Transcript LIFE-SPAN DEVELOPMENT

Living with
Cerebral Palsy
Life-span Considerations
Mary Rose Franjoine, PT DPT MS PCS
Margo Prin Hanynes PT DPT MA PCS
Recommended Reading
Aging in Individuals with Lifelong
Disabilities
Barbara H. Connolly
Physical and Occupational Therapy in
Pediatrics, 2001
– Volume 21, Issue 4; Pages 23-47
Background Resource
Cech and Martin
Functional Movement Development Across the Life Span, 2nd edt.,
WB Saunders, 2002
Learning Objectives
At the conclusion of this lecture the learner will:
 Describe psychosocial factors that impact on
quality of life in individuals living with
developmental disabilities.
 Discuss physical factors that impact on the
quality of life in individuals living with
developmental disabilities.
 Identify strategies that can be included in a
plan of care to improve the quality of life for
individuals living with developmental
disabilities.
The Aging Process….
• Maturity
• Varies within body systems
• Variability between individuals
• Physical Maturity
Intellectual Maturity
• Peak Physical Capabilities: 20 – 24 years of age
• Executive Functions: 26 -28 years of age
• Experience shapes the maturation process
• Key consideration for individuals living with
Cerebral Palsy and other developmental-based
disabilities
Life-span Motor Development
Key considerations:
• Multidirectional
• Efficiency is Gained and/or lost
• Plasticity
• Historical Influences
• Psychosocial Influences
Aging Process
Linier Model
C B
Inverted U Model
Death
Maturity
B
C
D
"Motor development should be
seen as a succession of
integrated milestones leading
to more complex and
independent function." Bobath
Demographics
• 1 out of 8 individuals living in the US is
over the age of 65!!!!!!
• 12% of individuals living in the US over the
age of 65 have a developmentally-based
disability
When does the Aging Process Begin????
• Physical Changes
• State of Mind
• Senior Citizen status
• Typical Adults: 65 years of age
• Developmentally Disabled Adults: mid-50’s
Declines in Daily Life
Functional Capabilities
• Typical Adult population
• 60 to 65 years of age
• Individuals living with Developmental
Disabilities
• 35 to 50 years of age
• Individuals living with Cerebra Palsy
• Decline in capabilities may begin in early 20’s
Predictors of Successful Aging
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Gender – Women
Community-dwelling
Ambulatory
IQ of 50 or greater (mild)
Verbal communication with natural or
assisted speech
What are the most common
changes associated with the
typical aging process?
Age-related changes within the
Central Nervous System
Beginning at age 20:
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Brain weight decreases
Brain volume decreases
Cortex thins
Glial Cells increase in number
Ventricular volume increases
Cerebral volume decreases (beginning in the 3rd decade of
life)
• Conduction velocities decrease
• Sensory changes precede motor
• Decline in peripheral nerve conduction velocities precedes
the decline centrally
Age-related changes within the
Central Nervous System
MRI studies have shown with increasing age brain tissue proportions decrease
• Sulci and Ventricular CSF proportions increase
• Cortical gray matter proportions decrease
• CSF volume increases
• Percentage of gray matter decreases
• Protein levels decrease
• Lipofuscin increases extracellularly
• Percentage of Neurofibrillary Tangles and Neuronal (Senile) Plaques
increase
• Cerebral blood flow decreases
• Brain metabolism decreases
• Dopamine up-take decreases
• Decrease in glucose utilization
CT and MRI studies seem to suggest that large neurons in the Temporal and
Frontal lobes shrink, while the smaller neurons die off.
PET scans have not confirmed these findings!
Age-related structural changes
are not consistent throughout
the Brain!
• Frontal and Temporal lobes are effected greater
than the Parietal lobe.
• The Primary Motor and Primary Sensory areas
of the Cortex are susceptible to neuronal loss
beginning at age 20.
• The Hippocampus, (Limbic System) can sustain
a 30 percent loss of neurons by age 30.
Functional Implications
Learning
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Cortex
Limbic system
Thalamus
Reticular formation
Brain stem
Studies have shown that intellectual abilities peak
between 20 and 30 years of age and last until 75 years
of age.
Functional Implications
• Decline of cognitive abilities in individuals living
with developmental disabilities is thought to be
increased when compared to age-matched peers
beginning in 30’s.
• Rate of decline is unknown
• Decline of Cognitive/Intellectual capabilities in
individuals living with Cerebral Palsy is unclear
• Blurred by psycho-social factors, and co-morbidities
• Linked with increase incidence of depression and
social isolation
Memory
Memory Storage
• Immediate
• Short term
• Long term
Types of Memory
• Reflexive also known as Procedural
Motor memory
• Declarative
Verbal performance
Memory changes occur across the life-span
Dementia
Alzheimer's Disease
Prevalence is thought to increase in individuals living
with developmentally-based disabilities.
• Individuals living with mild to moderate mental retardation
have an increased incidence of AD when compared to
age-matched peers.
• Individuals who have Learning Disabilities have a higher
than average incidence of early onset dementia and AD.
• Individuals living with developmentally-based disabilities
residing in institutional settings have an extremely high
incidence of dementia & AD when compared to
community-dwelling individuals with similar capabilities.
Dementia
Alzheimer's Disease
Individuals living with Down Syndrome
• Increased prevalence of memory loss
• Extremely high incidence of early-onset dementia
• 40% higher than age-matched peers at age 35 years
• 45% of adults with Down Syndrome over the age of
50 years experience moderate to severe dementia
• Overall aging process for individuals living with
Down Syndrome is thought to be accelerated
• Compared to typical age-matched peers
• Compared to individuals with similar cognitive
capabilities
What factors influence your
ability to learn, to retain new
information, or to recall
previously learned knowledge
or skills?
Age-related Changes within the
Sensory System
Decline in Sensory system function
• Begins in early adulthood - 20 to 30 years of age
• Progresses with increasing age
• Functional abilities typically not impacted until
Older adulthood – 70’s, 80’s
Tactile
Superficial Sensation
• Gradual declines have been described in the
literature
• Limited impact on functional abilities occurs until
late in life
• Studies suggest that beyond middle age, the ability
to detect the intensity of a noxious object
decreases.
Temperature
• Extreme temperature changes are generally
perceived by the elderly, but smaller changes are
less readily discerned.
• The ability to detect environmental
temperature changes also declines with age.
Pain
Perception and discrimination of a painful stimulus
declines with increasing age.
Two-point Discrimination
Decreases with age
Kinesthetic
Vibratory Sense
• Most common sensory loss in the elderly
• Initially seem in the lower extremities
• Studies have reported as much as a 60% loss in the
lower extremities of women in their 50’s.
Passive Movement Sense
• Detection thresholds increase with age, especially
in LE
• Change in UE detection are not reported
Position Sense
• Declines with age, especially in the lower
extremities
Passive Movement Sense
&
Position Sense
• Detection thresholds are twice as high in
individuals with Cerebral Palsy over the
age of 50 years
Praxis
Motor planning abilities decline with age beginning
at age 30.
Reaction Time
• Perception of Stimulus
Motor Response
Developmentally, RT is linked closely to the
myelinzation process
Fastest reaction times are seen in the 20's.
Studies have shown a 20 percent increase in
response time in a 60 year old when compared to a
20 year old.
Functional Implications
• Decline in Tactile, PS, PMS & VS may interfere with an
individual's ability to
• Access AT
• Communication devices
• Environmental control devices
• Mobility devices
• Complete BADLs & IADLs
• Interface with the world!
• Increases in RT may interfere with the ability to interact
with individuals and the environment
Hearing
Decline is due to loss of sensory cells in the
inner ear
• 40 percent of adults age 65 experience a hearing loss which
effects discrimination of speech sounds.
• 70 percent of adults over age 70 will experience a hearing
loss which effects discrimination of speech sounds.
• Changes may begin as early as age 30 years; progressing
up to age 80 years.
• High frequency hearing loss precedes low frequency loss
Hearing Loss
Suspect high rate of unidentified hearing
loss in individuals living with
developmentally-based disabilities
• Chronic ear infections
• Testing difficulty
• Access to testing
Loss of Vestibular Function
Vestibular nerve demyelization begins at age 40 years
• 40% loss of fibers by age 75 years
• Viscosity of fluid increases with age
• Membranes become brittle with age
• Hair cells decrease with age
• Vestibular dysfunction
• Commonly seen in individuals over the age of 50
years
Balance Dysfunction
• Functionally there is a decline in balance
abilities beginning in mid-50’s
• Dizziness and Vertigo: Two or more
episodes reported by 40% of typically
aging individuals by age 55 years
• Prevalence in individuals living with
Cerebral Palsy is unknown
• Suspect that there may be a high rate of
undiagnosed Vestibular Dysfunction
Vision
Visual acuity increases into the 20's and
remains stable through early adulthood.
• Decline in visual acuity begins between age 40
and 50 years.
• By age 85 there is an 80 percent loss of the acuity
level present at age 40 years.
• Beginning at age 40 years
• Loss of color vision – spectrum loss
• Dark adaptation slows
• Visual fields decrease
Vision Loss
Suspect high rate of unidentified vision
loss in individuals living with
developmentally-based disabilities
• Chronic eye infections
• Testing difficulty
• Access to testing
• Decline in functional vision may occur early in
life secondary to
• Poor eye coordination
• Poor gaze stability
Taste and Smell
Social and emotional aspects of eating are
thought to account for a loss of appetite in
the elderly verses structural changes in
the system.
• The ability to detect noxious odors declines with
age.
What are the life changes that
can lead to loss of appetite?
Loss of Appetite
Individuals living with developmental-based
disabilities have an:
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Increased threshold for taste and smell of food
Loss of pleasure from eating
Poor dietary intake
Loss of weight
Increased risk of infection
Compromise of Body Functions & Structures
Death
Malnutrition
Physical, social and emotional factors associated
with eating can lead to states of malnutrition
Calorie intake may need to exceed intake for
typical age-matched peers
Limited Caloric intake and poor nutritional status
may lead to:
• Decreased ability to repair – normal wear and tear
• Decreased ability to fight infection
• Decrease in Vitamins C and D: bone and skin health
Decreased Body Mass Index
• A “real” life threatening concern for 25%
of individuals living with developmentalbased disabilities
• Individuals living with Cerebral Palsy
prevalence of decrease BMI is unclear
• Need for nutritional supplements, or
supplementation of nutrition intake
Increased Body Mass Index
• New Epidemic in Children
• Numerous related health concerns
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Diabetes
Hearth Disease
Integumentary problems
...
Age-related changes within the
Musculoskeletal System
Skeletal System Changes
Maximal bone mass is obtained by the late 20’s or early 30’s.
Bone reabsorption exceeds bone formation between age 35 and
40 years.
Bone loss appears to vary between races and with gender.
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Women more so than men
Black males appear to be least affected.
Architectural changes occur within the bone matrix and in
collagen fibers that increase the brittleness of bone.
Age-related Changes within the
Musculoskeletal System
Muscle System Changes
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Gender differences in force generation ability appear in early adolescence
Grip strength doubles between 6 and 12 years of age
Strength doubles between 10 and 16 years of age
Muscle strength appears to peak in your 20’s
Functional muscle strength begins to decline in your 50’s
Muscle strength declines by 30% from the 50’s to the 70’s
Decline after age 70 is more rapid
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Structural changes within the muscle begin in the 50’s and lead to a decline in
the ability to generate power
Etiology of muscle mass loss is associated with loss of contractile proteins,
hormonal changes, and changes in motor units.
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• 1% of the total number of motor units is lost annually beginning in the 20’s
• Loss of muscle mass is greatest in the lower extremities, with the thigh showing the
greatest loss
Functional Implications
• Alteration of preferred movement patterns or functional
movement strategies:
• Osteoarthritis may result in pain, or a fear of falling that can
lead to a decrease in activity level.
• Osteoporosis and fear of a fall which may result in a fracture
can lead to a decrease in activity level.
• Inactivity can lead to a decrease in a muscle’s ability to
generate power, decrease in muscle mass, and a decline in
functional muscle strength.
Functional Implications
Individuals living with Cerebral Palsy report
decline in muscle strength which interferes
with performance of functional activities
Percentage/degree of strength loss is not
clear
• At age 30 years: 20% report perceived loss
• At age 40 years: 60% report
• Increased time to complete tasks
• Decreased proficiency and accuracy in task
completion
• Require “new level” of assistance: care provider or
AT
Osteoarthritis
Individuals living with Cerebral Palsy report early
onset of arthritic impaired movement & associated
pain syndromes
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Shoulder
Hands
Neck
Back/Low back
Hips
Knees
• Increased incidence of hip fracture in agematched peers beginning at age 40 years
Balance Dysfunction
• Functionally there is a decline in balance
abilities beginning in mid-50’s
• Loss of Muscle Strength
• Loss of flexibility
• Decrease in perception of sensory information
• Increase in reaction time
• Increase in sensory processing time
• Fear factor!
Fear of Falling
• Individuals living with Cerebral Palsy
report and increased fear of falling
impacting activity choices when compared
to age-matched peers beginning in mid20’s
• Fear of Falling with Injury is increased at
all ages – negatively correlated
Age-related Changes within the
Cardiopulmonary System
The Cardiac System
• Structural changes occur within the heart that result in an increase stiffness and
decrease compliance of the ventricles, which leads to an increase in HR, BP and a
decrease in CO.
• Maximal HR decreases with age.
• Heart valves become thicken and calcified decreasing their ability to function efficiently.
• SA node cells significantly decrease in number by age70.
Age-related Changes within the
Cardiopulmonary System
The Pulmonary System
• Structural changes in the thorax, (shorter and wider) lead to an
increase in the work of breathing.
• Beginning in your 20”s:
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Decrease in compliance: elasticity
Decrease in chest wall mobility
Increased resistance within the bronchopulmonary system
Decrease in number of alveoli
Alveolar surface area decreases
• Pulmonary Function Tests
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Decrease in Tidal Volume
Decrease in Total Lung Capacity
Increase in Residual Volume
Increase in Functional Residual Capacity
Decrease in Forced Expiratory Volume and FEV1
Functional Implications
Target HR
Exercise Tolerance
Aerobic capacity
Pulmonary Health
Growing Body of Evidence
Research supports aerobic exercise program
for individuals living with Cerebral Palsy
• Independent or AT assisted community-based
programs
Age-related Changes within the
Gastro-Intestinal and Urinary
Systems
• Decreased gastric and intestinal motility
• Decreased elasticity of bladder and urinary tract
Functional Implications
• Dietary changes
• Lifestyle changes
Program Planning
• When do we begin to modify our plan
of care to impact on the aging process?
• What factors should be considered in
OT, PT, & ST to facilitate optimal aging
for individuals with living Cerebral
Palsy?
References
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happening. Journal of Intellectual and Developmental Disability.
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• Bertoti, Dolores, B. Functional Neurorehabilitation Through the Life
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• Bertoti, Dolores, B. Workbook for Functional Neurorehabilitation
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• Bonder,B. and Wagner, M. Functional Performance in Older Adults,
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• Cech, D and Martin, S. Functional Movement Development Across
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• Connolly, Barbara H., Aging in Individuals with Lifelong Disability.
Physical and Occupational Therapy in Pediatrics , 2001: .21(4);
23- 43/
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References
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Sheets, Debera J. Aging with Disabilities: Ageism and More Generations: Aging in the
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Shumway-Cook, A and Woollacott, M. Motor Control Theory and Practical Applications.
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