Exercise and rehabilitation of older adults

P.KamalanathanAssociate professor of physiotherapySRM UNIVERSITY

How wewantto be

Reality? Stages and Age of ManCurrier and Ives print

Reality?

7%22%16%47%Lunney, JR, Lynn J, Hogan, C. Profiles of Older Medicare Decedents. JAGS 50:1108-1112, 2002Trajectories of DyingDementia Strokes Arthritis Parkinsons Hip FractureLung Heart LiverCancer

OverviewDefining disabilityWhat is rehabilitation?Decision makingTeamTechnologySettingThe role of exercise in rehabilitationThe Exercise PrescriptionDisease specific evidence

DYSFUNCTION AND DISABILITY

Dis-fitness Cycle

Etiology of deconditioning

Consequences of deconditioning

Disease Impairment Disability HandicapMalnutritionKnee arthritisDepressionWeaknessPainImmobilityApathyDifficulty walkingDifficulty shoppingSocial IsolationLoss of ability to live independentlyPhysical Environment (multi-story house)Social Environment(loss of spouse)Prin. Geriat. Med, 5th edition, p. 289

Prin. Geriat. Med, 5th edition, p. 289

Principal Hospital Diagnoses of Elderly Age 85+ (2006)AHRQ: 2006 Nationwide Inpatient Survey of adults age 85+

AHRQ: 2006 Nationwide Inpatient Survey of adults age 85+

Chart1

85378Fluid/ElectFluid/Elect

89689AMIAMI

99934Acute CVAAcute CVA

109291DysrhythmiasDysrhythmias

114410UTIUTI

115270SepticemiaSepticemia

119030Femur fxFemur fx

202676PneumoniaPneumonia

249733Heart failureHeart failure

Column2

Column3

Column4

Sheet1

Column1Column2Column3Column4

Fluid/Elect85378

AMI89689

Acute CVA99934

Dysrhythmias109291

UTI114410

Septicemia115270

Femur fx119030

Pneumonia202676

Heart failure249733

Muscle Strength & Aerobic CapacityVasomotorInstability Bone Density VentilationSensory ContinenceAlteredThirst andNutritionFragileSkinTendencyTo UrinaryIncontinenceImmobilizedHigh BedBed Rails

PlasmaVolumeAcceleratedBone LossClosingVolumeSensoryDeprivationIsolation

BarriersTetherRx DietImmobilizationSheeringForceDiapersTetherHazards of Bed Rest and Hospitalization+++++++++DehydrationMalnutritionTubePressureSoreInfectionFunctionalIncontinenceCatheterFamilyRejectionAspirationNursing HomeCascade to DependencyDeconditioningSyncopeFallFracturepO2DeliriumPhysicalRestraintChemicalRestraintFalse LabelTardiveDyskinesia

Hospital associated deconditioningLoss of ambulatory function or ADL or both in at least 1/3 of hospitalized patientsIncreased risk of institutionalization or deathDemand for rehabilitation will increaseStudies support acute inpatient rehabilitation, but limited for other settings

Functional decline during hospitalizationFunctionTimeNo rehabilitationHospital admissionPost RecoveryABRehabilitationThreshold of IndependenceAm J Phys Med Rehab, 2009, 88(1):66-77

Am J Phys Med Rehab, 2009, 88(1):66-77

Strength and Functional StatusFunctionStrengthPoorNormalLowHighHealthyAdultsFrailAdultsNearFrailTHRESHOLDEstablished Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology, 1994;49(3):M109-15y, 1994;49(3):M109-15

WHAT IS REHABILITATION?

Goal of rehabilitationReturn to independent living situationNursing home patients generally return to that environment

Decision makingPre-hospital settingSocial support availableCurrent active medical problemsCurrent tolerance of PT/OTCognitive ability

Decision makingPatient motivationPatient and family preferences Financial resourcesPotential for recovery

Contraindications to therapeutic rehabilitationUnstable angina, left main coronary dzEnd stage CHF or systemic diseaseUnstable arrhythmiasMalignant hypertensionExpanding aortic aneurysm

Contraindications to therapeutic rehabilitationCerebral aneurysm or intracranial bleedRecent eye surgery or retinal hemorrhageAcute/unstable musculoskeletal injuryAcute systemic illness (pneumonia, pyelo)Severe dementia/behavioral disturbance

Rehabilitation in generalComprehensiveMultidisciplinaryLong termMedical evaluationPrescribed exerciseRisk factor modificationCounseling/Education

Rehabilitative Interventions:A Team SportExerciseAssistive technologyPhysical modalitiesOrthotics and prosthetics

Physical TherapyBed mobility and transferGait and balance Ambulatory endurance +/- gait aid and stair climbingHip and knee extensor training

Occupational TherapyADL trainingFine motor training and adaptive equipmentIADL / homemaking / community survival skillsCognitive and safety awareness assessment and remediationROM / flexibility / stretching of upper extremityEnergy conservation and joint protectionMuscle strength and endurance training

Driving rehabilitation:www.driver-ed.org

Speech TherapyAll aspects of communicationSwallowing disordersTreatment of communication deficitsDiet and positioning changes for dysphagiaHazzard, Prin. Geriatric Med, 5th Ed., p. 292

NurseEvaluation of self-care skillsEvaluation of family and home care factorsSelf-care trainingPatient and family educationLiaison with communityHazzard, Prin. Geriatric Med, 5th Ed., p. 292

Social WorkerEvaluation of family and home care factorsAssessment of psychosocial factorsCounselingLiaison with communityHazzard, Prin. Geriatric Med, 5th Ed., p. 292

DieticianAssess nutritional statusAlter diet to maximize nutritionConsider liberalizing the diet

Hazzard, Prin. Geriatric Med, 5th Ed., p. 292

Recreation therapistAssess leisure skills and interestsInvolve patients in recreational activities to maintain social rolesHazzard, Prin Geriatric Med, 5th Ed. 292

Hazzard, Prin Geriatric Med, 5th Ed. 292

Mobility AidsCaneSupports 15-20% of weightOptions: single point, quad or hemi-caneSide opposite affected limbFitted to ulnar styloidContraindicationsArm weakness, moderate to severe gait or balance deficitPotential problem: inadequate support

Mobility AideWalkerSupports ~30% of weightOptions: 4 post, 2 wheel/2 post, 3 wheel, 4 wheel, 4 wheel with seat and hand brakes (Rollator), 4 wheel with safety bars and sling seat (Merry Walker), forearm supportsFitted to ulnar styloidContraindications:Environmental hazards, severe arm and gait weaknessProblem: slows gait, maneuverability

Mobility AidsCrutchesSupports full body weightOptions: underarm/forearmFitting: 2 inches under shoulder; do not lean armpit on crutchContraindications: arm weakness, shoulder arthritis, cognitive impairmentProblems: neuropathy, shoulder pain, difficult to learn to useWheelchairSupports full body weightOptions: manual/motorized; accessories; lower to ground or one-sided drive (hemi-chair); racing, handcycleFitting: 1-1.5 inches around hips and under knees; footplates clear floor by 1-2 inches; armrest at elbow height; removable footrests and armrestsContraindications: unable to sit, or able to walk safelyProblems: deconditioning, contractures, pressure sores

THE ROLE OF HOME IN REHABILITATION

J American Geriatrics Society, 2009, 57: 476-481Long Term Effect on Mortality of a Home InterventionABLE demonstrated that teaching elderly people new approaches to performing valued activities resulted in additional years of life.

Certified Aging-in-Place Specialists (CAPS)http://www.aarp.org/family/housing/articles/caps.html

Rehabilitation settings: which is best?Acute inpatient rehabilitation hospitals/unitsSub-acute nursing facilitiesHome health careOutpatient therapyCochrane Review: Care home vs. hospital and own home environmentsfor rehabilitation of older people. 2008, Issue 4. Art No: CD 003164

Insufficient evidence to compare

Exercise and rehabilitation

Exercise (Activity) Prescription for Older Adults Strength: Use It & Lose Less of itLossesSedentary people lose large amounts of muscle mass (20-40%)6% per decade loss of Lean Body Mass (LBM)

GainsLean body mass increases 1-3 kgResistance training improves strength by a range of 40-150%Muscle fiber area 10-30%

Aerobic Activity IS NOT sufficientto stop this loss!BOTTOM LINES:MUSCLE STRENGTHENING EXERCISES REQUIREDMUST INCLUDE BALANCE+FLEXIBILITY IN OLDER ADULTSFEWER FALLS, FRACTURES, DISUSE, FRAILTY AND SARCOPENIA

Mode:Aerobic+Strength +Balance+FlexibilityDurationFrequencyIntensity: Touch > No Touch > Eyes Closed for balance5-6/10 self-perceived exertionTimely Follow UpTherapy (Preventive and/or Therapeutic)The MD FITT Prescription(for the older adult)

Moderate Intensity(brisk walk)30 minutes5 times per weekExercise (Activity) Prescription for Older AdultsWhats Different for Older Adults?

2007 ACSM Guidelines For Older AdultsVigorous Intensity (jogging)20 minutes3 times per weekStrength Building Exercise(weight/resistance training)8-10 exercises2 times per weekFlexibility Activities(static stretch)10 minutes10-30 seconds/stretch3-4 repetitionsAll days of the weekBalance Exercise(not specified)3 times per weekIntensity

Rating 5-6/10

Intensity is relative to level of fitness

Exercise (Activity) Prescription for Older AdultsA little more about balance

StaticDynamicIntensity=sensory or time

CONDITION SPECIFIC REHABILITATION

Leading causes of deathCardiovascular diseaseCerebrovascular diseaseChronic lung diseaseAlzheimers DiseaseAccidents and fallsLeaving out pneumonia, influenza, malignancy

CARDIAC REHABILITATION

Cardiovascular rehabilitationLess than 1/3 patients participatewww.ahrq.gov/news/press/prsrl2.htmComponents include:ComprehensiveLong-termMedical evaluationPrescribed exerciseRisk-factor modificationEducationCounseling

Cardiac rehab outcomesImproved exercise tolerance for CAD and CHFDecreased symptoms in CAD and CHF Multi-factorial interventions improve lipidsMulti-factorial rehab reduces cigarette smoking (16-26% will quit)

AHRQ Technical Reviews and Summaries, AHRQ Supported Clinical Practice Guidelines, Chapter 17. Cardiac rehabilitation

AHRQ Technical Reviews and Summaries, AHRQ Supported Clinical Practice Guidelines, Chapter 17. Cardiac rehabilitation

Cardiac rehab outcomesImproved psychosocial well-beingMortality reduction of approximately 25% at three years (similar to B-blockers and ACE Rx)No increase in morbidity or mortalityCardiol J. 2008; 15(5): 481-7

Cardiol J. 2008; 15(5): 481-7

OutcomesAm Heart J. 2006; 152: 835-41

DiagnosisFunctional CapacityQOLMorbidityMortalityAMI+++++++++++CABG++++++++++Stable angina++++++++PCI++++++?CHF+++++++Cardiac Transplant+++++??Valve replacement+++++??

Am Heart J. 2006; 152: 835-41

STROKE REHABILITATION

Some ugly truthsRace disparities in use of stroke rehab programs and outcomesLess likely to receive if DNR or Medicaid recipient

Stroke rehabilitationInitial assessmentRisk factors for CVAMedical co-morbiditiesConsciousness and cognitive statusBrief swallowing assessmentSkin assessment and pressure ulcersMobility and assistance needsRisk of DVTEmotional/social support of the family

Reassessment of rehab progressGeneral Medical StatusFunctional statusMobility, ADL/IADL, Communication, nutrition, cognition, mood/affect/motivation, sexual functionFamily supportResources, caretaker, transportationPatient and family adjustmentReassessment of goalsRisk for recurrent CVA

Assessment of discharge environmentFunctional needsMotivation and preferencesIntensity of tolerable treatmentsAvailability and eligibility for benefitsTransportationHome assessment for safety

PULMONARY REHABILITATION

Lung disease rehabilitationCost effective and beneficial to systemComponents: Multidisciplinary, individual assessment, exercise training, education, medical therapy, psychosocial supportGoals: Reduce symptomsOptimize functionIncrease participationReduce healthcare costs Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.

Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.

Recommendations and evidenceMandatory exercise training (Level 1A)Six to 12 weeks of pulmonary rehab produces benefits that decline over 12-18 months (1A)Maintenance strategies have modest effect on long-term outcomes (2C)Lower extremity exercise at higher intensity has greater benefit (1B)

Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.

Recommendations and evidenceLow- and high-intensity exercise produce benefits (1A)Strength training increases strength and muscle mass (1A)No support for use of anabolic steroids (2C)No support for inspiratory muscle training (1B)Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.

Typical programStage III-IV COPD severity3-4 sessions/week, 3-4 hours/session6-12 week durationWalking/resistance trainingHorizon (?): heliox, O2, non-invasive ventilatory support, biofeedback, anabolic steroid

Casaburi, ZuWallack. NEJM 2009; 360: 1329-35

Casaburi, ZuWallack. NEJM 2009; 360: 1329-35

Problem areasCOPD cachexia-1/3 of patients dont improveNo uniform funding policy$2200/person costUnavailable to low-income, minority and rural populations

Casaburi, ZuWallack. NEJM 2009; 360: 1329-35

OutcomesImproves dyspnea (Level 1A)Improved Health Related Quality of Life (1A)Reduces hospitalization and utilization (2B), Cost effective (2C)Insufficient data for survival benefitPsychosocial benefits (2B)Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.

DEMENTIA REHABILITATION

Exercise to preserve cognition8/11 studies of aerobic exercise interventions showed increased fitnessLargest effects were:Motor function (1.17(?) effect size)Auditory attention (0.52 effect size)Delayed memory function (0.50 effect size)Cognitive speed (0.26 effect size)Visual attention (0.26 effect size)Angevaren, et. al. Cochrane Database of Systematic Reviews, 2008, Issue 2. CD005381

Angevaren, et. al. Cochrane Database of Systematic Reviews, 2008, Issue 2. CD005381

Physical activity for dementia patientsLimited RCTs of activity in ADGenerally improved:Psychological/physical performanceMobilityBalanceStrengthGait speedSleepMood/agitation/cognitive functionRolland, et al. JAMDA 2008; 9: 390-405

Rolland, et al. JAMDA 2008; 9: 390-405

Not a pretty pictureStudies highlight sedentary life of the elderlyAverage of 12 minutes a day of constructive activity in institutional settingsIs inactivity an early manifestation of dementia?

FALL AND FRACTURE REHABILITATION

Fall prevention:Cochrane Review of 11 RCTsWide variety of exercise programs5/11reduction in rate of falls or fall risk4 exercise only intervention1 multi-intervention + exercise

Conclusion: Exercise is effective in lowering the risk of falls in selected groups and should form part of fall prevention programmes. Lowering fall-related injuries will reduce health care costs

Injury rehabilitation (hip fracture)Seven trials earlySix trials after hospital dischargeThere is insufficient evidence from RCTs to establish the effectiveness of the various mobilisation strategies used in rehabilitation after hip fracture surgery.Handoll . Mobilisation strategies after hip fracture surgery in adults. CochraneDatabase of Systematic Reviews 2007, Issue 1. Art. No.: CD001704.

SummaryExercise as preventionExercise as therapyTeam RehabPrescribed exercise

**Why have these levels appeared?? The end of life trajectories as depicted 150 years ago.*This chart for Indicator 24 - Physical Activity shows that in 20052006, 22 percent of people age 65 and over reported engaging in regular leisure time physical activity. The percentage of older people engaging in regular physical activity was lower at older ages, ranging from 26 percent among people age 6574 to 10 percent among people age 85 and over. There was no signicant change in the percentage reporting physical activity between 1997 and 2006. ***