EVIDENCE SUPPORTING FUNCTIONAL EXPECTATIONS OF THE OLDER ADULT IN SENIOR LIVING – DISCOVERING WHAT IS POSSIBLE #ALFA2014
FACULTY DISCLOSURE
Tim Fox, PT, DPT, GCS, CCI Doctor of Physical Therapy Board Certified Geriatric Clinical Specialist Credentialed Clinical Instructor Founder & CEO tim.fox@foxrehab.org
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MEDICALLY WELL VS. FUNCTIONALLY WELL
OPTIMAL AGING #ALFA2014
DISABLEMENT AND QUALITY OF LIFE SERVICES IN THE NAGI DISABLEMENT MODEL *Adapted from Levine and Croog 1984
PROACTIVE HEALTHCARE #ALFA2014
“Believing is the absence of ageism” – Dale Avers, PT, DPT, PhD SUNY Upstate
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• Age biases lower expectations for high levels of function… • Lack of awareness of age based functional norms… • Only 7% of seniors receive key preventive services identified by geriatric experts, including an annual medication review and referral to nonmedical services such as support groups and exercise programs.*
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COMMON FUNCTIONAL OUTCOME MEASURES (FOMS) Timed Up and Go Test • Primary use: evaluate mobility, balance, walking ability and fall risk in older adults • MDC: 2.9 to 4.85 seconds depending on the population that was studied • MCID: 7.7 seconds • Number to remember: 13.5 seconds and above is associated with an increased risk of falls
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COMMON FUNCTIONAL OUTCOME MEASURES (FOMS) Gait Speed • Primary use: measurement of ambulatory capacity in the older adult as well as a tool that has been proven to identify a client with functional decline as well as predict the potential for decline in function • MDC: 0.1 m/s • Number to remember: 1.0 m/s and below indicates the patient is at increased risk for at least one limitation in regards to community participation
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COMMON FUNCTIONAL OUTCOME MEASURES TIMED UP AND GO
• • • •
Current Dosage: Sinemet 25/100 3x/day MDC= 2.9-4.85 seconds MCID=+ 7.7 seconds (inpatient rehab setting) (Brooks et al, 2006) Cut off scores= > 13.5 seconds associated with increased falls in community dwelling older adults (Shumway-Cook, 2000) #ALFA2014
FUNCTIONAL OUTCOME MEASURES: GAIT SPEED Value of Gait Speed • As a predictive tool • As an outcome measure • As a screening tool
(Studenski, JAMA, 2011)
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FUNCTIONAL OUTCOME MEASURES Gait Speed Predicts • Future health status (Studensky 2003) • Functional decline (Fritz 2009) • Hospitalization (Montero-Odasso 2005) • Discharge location (Salbach 2001) • Morbidity and mortality (Studensky 2003) • Potential for rehabilitation (Goldie 1996)
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CLINICAL USE OF GAIT 3 Reasons • Screening tool: < 1.0 m/s indicates risk of falls (Fritz, 2009) • Outcome tool: a change of 0.1 m/s indicates a true change (Fritz, 2009) • Predictive tool: ADL, hospitalization likelihood, fall risk, d/c disposition, general ambulation ability.
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(Fritz, Phys Ther. 2009)
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GAIT SPEED, COMMUNITY PARTICIPATION & MORTALITY
(Fritz, Phys Ther. 2009)
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(Studenski, JAMA, 2011)
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(Studenski, JAMA, 2011)
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OVER PRESCRIBED
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GERIATRIC REHABILITATION Is relatively newâ&#x20AC;Ś.those chronic conditions which were once the cause of our patients premature mortality are now being managed well, thanks to the physician and modern medicine. Though as our patients age and live well with such conditions, how are we addressing the progressive functional decline that is occurring?
The slippery slope of functional decline
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NORMAL AGING SLIPPERY SLOPE OF AGING Where we should be
Current practice is here
(Schwartz, RS. 1997)
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GERIATRIC SYNDROMES Includes, but not limited to: • Functional disability • Falls • Cognitive impairment • Frailty • Incontinence • Sensory impairments • Delirium • Depression • COPD • Diabetes
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THE FRAIL ELDERLY Frailty can be minimized or even reversed with low intensity exercise â&#x20AC;&#x201C; Frailty is the lack of overload. (Brown M, Sinacore DR et al., 2000; Evans WJ, 1999)
Frail elders can improve gait, gait speed, ability to rise from a chair, perform transfers, and stair climbing with a LE strengthening program (Chandler JM, Duncan PW et al., 1998)
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THERAPEUTIC EXERCISE: So Potent It Needs a Prescription
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JACK LALANNE at 70 years old
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JACK LALANNE - OBLIGATED
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PHYSICAL ACTIVITY GUIDELINES FOR AMERICANS • Regular physical activity reduces the risk of many adverse health
outcomes • Some physical activity is better than none. • For most health outcomes, additional benefits occur as the amount of
physical activity increases through higher intensity, greater frequency, and/or longer duration. • Most health benefits occur with at least 150 minutes (2 hours and 30
minutes) a week of moderate-intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity.
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PHYSICAL ACTIVITY GUIDELINES FOR AMERICANS (aged 18 to 64) • Adults should do 2 hours and 30 minutes a week of moderate- intensity,
OR 1 hour and 15 minutes (75 minutes) a week of vigorous-intensity aerobic physical activity. • Additional health benefits are provided by increasing to 5 hours (300
minutes) a week of moderate-intensity aerobic physical activity, or 2 hours and 30 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both. • Adults should also do muscle-strengthening activities that involve all
major muscle groups performed on 2 or more days per week.
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FUNCTIONAL OUTCOME MEASURE: TALK TEST CARDIOVASCULAR STAMINA / RPE
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PHYSICAL ACTIVITY GUIDELINES FOR AMERICANS (aged 65 and older) â&#x20AC;˘ Older adults should follow the adult guidelines. If this is not possible due to limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Older adults should do exercises that maintain or improve balance if they are at risk of falling. â&#x20AC;˘ For all individuals, some activity is better than none. Physical activity is safe
for almost everyone, and the health benefits of physical activity far outweigh the risks. People without diagnosed chronic conditions (such as diabetes, heart disease, or osteoarthritis) and who do not have symptoms (e.g., chest pain or pressure, dizziness, or joint pain) do not need to consult with a health care provider about physical activity.
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SCIENTIFIC EVIDENCE Strong Evidence •
Lower risk of: – – – – – – – –
•
Early death Heart disease Stroke Type 2 diabetes High blood pressure Adverse blood lipid profile Metabolic syndrome Colon and breast cancers
Prevention of weight gain #ALFA2014
STRENGTHENING • In the average adult, strength decreases at a rate of 10% per decade starting at age 30, accelerating to 15% per decade after 60. • Older adults can gain strength in the same manner as younger adults • Even with high intensity training, no long term injuries have been reported. (Geriatric Physical Therapy, 80)
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BALANCE OF EXERCISE AND NEUROMUSCULAR TRAINING Evidence shows that isolated use of Progressive Resistance Training in older adults does not consistently improve balance. Overall recommended dosage in the literature for balance training in older adults (generalization, this depends on patient characteristics and diagnosis) • • •
12 weeks, 2 hours per week ongoing 3 time or more per week Move from closed, single task activities (97112) to more complex tasks and then finally to functional activity (97530). Gentile’s taxonomy. (Orr, 2008)
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BALANCE OF EXERCISE AND NEUROMUSCULAR TRAINING • Balance training can be effective as single intervention • Strength training alone is not effective in reducing falls • Home-based is best • Balance training needs to include reducing BOS, moving COG, reducing UE support • Greater benefit from higher dose of balance (Shubert used 50 hours as minimal cut-off) • At least 2 hours per week ongoing to maintain benefits (Sherrington 2011, Shubert 2011, Gillespie 2012)
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EXERCISE PRESCRIPTION SUMMARY
• Frequency • Duration • Intensity
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THANK YOU!
Tim Fox, PT, DPT, GCS, CCI Doctor of Physical Therapy Board Certified Geriatric Clinical Specialist Credentialed Clinical Instructor Founder & CEO tim.fox@foxrehab.org
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