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The science of rehabilitating elderly patients that face weakness, imbalance, or both is improving and must continue to advance in both proficiency and popularity. The cost of functional dependence, due to caregiving expenses, or the medical care after a fall – is saddling our economy and Medicare to a greater extent each year.1
Many medical professionals have the opportunity to influence the quality of life in our aging population, whether it be directly in exercise, rehabilitation, pain control or indirectly in the referral to those that can. To this end, this article will review the true science and practical capacities to improve strength, balance and endurance after 65, detail the financial attributes associated with falls, debunk the myths of aging, and suggest avenues for meaningful change.
The Myths of Aging – “Too old to improve?”
Myths of aging are both pervasive and insidious. Many healthcare professionals and more laypersons continue to hold the opinion that, “falling is a part of aging” and that , “an individual over 80 cannot gain strength”. When elderly patients believe these to be true, it can be even more subversive. The facts are, balance rehabilitation in the elderly and strengthening for those that have lost conditioning – are effective.2-5
The financial and societal impact
“Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall.”6
The cost of medical care after a fall is over 13,000 on average.7 If a hospitalization is required, over $35,000 per fall. If you were concerned about medical costs expanding in the U.S. – you may consider prioritizing falls screening and prevention, should you consider product of 11 seconds x $13,000? By 2020, the annual cost for healthcare after a fall (including emergency, surgical, hospitalization and rehabilitative) will exceed 43.8 billion dollars. 8 To improve the application of falls prevention, the CDC developed a sophisticated falls screening tool, known as STEADI (Stopping Elderly Accident and Death Injuries).9
A change in the reimbursement landscape…
The financial incentives of preventing a fall, as detailed above, have now expanded into financial DISINCENTIVES (penalties) of readmission due to a fall. Beginning in October 2008 Medicare stopped reimbursing hospitals for certain injuries if they were the result of a fall that occurred during hospitalization. Earlier this year, the test markets for Medicare’s Commission on Joint Rehabilitation (CJR) program started, which essentially places a financial cap for the cost of post-surgical care.10 Clearly, a fall prevented means dollars saved – affecting the entire continuum of care.
Reimbursement changes have not, and will not, stop there. Estimates are that by 2019 the MACRA (Medicare and CHIP Reauthorization Act). APTA Director of Regulatory Affairs Roshunda Drummond–Dye says that members of the profession can be assured that it’s only a matter of time. “It’s clear that CMS hasn’t forgotten physical therapy,” she said. “MACRA is the first tangible step toward mandating a payment system that bases reimbursement on quality of care and outcomes…”11. Therapists should hold themselves accountable and take pride in standardized, objective measures and data collection regarding fall prevention and strengthening in the elderly. If what you are doing is not working – change it! If what you are doing IS working – measure, refine, disseminate, and continue to apply “it”.
Importance of and evidence for intensity in training
People over 65, even over 85 can and should improve – if the science is applied with the appropriate dosage. No matter whether we are speaking of pre-habilitation (before joint replacement) or falls prevention (when STEADI indicates the need); “dosage matters”. Frequency, intensity, time and type (FITT)12 must be considered in regard to strength, endurance and balance training. It takes hard work to improve in any of these capacities, as Bette Davis said, “Old age is no place for sissies.” Many times, therapists’ under-dose or practice without sufficient intensity, allowing their own perceptions to limit the (intensity) of care, before the elderly patient’s body does.
Strength training
Readers are directed to excellent literature on the science of strength training in the elderly. 2-5 While it is an injustice to attempt to summarize the research here, a few points of application should be highlighted:
Strengthening does not have to be equipment-based. Consider 10 repetitions of sitting to standing with some intensity, three times per week. This can be adjusted to include upper extremity support, at different heights, with controlled eccentric loading, etc.
With bed rest after medical complications, pneumonia, fall, or surgery – the ill-effects of disuse atrophy are more prevalent in the elderly. However, there appears to be some confusion when it comes to seeing a difference between “getting stronger with aging” and “recovering strength in old age”. There is no disputing that the aging process includes sarcopenia, decreased force production and loss of both type I and type II muscle fibers. So,“Do we lose strength as we age?” Yes, we do. However, “Can seniors regain strength after inactivity or medical complication?” Yes. BOTH are true. Rehabilitation plays a key role after periods of deconditioning, or in response to reversing the effects of disuse. We need to recognize, apply, and educate on these facts.
Endurance training: Muscular and cardiovascular
As with strength training, I will not attempt a meta-analysis on endurance training in the elderly here. Some of these cited articles have defined the science of endurance “dosage”.2 A summary includes:
Again, as with the confusion about gaining strength with aging, we debunk the myths and clarify, “Do we lose aerobic capacity as we age?” Yes, we do, as a function of heart rate, cardiac output and VO2 max. However, “Can seniors regain endurance” after periods of deconditioning, or in response to reversing the effects of inactivity – again, yes.
Balance training
Who is at risk for falls? The science of balance rehabilitation is becoming more sophisticated each month, through research on valid testing/screening, through technology for examination, and technological advances in treatment. As noted above, the Centers for Disease Control (CDC) released a comprehensive approach to falls screening, called STEADI in 2012. Using fall history, performance on a 3-item battery and other risk factor calculations, this is a quick, reliable, and user-friendly tool that should be a staple of fall prevention for all primary care practitioners.
Technological advances in balance testing help therapists to more accurately define the parameters of a balance problem, and more precisely rehabilitate the same. Recent advances include wireless gyroscopes capable of detecting three-dimensional motion for sway, coordination and symmetry; as well as forceplate-enabled treadmills, for motion and ground reaction force analysis. 14
We know that balance activities must be processed regularly to be effective. Some citations report 50 hours of practice15, others report 1-7x/week5. We do have more to learn about the science of dosage both for frequency AND difficulty. A recent study from the 2014 meeting of the Society of General Internal Medicine revealed the effectiveness of four recommendations (and their respective utilization) to prevent falls in the elderly: physical therapy (81%), exercise (71%), Vitamin D (46%), and opthamology (46%). The intervention tracked 32 subjects and found that of the 28/32 patients who fell prior to the FC visit, only 12/28 fell after the FC visit. The average number of falls in the 6 months prior to the appointment was 2.97 versus 0.28 in the 6 months following the appointment.16
What we do know, is that with the aging process, even community-dwelling elderly experience a reduction in sensory and motor conduction velocity. This leads to increased reaction times. When combined with sarcopenia – the result is reduced power (force applied within a constrained time) for a quick and effective balance reaction. Balance, therefore, cannot be trained in isolation from strength and endurance.
Additionally, the battle against the epidemic of falls has led to policy and practice changes, bringing us community-based fall-prevention programs that are both affordable and accessible. The most well-known and widely practiced of these—OTAGO, Tai Chi, Stepping-On, and a Matter of Balance—are endorsed by the NIH and CDC fall-prevention action committee.1, 17, 18 We are coming to believe that many falls can be prevented through increased exercise and regular activity, as the OTAGO exercise program has shown.17
Go forth and prevent!
No matter if you are in a position to directly provide rehabilitative or exercise interventions, or make the necessary referral to those qualified to do so. Know that it is not only possible to improve – it is evidence-based that we can effect a positive change. If we continue to perpetrate the message that failing function is a part of aging that we cannot impact, we create a self-fulfilling prophecy for all of our community-dwelling elderly. We can do better to help those that have lost strength, endurance, or balance. We must commit to them, or they have no reason to commit to the work that it will take to improve. Be ready to effect a change – to your practice and your patients – before National Falls Prevention Awareness Day (the first day of Fall, every year) on September 24th, 2016. Perhaps, it is time to change the phrase and meaning of, “Old habits die hard”, to, “Those with good habits, live long.”.
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