Transcript Geriatric Rehabilitation: What do I need to know?

Geriatric Rehabilitation:
What do I need to know?
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and
Chairman Department of PM&R
Virginia Commonwealth University Health
System
Geriatric Rehabilitation Education
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Cifu DX, Currie DM, Gershkoff AM, Means KM: Geriatric rehabilitation. Arch Phys
Med Rehabil 1993; 74: S399-S424.
Guidelines for the Prevention of Falls in Older Persons, American Geriatrics Society,
British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on
Falls Prevention. J Am Geriatr Soc. 49:664-672,2001.
AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in
older persons. J Am Geriatr Soc 2002 Jun;50(6 Suppl):S205-24
American Geriatrics Society. Hartford Foundation. A statement of principles: Toward
improved care of older patients in surgical and medical specialties. Arch Phys Med
Rehabil 2002; 83: 1317-1319.
Strasser DC, Solomon DH, Burton JR. Geriatrics and physical medicine and
rehabilitation: Common principles, complementary approaches, and 21 st century
demographics. Arch Phys Med Rehabil 2002; 83: 1323-1324.
Bodenheimer C, Cifu DX, Phillips E, Roig R, Stewart D, Worsowicz G: Geriatric
rehabilitation. Arch Phys Med Rehabil 2004 (in press)
Demographics of Aging
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1900: 3 million people > 65 years (4 % total)
2000: 35 million people > 65 years (14%)
2030: 1 in 5 Americans will be 65 or older
85 year and older age category is the most rapidly
growing segment of the United States population.
 From 2000 to 2050, this group will increase from
2% to 5%.
Federal Interagency Forum on Age-Related
Statistics Older Americans 2000. Key Indicators of
Well-Being. Washington DC: U.S. Government
Printing Office, 2000.
Measurement Tools in the Elderly
 The Functional Independence Measure (FIM) has been
tested for adults, including the elderly.
 An analysis of the construct validity and retest reliability of
the FIM for persons over age 80 found that
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the motor subscale of the FIM (items A - M) was both valid and
stable.
The cognitive subscale (items N - R) was found to have construct
validity but was less stable.
The FIM score can be used to determine a rehabilitation efficiency
ratio or the FIM change over the length of stay.
higher medical co-morbidities have been shown to correlate with
lower rehabilitation efficiencies
Pollak: Arch Phys Med Rehabil 1996;77(10):1056-61
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Measurement Tools in the Elderly
 Timed “Get up and Go” test
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a patient is asked to rise from an armchair, walk 3 meters or 10
feet, turn around, walk back to the chair, and sit down again.
The score is the time in seconds it takes to complete these tasks.
 It has been found to have significant inter-rater reliability
as well as content reliability.
 It predicts whether a patient can walk safely alone outside.
Podsiadlo:J Am Geriatr Soc. 1991;39(2):142-8
Measurement Tools in the Elderly
 The Berg Balance Measure is
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a 56 point scale to evaluate performance during 14 common
activities, such as standing, turning and reaching for an object on
the floor
has high interrater and intrarater reliability
 While designed to be use as a clinical assessment tool,
Berg balance test scores have been shown to correlate with
laboratory test of balance.
Berg: Arch Phys Med Rehabil. 1992;73(11):1073-80.
Measurement Tools in the Elderly
 The (Folstein) Mini-Mental State Exam (MMSE
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contains questions on orientation, attention, and other cognitive
functions
it is not a diagnostic test for dementia, it is a brief screening tool
that allows quantification of cognition over time
may not detect dementia in people with premorbid high intellectual
functioning or inaccurately suggest dementia in cases of the
dementia syndrome of depression, previously known as
pseudodementia, because of insensitivity of the instrument
Screening separately for both dementia and depression is
important.
Tombaugh: J Am Geriatr Soc. 1992 Sep;40(9):922-35
Measurement Tools in the Elderly
 The Geriatric Depression Scale – Short Form
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is a brief (15-item) questionnaire with yes/no answers that the
patient can self-administer
has been validated in persons over 55 years old
Yesavage:J Psychiatr Res. 1982-83;17(1):37-49.
Measurement Tools in the Elderly
 The CAGE (Cut down, Annoyed, Guilty or Eye opener)
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is a screening tool of alcohol use designed for the young adult
population
is the most widely used clinical screening tool for alcohol abuse
elderly men are more likely to test positive on the CAGE than on
other screening test, such as the Short Michigan Alcoholic
Screening Test-Geriatric Version (SMAST-G)
Clinicians should be aware that detecting excessive alcohol use in
the elderly, even with screening tools, is difficult.
Moore: J Am Geriatr Soc. 2002 May;50(5):858-62.
Measurement Tools in the Elderly
 Norton Pressure Ulcer Risk Scale and the Braden Scale for
Predicting Pressure Sore Risk are assessment tools which
help to determine the risk of skin breakdown or decubitus
ulcer.
 These scales assess risk of skin breakdown based on the
following factors: sensory perception, moisture, activity,
bed mobility, nutrition, friction, and shear.
 They are widely used and can help to identify persons most
at risk for skin breakdown.
Bates-Jensen: Ann Intern Med. 2001; 135:744-51.
Preventing Falls
 The maximal effectiveness occurs when these
interventions are components of a multifactorial
intervention.
 Reviewing and modifying medication regimen has been
shown to reduce falls.
 Exercise programs with balance, strength and endurance
training, and treatment of postural hypotension are
fundamental interventions are beneficial.
 Tai-Chi exercise may be effective in improving balance.
Preventing Falls
 Assistive devices such as a walker or cane improve
mobility.
 Shoe wear must be optimized to allow for appropriate fit
and support.
 Optimizing medication management of concomitant
morbidities, for example lower extremity pain or
abnormalities of tone, may also reduce risk of falls.
 Hip protectors will reduce the risk of hip fractures in highrisk fallers with osteoporosis.
Preventing Falls
 Attempts should be made to correct modifiable
environmental factors. These include
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improved lighting to reduce shadows
elimination of obvious tripping hazards such as electric cords,
thresholds, uneven pathways, scatter rugs, cluttered rooms, and
moveable furniture
Minimizing environmental hazards can be accomplished with a
home safety evaluation by an occupational therapist.
Guidelines for the Prevention of Falls in Older Persons, American Geriatrics
Society, British Geriatrics Society, and American Academy of Orthopaedic
Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 49:664-672,2001.
Rubinstein: Clin Geriat (11)1;52-60, 2003
Wolf: Physical Therapy 1997;77(4):371-381
Pain Management
 It is a myth that the elderly do not feel pain as much as
younger people. “In the final analysis, age-related changes
in pain perception are probably not clinically significant.”
Harkins: Clin Geriatr Med 1996;12:435-459.
 Presence of pain in the elderly has functional significance:
they will do less and more likely rate their health status as
“poor.”
 Epidemiological studies have demonstrated that pain is
overlooked as a potential cause of disability. Fall risk is
increased with pain and reduced with use of analgesic
medications.
Leveille: J Am Geriatr Soc, 2002:50,671-78.
Pain Management
 Modalities, wraps, ointments, liniments, activity and
formal therapy are preferred over systemic medications.
 If oral medications are required, establish an analgesic use
history noting the efficacy and side effect of prior
medications including over-the-counter and natural
remedies.
 Non-steroidal anti-inflammatory drugs (NSAIDS)
including COX-2 inhibitors pose particular risks related to
the higher risk of gastric bleeds in those above age 65, and
must be avoided in renal failure and bleeding diathesis.
Pain Management
 Standing doses of acetaminophen up to 1000mg PO QID
may be equally effective with reduced side effects for mild
pain (1-3 on a scale of 10).
 In long-standing, moderate pain (4-6 on a scale of 10), low
doses of weak narcotics may provide better relief with
fewer side effects than with NSAIDs.
 Stronger opioids should be reserved for severe pain (7-10
on a scale of 10).
 Prophylactic bowel medications should be given to avoid
constipation. Caution must be applied to long-half life
medications because of decreased metabolism in the
elderly.
Pain Management
 AGS Panel on Persistent Pain in Older Persons. The
management of persistent pain in older persons. J Am
Geriatr Soc 2002 Jun;50(6 Suppl):S205-24
 Ferrell BA, Pain Management, Clin Geriatric Med 2000
Nov;16(4):853-74
 AGS Panel on Chronic Pain in Older Persons. The
Management of Chronic Pain in Older Persons, JAGS
46:635-651,1998.
Arthritis
 By age 60, 100% have histological changes of OA
degeneration; 40% report arthritis, and 10% have activity
limitations. Arthritis affects over 60% of women and 50%
of men aged 70 years or older.
 Aerobic exercise, such as walking or aquatics, in both
rheumatoid arthritis and osteoarthritis patients, is reported
to increase aerobic capacity and 50-foot walking time
while decreasing depression and anxiety, when compared
to range of motion.
 There was no difference between the groups for flexibility,
number of clinically active joints, duration of morning
stiffness, or grip strength.
Minor: Arthritis Rheum. 1989;32:1396-405.
Arthritis
 By age 60, 100% have histological changes of OA
degeneration; 40% report arthritis, and 10% have activity
limitations.
 Research on osteoarthritis has revealed risk factors, some
of which are preventable:
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increased age
obesity is the strongest preventable risk factor for knee OA.
• By losing just 10 pounds, a person can reduce their risk of developing
symptomatic osteoarthritis by 50%.
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quadriceps weakness
heavy physical activity
knee injuries
poor proprioception
lack of estrogen replacement
Loeser: Rheum Dis Clin North Am 2000;26(3):547-67
Arthritis
 In rheumatoid arthritis, high-intensity progressive
resistance training in patients is reported to not increase the
number of painful or swollen joints and reduced selfreported pain scores, fatigues scores, 50-foot walking
times, and balance.
Rall: Arthritis Rheum. 1996;39:415-26
 Low load, high-repetition resistive muscle training
increased self-reported functional capacity and was a
clinically safe form of exercise in functional class II and III
RA (mean duration 10.5 years).
Komatireddy: J Rheumatol. 1997;24:1531-9
Stroke
 75% of strokes occur in individuals aged 65 years and
older.
 An individual’s risk for stroke doubles with each
decade of life after age 55.
 When compared to their younger cohorts, older adults
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require longer lengths of rehabilitation stays
demonstrate slower functional improvements
demonstrate greater long-term functional dependency
require nursing home placement more frequently
Flick: Arch Phys Med Rehabil 1999 May;80(5 Suppl 1):S21-6.
Traumatic Brain Injury
 Individuals aged > 70 years are in second highest risk
group for TBI.
 An injury severity-matched investigation in TBI revealed
that individuals aged 55 years and older had
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twice the rehabilitation lengths of stay and costs
half the rate of functional recovery
greater cognitive impairment at discharge
twice the nursing home placement rate
the same level of physical impairment at discharge
Cifu: Arch Phys Med Rehabil 1996;77:883-8.
Spinal Cord Injury
 Individuals aged > 70 years are in second highest risk
group for SCI.
 Injury severity-matched investigations in SCI revealed that
individuals aged 55 years and older with paraplegia had
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increased rehabilitation lengths of stay
decrease in functional recovery and efficiency
No differences in acute care lengths of stay, nursing home
placement, or neurologic recovery were noted.
Seel: J Spinal Cord Med 2001;24:241-50.
McKinley: Neurorehabil 2003;18:83-90
Spinal Cord Injury
 Individuals aged > 70 years are in second highest risk
group for SCI.
 Injury severity-matched investigations in SCI revealed that
individuals aged 55 years and older with tetraplegia had
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an increased nursing home placement rate
a decrease in neurologic recovery
a decrease in functional recovery and efficiency
No differences in rehabilitation and acute care lengths of stay or
nursing home placement were noted.
Cifu: Arch Phys Med Rehabil 1999;80:733-40
McKinley: Neurorehabil 2003;18:83-90
Parkinson’s disease
 In the older adult population, 1% suffers from PD.
 PD has a prevalence of 128 to 187 per 100,000, with an
incidence of 20 per 100,000 in the United States.
 Symptoms are varied and include tremor, rigidity,
bradykinesia, akinesia, postural abnormalities, hypokinetic
dysarthria, and dementia. Rehabilitation interventions are
diverse depending on the clinical findings.
Parkinson’s disease
 A critical review of the exercise therapy literature support
the efficacy of several different types of physical and
occupational therapy on improving activities of daily living
independence and walking ability (walking speed, stride
length), but not on neurologic symptoms or quality of life.
De Goede: Arch Phys Med Rehabil 2001;82:505-15
Parkinson’s disease
 A descriptive review of the speech and language pathology
similarly supported the efficacy of speech therapy on
improving voice and speech function. Education regarding
appropriate dietary modifications and swallowing
techniques (e.g., chin tuck, head positioning) has also been
reported to assist in dysphagia with PD.
Schulz: J Commun Disord 2002;33:59-88.
 There is no available literature that critically examines the
specific efficacy of interdisciplinary rehabilitation services
(inpatient or outpatient) on functional limitations because
of PD.
Osteoporosis
 The estimated lifetime risk of hip fracture for a white
woman aged 50 in the USA is 17% as opposed to only 6%
for a white man of the same age.
 Fractures of the vertebrae (spine), proximal femur (hip)
and distal forearm (radius) are considered to be
quintessential osteoporotic fractures and commonly occur
with only mild or moderate trauma.
 In addition to fractures, osteoporosis can limit mobility by
increasing the fear of failing in the elderly leading to many
of the side effects of immobility.
Lim: Arch Phys Med Rehabil. 2000 Mar;81(3 Suppl 1):S55-9
Osteoporosis
 Osteopenia or low bone mass – hip BMD greater than 1
SD below the young adult female mean (T score <-1 and
>-2.5)
 Osteoporosis – hip BMD 2.5 SD or more below the young
adult female mean (T score -2.5)
 Severe osteoporosis – hip BMD 2.5 SD or more below the
young adult female mean in the presence of one or more
fragility fractures.
Osteoporosis
 Use of clinical risk factors in assessing patients allows
more accurate risk-stratification than BMD alone.
 Risk factors for fracture which are independent of BMD
include:
age
previous fragility fracture
low body weight
glucocorticoid therapy
cigarette smoking
neuromuscular impairment
poor visual acuity
impaired tandem walk and gait
speed
Dargent-Molina: Lancet 348, no. 9021 (July 1996): 145-9
Kanis: Lancet. 2002 Jun 1;359(9321):1929-36.
Osteoporosis
 Prediction of hip fracture risk is more accurate when a
combination of fall-related factors and femoral neck BMD
is used.
 Characteristics of the fall (direction, fall height) as well as
body habitus, as indicated by Bone Mass Index (BMI),
also predict the likelihood of hip fracture.
Dargent-Molina: Lancet 348, no. 9021 (July 1996): 145-9
Greenspan: JAMA 271, no. 2 (January 1994): 128-33
Osteoporosis
 Increased cardiovascular disease and breast cancer risks
were documented in the Woman’s Health Initiative (WHI)
trials, however, the HRT group was shown to have fewer
hip and vertebral fractures than the control group (Relative
Risk of 0.66 for both types of fractures).
Women's Health Initiative Investigators: JAMA. 2002;288:321-333
 Biphosphanates prevent further loss of bony mass. In
women with vertebral fractures, alendronate decreases the
incidence of subsequent vertebral fractures in half.
Esophageal irritation is the most common side effect of the
present generation of biphosphanates.
Osteoporosis
 In most countries, supplementation is needed by women to
achieve an adequate calcium intake of 1200 – 1500 mg per
day.
 Vitamin D supplementation is necessary in the northern
United States and most likely in other climates where sun
exposure is limited for a significant portion of the year.
The recommended dose of Vitamin D is between 400 and
2000 units per day.
 Calcitonin is a peptide hormone produced by thyroid C
cells. Nasal spray calcitonin has been shown to reduce
vertebral but not peripheral fractures.
Osteoporosis
 Regular weight bearing physical activity enhances bone
maintenance.
 Fitness may protect people from fractures by reducing the
risk of falls as well.
 Daily exercise focusing on both balance and weight
bearing such as Tai Chi Chuan may help retard bone loss in
the weight-bearing bones of postmenopausal women.
Incontinence
 Urinary incontinence is present in:
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10-30% of community dwelling elders
25-30% of older patients discharged after a hospitalization
more than 50% of homebound and institutionalized elders
 Many of the causes of transient, treatable urinary
incontinence are associated with other problems frequently
seen and treated in rehabilitation patients.
AHCPR Publication No. 96-0682: March 1996 Urinary Incontinence in Adults:
Acute and Chronic Management Clinical Practice Guideline Number 2 (1996
Update) Rockville, Md.: U.S. Department of Health and Human Services, Public
Health Service, Agency for Health Care Policy and Research, March 19
Incontinence
 The mnemonic DIAPPERS is useful to remember common
causes of urinary incontinence:
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Delirium
Infection (urinary)
Atrophic urethritis and vaginitis
Pharmaceuticals
Psychological disorders
Excessive urine output
Restricted mobility
Stool impaction
Vapnek: Geriatrics. 2001 Oct;56(10):25-9
Dementia
 Dementia is a clinical syndrome of persistent intellectual
deterioration that is severe enough to interfere with social
or occupational functioning.
 Memory deficits are the main features but amotivational
syndrome and language deficits are common and impact
directly on the rehabilitation process.
 In addition to memory and language dysfunction, dementia
is characterized by the presence of one of the following
symptoms: aphasia, apraxia, agnosia, and executive
dysfunction.
Knopman: Neurology 2001 May 8; 56(9):1143-53.
Is it really dementia?
 The attempt to distinguish delirium, dementia, and
depression by their DSM-IV characteristics may be
difficult.
 Anxiety may also be included in the differential diagnosis.
Premorbid anxiety may be worsened by pain, physical
dysfunction or hospitalization.
 Significantly, dementia is a strong risk factor for both
delirium and depression because the brain is more
vulnerable. The etiology of this individual’s mental status
changes is likely viewed as multi-factorial. A chronic
underlying condition with exacerbating factors is common.
Is it really dementia?
 Therefore, to best discriminate the complexities of mental
status changes in the elderly consider the more unified,
simple definition of cognitive impairment as a decline in
cognitive function from baseline.
 The two major categories then include the potentially
reversible diagnoses of delirium and depression from the
chronic changes in cognitive impairment from dementia.
 It is important to treat all reversible factors and not to stop
at one. Mental illness in the elderly is generally underrecognized and undertreated. However, when treatment is
rendered it is as effective as treatment in younger
individuals.
Delirium
 The DSM-IV defines delirium as a disturbance of
consciousness with inattention that develops over a short
time. Delirium is commonly described as an acute
confusional state or metabolic encephalopathy. Waxing and
waning of attention and performance throughout the course
of the day may be suggested by disparate reports from
therapists treating the patient at different times of the day.
 Delirium has a fluctuating course with changes in
cognitive function not explained by dementia.
Delirium
 The mnemonic DELIRIUM summarizes common causes
of delirium in the older adult:
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Drugs
Electrolyte imbalance (dehydration)
Lack of drugs (withdrawal, uncontrolled pain)
Infection (e.g., UTI or pneumonia)
Reduced sensory input (e.g., vision and hearing deficits)
Intracranial (e.g. CVA, subdural)
Urinary retention/fecal impaction
Myocardial/: Pulmonary.
Lishman, William Alwyn. Organic Psychiatry,3rd Ed. Blackwell
Science, Inc. Malden Massachusetts, 1998.
Depression
 The mnemonic SIG E CAPS summarizes common
symptoms of depression in the older adult:
S Sleep
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I Interest
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G Guilt
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E Energy
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C Concentration
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A Appetite
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P Psychomotor agitation/retardation
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S Suicidality
4 positive suggests significant depressive symptoms.
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Elder Abuse
 Clinicians should actively screen for evidence of elder
abuse, especially in vulnerable populations.
 Prevalence estimated to be just slightly less than that of
child abuse
 The majority of all elder abuse occurs in community
residential, not institutional settings, and most often the
perpetrator is the victim’s adult child or spouse.
 Elder abuse in its many forms (physical/sexual 14.6%,
financial exploitation 12.3%, and neglect 55%) is seldom
recognized and reported, especially by physicians (<2% of
all reports).
Clarke: Emerg Med Clin North Am. 1999 Aug;17(3):631-44
Elder Abuse
 Every state has at least one statute providing immunity
from civil or criminal liability to anyone who makes a
report of abuse in good faith.
 An appropriate approach to take with an older adult might
be:
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Has anyone touched you without your permission?
Do you feel safe at home?
Elder Abuse
 Research has shown that the abusers are more likely to
have problems related to alcohol and drugs.
 The mnemonic SAVED can determine if the person is at
risk for abuse:
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Stress – in the life of the caregiver
Alcoholism – or other substance abuse
Violence – domestic violence grown old
Emotions – ineffective coping strategies for emotions on the part
of the caregiver
Dependency – particularly if either the victim or abuser is
financially, emotionally or physically dependent.
Marshall:Geriatrics. 2000 Feb;55(2):42-4, 47-50, 53
Driving
 Motor vehicle injuries are a leading cause of injury-related
deaths in the older population, (persons 65 years and
older).
 Per mile driven, the fatality rate for drivers 85 years and
older is nine times higher than the rate for drivers 25 to 69
years old.
 Accident rates for drivers 80-85 are 4 times greater than
40-45 year-olds. Drivers over 85 are 10 times more
accident-prone.
Dubinsky: Neurology - 27-Jun-2000; 54(12): 2205-11
Driving
 Heart disease, stroke, arthritis among women, dementia,
diabetes and multiple medications have been associated
with increased risk of accident.
Carr: Am Fam Physician 2000;61(1):141-8
 Many driving skills tests have been devised to evaluate for
safe driving ability prior to road testing.
Klavora:Arch Phys Med Rehabil. 2000 Jun; 81(6):701-5.
Driving
 Older adults with mild Alzheimer’s disease (Clinical
Dementia Rating (CDR) of 0.5) are more accident prone
than alcohol-impaired teenagers (blood alcohol
concentration < 0.08%).
 Specific practice parameters exist for driving with
Alzheimer’s dementia.
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CDR of >1 have a substantially increased accident rate and
driving performance errors, and therefore should not drive an
automobile.
CDR 0.5-0.9 pose a significant traffic safety problem when
compared to other elder drivers and need referral for a driving
performance evaluation by a qualified examiner with reexamination every 6 months.
Dubinsky: Neurology 2000;54(12): 2205-11
Driving
 The Council on Ethical and Judicial Affairs of the
American Medical Association concluded in 1999 that a
“…tactful but candid discussion with the patient and
family about the risks of driving is of primary importance”
by physicians.
 Doctors must render opinions on driving fitness, but
surveys have shown that their knowledge is very poor on
current licensing policies and actions to be taken for
potentially ineligible drivers related to epilepsy,
myocardial infarction, stroke, and diabetes mellitus
complications.
Kelly: 1999; 75(887): 537-9
Conclusions
 Geriatric rehabilitation represents an outstanding
opportunity for growth in the field of PM&R.
 Interdisciplinary care is the gold-standard in the treatment
of the older adult.
 Heightened awareness of the specialized physiologic and
clinical aspects of the older adult are necessary.
 Heightened awareness of the significant non-”medical”
aspects of care of the older adult are of equal importance.