatiotemporal gait analyses comparing aided gait with non-aided gait are scarce. However, the more conservative gait pattern characterized by slower gait, decreased cadence, step length swing percentage, and increased step time and stance percentage of older adults using walking aids in this population seems plausible. Although there was a trend (P = .059 and .089, respectively), stance and swing percentage did not reach significance level when comparing both populations. This may be attributed to the small population sample. Stance and swing percentage seemed to be univariate fall risk factors and mediators of the walking aids/falls relationship (30.2% and 29.4% reduction of OR). It might be surprising that this was not the case for gait speed. However, Verghese et al32 observed a similar finding in that their analyses identified gait variables such as swing phase to be better predictors of falls than speed. The other mediators, age and psychotropic drug use, are commonly accepted fall risk factors among older adults.33–38 Because mobility problems increase with age, it is not surprising that mean age of the subpopulation using walking aids was significantly higher than that of the subpopulation not using walking aids. The higher psychotropic drug intake might be attributed to the fact that using walking aids may serve as a marker of poorer general health with eventual concomitant depressive symptoms, potentially requiring psychotropic agents. Common side effects of psychotropic drugs such as drowsiness and dizziness may result in balance problems, eventually leading to falls. It might thus be that ambulation aids are prescribed because of these medication-induced balance impairments. This however can not be confirmed by this study because no information was collected considering starting dates of using walking aids and taking psychotropic drugs.
Together with the fact that dosage of the psychotropic drugs was not entered in the analyses, this can be considered a limitation. The major limitation of this study, however, lies in the lack of a comprehensive investigation and registration of fall events and the accompanying circumstances, which is essential for better understanding the actual contribution of walking aids in fall events. Because only 5 fall-related injuries were reported in this study, it was statistically not warranted to elucidate potential relationships between using walking aids and fall-related injuries. Furthermore, it is questionable whether this information would correctly have been reproduced and reported by the older adults. It however would be interesting to further investigate this with video recording in future research among larger samples. Nevertheless, it might still be difficult to draw cause–effect conclusions.39 Extrapolation of the current findings to clinical populations should be made with caution because a rather small and nondisabled population with no apparent physical or cognitive dysfunction was studied.
This study demonstrated that using walking aids is a risk factor for future falls among a nondisabled older population living in residential settings. A substantial proportion of the relationship between walking aids and future falls could be explained by an altered spatiotemporal gait pattern, increased age, and psychotropic drug intake. This finding supports the aim of extensive training periods and appropriate instructions on the proper use of walking aids in terms of adequate and safe gait patterns. Normalization of the mediating spatiotemporal gait parameters and reducing psychotropic drug intake (if justified) are likely to reduce fall risk among older residents using walking aids.
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