In 2017, the Institute for Healthcare Improvement (IHI), the John A Hartford Foundation (JAHF), the American Hospital Association (AHA), and the Catholic Health Association (CHA) of the United States addressed the development of age-friendly health systems using a clinical framework to improve the complex care of older adults.

These organizations defined and operationalized age-friendly care following the guidelines of beneficence, evidence-based medicine, and patient/family aligned goals and concerns. The 4M Framework was the result: What Matters Most, Mentation, Mobility, and Medication.  A 5^th M is often incorporated to include Multi-Morbidity, which calls attention to the multiple, often inter-related, health problems that many older adults face. This Geriatric Fast Fact focuses on Mobility.

Adequate mobility is critical to function and quality of life.  Mobility allows individuals to interact with their environment and to perform essential basic and instrumental activities of daily living safely.  On a population health level, decreasing functional decline decreases healthcare costs.  Mobility is often considered a surrogate marker of disease progression, and is featured in many prognostic calculators.

Understanding an older adult’s mobility helps identify:

• Areas of functional strength and/or frailty.
• Adaptive equipment or caregiver supervision to support the older adult.
• Rehabilitative or therapy programs to improve mobility and function. 
• Housing/living options to best balance safety and independence.

Mobility assessment through history taking may include:

• Presence or absence of falls, including circumstances surrounding the fall, and resultant injuries.
• Current and past assessments of gait, balance, and function.
• Presence of medical comorbidities that may directly or indirectly impact mobility.
• Presence of associated symptoms or signs (e.g., dizziness, pain, shortness of breath, chest pain, joint pain, visual loss, fatigue, neurologic changes) increasing risk of falls and decreased mobility.
• Home safety evaluation (e.g., presence of stairs, throw rugs, door thresholds, lighting, bathroom equipment).

Mobility assessment through physical examination may include:

• Vital signs before and during mobility testing, (e.g., pulse, oximetry, orthostatic blood pressures).
• Neurocognitive exam (e.g., safety awareness, ability to problem solve mobility or safety scenarios).
• Cardiopulmonary exam.
• Musculoskeletal exam.
• Neurologic exam (e.g., reflexes, strength, sensation/proprioception of upper and lower body, vision and balance).
• Functional mobility tests (see below).

Mobility assessment tools include:

• Timed Up and Go Test (TUGT) – this test times an individual’s ability to rise from a chair, walk 3 meters, turn, return to the chair and sit.  A time of >13.5 seconds is associated with a greater risk for falls. Adaptive equipment is permitted, but assistance is not. Scores of 14-20 seconds correlate to a moderate fall risk, and scores >20 seconds indicate a high fall risk.
• Six minute walk test - this test measures the distance an individual can walk in 6 minutes, allowing for rest breaks if necessary, and it measures the change from resting to exertional pulse oximetry. 

https://www.physio-pedia.com/Six_Minute_Walk_Test_/_6_Minute_Walk_Test.

• Tinetti balance and gait evaluation – this test combines gait and balance tasks scored from 0 to 2, with scores of 19-24 indicating some fall risk, and 25-28 with low fall risk. Scores <19 are associated with high fall risk.

https://www.uclahealth.org/sites/default/files/documents/2a/tinetti-gait-and-balance.pdf?f=4b27bebf.

• Berg Balance scale – this is a functional task test with an optimal total score of 56; scores of 41-56 are associated with a low fall risk, 21-40 with a moderate risk, and 20 or less with a high risk. The test also determines if assistive devices are needed. 

https://www.brandeis.edu/roybal/docs/Berg-Balance-Scale_Website.pdf.

Inpatient and outpatient assessments of mobility are similar, but acutely ill hospitalized patients may not be at their functional baseline, and the test may demonstrate acute impairment rather than baseline ability. Regardless, the tests remain useful in gauging levels of deconditioning or functional decline, and in determining safe disposition requirements.

Healthcare systems often have a preferred mobility test; in this case, consistency is important to have comparable and trackable results.