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Recent study sought to monitor pattern of HRT
use from 1993 to July 2003.
From 1993 to 1999, annual prescriptions rates rose
from 58 to 90 million and remained steady
until June 2002.
However, from July 2002 until July 2003- after
the publication of HERS, HERS II and WHIprescriptions fell by roughly 50% or 57 million
prescriptions.
Hersh AL et al. National use of postmenopausal hormone therapy: Annual
trends and response to recent evidence. JAMA 2004;291(1):47-54.
Care of the Chronic and Terminally
Ill Patient.
COLDs
• Affects 15 million Americans
• 5th leading cause of death
• Epidemiological evidence indicates that
incidence of COLDs has risen more rapidly
than any of the 10 other most common
causes of death among persons over age 65.
Estimated that 80% of all COLDs
directly related to smoking.
Onset may be in 70s or 80s, even if
stopped smoking decades earlier.
S & S: productive cough, dyspnea, wheeze.
If osteoporotic: Increased freq of #
pink puffers blue bloaters.
Treatment: bronchodilators, anticholinergic inhalers
Asthma
• 10% of elderly Americans
• Half of elderly asthmatic patients have
onset of symptoms after age 65.
• Mortality 20-fold greater among adults
over age 45 compared to children.
S & S: wheeze, SOB, chest tightness, nonproductive cough, and persistent URTI.
6 Key Strategies to Manage Asthma
1.
2.
3.
4.
Education
Objective measurements of lung capacity
Environmental control
Pharmacological therapy for chronic
asthma.
5. Pharmacological therapy for acute
asthma.
6. Regular follow-up care.
Symrnios NA. Asthma: a six-part strategy for managing older
patients. Geriatrics 1997;52(2):36-44.
Other suggestions
• cover mattress and pillow with plastic
• damp wipe mattress every 2 weeks
• wash bedding weekly in hot water
• replace feather pillows
• avoid basement bedrooms
• cover air ducts with filters
• maintain smoke-free environment
• remove or vacuum any carpet weekly
• humidity at 30-50%
•wash pet regularly
•increase ventilation with A/C
Jones AP. Asthma and the home environment. J Asthma 2000;37:103-24
SMT and Asthma
Although no change in FEV following
SMT in a RCT, there were improvements
in QOL, decreased drug usage and
decreased symptoms. *
Reviewers of the Cochran Library
concluded that there was insufficient
evidence to support or refute SMT for asthma.
* Balon J et al. NEJM 1998;339:1013-1020
**Hondras MA et al. Cochrane Library, Issue 2, Oxford: 2000;17
Did SMT in addition to optimal medical
management result in clinically important
changes in asthma-related symptoms
among children.
Outcomes: Pulmonary function test; patient
and parent rated asthma-specific
QOL and asthma severity
questionnaires; morning and
evening peak expiratory flow rates;
daily diary-based day and nighttime
symptoms.
After 3 months, the use of SMT and optimal
medical management children rated their
QOL substantially higher and their
asthma severity substantially lower.
Bronfort G, Evan RC, Kubic P et al. Chiropractic pediatric asthma and
chiropractic spinal manipulation: A prospective clinical series and
randomized clinical pilot study. JMPT 2001;24(6):369-377.
Cancer
• In general, rates of cancer declined 0.7%
between 1990-1995.
• Death rates from 4 most common cancers
(lung, breast, prostate and colorectal)
all declined.
• Likelihood of developing a cancer within
a person’s life: 40%
• Primarily disease of the elderly, with age
the major determinant of cancer risk.
One third of all cancers occur in persons
over age 70.
May be related to prolonged exposure
to environmental carcinogens.
Decrease in mitochondrial activity
Impaired cellular repair ability
Impaired immune system
In the field of oncology
Because older patients thought to have:
• poor prognosis
• cognitive impairments
• decreased quality of life
• decreased social worth
• limited life expectancy
They receive:
• less screening for cancer
• less staging for diagnosed cancer
• less aggressive therapy,
• and often no treatment at all.
Older patients less likely to receive proper
pain management for cancer
Cleary JF, Carbone PP. Palliative medicine in the elderly.
Cancer 1997;80(7):1335-47.
As A Result:
Older patients are often labeled as being
resistant to treatment, clinically
uninteresting, and are often provided
with only generic and narrow treatment
options.
Palmore EB. Ageism: Negative and Positive.
New York: Springer Pub Co. Inc. 1999.
Lung Cancer
• WHO estimates 3 million people die worldwide due to Lung cancer, with highest rate
among North Americans.
• 178,000 new cases a year
• Most common cause of cancer death
(160,000 annually).
• Incidence dropped among men since 1980s
• Increased among women, more common
than breast cancer
Highest risk factor is smoking
• Apparent by demographic studies with
a 20 year time lag.
• 80-90% of lung cancer attributable to
smoking.
• Proportional to both total number of
years person has smoked and number
of cigarettes person smokes.
• Earlier quit: greater impact
• 3,000 die/yr from second-hand smoke
S & S: Most cases untreatable at time of Dx.
Lung cancer tends to be clinically silent
until detected.
Unexplained weight loss, dyspnea, chest pain,
bone pain, haemoptysis, wheezing, signs
associated with brain mets, recurrent and
unresolving pneumonia.
TNM Staging : Medically managed
Prognosis: 5 year survival= 10-15%
Breast Cancer
• Most commonly diagnosed cancer among
Canadian and American women, and second
only to lung cancer in terms of cancer deaths.
• Affects 1:9 women.
• 150,000 new cases a year. 44,000 deaths
• 29% of all cancer among women
• 18% of all cancer deaths
• Among women age 15-54, leading cause
of cancer death.
• 70% of cases dx in women over age 50.
Risk Factors
Gender
Age
Exposure to estrogen
Diet
Genetic factors BRCA 1 and p53 (#17)
Family History
S-E factors (more common in high SE)
Radiation exposure
Personal history of endocrine cancer
History of benign breast disease
In general, the longer a women exposed
to estrogen, the greater her chance of
developing breast cancer.
ie early Menarche or late Menopause
(late menopause =twice the risk).
Some protection conveyed by pregnancy
(related to increase in prolactin).
BC Pill (?)
Also related to large body mass and
abdominal obesity.
Diet: increased risk with change in
diet with more fat and total calories.
Screening Protocols
Monthly self-examination
Mammogram between age 35-40.
Every 2 years between age 40 to 50
Yearly thereafter.
S & S: non-painful, tender, firm palpable
mass.
Treatment
• Depends on stage of disease
• Lumpectomy or mastectomy
lymph node dissection and radiotherapy.
• Unconventional treatments:
Iscador, 714-X, green tea, vitamin A,C, E.
Essiac and hydrazine sulfate.
Berestiansky J. Breast cancer: a current summary. Top Clin
Chirop 1999;6(1):18-24.
Prognosis: related to presence or absence
of axillary lymph nodes.
Primary Prevention: exercise, balanced diet
(antioxidants), increase in linolenic acid,
decrease use of BC pill.
Secondary Prevention: Breast self-exam.
Clinical exam. Mammography.
Tertiary Prevention: Post-op care, follow-up
visits, patient education.
Prostate Cancer
•50% of men over age 70 have evidence of
prostatic cancer.
• Second most common cause of death.
• 244,000 diagnoses a year. 40,000 deaths
• Afro-Americans have highest incidence
in world (1:9).
Tends to be clinically silent.
Often metastasis to bone
Screening: Digital rectal exam.
PSA testing.
Bone scan for mets.
Medical management.
TURP
Gynecological Cancers
Endometrial cancer most common of
gynecological cancers.
Harbinger: Post-menopausal bleeding.
Cervical: Second most common.
Peak incidence fifth and sixth decade.
Related to viruses.
Ovarian: Less common, more deadly.
Leading cause of gynecological cancers deaths
in USA. Incidence is highest in 65-85 year old.
Colorectal & Pancreatic Cancer
• Highly prevalent among older patients.
• Second only to lung cancer as the most
common malignancy among both men
and women.
• 90% of all cases occur over age 50
• 150,000 new cases/year.
• Adenocarcinoma constitutes 95% of all
cases
Associated with diets that are high fat,
high refined sugars and char-grilled
meats and low fibre.
Other risk factors: family history, IBD,
polyps other colon tumors.
Typically asymptomatic until found.
Suspected if presence of occult blood, Fedeficiency or abdominal mass.
Pancreatic Cancer
• Fourth most common cancer in USA
• 25,000 cases annually
• Related to cigarette smoking, diabetes,
high -OH use, saturated fat and coffee,
chronic cholecystisis, exp to carcinogens.
S&S: unexplained wt loss, jaundice, GI pain
Prognosis: 5 year survival= 10%
Myeloproliferative Disorders
CLL is most common leukemia among elderly.
May be related to Epstein-Barr virus.
Often incidental findings.
Multiple myeloma. More common among
Afro-Americans. Usually persons over age 50.
•Genetic, radiation, toxins and viruses.
•Bone pain most common presenting complaint
•Multiple biconcave compression # on X-ray
Chronic Illness
Recall studies by Hawk (JAGS 2000), Bressler
(Spine 1999) and Rupert (JMPT 2000).
Estimated that 80-85% of all people will
experience a significant health problem
that predisposes them to pain after age 65.
• 20-50% significant pain
• 45-80% if in nursing home
Gallagher et al. Sources of late-life pain and risk factors for disability.
Geriatrics 2000;55(9):40-47.
BUT...
Prevalence of pain declines with age.
• Age-related changes to nociceptors
• More reluctant to report pain
• Artifact of high mortality rates/institutionization.
That said: 36-83% of elderly report pain
interferes with ADLs and QOL.
Mobily PR et al. An epidemiological analysis of pain in the elderly:
the Iowa 65+ study. J Aging Health 1994;6:139-154.
Chronic pain in and of itself does not
lower QOL. Related to changes in sleep,
physical and social functioning, depression,
and increased need for health services
Symptoms of pain and depression intensify
each other.
Health related QOL scores of people with
chronic non-malignant pain are among
lowest observed for any medical condition.
Gallagher et al. Ibid
Development of chronic pain influenced by:
• Patient’s interpretation of pain.
• patient’s reaction to pain.
• Other biopsychosocial factors.
• Score of MMPI
• involvement of worker’s comp or litigation=
90% more likely to develop chronic pain.
Hoffman B. Confronting psychosocial issues in patients with low
back pain. Top Clin Chirop 1999;6(2):1-7.
Breaking Bad News
‘situation where there is either a feeling of no
hope, a threat to a person’s mental or
physical well-being, a risk of upsetting an
established lifestyle, or where a message is
given which conveys to an individual fewer
choices in his or her life’.
Bor R et al. The meaning of bad news in HIV disease; counseling
about dreaded issues revisited. Counsel Psych Q 1993;6:69-80.
However, different people interpret
bad news differently. Depends on
personality, interpersonal skills,
news-specific variables, situation-specific.
May only be confirming patient’s
suspicion.
Must be certain of news before its conveyed!
• Cannot be delegated to a surrogate
• Jurisprudence dictates informing pt
• Fortify rapport between patient and
doctor if done well. Conversely, if done
poorly, may impede patient’s long-term
adjustment to news.
Three ways to convey Bad News
1. Bluntly and insensitively
2. Kindly and sadly
3. Understanding, positive and flexible
Key: Convey info in such as manner as to
facilitate acceptance and understanding,
minimizing risk of denial, ambivalence,
unrealistic expectation, overwhelming distress
patient.
Strategies to Convey Bad News
Bowers L. “I’ve got some bad news…” Top Clin Chirop
1999;6(1):1-8.
Studies indicate that delivering bad
news is stressful for the clinician as well.
May be afraid will be blamed, fear of unknown,
fear of unleashing emotional response from pt,
discomfort of not having all the answers,
personal fear of unknown or death.
Therefore, clinician should not give news if he or
she is anxious or uncomfortable. Beware of burn-out
Ptacek JT et al. Breaking bad news. A review of the literature.
JAMA 1996;276:496-502.
End of Life Issues
Palliative care
• Provide dignity and comfort
• Best QOL.
• Address physical, mental, emotional and
spiritual needs.
Encourage opportunities to reminisce.
Be a good listener.
Empower individual by involving them in
own health care decisions.
Remind patient to have a ‘living will’.
• What heroic means (DNR)
• Organ donation
• When to withhold care.
Can achieve ‘good death’
Fisher R et al. A guide to end-of-life care for seniors. University of
Toronto and University of Ottawa. Health Canada 2000.
Recent study reported that half of caregivers
(n=217) of patients with dementia reported
spending at least 46 hours/week assisting
with ADLs or IADLs.
More than half reported that they were
‘on-duty’ 24 hours a day, that the patient
has frequent pain and that the caregiver had
to end or reduce employment owing to
these demands.
Caregivers exhibited high levels of
depression but showed remarkable
resilience after the death of the person
under care (symptoms of depression
started to lift by 3 months).
72% of caregivers reported that they found
the person’s death to be a relief to them,
and 90% thought it was a relief to the patient.
Schulz R et al. End-of-life care and effects of bereavement on family
caregivers of persons with dementia. NEJM 2003;349(20):1936-42.
A recent study investigating the experience
of 1578 patients who had died.
Last place of care: 67% institution (1059)
33% at home (507)
Of these 507, 198 (38%) did not receive
nursing services, 65 had nursing services
and 256 (49%) had home hospice service.
One quarter of all patients with pain or
dyspnea did not receive adequate treatment,
and one quarter reported concerns with
physician communication.
More than one third of patients under home
health agency/nursing home/hospital care
reported insufficient emotional support,
compared to only 1 out of 5 patients
receiving hospice care.
Family members of patients receiving
hospice services were more satisfied with
overall quality of care.
* Many patients in institutions had unmet
symptom amelioration, physician
communication, emotional support, and
being treated with respect.
Teno JM et al. Family perspectives on end-of-life care at the
last place of care. JAMA 2004;291(1):88-93.h
‘Hospice Model’
i. Each person is unique.
ii. Everyone dies.
iii. Comfort and happiness are very important.
iv. Adverse consequences of medical evaluations
and treatments.
v. Compromise in carrying out plans.
vi. Ability to treat without diagnosing.
Goodwin JS. Geriatrics and the limits of modern medicine.
N Eng J of Med 1999;340(16):1283-1285.
“Evidence-based medicine is not kind to
the elderly. This movement trusts only the
products of randomized clinical trial or,
preferentially, meta-analyses of those
trials. But subjects over the age of 75
years are rarely found in such trials,
thus rendering this population invisible
to scientific medicine …”
If we teach only what we know, and if we
know only what we can measure in clinical
trials, then we can say little of importance
about the care of the elderly. The most
important resources required in caring for
the old- sufficient time and empathy- are
not included in the critical pathways of
managed care”.
Goodwin JS. Geriatrics and the limits of modern medicine.
N Eng J of Med 1999;340(16):1283-1285.
Sleep Disorders
Very common in the elderly
45% report a problem sleeping
25% report that the problem is serious
Affected patients often have concomitant
pathological disorders that disturbs their
sleep patterns
Only those problems that persist for longer
than one month are considered
clinically significant
disturbances of sleep include:
More time in bed & less time asleep
More easily aroused from sleep
Experiencing daytime fatigue & napping
Less tolerant of phase shifts
of the sleep-wake cycle
Botanical Medicines for Sleep Disorders
German Chamomile
Passion Flower
Hops
Lemon Balm
Psychological stress:
the self-fulfilling prophesy of
not being able to sleep
Treatment of sleep disorders
Advisable to use sleeping pills as a last
resort, many different non-pharmacological
approaches
1.
Sleep Hygiene:
Establish a regular sleep schedule
2.
Environment:
Ensure a comfortable temperature
& noise-free surroundings
3. Activities:
It is suggested not to associate the bed
with frustration of not falling asleep.
The patient should not use the bed
for such non-sleep activities
such as reading or watching TV.
If the patient cannot fall asleep for more
than 30 minutes, the person should leave
the bedroom, do something else, & return
4.
Fluid, drugs & exercise:
Avoid nocturia by discontinuing
fluids after a certain time.
The patient should avoid
foods or drinks with stimulants
Exercise is extremely beneficial
in the treatment of sleep disorders
The pharmacological approach involves
the prescription of certain
established drugs.
However,
many of these medications
have serious side-effects
DRUG
SIDE EFFECT
Antidepressants
Postural hypotension
& confusion
Benzodiazepines
(ie. Diazepam)
Problems of tolerance,
dependency & withdrawal
Decrease Stage IV sleep
DRUG
SIDE EFFECT
Chloral hydrate
Development of tolerance
to dosage.(increase in
serum anticoagulants)
Anti-histamines
(ie. Benadryl)
Anticholinergic effects
can result in mental
confusion & urinary
changes
Iatrogenic
Drug
Reactions
Definitions
Iatrogenic:
caused by medical tx.
Polypharmacy: use of medications
for treatment of
multiple co-morbid
conditions.
Adverse Drug Reaction:
World Health Organization
Any noxious, unintended or undesired
effect of a drug, which occurs a doses use
in humans for prophylaxis, diagnosis or
treatment.
Does not include therapeutic failures,
intentional or accidental overdoses, errors
in administration or non-compliance.
Medical Statistics of Drug Use
and The Prescription Cascade
30% of all drugs and 40% of overthe-counter drugs are purchased
by those over age 65.
2/3 of older Americans use at least
one drug a day. 45% more than
one a day.
25% of older patients receive
inappropriate medication.
The most frequent medical
intervention performed by a
medical doctor is the writing
of a prescription.
67% of physician visits
result in a drug prescription
40% involve the
prescription of 2 or more
medications.
In the United States,
estimated annual cost
of treating drug-related
mortality & morbidity is
$ 76.6 billion
It has been estimated that 45%
of the elderly
are taking
SEVERAL
prescription medications
CONCURRENTLY
The number of drugs that the
average geriatric patient
is taking, including
prescription medications,
supplements and
over-the-counter
drugs is
The most commonly misused
prescription medication are
Antibiotics
It has been estimated that 60%
of antibiotic use is either
unnecessary or inappropriate
Age-Related Changes to Pharmokinetics &
Pharmodynamics
Kidney: 30% decline in glomerular
function rate, renal mass and
blood flow.
Liver:
Decline in hepatic function,
mass and blood flow.
Less drug clearance and Increase in
Bioavailability of Drug.
Tissue more susceptible
to pharmacological effects
of the drugs prescribed.
Geriatric Paradox
Older patients more commonly
prescribed medications, despite that
fact that they are the least able to
handle their side-effects.
Besides the problems of
tolerance and dependency,
there is the risk of developing a
Prescription Cascade
occurs when an adverse reaction to a drug
is misinterpreted as a new symptom
A new drug is then prescribed, increasing
the risk of still more symptoms and
pathological developments
Initial Drug
Adverse Drug
Subsequent
Treatment
NSAIDs
Rise in blood
pressure
Anti-hypertensive
medication
Thiazide
diuretics
Hyperuricemia
Treatment
for gout
Parkinsonian
symptoms
Treatment with
Levodopa
Metaclopramide*
* Often used to reduce gastric reflux from diabetes
and antimetic after chemotherapy
To prevent the Prescription Cascade:
Doctors should ALWAYS consider ANY sign
or symptom as a possible consequence of
current drug treatment.
Before a new drug is prescribed, the
need for the new medication should be
re-evaluated and a non-drug treatment
should be considered
This problem is only compounded by
the common of practice of older people:
1. Self-medicating themselves
2. Sharing medications with their friends
who say they have the same problems.
McCarthy KA. Peripheral neuropathy in the aging patient:
common causes, assessment, and risks. TICC 1999;6(4):56-61
Other Problems:
Tolerance
Dependence
Withdrawal
NSIADs
8,000 to 16,000 deaths annually
100,000 hospitalizations
Cohen J. Avoiding adverse reactions. Effective lower-dose drug
therapies for older patients. Geriatrics 2000;55(2):54-64.
10% to 17% of all hospitalizations
for older patients are the direct
result of inappropriate drug use.
Cohen J. Avoiding adverse reaction. Effective lower-dose drug
therapies for older patients. Geriatrics 2000;55(2):54-64.
The Boston Collaborative Drug Surveillance
Project estimated that about 30% of all
hospitalized patients experience an ADR,
and that 3-28% of all hospitalizations
are related to ADRs.
Other studies* have estimated that the rate of
ADRs to be 6.5/100 hospitalized patients,
of which 28% were judged to be preventable.
Bates DW et al. The cost of adverse drug events
in hospitalized patients. JAMA 1997;277:307-311.
One study estimated that cost of ADEs
was $2,595 for all ADEs, and $4,685 for
those ADEs thought to be preventable.
57% of ADEs judged to be significant
30% serious 12% life-threatening &
1% fatal.
18% target GI or CNS, 16% CVS or allergic
Estimated that the cost to a 700bed hospital to be:
$5.6 million for all ADEs
$2.8 million for preventable ADEs
Bates DW. The cost of adverse drug reaction in
hospitalized patients. JAMA 1997;277:307-311.
One study:
For every dollar spent on
drugs in nursing homes,
$1.33 in health care
resources were consumed
in the treatment of drugrelated problems.
Andrews et al. An Alternate Strategy for studying adverse drug
reaction. Lancet. 1997;349(9048): 309-313
Recently published study of over 1000
patient hospital files found 18% had at
least one serious ADR while under
hospital care, and the likelihood of
experiencing an ADR increased 6% for
each day spent in the hospital.
Andrews LB et al. An alternative strategy for studying
adverse events in medical care. Lancet 1997;349:309-313.
Cohort study of all Medicare enrollees
(30 397 person-years) cared for in a
multispecialty clinic over a 12-month
period.
Investigators found 1,523 identified ADEs,
of which 28% were considered preventable.
Of these, 38% were serious, life-threatening
or fatal.
Most errors occurred at the prescription
stage (58%), monitoring (61%) and
errors in patient adherence (21%).
Cardiovascular Rx most commonly involved,
followed diuretics, nonopiod analgesics.
hypoglycemics and anticoagulants.
System most commonly involved:
electrolyte/renal, GI, hemorrhagic, metabolic/
endocrine and neuropsychiatric.
Conclusions:
“More serious adverse drug
events are most likely to be
preventable”.
Gurwitz JH, Field TS, Harrold LR. Incidence and preventability
of adverse drug events among older persons in the ambulatory
setting. JAMA 2003;289(9):1107-1116.
**
2,216,000 patients have serious
ADRs annually.
106,000 fatal ADRs a year.
Four to sixth leading cause of death.
Lazarou et al. Incidence of Adverse Drug Reacations in
Hospitalized Patients. JAMA. 1998;279(15): 233-7
Examples of Adverse Reactions
to commonly used drugs
Adverse
Reaction
Sedation
Example
Drowsy,
sleepy
Confusion Disoriented
delirium
Common
Cause
Narcotic-analgesics
Anti-psychotics
Sedatives
Anti-depressants
Narcotic-analgesics
Anticholinergics
Adverse
Reaction
Example
Depression Intense sadness
Common
Cause
Apathy
Barbituates
Anti-psychotics
Alcohol
Orthostatic
hypotension
Dizziness
Syncope
Anti-hypertensives
Anti-anginals
Fatigue or
Weakness
Decrease in
strength
Muscle relaxants
Diuretics
Adverse
Reaction
Dizziness
Anticholinergic
effects
Example
Fall, loss of
balance
Common
Cause
Sedatives
Anti-psychotics
Narcotic-analgesics
Antihistamines
Confusion
Antihistamines
Anti-depressants
Nervousness
Anti-psychotics
Dry mouth
Constipated
Urinary changes
Botanical Med Cross-Reacting
Potential
or Herb
Drugs
Consequence
___________________________________________
Echinacea
Anabolic steroids
Amidarone,
Methotrexate
Hepatoxicity
Feverfew
NSAIDs
Negates effect
on headache
Feverfew, garlic
Gingko, Ginseng
Warfarin
Alter bleeding
time
Botanical Med Cross-Reacting
Potential
or Herb
Drugs
Consequence
___________________________________________
St John’s wort
MAO inhibitors,
SSRIs
Headache,
sweating
Valerian
Barbiturates
Sedation
Evening Primose Anticonvulsants
Lower Sz.
threshold
Botanical Med Cross-Reacting
Potential
or Herb
Drugs
Consequence
___________________________________________
Ginseng
HRT, corticosteroids
Addictive
Hawthorn
Siberian ginseng
Chamomile
Digoxin
Cardiac
dysfunction
Anticoagulants (?)
Change
coagulation.
Miller LG. Herbal medicines. Selected clinical manifestations focusing
on known or potential drug-herb interactions. Arch Intern Med
1998;158:2200-11
General Effects
of
Exercise
Physiological Effects
+
+
+
-
in blood flow
in endurance
in ROM & flexibility
in blood pressure
in resting heart rate
Physiological Effects
- in bone loss
- in loss of strength
+ in oxygen uptake
+ in neurological function
- in peripheral body fat
Exercise is also a
non-pharmacological therapy for:
Stress
Sleep Disorders
Anxiety
Diabetes
Coronary Heart Disease
Hyperlipidemia
Obesity & Hypertension
Frailty
This occurs when an older person loses
their physical reserve: when they are no
longer capable of carrying out their
IADLs.
It is usually a combination of severe muscle
wasting and cognitive decline.
Morley JE, Thomas DR. Recent advances in geriatrics.
Top Clin Chhiro 2002;9(6):1-6
Other definitions of frailty include
three or more of the following:
unintentional weight loss, self reported
exhaustion, weakness (grip strength),
slow walking speed, and low physical
activity.
Prevalence of 6.9%
Loss of muscle mass (sacropenia) is major
component of frailty, which is related to
physical disability and inactivity.
Over-weight people with low muscle mass
(‘fat frail) most disabled.
Morley JE, Thomas DR. Recent advances in geriatrics.
Top Clin Chhiro 2002;9(6):1-6
The Necessity
of Strength Training
For the Older Patient
Muscle Strength
is considered to be the most
physiologically-limiting factor
in the older adult.
Changes in Muscle with Age:
Loss of Muscle Mass (sarcopenia)
Decrease in Number of Muscle Fibres
Decrease in Muscle Fibre Size
Remodeling of Neuro-Muscular Junction
Decline in Number of Motor Units
Collateral Innervation
partially compensates for decrease
in motor unit numbers.
But this results in decline in
Motor Control
Non-uniformity of
Muscle Strength Decline
UWO: Atrophy of Quadriceps muscle
Less than
Atrophy of Tibialis Anterior & Biceps
However: Impairment in ADL and
Increase in Risk of Falling
Risk of Falling
Leading cause of morbidity in the older patient
Leading cause of death due to injury
Accounts for 90% of hip,
forearm and pelvic fractures
20% of patients who sustain a pelvic fracture die
20% never walk again
Uncompensated decline in muscle strength
results in a spiraling decline in
Functional Independence
Mitigated or Reversed by
Strength Training
UWO Research
Measurable gains in strength
in as little as 6 weeks
even among frail elderly.
Gains can last up to 1 year
even with de-training.
Relationship Between
Strength Gains &
Functional Improvement
Gait, Balance, Decrease in Risk of Falling
Gains in Chair-rising abilities, modality tasks
( stooping, transferring, stair climbing )
The Threshold Value
Minor improvement in strength
can result in remarkable gain
in functional abilities.
Threshold Value
work
Quality
of
Life
socialize
mobile in home
chair bound
Exercise Tolerance
Psycho-emotional gains have also
been attributed to strength gains.
Increase in confidence & self-esteem,
and progressive resistive training
was found to be an effective antidepressant among depressed people.
Singh N, Clement K, Fiatarone M. A randomized control trial
of progressive resistive training in depressed elders.
J Gerontol A Biol Sci Med Sci 1997;52(1):M27-35.
Strength Training can
be a benefit
to all five of the
Five “I” s
that challenge the
older patient.
The 5 I’s of Geriatrics
Intellectual Impairment
Immobility
Instability
Incontinence
Iatrogenic Drug Reaction
Risk of Strength Gains ?
Increase in
Physiological Burden ?
McMaster: subjects engaged in moderate strength training
(weight training) exposed to no more circulatory risk
than created by a few minutes of incline walking.
No other evidence of increase in frequency of injury
occurrence in those patients undergoing either
supervised or unsupervised strength training with
clear instructions.
Main motivational factors for
older person to adhere
to exercise program:
Health Maintenance
Social Cohesiveness
“
Prescription” of Strength Training
can be considered to be:
Primary
Secondary
& Tertiary Prevention
and a
“Therapeutic” Necessity
Mechanical Joint Pain
Most common presenting Chief
Complaint to a chiropractor’s office.
Generator of the pain poorly understood.
Joint dysfunction/subluxation*.
Assessed by history and NMS exam.
One author has suggested that the disease
management paradigm that serves medicine
so well often fails in the field of LBP.
“Thus, back pain in primary care has sometimes been characterized as ‘an illness in
search of a disease’, analogous to…
fibromyalgia, IBS or chronic fatigue
syndrome”.
Deyo RA. Diagnostic evaluation of LBP.
Arch Intern Med 2002;162:1444-7
This diagnostic challenge is further
frustrated by the common findings
of anatomic abnormalities such as
herniated discs, bulging discs and
annular tears among healthy,
asymptomatic patients.
Deyo RA. Diagnostic evaluation of LBP.
Arch Intern Med 2002;162:1444-7
Recent article directed at medical
physicians emphasized importance
of history taking in order to reach
a diagnosis.
Pain characteristics, intensity, timing
(onset, duration and pattern), location,
radiations and associated factors.
Cohen RI, Chopra P, Upshur C. Low Back Pain, Part I.
Primary care work-up of acute and chronic symptoms.
Geriatrics 2001;56(1):26-37.
Assessing pain behaviors, medication history
and ‘Alternative’ interventions.
Physical Exam: posture, gait, palpation,
SLR, Patrick’s, Flexion,
Extension, Kemp’s &
Neurological exam.
Use of Imaging.
Cohen et al. Ibid.
Stated that mechanical low back or
leg pain account for 97% of patients
with LBP in primary care.
70%
10%
4%
3%
4%
Idiopathic (includes FM/MPS)
DJD
Herniated disc
Spinal stenosis*
OP #*
By contrast:
1% Non-mechanical
(cancer, infection, arthritide)
2% visceral (prostate, PID, renal disease
aortic aneursym, GI)
Conservative Treatment
Review and modifications of ADLs
Ice, heat, modified sleep positions.
“To date, evidence-based literature reviews
show no advantage to acupuncture for back
pain when compared to trigger point
injections or TENS”.
Cohen RI, Chopra P, Upshur C. Low Back Pain, Part II.
Guide to conservative, medical and procedural therapies.
Geriatrics 2001;56(1):38-47.
“Spinal manipulation has shown
a minimal advantage. Massage
therapy, as compared to TENS
and manipulation, is not
advantageous”.
Three-step analgesia
Step 1: NSAID, Cox-2 inhibitors
Step 2: Opioid therapy (codeine)
Step 3: Morphine, methadone
May need to add adjuvant medications to any
of the above steps .
Patient education: exercise, ADLs,
nutrition, sexual concerns.
Surgery: decompressive laminectomy
fusion, disketomy.
Some studies suggest the results of treatment
of pain, instability, spinal stenosis and
nonacute spondylolisthesis with decompression
or fusion may not be more efficacious as
compared to conservative treatment.
“[Although] conservative management
is the recommended first-line management,
appropriate medical management includes
the generous and thoughtful prescription of
single of multiple drug regimens, based on
patient’s pain levels and extent to which
pain interferes with activities of daily living”.
Cohen et al. LBP. Ibid
Spinal Manipulative Therapy
SMT: Passive movement by external force
into the paraphysiological space, but
not exceeding anatomical limit.
High Velocity, Low Amplitude thrust.
Adjustment: Any procedure that utilizes
force, leverage, direction, magnitude,
amplitude and velocity directed at
specific joint.
Seventy-three RCTs on SMT have been
published in peer-reviewed journals.
Often compare SMT to placebo, other
therapeutic options, and to common
medical management approaches.
Most studies demonstrate either clinical
effectiveness, some showed no difference.
None found SMT less effective.
Meeker WC, Haldeman S. Chiropractic: A profession at the Crossroads
of mainstream and alternative medicine. Ann Int Med 2002;136:216-227
43 RCTs of SMT for treatment of acute,
subacute and chronic LBP have been
published.
30 favored SMT
13 found no significant difference
“No trial to date has found manipulation
to be statistically or clinically less
effective than the comparison treatment”.
Of the 11 RCTs investigating SMT and
neck pain, 4 positive: 7 equivocal.
Seven of 9 RCTs on SMT and headache
were positive.
Systematic reviews and meta-analyses
made cautiously positive or equivocal
statements about the effectiveness of
SMT for LBP, neck pain and headaches.
“There are many studies, comprehensive
reviews of the literature, and authoritative
opinions that support chiropractic care
as safe, appropriate, clinically useful, and
[often] cost effective compared with surgery,
drug therapy, bed rest, physical therapy
and patient instruction”.
Cooperstein R et al. Chiropractic Technique Procedures for
Specific Low Back Conditions: Characterizing the Literature.
JMPT 2001;24(6):401-24
SMT & The Older Patient
Gleberzon BJ. Chiropractic care of the older person:
Developing an evidence-based approach. JCCA
2001;45(3):156-171
Case Studies N=25
Successful management of:
Cervical spondylotic radiculopathy
Diabetic neuropathy of tarsals
Dislocation of S-C joint
Rotator cuff tear
Vertigo and tinnitus
Post-surgical repair to quads.
Spinal stenosis
TOS
DISH
Re-habilitation
Myastenia gravis
Back pain and
short leg
Other studies emphasize importance of
being vigilant to other pathologies that
may present as uncomplicated back pain.
Prostatic metastasis
Synovial facet joint cyst
Bronchial carcinoma
Thalamic pain syndrome
Abdomnianl aortic aneursym
MVA: Cerebellar infarct or Jefferson’s fracture
Fracture of femoral neck following radiation therapy
Chrondrosarcoma and myositis ossificans
Clinical Guidelines N=18
Challenges of assessing older person
Elder abuse
Falls, injuries, trauma
Exercise
Strength training
Nutrition
Special consideration for X-ray use
Special consideration for SMT
Clinical Trials N=4
All four studies investigated benefits of osteopathic
manipulation on older patients for:
1. changes in bowel habits
2. prevalence of falling
3-4. patient with pneumonia
Only patients with pneumonia showed any clinical
improvements: reduced antibiotic use and hospital stay.
SMT and the Older Person
Most clinical trials exclude by design older
patients.
Therefore, must extrapolate from studies
involving younger persons which have
demonstrated efficacy of SMT for acute and
chronic neck and low back pain, and certain
types of headaches.
Cooperstein and Killinger
Review of available research on chiropractic technique
Older persons do not appear to suffer more adverse
reactions to SMT than younger persons, and they may
suffer fewer.
Patient variables ie greater joint stiffness
Doctor variables ie rely on low force techniques
greater prudence
Cooperstein R, Killinger LZ. In: Gleberzon BJ. Chiropractic Care of the
Older Patient. 1st Print. Butterworth-Heinemann, 2001.
Cooeperstein and Killinger con’t
Issue related to SMT may be less one of force
and more one of pressure.
Alternative to HVLA SMT
Instrument-assisted techniques (Activator)
Blocking techniques (SOT)
Drop-assisted techniques (Thompson)
Mechanically-assisted techniques (Cox)
Upper cervical techniques (NUCCA)
Risks of Spinal Adjustments/Manipulations
No serious complications noted in more than
73 RCTs or any prospectively evaluated case
series.
49% among persons age 47-65 reported a side-effect.
Most local discomfort (53%), headache (12%)
or tiredness (11%). Mild to moderate in 85% of cases.
Disappeared within 24 hours in 74% of cases.
Senstead O et al. Spine 1997;22(4):435-441
Rehabilitation of the older person
Impact of age-induced changes on rehab
is over-estimated.
McGill reported that endurance of back
muscles is of primary concern in any
exercise program, rather that absolute
strength.
McGill S. Low back exercises: evidence for improving exercise
regiments. Phys Ther 1998;78:754-765.
Exercise Programs (in general)
• Modified to patient’s particular
abilities.
• Enjoyable for patient
• Social interaction where possible
• Affordable (cost/ space).
• Re-check if give stretches.
Most back injuries are not due to
frank trauma but more likely the results
of trivial events associated with motor
control errors causing inappropriate
muscle activation and aberrant joint
motion.
Jull GA, Richardson CA. Motor control problems in
patients with spinal pain: a new direction for therapeutic
exercise. JMPT 2000;23:115.
In general, supervised training
has been shown to be far superior
to non-supervised efforts: patients
achieve better results when they
are under the direct guidance of
a trainer.
Reilly K et al. Differences between a supervised and
independent strength and conditioning program with chronic
low back symptoms. J Occup Med 1999;31:540-550.
Klaber Moffett program
Patients up to age 60 with chronic LBP
8 1-hour evening classes over 4 weeks
consisting of stretching, low-impact
aerobics, and strengthening exercises.
Improvements in disability, coping-withlife skills and lost work time.
Klaber Moffet J et al. Randomized controlled trials of exercise for LBP:
Clinical outcomes, costs and preferences. BMJ 1999;319:270-83.
Other rehab programs documented in
well-conducted clinical research trials
have successfully managed older patients,
addressing areas of flexibility, strength,
endurance, coordination, and balance.
Byfield D. Spinal Rehabilitation and stabilization for the
geriatric pain with back pain. In Chiropractic Care of the
Older Patient (BJ Gleberzon ed). BH. First Printing, 2001
Cornerstone of Low Back rehab is
extensor muscle endurance and motor
control.
Principles of program design:
1. Address functional loss
2. Establish training objectives
3. Reach sufficient intensity, dosage and duration.
Lateral flexors, particularly QL,
are considered to be one of the
most important stabilizers of the
lumbar spine.
Byfield D. Spinal Rehabilitation and stabilization for the
geriatric pain with back pain. In Chiropractic Care of the
Older Patient (BJ Gleberzon ed). BH. First Printing, 2001
McGill Ibid.
5 Main Areas
1. Extensor muscle endurance and
co-contraction
2. Trunk muscle balance
3. Spinal stabilization
4. Balance and coordination
5. Lower limb strength.
Flexor/extensor ration: 1/1.5:1
Cervical Spine Rehab
Cornerstone : strength training.
Although C/S muscles represent only 8% of
total body weight, compared with 65% for
lumbar muscles, cervical muscles are twice
as strong overall.
Postural demands, and balance weight of head
during ADLs
Exercise Programs (in general)
• Modified to patient’s particular
abilities.
• Enjoyable for patient
• Social interaction where possible
• Affordable (cost/ space).
• Re-check if give stretches.
Issues of Jurisprudence
Consent:
PARQ
i. Voluntary
ii. Personal and limited to specific act
iii. Mental capacity
iv. Proof it was obtained
v. Risk/benefit if material risk*
Confidentiality
Record Keeping
Mandatory Reporting
i. Child abuse
ii. Sexual abuse
iii. Ability to operate a car
House Calls
Advantages vs. Disadvantages