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Considerations in Aging with a Disability

Considerations in Aging with a Disability. Carolyn P Da Silva, PT, DSc, NCS Texas Woman’s University School of Physical Therapy cdasilva@twu.edu. Acknowledgement.

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Considerations in Aging with a Disability

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  1. Considerations in Aging with a Disability Carolyn P Da Silva, PT, DSc, NCS Texas Woman’s University School of Physical Therapy cdasilva@twu.edu

  2. Acknowledgement • This slide deck was developed by Dr. Carolyn DaSilva as part of her faculty role in the HRSA sponsored Houston Geriatric Education Center. Please credit her for the work if this presentation is utilized.

  3. Learning Objectives Successful students will be able to : • Understand the organization and levels of the ICF framework as it pertains to people growing older with chronic conditions; • Discuss importance of assessing people aging with a disability, at various levels within the ICF framework; • Discuss specific barriers and facilitators to health promotion and illness prevention in people with disability, and; • Integrate knowledge into management of patient condition to promote healthy aging.

  4. World Health Organization: “an umbrella term for impairments, activity limitations and participation restrictions” Contemporary Definition of Disability WHO 2001

  5. The International Classification of Function, Disability, and Health (ICF): 3 Levels of Human Function • Functioning at level of: • Body/body parts • Body function/structure • Problems lead to impairments • Whole person • Activities • Problems lead to activity/functional limitations • Whole person within complete environment • Participation • Problems lead to participation restriction/disability Jette 2006

  6. The International Classification of Function, Disability, and Health (ICF): Contextual Factors • Personal factors • Comorbidities • Personality • Environmental factors • Physical environment • Social support • Financial issues Jette 2006

  7. Why are these distinctions important? • Consider 2 63-year-old females with these health conditions: • Osteoarthritis (OA) in B knees, R hip, lumbar spine • Overweight (non-obese) • Hypertension (HTN) • Body structure/function of both females: • OA seen per x-ray • No prior orthopedic surgeries • Pain levels of 4-6/10 in respective joints with activity, 1-2/10 while resting • Strength 4 or 5/5 in B legs, 5/5 in B arms • Passive range of motion (PROM) of B knees, R hip ~80% of normal • Resting BP 138/85, HR 88

  8. Importance of Distinctions (cont.) Activities of Marge: Activities of Sue: Slow, painful gait without device Modified independence in basic and instrumental ADL Works full-time Drives • Slow, painful gait without device • Modified independence in basic and instrumental activities of daily living (ADL) • Works full-time • Drives

  9. Importance of Distinctions (cont.) Social participation of Marge: Social participation of Sue: Has difficulty fulfilling societal roles: Wife of husband with metastatic bone cancer Full-time employee as day care teacher of 2-year-olds Taking care of their horse & 3 dogs Housework and cooking hard to complete Yard work now a new responsibility and cannot complete Able to care for 5 year old granddaughter • Able to fulfill societal roles: • Wife • Full-time employee as secretary of large church • Enjoying hobbies such as reading and fishing • Keeping up with housework and cooking, though slowly • Has difficulty with: • Gardening • Caring for 9 month old grandson

  10. Contextual Factors • What differences existed between Marge and Sue? • Environment • Physical environment • Interpersonal • Personal

  11. How can a person’s status change along the ICF continuum? • For Marge/Sue, as their OA progresses (health condition), what changes might we see in: • Body structure/function? • Activities? • Participation? • Contextual factors? • What impact might the passing of Sue’s husband (contextual factor) have on her: • Health conditions? • Body structure/function? • Activities? • Participation?

  12. Measurement of Health Conditions • What types of measures/tests do we use? • Includes differential diagnosis

  13. Measurement of Body Structure/Function: Impairments • Primary impairments • Arise directly from the health condition • Ex: weakness, spasticity, sensory deficits due to stroke • Secondary impairments • May indirectly arise if spontaneous recovery and/or therapeutic interventions are insufficient • Ex: ankle plantarflexion contracture, deconditioned cardiovascular state from residual hemiparesis over time

  14. Measurement of Body Structure/Function: Impairments (cont.) • What types of measures/tests do we use?

  15. Measurement of Activity • What types of measures/tests do we use?

  16. Measurement of Activity: Gait Speed • Can gait speed be a new vital sign? • Gait speed associated with survival in elders • Predicted survival of 34,485 elders based on age, sex, gait speed was as accurate as that predicted by: • Age, sex, use of mobility aids, self-reported function, or • Age, sex, chronic conditions, smoking hx, BP, BMI, hospitalization. • Speed of 0.8 m/s (1.79 mph) indicates average life expectancy. Studenskietal2011

  17. Gait Speeds in Perspective • Perry at al. categorized functional walking in patients with chronic stroke according to gait speed: • Unlimited household ambulation: 0.27 m/s • Limited community ambulation: 0.58 m/s • Unlimited community ambulation: 0.80 m/s • Average gait speed: • Adults 20-69 years old: 1.32 – 1.37 m/s (2.96 – 3.06 mph) • Adults 70+ years old: 1.12 – 1.24 m/s (2.51 – 2.77 mph) • Speed needed to cross commercial street: • 2.0 m/s (4.47 mph) Perry et al 1995, Rancho Los Amigos 2001

  18. Measurement of Participation • How do we do this? • What areas does this address? • What areas tend to be avoided or not thought about? • What types of measures/tests do we use? • Quality of life • Mood/emotion

  19. A Paradigm Shift from Disability Prevention to Prevention of 2o Conditions • “The aims of a health promotion program for people with disabilities are to • Reduce secondary conditions (eg. obesity, hypertension, pressure sores), • Maintain functional independence, • Provide an opportunity for leisure and enjoyment, and • Enhance the overall quality of life by reducing environmental barriers to good health.” Rimmer, 1999 • Greater emphasis on community-based programs necessary

  20. “It occurs after an individual acquires or is born with a disability, The characteristics of the condition are not associated with the trauma, It is more prevalent in people who have a disability than in those who do not have a disability, It is not caused by medication or intervention, and It is a health condition (versus a risk factor for a health condition).” Definition of Secondary Condition Rimmer et al 2011

  21. Old versus New Definitions of Health • No longer just the absence of disease • World Health Organization • Well-being of person within these domains • Physical • Mental • Social • Dynamic interactions of these domains and includes person within environment • Rimmer 1999

  22. Dynamic Aspects of Health • Multifactorial • Shifts along continuum of life • A person with a disability will have dynamic changes in health during life, too. • However, a minor condition can affect a person with a disability more severely than one without a disability. • Ex: Rotator cuff repair for person who uses manual wheelchair or crutches full-time Rimmer 1999

  23. What are the typical aging processes? • How are these different in people with disabilities?

  24. “The lack of knowledge and understanding on the part of health care professionals concerning my disability and how it is affecting me as I age is extremely frightening to me.” Kailes 2006

  25. Why the paradigm shift? • People with disabilities are living longer, some with normal life expectancies. • Modern medicine is allowing more people with severe impairments to live, then age. • Up to 50% of polio survivors develop post-polio syndrome. • ~25% of people with spinal cord injury have increased functional limitations more than 15 years later. Rimmer 1999

  26. Secondary Conditions are a Prevalent Public Health Concern • Individuals with physical disabilities at high risk for 2o complications/conditions and have higher frequency of conditions Heath 1997, Rimmer 2011 • Certain precautions important with people with disabilities Nash 2005, Frankel 2001 • Inclusion of disability-related issues in Healthy People 2010 and greatly expanded in Healthy People 2020 • http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=9

  27. Prevalence of Disabilities • ~20% or 54 million Americans are disabled. • Significant increase in younger populations since 1970 Healthy People 2020 • Disparities exist in: • Physical activity levels between people with and without disabilities Healthy People 2020, Rimmer 2004 • Proportion of women and minorities with disabilities Rimmer 2000 • Women with and without disabilities have similar health behaviors except for EXERCISE. Rimmer 2000

  28. Health Promotion Topics of Interest • Topics of most interest of 604 women with disabilities: • Aging with disability 66% • Stress management 64% • Exercise 63% • Nutrition 62% • General health promotion 56% • Mental health 54% • Of least interest: • Smoking cessation 8% • Reproductive issues 8% Smeltzer, Zimmerman 2005

  29. Let Us Look at 2o Conditions • Related to physical inactivity, and can worsen disability itself • Diabetes • 3 to 4 x incidence in people with disabilities Healthy People 2020 • Heart disease Khan et al 2011 • Osteoporosis Coyle et al 2000, Nosek et al 2005, Mohammad et al 2009 • Insufficient muscle mass active to keep bones strong • Unilateral vs bilateral issues • Obesity • Significantly more obesity in people with disabilities • More disparity noted in women with/without disabilities Healthy People 2020

  30. Secondary Conditions After Stroke • In 98 people 24-180 days following stroke, with no prior history of diabetes (DM), 52% have impaired glucose tolerance (IGT) or DM type 2. • In 216 people with chronic stroke, 81% had IGT or DM 2. Ivey et al 2008

  31. Muscle Fiber Type Changes • Muscles normally ~50% fast and slow twitch • After stroke or spinal cord injury, big decrease in # and % of slow twitch • Fast twitch fibers less insulin sensitive • Muscles fatigue more easily • Affected leg 67% fast twitch, unaffected 51% • With aggressive training in normals, will see 3% change. Ivey et al 2008

  32. Greater degree of impairment Greater switch to fast twitch Greater insulin resistance Ivey et al 2008

  33. Fat and Other Muscle Cell Changes • Paretic leg differences from non-paretic leg: • Fat content 25% higher • Muscle mass 20% lower • Fat content of paretic leg is higher predictor of insulin resistance than central obesity. Ivey et al 2008

  34. Treadmill Study with Chronic Stroke • 6 months, 3 x/week • Significant improvements in: • Insulin sensitivity • Slow to fast twitch fiber ratios • Blood flow • Fibrinolytic markers for at least 1 hr after exercise • Increased tPA • Decreased PAI-1 • These changes not seen in normals – evidence of inflammatory processes after stroke • May protect against new stroke or exertional MI • No changes in body mass or % fat Ivey et al 2008

  35. How unfit are stroke survivors? • Tested in 156 full-time community ambulators • Mean age – 67 years • Mean time since stroke – 3 years • Hemiparetic gait costs twice as much as normal. • Fitness levels are 50% lower than age and gender matched sedentary controls. Ivey et al 2008

  36. Why are chronic stroke survivors so unfit? • Altered central nervous system motor control • Difficulty activating the muscles • 2o biological changes in muscle/fat composition • Cardiovascular deconditioning • DISUSE Ivey et al 2008

  37. Conceptual Model of Onset, Course, and Outcomes of Secondary Conditions in People with Disabilities • Primary disability • Onset & course of secondary conditions • Nonmodifiable antecedents • Sociodemographic • Pre-existing conditions • Disability-related • Associated conditions

  38. Conceptual Model of Onset, Course, and Outcomes of Secondary Conditions in People with Disabilities 2 • Onset & course of secondary conditions (cont.) • Modifiable risk factors • Personal • Overuse/disuse • Diet • Medication adherence • Physical activity • Rehabilitation adherence • Substance use/abuse Rimmer et al 2011, p 1733, fig 2

  39. Conceptual Model of Onset, Course, and Outcomes of Secondary Conditions in People with Disabilities 3 • Onset & course of secondary conditions (cont.) • Modifiable risk factors • Environmental • Health care • Health promotion access • Built environment access • Social support Rimmer et al 2011, p 1733, fig 2

  40. Conceptual Model of Onset, Course, and Outcomes of Secondary Conditions in People with Disabilities 4 • Outcomes of secondary conditions • Onset, progression, severity • ICF levels: body structure/function, activities, participation • Individual level outcomes (micro) • Health-related quality of life • Health care utilization • Community participation • Employment • Societal level outcomes (macro) • Cost of health care • Health disparity

  41. Onset and Course of Secondary Conditions: Case Study of Mr. C • Patient with SCI who develops shoulder pain • Nonmodifiable antecedents • Age • Previous shoulder injury • Tetraplegia • Limited trunk control • Modifiable risk factors • Personal • Overuse of shoulder • Time of WC use • Environmental • Propelling WC on incline Rimmer 2011, p 1736, fig 3

  42. Onset and Course of Secondary Conditions: Case Study of Mr. C 2 • Secondary condition of shoulder pain • Muscle strength/flexibility • ADLs, transfers, WC propulsion • Social, work • Individual level outcomes Societal level outcomes • Decreased Increased • Health-related QOL Cost of health care • Community participation Health disparity • Ability to work • Increased • Health care utilization • Cost of health care

  43. Prevention to Intervention Strategies for Mr. C • Rehabilitation • WC propulsion mechanics • Axle alignment • Health promotion • Ex program • Assistive technology • Power assist WC • Policy • Advocacy for DME • Advocacy for affordable fitness memberships

  44. What are the barriers to exercise?

  45. Types of Barriers & Facilitators • Internal • Interpersonal • Environmental • What are some examples of barriers and facilitators that fit within each category? Meyers et al 2002

  46. Barriers for African American Women with Severe Disabilities • Barriers to exercise studied with 50 women • Most frequent conditions reported were: • Arthritis • Stroke • MS • New instrument developed: Barriers to Physical Exercise and Disability (B-PED) • 31 questions: yes, no, don’t know responses • 3 open ended questions • Phone interview Rimmer et al 2000

  47. Barriers for African American Women with Severe Disabilities (cont.) • Results • 82% liked to exercise • 82% wanted to begin an exercise program • 72% exercise would be helpful • 72% not knowing of program they could get to • 62% denied having concerns about exercising in a fitness center • 5.3% believed the facility would NOT have an instructor that would be able to help them • Most denied fear of leaving home • 63% instructed by MD to exercise • Most aware of what types of activities to perform Rimmer et al 2000

  48. Barriers for African American Women with Severe Disabilities (cont.) • Results (cont.) • Most frequent barriers to exercise reported: • Costs of program • Insufficient energy • Lack of transportation • Not knowing where to go • Different barriers than reported by general population • Lack of time • Lack of motivation or interest • Laziness Rimmer et al 2000 • Similar to barriers reported by patients with spinal cord injury Scelza,et al2005 • Lack of motivation • Lack of energy • Costs • Not knowing where to go • Lack of transportation was last on their list

  49. Importance of Caregiver Support • 12-week aquatics program for adults with progressive MS • 19 of 31 subjects completed the 24 classes • Out of the 196 total missed sessions, the most frequent absences were: • Medical/physical symptoms (58) • Transportation difficulties (25) • Social conflict (25) • Significant other not available (24) Roehrs, Karst 2004 • Importance of caregiver support seen in a study with adults with cerebral palsy Heller et al 2002 • Stresses and needs of caregivers of stroke survivors explored qualitatively King, Semik 2006

  50. Shifting Towards Community • Review of studies of fitness centers in Kansas and Oregon • None were 100% compliant with Americans with Disability Act (ADA) standards • 8% of equipment areas were accessible Rimmer 2004

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