Wellness, Health Promotion, and Exercise

Training in Geriatrics

Min H. Huang, PT, PhD, NCS

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

Reading assignments

• Guccione: Ch 24

• Guccione: Ch 5

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

Physical activity resources and publications for health professionals

• www.cdc.gov/physicalactivity/resources/index.html

• www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html

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.

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.

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

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

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

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

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”)

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

Transtheoretical Model

• Processes of Change involve a set of independent variables promoting the transitions between the stages of change

Precontemplation

• No intention to change behavior in the foreseeable future.

• Many individuals in this stage are unaware or under-aware of their problems.

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

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

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.

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

5 steps for a Wellness/ Health Promotion Plan

1. Identify the problem, explain why it is a problem, describe its implications, identify all behaviors that might influence

2. Determine readiness to participate: past hx of compliance, support systems

3. Develop intervention plan with specific goals and realistic time frames

4. Begin the intervention, give support prn

5. Evaluate the person’s success and eliminate risk behaviors

J. Blackwood

Strategies for Health Behavior Change

• Health literacy

• Chronic disease self-management

• Lifestyle redesign

J. Blackwood

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

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

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

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

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

www.easyforyou.info/index.asp

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

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

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

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

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 Rehabil 2004;85:1345-50

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 theexaminer. 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 resistancefor grade 2, and no active resistance for grade 0.

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

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

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

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.

39J. Blackwood

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

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.

ACSM adopted

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

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.

47J. Blackwood

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

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.

Progression of a functional exercise program is obtained by moving from

1. simple movements to more complex movements,

2. normal speed to either quicker or slower movements,

3. stable surfaces to unstable or compliant surfaces,

4. eyes open to eyes closed, and

5. an emphasis on form to an emphasis on intensity and the working over from base of support to working outside the base of support

Types of muscle contractions

• Analyze functional activities to identify the type of muscle contraction needed ―Trunk muscles stabilizers isometric contraction―Gait cycle 60% eccentric contractions

oe.g. dorsiflexors contract eccentrically at heel strike to foot flat, gluteus medius contracts eccentrically during midstance

• Slowing the speed of the movement overloads the activity, e.g. sit down as slow as possible

Eccentric contraction training for gluteus medius to improve gait

• If right gluteus medius is weak

have a patient stand on the right leg while performing a rapid contraction of the left gluteus medius against an elastic band

causes the right gluteus medius to contract both rapidly and eccentrically (similar to the way it is used in gait)

Aerobic/Endurance Training

• Endurance training, which is the best exercise to increase/maintain mitochondrial concentration with aging, has generally resulted in relatively small functional benefits, e.g. in nursing home patients, older adults with Parkinson’s disease

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Calculating Target Heart Rate for older adults

• Traditional formula ―(60% to 80%) × [220 − age]

―May underestimate the heart rate load

• Karvonen method ―Solution is to use a percentage of heart rate

reserve

― [(60% to 80%)×(220− age− resting heart rate)]+ resting heart rate

Stretching

• A 60-second hold is required to achieve a long-term effect in older adults 65+ years

• 4 reps X 60-second hold

• 5 to 7 days a week

• Static stretching is preferred to dynamic stretching to improve muscle length. ―Loss of joint ROM is not just from muscle-tendon

complex and other soft tissue, e.g. joint capsule or ligaments, fascia, and connective tissue.

Measurement of functional ROM: Two items from Senior Fitness Test

Chair sit and reach test

• toolboxes.flexiblelearning.net.au/demosites/series8/805/fit_tb/fit011_1_lr10/fit011_1_lr10_1_5.htm

Back scratch test

• toolboxes.flexiblelearning.net.au/demosites/series8/805/fit_tb/fit011_1_lr10/fit011_1_lr10_1_6.htm

Plyometrics (“Plyos”) exercise

• Use the stretch reflex of the muscle spindle and the elastic energy that is stored in a stretched muscle to enhance an immediate reciprocal contraction in that muscle.

• Usually consists of an eccentric (lengthening) contraction followed by a concentric (shortening) contraction of the same muscles

• The ability to increase the explosiveness (speed & power) of the muscle contraction

• May improve bone formation

Rapidly squat jump (energy is stored in the gastrocnemius as the ankle dorsiflexes and in the quadriceps as the knee extends)

Plyometric exercise jumping onto and off of a step.

Interval training in patients with COPD

• Severe COP―with FEV1 <50%, patients can only sustain 4-5 min of

work (and up to 13 minutes for lower intensities)

• Implementing continuous exercise for patients with advanced COPD may be ineffective

• Frequency: 3-4x/wk, 30 seconds exercise, 30 seconds rest, (or 20 sec/40 sec)

J. Blackwood

Effect of progressive resistive training on balance function in older adults

• 2008 systematic review by Orr et al.

• 29 studies with RCT design

• Various interventions with PRT

• Conclusion: “limited evidence presented in currently published data has not consistently shown that the use of PRT in isolation improves balance in this population”

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Effect of progressive resistive training on balance function in older adults

• Further research should explore optimal resistance training regimens that―Focus on the muscles most pertinent to

balance control

―Best target neuromuscular adaptations that protect against postural challenges

―Elucidate mechanism(s) by which PRT may affect balance control

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Low v. High Intensity PRT exercise in frail elderly (Seynnes et 2004)

• RCT of institutionalized adults (age = 81.5)

• Low: 40%1RM vs. High: 80% 1RM vs. Placebo

• 3 sets 8 reps, 3x/wk for 10wks

• Assessed: knee strength, endurance, 6MWT, chair rising time, stair climbing power

• Results: Supervised HIGH INTENSITY, free weight-based training for frail elders appears to be as safe as lower intensity training but is more effective physiologically and functionally

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Optimal load for increasing muscle power in older adults (deVos 2008)

• 112 older adults (average age = 69)

• 20%, 50%, 80% 1RM

• 2x/wk; 3 sets of 5 exercises ; 8-12 wks

• Fast concentric, slowed eccentric

• Results: A dose-response relationship between training intensity and muscle strength and endurance changes

• Heavy loads: most improvement in strength, power, and endurance J. Blackwood

Muscle Weakness and markers of inflammation

• High serum levels of inflammation: interleukin (IL-6) are strong predictors of disability.

• Chronically elevated levels of IL-6 accelerate muscle catabolism

• 2008 JAGs study:― Older women with high IL-6 serum levels have a

higher risk of developing physical disability and experience a steeper decline in walking ability than those with lower levels

―Parallel decline in muscle strength.J. Blackwood

Exercise & Osteoporosis

• High intensity strength ex provided for post menopausal women 2x/wk for 1yr

• Results: High-intensity strength training exercises are an effective and feasible means to preserve bone density while improving muscle mass, strength, and balance in postmenopausal women.

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