Geriatric Rehabilitation: What do I need to know?

1. 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

2. Geriatric Rehabilitation Education • 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 21st 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)

3. Demographics of Aging • 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.

4. 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 • 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.

5. Measurement Tools in the Elderly • Timed “Get up and Go” test • 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

6. Measurement Tools in the Elderly • The Berg Balance Measure is • 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.

7. Measurement Tools in the Elderly • The (Folstein) Mini-Mental State Exam (MMSE • 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

8. Measurement Tools in the Elderly • The Geriatric Depression Scale – Short Form • 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.

9. Measurement Tools in the Elderly • The CAGE (Cut down, Annoyed, Guilty or Eye opener) • 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.

10. 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.

11. 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.

12. 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 high-risk fallers with osteoporosis.

13. Preventing Falls • Attempts should be made to correct modifiable environmental factors. These include • 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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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: • 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%. • quadriceps weakness poor proprioception • heavy physical activity lack of estrogen replacement • knee injuries Loeser: Rheum Dis Clin North Am 2000;26(3):547-67

20. 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 self-reported 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

21. 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 • 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.

22. 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 • 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.

23. 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 • 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

24. 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 • 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

25. 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.

26. 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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

32. 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.

33. 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.

34. 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.

35. Incontinence • Urinary incontinence is present in: • 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 1996Urinary 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

36. Incontinence • The mnemonic DIAPPERS is useful to remember common causes of urinary incontinence: • 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

37. 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.

38. 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.

39. 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 under-recognized and undertreated. However, when treatment is rendered it is as effective as treatment in younger individuals.

40. 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.

41. Delirium • The mnemonic DELIRIUM summarizes common causes of delirium in the older adult: • 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.

42. Depression • The mnemonic SIG E CAPS summarizes common symptoms of depression in the older adult: • S Sleep • I Interest • G Guilt • E Energy • C Concentration • A Appetite • P Psychomotor agitation/retardation • S Suicidality 4 positive suggests significant depressive symptoms.

43. 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

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: • Has anyone touched you without your permission? • Do you feel safe at home?

45. 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: • 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

46. 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 timeshigher 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

47. 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.

48. 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. • 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 re-examination every 6 months. Dubinsky: Neurology 2000;54(12): 2205-11

49. 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

50. 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.