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Geriatric Rehabilitation. 2, Physiatric Approachto the Older AdultDeboruh G. Stewart, MD, Edward M. Phil@s, MD, Carol F. Bodenheimer, MD, David X. Cifu, MD

ABSTRACT. Stewart DG, Phillips EM, Bodenheimer CF,Cifu DX. Geriatric rehabilitation. 2. Physiatric approach to theolder adult. Arch Phys Med Rehabil 2004;85(Suppl 3):S7-11.

This self-directed leaming module highlights the physiatricapproach to the older adult. It is part of the study guide ongeriatric rehabilitation in the Self-Directed Physiatric Educa-tion Program for practitioners and trainees in physical medicineand rehabilitation (PM&R) and geriatric medicine. This articlespecifically focuses on the advantages of the physiatric ap-proach, PM&R training in geriatric rehabilitation, metrics ingeriatric assessment, prevention, symptom management, med-ical management, falls, pain, and pharmacology.

Overall Article Objective: To summarize the physiatricapproach to the older adult.

Key Words: Falls; Geriatrics; Pain; Pharmacology; Preven-t ion; Rehabil i tat ion.

A 2004 by the American Academy o/'Physical Medicine andRehubilitation

2.1 Clinical Activity: To support physiatric referral for a78-year-old man with rheumatoid arthri t is who ishaving increasing dif f iculty caring for himself and hishome.

rnHE 65-YEARS-AND-OLDER populat ion is growing,I with the "oldest old" group, persons at or over the age of

85 years, being the fastest growing scgment of US society'Although the conelat ion befween age and disabi l i ty is not l :1,the incidence and prevalence ofdisease and chronic condit ionsincrease with advancing age. The geriatric patient can presentwith a complex set of issues and associated disability. He/shemay have health, financial, and psychosocial issues overlying Ior more disabling conditions. This corrplexity requires com-prehensive assessment and an integrated approach. Physicianstrained in physical medicine and rehabilitation (PM&R) havethe necessary tools to address the myriad issues presented bygeriatric patients. The special training and cducation physia-trists receive concerning the often complex needs of olderpatients enables them to provide improved care that addressesage-specifi c differences. I

Principles of rehabilitation practice emphasize a holisticassessment of medical condition, functional impairments,handicaps, societal constraints, and the utility of adaptive

equipment. This comprehensive approach has been shown toimprove outcome in geriatric patients.2'3 The comerstone ofrehabilitation medicine is interdisciplinary team work.Whereas most medical settings incorporate a variety profes-sionals (ie, a multidisciplinary approach), few are able todevelop a truly interdisciplinary team process. The interdisci-plinary model can result in better outcome than that providedby the traditional multidisciplinary methods typically used inacute care hospitals, skilled nursing or subacute facilities, out-patient services, or by other medical specialists. The interdis-ciplinary approach differs from the multidisciplinary approachin 3 fundamental ways: (1) focus on common patient and teamgoals, rather than a discipline-specific focus; (2) regular andeffective communication; and (3) coordination and integrationof care. These differences are not trivial but reflect the teamdynamic at work. Regular team communication is necessary todiscuss patient goals and outcomes to adjust the programaccordingly. The interdisciplinary model is ingrained in PM&Rspecialists as a fundamental component of their training.

Learning how to work with and lead a team is a core clinicalcompetency of physiatrists. Interdisciplinary treatment bothimproves functional outcome and decreases nursing homeplacement.2 Rehabil itation medicine has embraced the princi-ples of "improving care of older patients" as set forth by theAmerican Ceriatrics Society.a's Ongoing evidcnce of the spe-cialty's commitment to providing geriatric care is the studyguide issue of Archives o/'Physical Medicine and Rehabilita'tion, first published in 1993.6

2.2 Educational Activity: To discuss the fiscal and clinicalimplications of performing accurate functional assess-ments in an older adult with mild dementia and a hipfracture,

Interdisciplinary geriatric assessment benefits the geriatricpopulation in several ways. Ceriatric assessments, which in-clude functional as well as traditional medical evaluations,provide better clinical care by targeting planned interventions.The ability to reliably test persons over time supports researchthat, in turn, supports care models that are optimal for olderadults. Quantiffing a person's functional status may providebetter reimbursement and insurance coverage for outpatient orhome-based interventions. Some assessment systems, such asthe prospective payment systemT and Long-Term Care Mini-mum Data Set? (MDS) are mandatory for patients admitted torehabilitation or nursing home facilities. The MDS is a nationaldatabase that collects information on the medical conditions,needs, and functional levels of every person who resides in anursing home certified to participate in the Medicare and Med-icaid programs.

There are several measures of disability and ability that arewidely used both as clinical assessment tools and in geriatricresearch. The FIM instrument8 has been tested for adults,including the elderly. The FIM measures disability and itsscores conelate with level of assistance that is required forbasic functions. A score of 18 is completely dependent, and ascore of 126 is completely independent. An analysis of the

From the Brooks Health System Administration, Jacksonville, FL (Stewart); De-

partment of Physical Medicine and Rehabilitation, Haward Medical School, Spaul-

ding Rehabilitation HospitEl, Boston, MA (Phillips); Department of Physical Med!

cine and Rehabil itation, Philadelphia VA Medical Center, Philadelphia, PA

(Bodenheimer); and Department of Physical Medicine and Rchabilitation, Virginia

Commonwealth UniversityA4edical College of Virginia, Richmond, VA (Cifu).

No commercial party having a direct financial interest in the results of the research

supporting this article hm or will confer a benefit upon the authors(s) or upon any

organization with which the author(s) is/are associated.Reprint requests to Deborah G. Stewart, MD, Brooks Rehabilitation Hosp, 3599

Univcrsity Blvd, Jacksonville, FL 322 16, e-mzil: deborah.stewan@brooksheallh org.

0003-9993/04/8507-92 I 6$30.00/0doi: I 0. I 0 I 6/j.apmr.2004.03.006

Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

s8 PHYSIATRIC APPROACH TO THE OLDER ADULT. Stewart

constnrct validity and retest reliability of the FIM for personsover the age of 80 years found that the motor subscale of theFIM (items A-M) was both valid and stable. The cognitivesubscale (items N-R) was found to have construct validity butwas less stable. The FIM score can be used to determine arehabilitation efficiency ratio or the change in FIM score overthe length of stay. Compared with younger patients, olderpatents have more medical comorbidities. This is significantbecause higher medical comorbidities have been shown tocorrelate with lower rehabilitation efficiencies.e

The Katz index of independence in activities of daily livings(ADLs) is a widely used scale in the field of geriatrics; itmeasures ADLs but does not include measures of mobility suchas walking or stairclimbing. The Katz scale can be self-admin-istered by the patient or a caregiver rather than by the clinician.It is not very sensitive to change, however. The Barthel Index8is widely used and is an ordinal scale of l0 self-care andmobility items. A score of 0 is completely dependent, and ascore of 100 is completely independent. It is not very sensitiveto changes.

In the timed "Up & Go" test'o (TUG), a patient is asked torise from an armchair, walk 3m (10ft), turn around, walk backto the chair, and sit down again. The score is the time inseconds it takes to complete these tasks. This test has signifi-cant interrater reliability as well as content reliability. It pre-dicts whether a patient can walk safely alone outside.lo TheBerg Balance Scale" (BBS) is a 56-point scale to evaluateperformance during 14 common activities, such as standing,turning, and reaching for an object on the floor. It has highinterrater and intrarater reliability. Although it is designed to beused as a clinical assessment tool, scores on the BBS have beenshown to correlate with laboratory tests of balance.rl

The Mini-Mental State Examinationr2 (MMSE) containsquestions on orientation, attention, and other cognitive func-tions. Although it is not a diagnostic test for dementia, it is abrief screening tool that allows quantification of cognition overtime.12 Because of the instrument's insensitivity, the MMSEmay not detect dementia in people who are premorbid but havehigh intellectual functioning or it may inaccurately suggestdementia in cases of the dementia syndrome of depression,previously known as pseudodementia. It is important toscreen separately for both dementia and depression. TheGeriatric Depression Scale-Short Formr3 has been validatedin persons over the age of55 years. I t is a br ie f (15- i tem)questionnaire with yes-no answers that the patient can self-administer.

The CAGE (Cut down, Annoyed, Cuilty or Eye opener)ra isa screening tool of alcohol use designed for the young adultpopulation. It is the most widely used clinical screening tool foralcohol abuse. However, elderly men are more likely to testpositive on the CAGE than on other screening tests, such as theShort Michigan Alcoholic Screening Test Geriatric Version.laClinicians should be aware that detecting excessive alcohol usein the elderly, even with screening tools, is difficult.t4

The Norton Pressure Ulcer Risk Scalers and the BradenScale for Predicting Pressure Sore Riskta are assessment toolsthat help to determine the risk of skin breakdown or decubitusulcer. These scales assess risk of skin breakdown based on thefollowing factors: sensory perception, moisture, activity, bedmobility, nutrition, friction, and shear.rs They are widely usedand can help to identify persons most at risk for skin break-down.

Arch Phys Med Rehabil Vol 85, Suppt 3, Juty 2004

Table 1: Interventions to Reduce Risk of Falls and Resultant Iniury

Treat pain

In i t iate proper footwearPrescr ibe bone strength€ning medicat ionsProvide cardiac pacingRevise prescr ipt ion for g lasses or ophthalmic intervent ionAvoid restraintsln i t iate gai t assist ive deviceslmprove l ight ingFi tness: improve range of mot ion, st rength, and powerInstal l bathroom safety equipment

2.3 Clinical Activi ty: To advise a 62-year-old woman onways to reduce the fall risk for her father who recentlymoved into her home.

A fall is defined as an unintentional change in position withthe person coming to rest at a lower level. Falling is bestunderstood as a symptom, not a diagnosis. It is usually amanifestation of multiple etiologies rather than a single dis-ease. Moreover, the risk of falls and resultant iniury increaseswith advancing age and increases exponential ly ai addit ionalrisk factors are added. Most falls in thc elderly are pathologic,because of underlying disease and functional impairments,rather than accidental, because of environmental factors.r6

Eliciting a history of falls and the circumstanccs of any fallsfrom the older man and his daughter is important. A simplescreening test such as the TUG test (ie, arise from a chairwithout arms, walk several paces and return) would be appro-priate in a nonfal ler. A person who has fai lcd this tcst or has ahistory of falls would require a more complete evaluation.Because elderly persons often underestimate the risk of fallsuntil an injury occurs, proactive intervention to assist her fatheris critical. Her father should be involved as much as possible inthe assessment and interventions recommended.tT

This woman should be counseled that there are both intrinsicand extrinsic risk factors influencing her father's risk offalling.The design of an effective therapeutic program to reduce faJlrisk would include identifuing and treating all predisposingfactors and treatment ofunderlying diseascs. To best reduce hisrisks of falling and lessen potential injury from falls, multiplemodifications to his environment as well as any modifiableimpairment should be simultaneously addressed.

Reviewing and modi$ing the elderly person's medicationregimen has been shown to reduce fal ls (tables 1,2). Exerciseprograms with balance training, strength and endurance train-ing, and treatment of postural hypotension are beneficial fun-damental interventions. Tai-Chi exercise may be effective inimproving balance.r8 Assistive devices such as a walker orcane improve mobil i ty.r8 Optimizing medication managementof concomitant morbidities, for example, lower-extremify painor abnormalities of tone, may also reduce risk of falls. Hipprotectors will reduce the risk of hip fractures in hieh-riskfallers with osteoporosis. The maximai effectiveness islainedby making these interventions components of a multifactorialjn{9rusnfi6n. tr,zo

Attempts should be made to correct modifiable envrronmen-tal factors. These include improved lighting to reduce shadowsand elimination of obvious tripping hazards, such as electriccords, thresholds, uneven pathways, scatter rugs, clutteredrooms, and moveable furniture. Minimizine environmentalhazards can be accomplished with a home-safJty evaluation by

PHYSIATRIC APPROACH TO THE OLDER ADULT, Stewart s9

Table 2: lntrinsic Risk Factors for Falls in the Older Adult

General factorsWidespread or lower-extremity pain

Muscular wsaknessBalance def ic i tCogni t ive impairment

Age >80y

DepressionPerceptual deficits

CataractsMacular degenerat ionHear ing lossPer ipheral neuropathyLabyr inth ine disorders

0rthopedic and rheumatologic d iseases

Orthopedic in iury

Skeletal deformityKyphoscol iosisArth ritisTendoni t isPaget 's d isease

Cardiovascular issues

Decreased cerebral perfusion f rom arrhythmias

Valvular heart d iseasel schem iaPostural hypotension

SyncopeNeu romuscu la r i s sues

StrokeTransient ischemic at tacksParkinson's d iseaseMult ip le sclerosisMyopathyCerebral palsy

Amyotrophic lateral sc lerosis

Medicat ions4+ of any medicat ions, part icular ly

Thiazidesc-blockersAnt i hype r tensives

Sedat ives and hypnot ics ( long-act ing)

Psychotropics wi th ant ichol inergic and extrapyramidal

side effectsAnt ih istamines

lying functional reserve is probably less than the youngerman's. Therefore, after a period of immobilization to treat thesprain, he will require more strengthening and rehabilitation torestore his function. It is important to fully assess the globalimpact of even this isolated, acute, musculoskeletal injury onhis overall physical and emotional functioning.

Pain in the elderly is a dramatically common occurrence,although it is not necessarily synonymous with aging. The 33%prevalence of chronic joint pain and arthritis estimated for theUS population increases with age.2r Even so, pain in the elderlyis generally underdiagnosed and undertreated in all settingsfrom the community to nursing homes.

When managing pain for the 74-year-old golfer's anklesprain, it is important to assess for multiple sites and etiologiesof pain. A single site does not generally explain all of thecomplaints of pain in the elderly. The presence of a chronicsore back or widespread pain in the older man may increase hiscomplaints of pain from the ankle sprain. Common underlyingsouraes of pain, including peripheral neuropathy or arthritis ofthe lower-extremity joints, will complicate the assessment andmanagement of acute pain,

It is a myth that the elderly do not feel pain as much asyounger people. "ln the final analysis, age-related change^s-inpain perc'eption are probably not clinically significant."22(ps206)The older man's complaints of pain will impact more heavilyon him, decreasing his self-reported health status. Presence ofpain in the elderly has functional significance: they will do lessind will more likely rate their health status as "poor'" Epide-miologic studies2r have shown that pain is overlooked as apotential cause of disability. Fall risk is increased with pain andreduced with use of analgesic medications.23 A common psy-chologic sequela of undertreated pain is depression.

In older adults, acute pain from a sprain must be treatedaggressively. Nonpharmaceutical options should be encour-aged. Ueat or cold modalities may be applied after checking foradequate sensation. Compressive wraps and supportive bracingto reduce swelling and improve stability of the joint should beused after assessing skin integrity. Liniments (eg, over-the-counter [OTC] ointments giving the sensation of heat or cold)and topical agents applied as counter-irritants (eg, capsaicin)may provide-relief *ith fewer side effects compared withpharmaceutical agents and are often well acceptcd.

If oral medications are required, establish an analgesic usehistory, noting the efficacy and side efl'ect of prior medications,including OTe and natural remedies. Nonsteroidal anti-inflam-matory drugs (NSAIDs) including cyclooxygenase-2 inhibitorspose particular risks related to the higher risk of gastric bleed-ing in those above age 65 and must be avoided in patients withreial failure and bleeding diathesis. Scheduled doses of acet-aminophen up to l000mg by mouth 4 times daily may beequally effective with reduced side effects for mild pain (l-3on a siale of l0). In long-standing, moderate pain (4-6 on ascale of l0), low doses of weak narcotics may provide betterrelief with fewer side effects than with NSAIDs. Strongeropioids should be reserved for severe pain (7-10.on a scale of1b). Prophylactic bowel medications should be given to avoidconstipaiion. Caution must be applied to medic-ations witha tong tratf-t ife because of decreased metabolism in theelderly.2'24'2s

Diagnosing pain in the cognitively impaired. population isrno.. ihull.nging but achievable with appropriate tools (eg,pictorial visual aialog scales) and with careful attempts to elicitoain complaints and observations of pain behavior. This pop-i-rlation, especially, should be treated with scheduled doses ofanalqesics rather than as needed. End-of-life pain management

an occupational therapist. Shoe wear must be evaluated toensure appropriate fit and support're'20

An appropriate rehabilitation program must address the lossof confidence in walking and the fear of falling that commonlyfollows falls and lead to self-imposed immobility and increasedrisk of subsequent falls. Although the best treatment is activeretum to walking, psychologic counseling may also be indi-cated. Appropriaie intervention to reduce the risk of falls andresultani injury will reduce the chance of premature nursinghome admission in the previously described scenario.

2.4 Clinical Activity: To distinguish the key assessmentand treatment elements of an ankle sprain in a 74-year-old businessman from those of a similar sprain inhis 48-year-old golfing Partner.

The functional impact of similar ankle sprains in the 2golfers will likely be more severe in the older man' His under-

Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

in cancer and nonmalignant terminal conditions must be con-sidered. Providing comfort and dignify is paramount.26

2.5 Educational Activity: As medical director, construct arisk management strategy to minimize polypharmacyin your nursing home.

Managing pharmacologic therapy in older adults requiresknowledge of drug effects, age, disease-related alterations inmetabolism, drug interactions, and patient compliance issues.Persons at or over the age of 65 years represent only about 13%of the population, but they spend 4 times as much on drugs aspersons younger than 65 years.21 It has been estimated thatolder adults take, on average, 4.5 medications daily. prescrip-tion medications are often combined with OTC drugs, nutri-tional supplements, and nutraceuticals, with or without thephysician's knowledge. Undesirable effects of medications arealso more likely and more pronounced in geriatric patients.Psychotropic medications, class la antiarrhythmic drugs (eg,procainamide), digoxin, and diuretics, according to I meti-analysis,2s significantly increase the risk of falls.

Polypharmacy, or use of multiple medications, increases thelikelihood of adverse effects and reduces compliance with drugregimens. It is incumbent on the physician to evaluate carefullymedications for need, appropriate dose, potential side effects,and drug interactions and to make necessary adjustments. Mak-ing drug adjustments for chronic conditions during rehabilita-tion may be difficult, particularly if the practice site is not partof a system of care. The ideal model of care would have asystem that integrated computer-based information, pharma-cists, and all treating physicians.2e Additional features thatwould enhance outcome, reduce errors, and certainly reducecosts would be clinical decision support systcms or protocols(eg, care pathways).:o':t Following evidence-based guidelinesor recommendations will enhance outcome and patient safetv.

Providing the patient and caregiver with information aboutdrug use and side effects is another important component ofpharmacologic therapy. Clinicians must provide iniormationabout drug therapy options, as well as their risks and benefits.Oneto-one education significantly improves compliance andclinical outcome.32

Frequent monitoring of medication by the treatment team isan effective strategy for minimizing complications. However,in geriatric patients, the risks are greater and, therefore, requiremore consideration. Overdosing, underdosing, misinterpretingside effects as the onset ofa new illness or even ofaging itsel{and overuse or underuse ofneeded medications all are potentialissues in drug therapy.

l. Strasser DC, Solomon iiiS'ffilJR. Geriatrics and physicalmedicine and rehabilitation: common principles, complementaryapproaches, and 2lst century demographiis. Arch

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