Treatment Strategies for the Geriatric “Athlete” An Evidence ‐ Based Approach Andrew Morgan, PT, DPT, MBA, COS ‐ C 1
Introduction • Bachelor of Science in Education, May 1999 • Master of Business Administration, May, 2005 • Doctor of Physical Therapy, May 2013 • Texas PT license since 2002 • Background primarily in home health • Auditor, adjunct faculty, presenter, regulatory compliance officer 2
Objectives • Implement effective strategies for identifying those at risk for falls and reducing the risk • Evaluate geriatric age ‐ related changes that adversely affect functional mobility • Assess the effectiveness of various interventions including impairment ‐ based exercise and function ‐ based exercise at improving outcomes • Utilize effective documentation techniques to indicate skilled care and reduce risk of denials • Discuss evidence ‐ based methods to improve adherence to home exercise programs • Develop an effective multidisciplinary approach that addresses a patient's functional needs 3
Definitions • Evidence ‐ Based Medicine • Mosby’s Medical Dictionary, 9 th edition • The practice of medicine in which the physician finds, assesses, and implements methods of diagnosis and treatment on the basis of the best available current research, the physician's clinical expertise, and the needs and preferences of the patient. 4
Definitions • 3 Pillars of Evidence ‐ Based Medicine • Clinician’s expertise • “Based off of my 20 years of clinical experience treating hundreds of patients with your condition, I feel you would benefit from…” • Patient preferences and needs • “When my neighbor fell, she told me that she received physical and occupational therapy, and both helped. I think I would benefit from both services too.” 5
Definitions • 3 Pillars of Evidence ‐ Based Medicine • Best available current research • Level V opinions, case studies • Level IV non ‐ experimental studies • Level III non ‐ randomized studies • Level II randomized study • Level I systematic review • Which of the 3 pillars is most important? 6
The Ageing Adult • Sarcopenia • Decline of skeletal muscle tissue with age • Results in gradual loss of muscle tissue with age • Physically inactive people are at a higher risk • Can have a 3% ‐ 5% loss in muscle mass every decade after 30 • Loss speeds up with age • Chronic illness causes faster degeneration • CVA, Parkinson’s, MD, CHF 7
Definitions • The Geriatric “Athlete” • The International Classification of Functioning, Disability, and Health (ICF model) • Health condi � on → Body structures and Func � ons → ac � vity limita � ons → par � cipa � on restric � ons • Evolved from the Nagi model of Disability • Pathology → Impairment → Func � onal Limita � ons → Disability • Examples 8
The Ageing Adult • Cardiovascular changes • Slowed heart rate as a result of fatty deposits • Cardiac arrhythmias such A ‐ fib (risk factor for CVA) • Heart valves become thicker • Can result in heart murmur • Thicker capillary walls • Slows exchange • Slower production of red blood cells 9
The Ageing Adult • Age ‐ Related Diagnoses • Osteoarthritis • Degeneration of cartilage in the joint • Affects women 3 to 2 vs men • One of the leading causes of elective surgery in older adults • Rheumatoid arthritis • Autoimmune disorder resulting in inflammation of the joints • Increases in prevalence with age (peaks in 50s) 10
The Ageing Adult • Age ‐ Related Diagnoses • Cerebrovascular accident (CVA) • Interruption of normal blood flow to the brain resulting in focal lesions of neural tissue • Symptoms? • Transient ischemic attacks (TIA) • Commonly referred to as a mini stroke • Symptoms generally resolve quickly • Can be a warning for a CVA 11
The Ageing Adult • Age ‐ Related Diagnoses • Parkinson’s disease • Affects dopamine production in the brain resulting in rigidity and tremors • Congestive heart failure • Cardiac muscle strength has deteriorated, leaving heart inefficient at pumping blood • Leading cause of hospitalization in people older than 65 • Causes include arterial disease, myocardial infarction, hypertension, and others 12
The Ageing Adult • Age ‐ Related Diagnoses • Osteoporosis • Weakness of bones resulting from a decrease in bone density • Increases the risk of fractures from a fall or loss of balance • Question, do you fall and break you hip or break your hip and fall? • NIDDM or Type 2 diabetes • The cascade 13
The Ageing Adult • Age ‐ Related Diagnoses • What do all of the aforementioned diagnoses have in common? • Fill in answer below: 14
The Ageing Adult • Managing age ‐ related changes • Diet • Many adults over 50 are B ‐ 12 deficient • Fatigue, malaise, weakness • Older adults become deficient in calcium and vitamin D • Leads to bone density loss • Potassium deficiency • Essential for bone health and muscle function • Symptoms include weakness, cramps, lethargia 15
The Ageing Adult • Managing age ‐ related changes • Exercise • All of the previous age ‐ related diagnoses result in a lack of mobility • Some (CVA and osteoporosis) may result from a lack of mobility • Helps maintain functional mobility and independence throughout lifespan • Helps to reduce risk for many chronic illnesses • Reduces fall risk in older adults 16
Therapeutic Exercise Selection, Instruction, and Implementation • Defining functional limitations • Nagi model: Restrictions in the ability to actions, tasks, and/or activities • ICF model: restriction in the execution of a task or action by an individual • Deficits in: transfers, gait, dressing, bathing, cooking • Other examples? 17
Therapeutic Exercise Selection, Instruction, and Implementation • Defining impairments • A loss or abnormality at the tissue, organ, or body system level, per the Nagi model • The ICF model’s corresponding section considers problems in body structure or function such as significant deviation or loss • Deficits in: range of motion, strength, endurance • Other examples? 18
Therapeutic Exercise Selection, Instruction, and Implementation • Impairments vs functional limitations • Which requires the complex training of a therapist to identify? • Functional limitations are loss of a task • “My father has problems standing from his recliner” • A layperson can identify the lack of function • Impairments are the underlying reason why • “Your father is lacking range of motion in his knees and strength in his hips” • Identifying why is the therapists’ domain 19
Therapeutic Exercise Selection, Instruction, and Implementation • Impairment ‐ based exercises • Range of motion • Progressively taking the joint beyond its available end range in order to achieve a new range • Assessment of range of motion • Can include stretching • Is the only goal of a range of motion exercise to improve range of motion? What else can be gained? 20
Therapeutic Exercise Selection, Instruction, and Implementation • Impairment ‐ based exercises • Strength • Defined as the amount of force a muscle can produce in a single effort. • Assessment of strength • Walter Frontera, MD was the first researcher to use 80% of a 1 repetition max as a basis for measuring strength improvement (landmark 1988 study) • Guidelines for improving strength • What else improves when strength improves? 21
Therapeutic Exercise Selection, Instruction, and Implementation • Impairment ‐ based exercises • Endurance • Muscular endurance • ability of a muscle to exert force against resistance while avoiding fatigue • Can also be defined as musculoskeletal strength over time • Assessment of muscular endurance • Cardiovascular endurance • The ability of the heart, lungs, and vascular system to deliver blood and oxygen to the body’s tissues while working • Assessment of cardiovascular endurance 22
Therapeutic Exercise Selection, Instruction, and Implementation • Exercise progression • Range of motion progression • It needs to move before it can be strong • Objective progression • Strength progression • It needs to be strong in order to sustain • Objective progression • Endurance progression • Muscular endurance vs cardiovascular endurance • Objective progression 23
The Multidisciplinary Assessment of Functional Status • Assessment of functional status • A functional limitation is usually defined by the amount of assistance a patient requires to complete a task • Ranges from totally independent to total assistance • And every thing in between • Modified independent, supervision assistance, minimal assistance (up to 25%), moderate . assistance (26% ‐ 50%), maximum assistance (51% ‐ 75%) 24
The Multidisciplinary Assessment of Functional Status • Defining functional limitations (revisited) • As defined by the Nagi model, restrictions in the ability to actions, tasks, and/or activities • Obvious deficits that DO NOT require the complex skills and training of a therapist to identify • Deficits in gross motor tasks such as transfers, gait, dressing, cooking, and bathing • Frequently a reason that an older adult will seek • out therapy 25
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