Exploring the intersection of structural racism and ageism in healthcare.

The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.

Dual-task performance in older adults during discrete gait perturbation.

The dual-task (motor and cognitive) performance of eight older adults (72.0 ± 6.4 years; 5 female; 3 male) was evaluated. Vocal choice reaction times (cognitive task) were measured at standstill as well as during unperturbed and perturbed gait (motor task). The perturbation was administered using customized shoes instrumented to lower a small (18.4 mm high) aluminum flap suddenly under the medial or lateral forefoot during a single swing phase of 12 of 30 gait trials. The ankle inverted or everted an average of 10 or 9 degrees, respectively, depending on the flap deployed. Medial and lateral perturbations were randomized between the left and right feet. The results show that vocal choice reaction time was significantly prolonged by gait, both perturbed (614.7 ± 80.2 ms) and unperturbed (529.9 ± 119.3 ms), compared to standstill (332.8 ± 76.5 ms; p = 0.0015). Further, the prolongation associated with gait perturbation was significant, compared to that with unperturbed gait (p = 0.016). The kinematics of the first post-perturbation (recovery) step, with or without concomitant vocal choice reaction task performance, was not significantly different from those of the average step during unperturbed gait. We conclude that in healthy older adults, the requirement to respond to a gait challenge resulted in deterioration in the performance of a concurrent cognitive task as indicated by significant prolongation of response time in the vocal choice reaction task. In contrast, performance of the motor task was not adversely affected.

Balance and its Clinical Assessment in Older Adults - A Review.

BACKGROUND: Human beings rely on multiple systems to maintain their balance as they perform their activities of daily living. These systems may be undermined functionally by both disease and the normal aging process. Balance impairment is associated with increased fall risk. PURPOSE: This paper examines the dynamic formulation of balance as activity and reviews the biological mechanisms for its control. A "minimal-technology" scheme for its clinical evaluation in the ambulatory care setting is proposed. METHODS: The PubMed, Scopus and CINAHL databases were searched for relevant articles using the following terms in combination with balance: aging, impairment, control mechanisms, clinical assessment. Only articles which describe test procedures, their psychometrics and rely exclusively on equipment found in a regular physician office were reviewed. RESULTS: Human bipedal stance and gait are inherently low in stability. Accordingly, an elaborate sensory apparatus comprising visual, vestibular and proprioceptive elements, constantly monitors the position and movement of the body in its environment and sends signals to the central nervous system. The sensory inputs are processed and motor commands are generated. In response to efferent signals, the musculoskeletal system moves the body as is necessary to maintain or regain balance. The combination of senescent decline in organ function and the higher prevalence of diseases of the balance control systems in older adults predisposes this population subset to balance impairment. Older adults with balance impairment are likely to present with "dizziness". The history should concentrate on the first experience, with an attempt made to categorize it as a Drachman type. Since the symptomatology is often vague, several of the recommended physical tests are provocative maneuvers aimed at reproducing the patient's complaint. Well-validated questionnaires are available for evaluating the impact of "dizziness" on various domains of patient's lives, including their fear of falling. Aspects of a good history and physical examination not otherwise addressed to balance function, such as medications review and cognitive assessment, also yield information that contributes to a better understanding of the patient's complaint. Ordinal scales, which are aggregates of functional performance tests, enable detailed quantitative assessments of balance activity. CONCLUSION: The integrity of balance function is essential for activities of daily living efficacy. Its deterioration with aging and disease places older adults at increased risk of falls and dependency. Balance can be effectively evaluated in the ambulatory care setting, using a combination of scalar questionnaires, dedicated history-taking and physical tests that do not require sophisticated instrumentation.

Effect of age on the ability to recover from a single unexpected underfoot perturbation during gait: kinematic responses.

A sudden underfoot perturbation can present a serious threat to balance during gait, but little is known about how humans recover from such perturbations or whether their response is affected by age. We tested the hypothesis that age would not affect the stepping responses to a nominal 10 degree inversion or eversion of the stance foot during gait. Twenty-three healthy young (22.7±3.35 yrs) and 18 healthy old adults (68.0±7.19 yrs) performed 60 walking trials along a 6-m level walkway at a normal gait speed. In 16 of these trials, a single medial (MP) or lateral (LP) perturbation was randomly administered once under the left or right foot. Recovery step width (SW), step length (SL), trunk kinematics and walking speed were measured optoelectronically. Repeated-measures analysis of variance and post hoc t-tests were used to test the hypotheses. The results show that a MP or LP altered the recovery SL (p=0.005) and age affected the number of recovery steps (p=0.017), as well as the first recovery SW and SL (p=0.013 and p=0.031, respectively). Both MP and LP caused young adults to have wider SW (p<0.02) and shorter SL (p<0.005) without changing trunk movement during their first recovery step. Older adults, however, significantly changed lateral trunk inclination during the first recovery step, decreased their fourth recovery SL (p<0.001). We conclude that young adults adjust the step kinematics of as many as four recovery steps following this perturbation, a response that was delayed and significantly weaker in older adults who instead exhibited an immediate torso inclination consistent with a hip response strategy.

Effect of a vocal choice reaction time task on the kinematics of the first recovery step after a sudden underfoot perturbation during gait.

Thirty-two healthy young adults (15 women) were tested for their ability to maintain their comfortable step pattern following an unpredictable underfoot perturbation in the presence and absence of a concurrent vocal choice reaction time task. Custom instrumented shoes were used to randomly deliver an unexpected medial or lateral forefoot perturbation that inverted the mid-foot an average of 10° or everted the midfoot an average of 9° during one stance phase of a gait trial. Medial and lateral perturbations were randomized between left and right feet in 12 of 30 gait trials. The results of the repeated measures analyses of variance show that, compared to the step parameters of unperturbed gait, the administration of the unexpected underfoot perturbation did not significantly lead to alterations in the step length or width of the first recovery step. In addition, the simultaneous administration of a vocal choice reaction time task with the underfoot perturbation did not significantly affect the kinematics of the first recovery step. We conclude that in young healthy adults an unexpected 9-10° underfoot perturbation, with or without a vocal reaction time task, will not affect their recovery step kinematics when walking at a comfortable gait speed.

Dynamic balance and stepping versus tai chi training to improve balance and stepping in at-risk older adults.

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.

Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults.

Falls account for significant morbidity and mortality in the older adult population. A comprehensive fall evaluation (CFE) is proposed, particularly for use in recurrent fallers, those who seek medical attention for a fall, and those with a gait and/or balance disorder. The CFE focuses on key factors in the medical and fall history, review of systems, and physical examination. Interventions utilize a multifactorial model, although balance exercise may be the most critical component. While some components may be marginally successful when presented individually as an intervention (such as correction of vision impairment or environmental hazard reduction), when presented together, fall risk can be significantly reduced.