A Functional Testing Approach To Geriatric Rehab T. Daniel Walters PT, DPT, GCS 1
Introduction • Prevalence of the older adult population • 50% case load are patients age 65 years and older • More than 37 million American adults are age 65 or older, about 13% of the general population. • By 2030 this number is expected to rise to 20% due to baby boomers, declining birth/death rates. • Of the 37 million aged 65 and older, 10% are over age 85 2
Introduction • Prevalence of falls • 30% age 65 and 40% age 75 will have a fall each year • Most common mechanism of injury and leading cause of death from injury in people age 65 and over • 1 year mortality rate following hip fracture is about 25% • 43 ‐ 60 billion in annual healthcare costs • Fun Fact ‐ Vitamin D may help prevent falls and fractures in older adults 3
Functional decline as defined by Schwartz Do what you want, Fun when you want, for as long as you want Functional Some degree of mobility disability Frail Requiring help with ADLs Complete dependence Failure 4
Frailty • Fried et al proposed criteria for frailty as a syndrome • 10 lb. or more of unintentional weight loss in the past year • Muscle weakness defined as grip strength <23 lbs. for females, <32 lbs. for men • Walking speed <0.8 m/sec • Low level of activity equivalent to sitting or lying down majority of the day • Self reported exhaustion 3 or more days per week • Meeting 3 of the above criteria is considered frail • May better indicate magnitude of need and support functional markers and goals 5
Common Age Related and Disease Processes • Aging process • Disease process • ↓ muscle mass (Sarcopenia) • Cachexia • ↓ bone mass • Osteoarthritis • ↓ In max HR, VO2 max, SA • Osteoporosis node cells and contractility of • Proximal femur, distal radius, vascular walls. vertebral bodies effected first • ↑ in vascular � ssue s �ff ness • Heart Disease and Heart • Slowed memory processes, ↓ Failure abstract thought, mild decline • Atrial fibrillation in executive function • After age 60, all physiological • Cerebrovascular accident systems decline at a similar • Hypertension rate, 20 ‐ 30% per decade • Dementia • Cognitive reserve may mask symptoms 6
Factoring In Medications • With age comes the potential for disease processes and need for medications, with possible multiple prescribers and drug interactions • Older adults are 13% of the population using 34% of all prescription drugs • www.drugs.com • It’s recommended as best practice that we perform a medication screening on all patients in every setting • http://www.moveforwardpt.com/ChoosePT/Toolkit • Campaign against opioids • America consumes 99% of the world’s hydrocodone 7
Pop Quiz! • Constipation • Metoprolol (beta blocker) • Orthostatic hypotension • Percocet (narcotic) • Fatigue and weakness • Furosemide (diuretic) • Dizziness • Amitriptyline (Tri cyclic Anti ‐ depressant) • Confusion • NSAIDs • Anterograde amnesia • Acetaminophen • Impaired bone healing • Prednisone prolonged use (glucocorticoid) • Liver toxicity • Ambien, Diazepam and other Benzodiazepines (sedative ‐ hypnotics) • Respiratory depression • Spiriva (anticholinergic, for COPD) • Muscle and bone catabolism • Decongestants • Dry mouth • Statins • Tachycardia • Hypertension • Muscle pain 8
Quantitative Drug Index (QDI) • Drug A ‐ dizziness= 1 • Drug B ‐ drowsiness, lethargy=2 • QDI total= 3 • Low impact drug group <0 • High impact drug group>0 9
Case Study 1 • 77 year old female referred to therapy with a diagnosis of back pain rated 6/10 on numeric scale located in mid ‐ thoracic region that started 2 weeks ago and the pain pattern appears inconsistent. Reports taking narcotic for pain every 4 ‐ 6 hours, Metoprolol, and Fosamax. Client recently had an increase in housekeeping duties due to her husband being hospitalized for pneumonia however her ability to participate in these ADLs effectively and safely is decreasing due to pain and fatigue. History of osteoarthritis in bilateral hips, HTN and osteoporosis. Previously able to ambulate community distances to essential places such as the grocery store without an AD, pain or reports of fatigue. Currently the patient reports increased pain with household ambulation and intermittent use of 4 WW. 10
Home Environment: Bang for the Buck • In a study published in sept. 2014, researchers at the university of Otago in New Zealand discovered that low cost ($300 ‐ 600) home modifications reduced injury rates caused by falls at home per year by 26%. • Handrails for outdoor and indoor stairs • high visibility slip resistant edging for outdoor stairs • grab bars for bathroom and toilet • adequate lighting • repairing lifted edges of carpets and mats • non slip bathmats • slip resistant surfacing for outdoor surfaces such as decks • window catches repairs. 11
Screening for Vertebral Compression Fractures • Osteoporosis and vertebral compression fractures (VCF) • Wall ‐ occiput test • Distance of greater than 7 cm between occipital prominence and the wall can accurately rule in thoracic VCF • sensitivity is relatively low, unable to effectively rule out VCF with distances less than 7 cm • Rib ‐ pelvis distance test • A distance of less than 2 fingerbreadths between inferior margin of ribs and superior surface of mid axillary pelvic line indicates further evaluation required. • A distance greater than 2 fingerbreadths can accurately rule out lumbar VCF • Positive findings may indicate need to refer out for further testing (DEXA scan) 12
Osteoporosis VCF Detection Algorithm • Age > 52 years • 2/5 or less helps rule out OVCF with sensitivity of • No presence of leg pain 95% • Body Mass Index < 22 • 4/5 or more helps rule in • Does not exercise OVCF with specificity of regularly 96% • Female gender • Anywhere from 67 ‐ 80% of OVCF’s are asymptomatic or have inconsistent pain patterns • Early detection can help limit future morbidity 13
Sensitivity Vs. Specificity • Sensitivity • Specificity • Helps rule out disease • Helps rule in disease when the test is negative when the test is positive • The higher the sensitivity, • The higher the specificity, the better the test is at the more certainty you identifying true positives have that a positive result and limiting false confirms disease negatives presence, limiting false positives • “Snout” • “Spin” 14
Likelihood Ratios • LR+ corresponds to the clinical concept of "ruling ‐ in disease" • LR ‐ corresponds to the clinical concept of "ruling ‐ out disease“ • LR > 1 indicates test result is associated with disease • LR < 1 is associated with absence of disease • Helps establish multiple cut points such as level of fall risk (low, medium, high) 15
Floor Vs. Ceiling Effects • Floor Effect • Ceiling Effect • occurs when a measure’s • occur when a measure’s lowest score is unable to highest score is unable to assess a patient’s level of assess a patient’s level of ability. ability. • For example a measure that • For example, a patient’s fall assesses fall risk may not be risk score may initially be in sensitive enough to assess range to rule in, but the low levels of fall risk among patient’s ability exceeds the older adults, making it measure's highest score difficult to rule out risk of over time, making it falls difficult to determine whether or not the patient continues to be at risk 16
MDC Vs. MCID • MDC= minimal • MCID= Minimal detectable change clinically important difference • the minimum amount • smallest amount of change in a patient's score that ensures the of change in an change isn't the result outcome considered of measurement error statistically significant • minimum amount of change required for the patient to feel a difference 17
Clinically Practical Functional Tests for Performance • VIDEO 18
Gait Speed: The Sixth Vital Sign • Timed walk over a set distance 4m, 6m, 10m with space to accelerate. Preferred or fast walking speed. Perform 3 trials and take the average • Slower gait speed has been shown to be the single best predictor of decline in health and function. • Predicts mortality, mobility disability, ADL disability, risk for hospitalization, risk for falls • Research also suggests gait speed as the best predictor of stair climbing ability • Normal gait speeds range 1.2 ‐ 1.4 m/sec (1m= 3.3 ft) • Approximate time to cross the street • MCID= 0.1 m/sec • Functional gait speeds • 0.5 m/sec= household ambulatory at risk for falls • 0.8 m/sec= community ambulatory • < 1.0 m/sec= risk for health related functional decline, > 1.0 m/sec= less likely for adverse events • <0.6 m/sec indicates likelihood for hospitalization, dependence with ADLs/IADLs 19
3 ‐ m Backwards Walk • Looked at 1 year retrospective falls in retirement community residents without neurological deficits • <3.0 sec.= unlikely • >4.5 sec= very likely • Compared to TUG, 5x sit to stand, 4 square step test • 3MBW demonstrated similar or better diagnostic accuracy for falls 20
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