Wellness, Health Promotion, and Exercise Training in Geriatrics

1. Wellness, Health Promotion, and Exercise Training in Geriatrics Min H. Huang, PT, PhD, NCS

2. Learning objectives • Analyze the factors contributing to physical, psychological, and social wellness in older adults • Discuss the role of physical therapists in the promotion of wellness for geriatric practice

3. Reading assignments • Guccione: Ch 24 • Guccione: Ch 5

4. What is Wellness? • WHO: health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” • Wellness is described in the domains of physical, psychological, and social wellbeing. • Optimal aging implies maximizing one's ability to function across physical, psychological, and social domains to one's satisfaction and despite one's medical conditions

6. Physical activity resources and publications for health professionals • www.cdc.gov/physicalactivity/resources/index.html • www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html

7. Physical Activity Guidelines • For older adults 65 years of age or older who are generally fit and have no limiting health conditions • Only 34% of older adults (ages 65 to 74 years) and 17% of older adults (aged 75+ years) exercise regularly.

8. Physical Activity Guidelines • 10 minutes at a time is fine • We know 150 minutes each week sounds like a lot of time, but it's not. That's 2 hours and 30 minutes, about the same amount of time you might spend watching a movie. The good news is that you can spread your activity out during the week, so you don't have to do it all at once. You can even break it up into smaller chunks of time during the day. It's about what works best for you, as long as you're doing physical activity at a moderate or vigorous effort for at least 10 minutes at a time.

9. Psychological wellness • Emotional wellness • Control of stress and effective coping with life situations • High stress levels with poor coping  negative physiological (e.g., CVP, MS), emotional (e.g., depression, anxiety), behavioral (e.g., inability to work, inefficiency) responses

10. Psychological wellness • Cognitive wellness • Skills and self-efficacy (a person's confidence in his or her ability to achieve a goal) • Interest in engaging intellectually in the world • Spiritual health • Values, morals, and ethics that guide an individual's search for a state of harmony and inner balance

11. Mental Health Issues that can affect Wellness • Depression • Risk factors: family hx, personal hx, hx emotional trauma, chronic illness or pain, widowers, divorcees • Perceived control • greater satisfaction in life if the patient has this • Self-efficacy • perceive self as functional  greater happiness • Problem solving coping strategies • information seeking or behavioral/cognitive actions are most effective J. Blackwood

12. Social wellness • Social wellness is the ability • to develop and maintain healthy relationships with others • to feel connected to a community or group • to interact well with other people • to have a support structure to call on during difficult times • Social supports significantly influence the ability to cope with life's stressors

13. Five major factors in the construct of social wellness • Social integration (“I feel close to other people in my community”) • Social contribution (“My daily activities are worthwhile to my community”) • Social coherence (“I can make sense of what's going on in the world”) • Social actualization (“Society is improving for people like me”) • Social acceptance (“People care about the social issues that are important to me”)

14. Health Behavior Change • For interventions to be effective, behavior must be altered • Transtheoretical Model: a continuum of motivational readiness leading to change of a problem behavior • Precontemplation • Contemplation • Preparation • Action • Maintenance J. Blackwood

15. Transtheoretical Model • Processes of Change involve a set of independent variables promoting the transitions between the stages of change

16. Precontemplation • No intention to change behavior in the foreseeable future. • Many individuals in this stage are unaware or under-aware of their problems.

17. Contemplation • People are aware that a problem exists • People are seriously thinking about overcoming it but have not yet made a commitment to take action

18. Preparation • Combines intention and behavioral criteria. • Individuals are intending to take action in the next month • Individuals have unsuccessfully taken action in the past year

19. Action • Individuals modify their behavior, experiences, or environment in order to overcome their problems. • Action involves the most overt behavioral changes and requires considerable commitment of time and energy.

20. Maintenance • People work to prevent relapse and consolidate the gains attained during action • For addictive behaviors this stage extends from 6 months to an indeterminate period past the initial action

21. 5 steps for a Wellness/ Health Promotion Plan • Identify the problem, explain why it is a problem, describe its implications, identify all behaviors that might influence • Determine readiness to participate: past hx of compliance, support systems • Develop intervention plan with specific goals and realistic time frames • Begin the intervention, give support prn • Evaluate the person’s success and eliminate risk behaviors J. Blackwood

22. Strategies for Health Behavior Change • Health literacy • Chronic disease self-management • Lifestyle redesign J. Blackwood

23. Chronic Disease Self-Management • Purpose • to enable persons to prevent complications and control/manage their health conditions • Individuals and families • Participate actively in the health care process • Self-monitoring of symptoms or physiological processes • Make informed decisions • Manage the impact of their health on daily life J. Blackwood

24. Designing a Wellness Program • Population based • Address the problems of the population, e.g. sedentary lifestyle, overweight • Programs are implemented outside of traditional health care settings • Mechanisms for funding are different • Personal, government, industry support • Emphasis is on prevention not remediation J. Blackwood

25. Barriers to a wellness program • Starting the activity/changing the behavior • Social intervention • Reward system • Goal setting and monitoring • Decrease financial barriers by promoting an activity that can be done anywhere without lots of equipment J. Blackwood

26. Ethical Issues with Wellness Programs • Many elderly are reluctant to spend their savings on themselves • Belief systems, locus of control and religious preferences support a person’s self esteem • Some risky behaviors are coping behaviors • Cultural norms may interfere with behavioral outcomes • Are values about health practices changing? • cheaper to pay for health promotion than treating the illness. J. Blackwood

27. Screening tool for physical activities and wellness programs - EASY • Six-question online screening tool • Identifies potential health problems that require health care provider clearance before exercising • Provides education about each problem and the value of exercise • Helps older adults choose appropriate exercises that may not first require a physician's approval

28. www.easyforyou.info/index.asp

29. Screening for osteoporosis: PT can ask for • Central DEXA (hip or pelvis) or Peripheral DEXA (heel, finger) (T-score below -2.5 indicates osteoporosis) • Family history of osteoporosis (mother, sisters, grandmother) • Low body mass index • History of vertebral or wrist fractures • Observe presence of kyphosis • Loss of height of >4 cm

30. Measurements of Physical Activity (Box 24-7) • Physical Activity Scale for the Elderly (PASE) • Self-reported occupational, household, and leisure activities during a 1-wk period providing prompts with examples of specific activities • Administer by phone, mail, or personal interview • Focus on activities commonly performed by older adults by giving more weight to these activities instead of sports

31. Measurements of Physical Activity (Box 24-7) • Pedometer • Simple, inexpensive • Generally, 10,000 steps per day is considered to afford a health benefit • Accelerometer • Computerized measures of step count and movement • Applicable for research http://orthocareinnovations.com/pages/stepwatch_tradefaq

32. How do you assess strength in the geriatric client? • MMT • ‘Make test’ • ‘Break test’ • Difficult to differentiate between 4/5 to 5/5 - Ceiling effect • Measurement error with MMT as high as 50% • 5/5 strength does not accurately reflect strength for functional activities • Other ways? • e.g. Holding a standing heel rise on one leg = 3/5

33. Supine hip extension MMT • Easier to perform in the clinic because so many older adults have difficulty lying prone • Distinct difference between the forces elicited at each muscle grade • grade 5, 175.6 N; grade 4, 103.1 N; grade 3, 66.7 N; and grade 2, 19.1 N • NOT validated against the gold standard of hand-held dynamometry in the prone position. Perry et al. Arch Phys Med Rehabil2004;85:1345-50

34. A. Starting position for test. B. Ending position for grade 5 (normal). Pelvis and back elevate as a locked unit while the leg is raised by the examiner. The hip maintains the fully extended, neutral position throughout the test. C. Ending position for grade 4 (good). Hip flexion occurs before pelvis elevates while the examiner raises the leg. D. Ending position for grades 3 (fair) and 2 (poor). Full elevation of the limb to the end of the straight-leg raising range with no elevation of the pelvis. Examiner feels “good” resistance for grade 3, little resistance for grade 2, and no active resistance for grade 0.

35. Measure RM for functional movements • Example: • If the chair is 21 in. high and the person can stand 10 times without using his or her arms  that is the 10 RM • If the person does more or less than 10 repetitions, the surface can be raised or lowered • Apply this principle to other movements • e.g. Bridges, lunges, wall squats, and step ups and step downs

37. Strength • Leg Strength has been found to be the SINGLE most important predictor of institutionalization and more important than physiological markers or disease. • An individual needs a certain level of strength (about 45% of his or her body weight) to rise from a chair • Older adults gain strength the same way that younger people gain strength

38. Conditions associated with muscle weakness • Iron deficiency anemia • Decreased Hgb and Hct • Hypercalcemia • Elevated Ca++ depress nervous system responses and muscle actions become sluggish and weak • Hypokalemia • Weakness progresses over weeks • Hypophosphatemia • Disrupt energy metabolism • Hyponatremia • Hypernatremia J. Blackwood

39. Principles of Specificity & Overload • Specific challenges with aerobic capacity result in endurance-training adaptations • Specific strength training results in strength adaptations. • Overload: challenge the muscle/system more than what is normal stimulus. J. Blackwood

42. Strengthening Exercise Prescription in Geriatrics • 60% 1RM minimal overload or 15 RM necessary for muscle adaptation in untrained individuals • 80% 1 RM X 10 reps is preferred, especially for concerns with pain or joint forces • a gradual increase beginning at 50% of 1RM for an individual who has been sedentary • Strengthening exercise would be the first type of exercise prescribed

43. Remember….. • Slow walking or lifting light weights such as 2 lb ankle weights to stimulate the quadriceps will NOT appreciably improve aerobic capacity or strength in most individuals.

44. ACSM adopted

46. Progression to Power • After an older adult can do 2 sets with good form and no pain • Incorporate training to increase power • Move quickly through concentric phase followed by a slow and controlled lowering of the load • Initial loads at 20% 1RM and progress towards 60% 1RM • Power found to be a strong predictor of loss of function, e.g. climbing stairs J. Blackwood

47. Guidelines for ex RX with CV • Consider: intensity, mode, frequency, duration, and progression • Monitor: HR, BP, SaO2, ECG, BORG scale (RPE), estimated VO2 max, MET levels. J. Blackwood

49. Injuries? • Many authors demonstrate safety of high intensity exercises • Requires 1:1 supervision • Monitoring of vitals • There are no absolute contraindications for strengthening exercises • Care must be taken to have the person use proper form and avoid holding his or her breath

50. Specificity of training • Specificity leads to the concepts of functional strengthening, i.e. strengthening a movement rather than a muscle. • Simply walking may not improve the patient's walking above a critical threshold if there is no overload or challenge present. • Overload the patient's gait • Increase speed of walking, ambulate on uneven surfaces, head turns while walking, carry a large object, obstacle course.