Unwin - USAFP 2010 GO Granny Go_ by fjwuxn

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									         Go Granny Go!
    Exercise Prescriptions for
          Older Adults
 Brian K. Unwin, M.D.
Colonel, Medical Corps,
 United States Army
 Uniformed Services
      University
     USAFP 2010
How we
 want
 to be
Reality? Stages and Age of Man




 Reality?


       Currier and Ives print
Spectrum of exercise in older
          adults
                 Overview
• The Federal Activity Guideline
• How do we get there?
  •   What is exercise for the older adult?
  •   Contraindications for exercise
  •   What does Granny need?
  •   What do we evaluate before we advise
      exercise?
• Disease specific recommendations
THE NEW FEDERAL
ACTIVITY GUIDELINES
 2008 Federal Activity Guidelines –
Older Adults (ages 65 years and older)
  • Follow adult guidelines. When not
    possible, be as physically active as
    abilities and conditions allow.
  • Do exercises that maintain or improve
    balance if at risk for falling.
  • Those without chronic conditions and
    symptoms (e.g., chest pain or pressure,
    dizziness, or joint pain) do not need to
    consult a health care provider about
    physical activity.
2008 Federal Activity Guidelines –
      Adults (ages 18–64)
• Minimum levels a week
  • 2 hours and 30 minutes (150 minutes)
    moderate-intensity aerobic activity; or
  • 1 hour and 15 minutes (75 minutes)
    vigorous-intensity aerobic activity; or
  • An equal combination
• Muscle-strengthening activities that
  involve all major muscle groups should
  be performed on 2 or more days of the
  week.
2008 Federal Activity Guidelines
       Adults (ages 18–64)

 • For additional health benefits
   • 5 hours (300 minutes) moderate-intensity
     aerobic activity a week; or
   • 2 hours and 30 minutes (150 minutes)
     vigorous-intensity aerobic activity a week;
     or
   • An equivalent combination
              For More Information




http://www.health.gov/paguidelines




                                 http://www.healthfinder.gov/getactive
                 Overview
• The Federal Activity Guideline
• How do we get there?
  •   What is exercise for the older adult?
  •   Contraindications for exercise
  •   What does Granny need?
  •   What do we evaluate before exercise?
            What is exercise?


• Lifestyle choice
  • Regular
  • Structured
  • Purposeful
• Organized sports
• Unstructured play
Exercise impacts body composition

                 • Genetic, lifestyle and
                   disease factors
                 • Metabolic,
                   cardiovascular and
                   musculoskeletal
                   systems impacted
                 • Lifestyle is under
                   patient’s control
       Increased Muscle Mass
• Endurance training
  emphasis
  • Walking isn’t enough
• Progressive
  resistance training
  • DM prevention?
  • Dependency
    prevention?
  • Falls and fractures
  • Disuse
  • Sarcopenia
  • Frailty
         Exercise burns fat
• Decreases in total body adipose tissue
  • Aerobic and resistive training
  • Energy restricted diets and/or high volume
    exercise (5-7 hours/week)
  • Visceral fat selectively mobilized
    What’s fat got to do with it?
•   Metabolic syndrome    •   Breast cancer
•   Vascular disease      •   Colon cancer
•   Osteoarthritis        •   Endometrial cancer
•   Gallbladder disease   •   Impotence
•   Diabetes              •   Osteoarthritis
•   Hypertension          •   Depression
•   Dyslipidemia          •   Disability
•   Sleep apnea
         Strength and Functional Status


  Normal
                                                             Healthy
                                                             Adults
“Function”                         Near
                                   Frail
                                                             THRESHOLD

  Poor              Frail
                   Adults


                                        “Strength”
             Low                                                            High
                    Established Populations for Epidemiologic Studies of the Elderly (EPESE) .
                    J Gerontology, 1994;49(3):M109-15
                    y, 1994;49(3):M109-15
How elders function and how they
              die…
                                                                             Terminal Illness
             Sudden Death
                                                                High                                            Cancer
    High



                                                           Function
Function                                                                                  22%
                   7%

                                                                                                              Death
                                      Death
                                                                 Low
     Low
                                                                                   Time
                 Time


                                                                                                            Dementia
                                               Lung                             Frailty
              Organ Failure                                                                                  Strokes
                                               Heart
                                                                                                             Arthritis
      High                                     Liver            High
                                                                                                           Parkinson’s
                                                                                                           Hip Fracture


  Function
                                                            Function                      47%

                   16%                                                                                 Death
                                              Death
                                                                 Low
       Low
                                                                                Time
                  Time

             Lunney, JR, Lynn J, Hogan, C. Profiles of Older Medicare Decedents. JAGS 50:1108-1112, 2002
                 Overview
• The Federal Activity Guideline
• How do we get there?
  •   What is exercise for the older adult?
  •   Contraindications for exercise
  •   What does Granny need?
  •   What do we evaluate before exercise?
    Contraindications to therapeutic
            rehabilitation

•   Unstable angina, left main coronary dz
•   End stage CHF or systemic disease
•   Unstable arrhythmias
•   Malignant hypertension
•   Expanding aortic aneurysm
    Contraindications to therapeutic
            rehabilitation
•   Cerebral aneurysm or intracranial bleed
•   Recent eye surgery or retinal hemorrhage
•   Acute/unstable musculoskeletal injury
•   Acute systemic illness (pneumonia, pyelo)
•   Severe dementia/behavioral disturbance
                 Overview
• The Federal Activity Guideline
• How do we get there?
  •   What is exercise for the older adult?
  •   Contraindications for exercise
  •   What does Granny need?
  •   What do we evaluate before exercise?
Disease Impairment                                  Disability Handicap

                                                     Difficulty
Malnutrition
                                                     shopping             Physical
                    Weakness                                            Environment
                                                                        (multi-story
                                                                           house)
                    Immobility
                                                    Difficulty          Loss of ability
 Knee
                        Pain                        walking                 to live
 arthritis
                                                                        independently


               Apathy

                                                      Social               Social
                                                    Isolation           Environment
 Depression
                                                                          (loss of
                                                                          spouse)
                               Prin. Geriat. Med, 5th edition, p. 289
      What does Granny need?
•   Individualized assessment
•   Patient’s definition of quality of life
•   Current active medical problems
•   Medications
•   Strengths Assessment
    • Cognitive
    • Emotional
    • Physical
     Individualized decision
            making
• Patient motivation
  • Importance of exercise
  • Confidence in their abilities
• Trade-offs of risk vs. benefit
• Patient and family preferences
• Financial resources
                 Overview
• The Federal Activity Guideline
• How do we get there?
  •   What is exercise for the older adult?
  •   Contraindications for exercise
  •   What does Granny need?
  •   What do we evaluate before exercise?
        What to evaluate?
• Strengths assessment
  • Cognitive
  • Emotional
  • Physical
• Physical exam
• Functional exam
Additional physical exam items
• Postural vital signs
• Visual Acuity
• Strength, reflexes,
  coordination, sensation
• Continence
• Foot examination
• Labs as indicated and
 Vitamin D
           Functional Exam
• Identify risks
• Establish a baseline
  •   Aerobic capacity
  •   Balance
  •   Gait
  •   Upper extremity strength and ROM
  •   Lower extremity strength and ROM
• Establishes goals
Aerobic capacity: Timed Walk
(or how far does Granny go?)
   Balance: Romberg’s test

• Test for proprioception primarily to
  differentiate sensory ataxia (central and
  peripheral) from cerebellar ataxia
• Sharpened Romberg’s may be helpful in
  the elderly
Sharpened Romberg’s
     Timed ‘Up and Go’ test
• Simple test of observing a person stand
  up from a chair, walk 10 feet, turn
  around, walk back, and sit down again.
           Sensitivity: 54-87%
• Correlates with ADLs 74-87%
           Specificity:
• Normal person takes < 10 seconds to
           for predicting falls
  complete the task
• Note: use of hands, staggering,
  unsteadiness
                 Podsiadlo 1991
   Functional Reach Test
• Measures forward and lateral balance;
  Sensitive to change over time
• Simple to administer
  • Arm extension with 90 degrees of shoulder
    flexion while patient is upright and leaning
    forward or sideways
• Results
  • < 6 inches related to falls
  • Minimal fall risk if >10 inches of reach
                        Duncan 1990
Functional Reach test
Gait evaluation
         Gait

Stance (left and right)
 Strike (left and right)
Swing (arms and legs)
Step width (6” or less)
    Path (straight?)

                     Alexander N. JAGS.
                      1996. 44: 434-451.
Assessing Upper Extremity
        Function



  Unwin’s Shampoo Test
Assessing Upper Extremity
        Function



   Hand grip
 dynamometer
 Assessing Lower Extremity
         Function



Unwin’s Socks and Shoes Test
      Single-leg stance test


• Best balance measure for any individual
• If one can stay on one leg for 10
  seconds, there are usually no significant
  balance problems



               Bohannon 1984, Janda 1996
Modified single leg stance
                   Next step
Exercise Prescription?   Rehabilitation?
          Physical Therapy
• Bed mobility and
  transfer
• Gait and balance
• Ambulatory
  endurance +/- gait
  aid and stair
  climbing
• Hip and knee
  extensor training
                     Mobility Aids
Cane
• Supports 15-20% of weight
• Options: single point, quad
  or hemi-cane
• Side opposite affected limb
• Fitted to ulnar styloid
• Contraindications
   • Arm weakness, moderate to
     severe gait or balance deficit
   • Potential problem:
     inadequate support
Mobility Aid
      Walker
       •   Supports ~30% of weight
       •   Options: 4 post, 2 wheel/2 post, 3
           wheel, 4 wheel, 4 wheel with seat
           and hand brakes (Rollator), 4
           wheel with safety bars and sling
           seat (Merry Walker), forearm
           supports
       •   Fitted to ulnar styloid
       •   Contraindications:
            • Environmental hazards,
              severe arm and gait
              weakness
            • Problem: slows gait,
              maneuverability
                  Mobility Aids
Crutches                         Wheelchair
• Supports full body weight      •   Supports full body weight
• Options: underarm/forearm      •   Options: manual/motorized;
                                     accessories; lower to ground or
• Fitting: 2 inches under            one-sided drive (hemi-chair);
  shoulder; do not lean armpit       racing, handcycle
  on crutch                      •   Fitting: 1-1.5 inches around hips
• Contraindications: arm             and under knees; footplates
  weakness, shoulder                 clear floor by 1-2 inches;
                                     armrest at elbow height;
  arthritis, cognitive               removable footrests and
  impairment                         armrests
• Problems: neuropathy,          •   Contraindications: unable to sit,
  shoulder pain, difficult to        or able to walk safely
  learn to use                   •   Problems: deconditioning,
                                     contractures, pressure sores
         Occupational Therapy
• ADL training
• Fine motor training
  and adaptive
  equipment
• IADL / homemaking /
  community survival
  skills                 • ROM / flexibility of
• Cognitive and safety     upper extremity
  awareness
  assessment and         • Energy conservation
  remediation              and joint protection
                         • Muscle strength and
                           endurance training
 THE ROLE OF ‘HOME’ IN
EXERCISE AND FUNCTION
  Environment hazards for exercise

• Indoor hazards – slippery floors,
  rugs/carpet, poor lighting, shoes,
  bathroom fixtures, height of chair and
  bed, unstable furniture, stairways.
• Outdoor hazards- uneven pavement,
  steps, snow and ice, neighborhood
  safety

                Nevitt 1989, Gill 1999
Pets and exercise
      Certified Aging-in-Place Specialists (CAPS)
http://www.aarp.org/family/housing/articles/caps.html




         J American Geriatrics Society, 2009, 57: 476-481
     “Long Term Effect on Mortality of a Home Intervention…”
“ABLE demonstrated that teaching elderly people new approaches to
   performing valued activities resulted in additional years of life.”
CONDITION SPECIFIC
REHABILITATION
      Leading causes of death
•   Cardiovascular disease
•   Cerebrovascular disease
•   Chronic lung disease
•   Alzheimer’s Disease
•   Accidents and falls
•   Leaving out pneumonia, influenza,
    malignancy
CARDIAC
REHABILITATION
 Cardiovascular rehabilitation
• Less than 1/3 patients participate
  • www.ahrq.gov/news/press/prsrl2.htm
• Components include:
  •   Comprehensive
  •   Long-term
  •   Medical evaluation
  •   Prescribed exercise
  •   Risk-factor modification
  •   Education
  •   Counseling
    Cardiac rehab outcomes
• Improved exercise tolerance for CAD
  and CHF
• Decreased symptoms in CAD and CHF
• Multi-factorial interventions improve
  lipids
• Multi-factorial rehab reduces cigarette
  smoking (16-26% will quit)
           AHRQ Technical Reviews and Summaries, AHRQ Supported Clinical Practice
                        Guidelines, Chapter 17. Cardiac rehabilitation
    Cardiac rehab outcomes
• Improved psychosocial well-being
• Mortality reduction of approximately
  25% at three years (similar to B-
  blockers and ACE Rx)
• No increase in morbidity or mortality



               Cardiol J. 2008; 15(5): 481-7
                     Outcomes
 Diagnosis    Functional         QOL               Morbidity       Mortality
               Capacity
AMI           +++          +++                 ++              +++
CABG          +++          +++                 ++              ++
Stable        +++          +++                 +               +
angina
PCI           +++          ++                  +               ?
CHF           +++          ++                  +               +
Cardiac       +++          ++                  ?               ?
Transplant
Valve         +++          ++                  ?               ?
replacement

                      Am Heart J. 2006; 152: 835-41
STROKE REHABILITATION
         Some ugly truths
• Race disparities in use of stroke rehab
  programs and outcomes
• Less likely to receive if DNR or
  Medicaid recipient
         Stroke rehabilitation
• Initial assessment
  •   Risk factors for CVA
  •   Medical co-morbidities
  •   Consciousness and cognitive status
  •   Brief swallowing assessment
  •   Skin assessment and pressure ulcers
  •   Mobility and assistance needs
  •   Risk of DVT
  •   Emotional/social support of the family
      Reassessment of rehab
            progress
• General Medical Status
• Functional status
  • Mobility, ADL/IADL, Communication, nutrition,
    cognition, mood/affect/motivation, sexual function
• Family support
  • Resources, caretaker, transportation
• Patient and family adjustment
• Reassessment of goals
• Risk for recurrent CVA
      Assessment of discharge
           environment
•   Functional needs
•   Motivation and preferences
•   Intensity of tolerable treatments
•   Availability and eligibility for benefits
•   Transportation
•   Home assessment for safety
PULMONARY
REHABILITATION
  Lung disease rehabilitation
• Cost effective and beneficial to system
• Components: Multidisciplinary, individual
  assessment, exercise training, education,
  medical therapy, psychosocial support
• Goals:
  •   Reduce symptoms
  •   Optimize function
  •   Increase participation
  •   Reduce healthcare costs
             Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical
                        practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.
     Recommendations and
          evidence
• Mandatory exercise training (Level 1A)
• Six to 12 weeks of pulmonary rehab
  produces benefits that decline over 12-
  18 months (1A)
• Maintenance strategies have modest
  effect on long-term outcomes (2C)
• Lower extremity exercise at higher
  intensity has greater benefit (1B)
          Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice
          guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.
     Recommendations and
          evidence
• Low- and high-intensity exercise
  produce benefits (1A)
• Strength training increases strength and
  muscle mass (1A)
• No support for use of anabolic steroids
  (2C)
• No support for inspiratory muscle
  training (1B)
         Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines.
         Chest 2007 May; 131(5 Suppl): 4S-42S.
         Typical program
• Stage III-IV COPD severity
• 3-4 sessions/week, 3-4
  hours/session
• 6-12 week duration
• Walking/resistance training
• Horizon (?): heliox, O2, non-
  invasive ventilatory support,
  biofeedback, anabolic steroid
             Casaburi, ZuWallack. NEJM 2009;
                        360: 1329-35
               Problem areas
•   COPD cachexia
•   ¼-1/3 of patients don’t improve
•   No uniform funding policy
•   $2200/person cost
•   Unavailable to low-income, minority and
    rural populations

        Casaburi, ZuWallack. NEJM 2009; 360: 1329-35
                  Outcomes
• Improves dyspnea (Level 1A)
• Improved Health Related Quality of Life
  (1A)
• Reduces hospitalization and utilization
  (2B), Cost effective (2C)
• Insufficient data for survival benefit
• Psychosocial benefits (2B)
         Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical
         practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S.
DEMENTIA
REHABILITATION
Exercise to preserve cognition
• 8/11 studies of aerobic exercise
  interventions showed increased fitness
• Largest effects were:
  •   Motor function (1.17(?) effect size)
  •   Auditory attention (0.52 effect size)
  •   Delayed memory function (0.50 effect size)
  •   Cognitive speed (0.26 effect size)
  •   Visual attention (0.26 effect size)
             Angevaren, et. al. Cochrane Database of Systematic Reviews,
                                2008, Issue 2. CD005381
Physical activity for dementia
           patients
• Limited RCTs of activity in AD
• Generally improved:
  •   Psychological/physical performance
  •   Mobility
  •   Balance
  •   Strength
  •   Gait speed
  •   Sleep
  •   Mood/agitation/cognitive function
                 Rolland, et al. JAMDA 2008; 9: 390-
                                  405
        Not a pretty picture
• Studies highlight sedentary life of the
  elderly
• Average of 12 minutes a day of
  constructive activity in institutional
  settings
• Is inactivity an early manifestation of
  dementia?
FALL AND FRACTURE
REHABILITATION
            Fall prevention:
       Cochrane Review of 11 RCTs
     • Wide variety of exercise programs
     • 5/11reduction in rate of falls or fall risk
        • 4 exercise only intervention
        • 1 multi-intervention + exercise

                    is effective in lowering the risk of falls
Conclusion: “Exercise
in selected groups and should form part of fall prevention
programmes. Lowering fall-related injuries will reduce
health care costs…”
Injury rehabilitation (hip fracture)
 There is insufficient evidence from RCTs to establish
 the effectiveness of the various mobilisation
 strategies used in rehabilitation after hip fracture
 surgery.

 • Seven trials early
 • Six trials after hospital discharge



          Handoll . Mobilisation strategies after hip fracture surgery in adults. Cochrane
          Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001704.
                Summary
•   Exercise as prevention
•   Exercise as therapy
•   Team Rehab
•   Prescribed exercise

								
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