Exercise and rehabilitation of

older adults
P.Kamalanathan
Associate professor of physiotherapy
SRM UNIVERSITY

How we
want
to be

Reality? Stages and Age of Man

Reality?

Currier and Ives print

Trajectories of Dying
Terminal Illness

Sudden Death

Function

Cancer

High

High

Function

7%

Death

Death

Low

Low

Time

Time

Organ Failure
High

22%

Lung
Heart
Liver

High

47%

Function

Function

16%
Low
Time

Death

Dementia
Strokes
Arthritis
Parkinsons
Hip Fracture

Frailty

Death

Low
Time

Lunney, JR, Lynn J, Hogan, C. Profiles of Older Medicare Decedents. JAGS 50:1108-1112, 2002

Overview
Defining disability
What is rehabilitation?

Decision making
Team
Technology
Setting

The role of exercise in rehabilitation

The Exercise Prescription
Disease specific evidence

DYSFUNCTION AND DISABILITY

Dis-fitness Cycle
Age
Related
Change
New or
Existing
Illness

Increased
Disease
Risk

Illness
Risk
Factors

Reduced
Physical
Activity

Etiology of
deconditioning

Consequences of
deconditioning

Disease Impairment
Handicap
Malnutrition
Weakness

Difficult
y
shoppin
g

Immobility
Knee
arthritis

Pain

Disability

Physical
Environme
nt (multistory
house)

Difficult
y
walking

Loss of
ability to
live
independen
tly

Social
Isolatio
n

Social
Environme
nt
(loss of
spouse)

Apathy

Depression

Prin. Geriat. Med, 5th edition, p. 289

Principal Hospital
Diagnoses of Elderly Age
85+ (2006)

AHRQ: 2006 Nationwide Inpatient

Survey of adults age 85+

Cascade to Dependency
Muscle
Strength
& Aerobic
Capacity

Vasomotor
Instability

Bone
Density

Ventilation

Sensory
Continence

Altered
Thirst and
Nutrition

Fragile
Skin

Tendency
To Urinary
Incontinence

Immobilization
Sheering
Force

Diapers
Tether

Hazards of Bed Rest and Hospitalization

Immobilized
High Bed
Bed Rails

Plasma
Volume

Accelerated
Bone Loss

Closing
Volume

Sensory
Deprivation
Isolation

Barriers
Tether
Rx Diet

Dehydration

Malnutrition

Syncope
pO2
Deconditioning

Tube

Delirium

Aspiration

Fall
Physical
Restraint

Chemical
Restraint

Fracture
False Label

Nursing Home

Tardive
Dyskinesia

Functional
Incontinence

Catheter

Pressure
Sore

Infection

Family
Rejection

Hospital associated
deconditioning

Loss of ambulatory function or ADL or both in

at least 1/3 of hospitalized patients
Increased risk of institutionalization or death
Demand for rehabilitation will increase
Studies support acute inpatient rehabilitation,
but limited for other settings

Functional decline during

hospitalization
Function

Hospital admission
Post Recovery

A
Rehabilitation
Threshold of
Independence

No rehabilitation

Time

Am J Phys Med Rehab, 2009,

88(1):66-77

Strength and Functional Status

Normal
Healthy
Adults
Near
Frail

Function

THRESHOLD
Poor

Frail
Adults

Low

Strength

High

Established Populations for Epidemiologic Studies of the Elderly (EPESE) .

J Gerontology, 1994;49(3):M109-15

WHAT IS REHABILITATION?

Goal of rehabilitation

Return to independent living situation

Nursing home patients generally return
to that environment

Decision making

Pre-hospital setting
Social support available
Current active medical problems
Current tolerance of PT/OT
Cognitive ability

Decision making

Patient motivation
Patient and family preferences
Financial resources
Potential for recovery

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

Rehabilitation in general

Comprehensive
Multidisciplinary
Long term
Medical evaluation
Prescribed exercise
Risk factor modification
Counseling/Education

Rehabilitative Interventions:
A Team Sport

Exercise
Assistive technology
Physical modalities
Orthotics and prosthetics

Physical Therapy
Bed mobility and
transfer
Gait and balance
Ambulatory
endurance +/- gait
aid and stair climbing
Hip and knee
extensor training

Occupational Therapy
ADL training
Fine motor training
and adaptive
equipment
IADL / homemaking /
community survival
skills
Cognitive and safety
awareness
assessment and
remediation

ROM / flexibility /
stretching of upper
extremity
Energy conservation
and joint protection
Muscle strength and
endurance training

Driving rehabilitation:
www.driver-ed.org

Speech Therapy
All aspects of communication
Swallowing disorders
Treatment of communication
deficits
Diet and positioning changes for
dysphagia

Hazzard, Prin. Geriatric Med, 5th Ed., p. 292

Nurse
Evaluation of self-care skills
Evaluation of family and
home care factors
Self-care training
Patient and family education
Liaison with community

Hazzard, Prin. Geriatric Med, 5th Ed., p. 292

Social Worker
Evaluation of family and
home care factors
Assessment of
psychosocial factors
Counseling
Liaison with community

Hazzard, Prin. Geriatric Med, 5th Ed., p. 292

Dietician
Assess nutritional status
Alter diet to maximize
nutrition
Consider liberalizing the
diet

Hazzard, Prin. Geriatric Med, 5th Ed., p. 292

Recreation therapist
Assess leisure skills and interests
Involve patients in recreational activities
to maintain social roles

Hazzard, Prin Geriatric Med, 5th Ed.

292

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 Aide
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

Options: underarm/forearm
Fitting: 2 inches under
shoulder; do not lean armpit
on crutch
Contraindications: arm
weakness, shoulder
arthritis, cognitive
impairment
Problems: neuropathy,
shoulder pain, difficult to
learn to use

Supports full body weight

Options: manual/motorized;
accessories; lower to ground or
one-sided drive (hemi-chair);
racing, handcycle
Fitting: 1-1.5 inches around hips
and under knees; footplates
clear floor by 1-2 inches; armrest
at elbow height; removable
footrests and armrests
Contraindications: unable to sit,
or able to walk safely
Problems: deconditioning,
contractures, pressure sores

THE ROLE OF
HOME IN
REHABILITATION

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.

Rehabilitation settings: which

is best?
Acute inpatient rehabilitation
hospitals/units
Sub-acute nursing facilities
Home health care
Outpatient therapy
Cochrane Review: Care home vs. hospital and own home environments
for rehabilitation of older people. 2008, Issue 4. Art No: CD 003164

Insufficient evidence to compare

Exercise and rehabilitation

Exercise (Activity) Prescription for Older Adults

Strength: Use It & Lose Less of it

Losses
Sedentary people lose
Aerobic
Activity
large amounts of muscle
massIS
(20-40%)
NOT
6% sufficient
per decade loss of
Lean Body Mass (LBM)

to stop this loss!

Gains
Lean body mass
increases 1-3 kg
Resistance training
improves strength by a
range of 40-150%
Muscle fiber area 10-30%

BOTTOM LINES:
1.MUSCLE STRENGTHENING EXERCISES REQUIRED
2.MUST INCLUDE BALANCE+FLEXIBILITY IN OLDER ADULTS

3.FEWER FALLS, FRACTURES, DISUSE, FRAILTY

AND SARCOPENIA

The MD FITT Prescription

(for the older adult)

Mode:
Aerobic+Strength +Balance+Flexibility
Duration
Frequency
Intensity:

Touch > No Touch > Eyes Closed for balance

5-6/10 self-perceived exertion

Timely Follow Up
Therapy (Preventive and/or Therapeutic)

Exercise (Activity) Prescription for Older Adults

Whats Different for Older Adults?

2007 ACSM Guidelines For Older Adults
Intensity
Moderate
Vigorous Intensity
Balance Intensity
Exercise
(brisk
walk)
(jogging)
Rating 5-6/10
(not
specified)
30 minutes
20 minutes
3 times
per week
5 times
per week
3 times
per week
Intensity
is relative to level
of fitness
Flexibility Activities
Strength Building Exercise
(weight/resistance training)

8-10 exercises
2 times per week

(static stretch)

10 minutes
10-30 seconds/stretch
3-4 repetitions
All days of the week

Exercise (Activity) Prescription for Older Adults

A little more about balance

Static

Dynamic

Intensity=sensory or time

CONDITION SPECIFIC
REHABILITATION

Leading causes of death

Cardiovascular disease
Cerebrovascular disease
Chronic lung disease
Alzheimers 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 Bblockers and ACE Rx)
No increase in morbidity or mortality

Cardiol J. 2008; 15(5): 481-7

Outcomes
Diagnosis

Functional
Capacity

QOL

Morbidity

Mortality

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, noninvasive ventilatory support,
biofeedback, anabolic steroid
Casaburi, ZuWallack. NEJM 2009;
360: 1329-35

Problem areas

COPD cachexia
-1/3 of patients dont 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: 390405

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
Conclusion: Exercise

is effective in lowering the risk of falls

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