Geriatric Rehabilitation 2018

Geriatric
Rehabilitation
DAVID X. CIFU, MD HENRY L. LEW, MD
Associate Dean of Innovation and System Tenured Professor and Chair
Integration University of Hawai’i School of Medicine
Virginia Commonwealth University Department of Communication Sciences
School of Medicine and Disorders
Richmond, VA, United States Honolulu, HI, United States
Herman J. Flax, MD Professor and Chair Adjunct Professor
Department of PM&R Virginia Commonwealth University
Virginia Commonwealth University School of Medicine
School of Medicine Department of Physical Medicine and
Richmond, VA, United States Rehabilitation
Senior TBI Specialist Richmond, VA, United States
Principal Investigator, Chronic Effects of
Neurotrauma Consortium MOOYEON OH-PARK, MD
U.S. Department of Veterans Affairs
Director of Geriatric Rehabilitation
Richmond, VA, United States
Kessler Institute for Rehabilitation
Director, Sports Sciences
Research Scientist
NHL Florida Panthers
Kessler Foundation
West Orange, NJ, United States
Professor
Vice Chair of Education
Department of Physical Medicine and
Rehabilitation
Rutgers New Jersey Medical School
Newark, NJ, United States
3251 Riverport Lane
St. Louis, Missouri 63043
GERIATRIC REHABILITATION ISBN: 978-0-323-54454-2
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Foreword
Currently, the total number of people aged 60 years and as cognitive impairment and psychiatric disorders. It is
older in the world is 900 million strong, and by 2050, our hope that this handbook will serve as a practical
it is expected to exceed 2 billion. With improvements in resource for rehabilitation specialists, geriatricians, and
public health and medical care, people are expected to other healthcare professionals who care for the elderly
live longer lives, but it does not mean that the geriat- population. We applaud the efforts of the editors (Dr.
ric population will automatically maintain functional David Cifu, Dr. Henry Lew, and Dr. Mooyeon Oh-Park)
independence and high quality of life. It is essential and authors for publication of this handbook.
that health professionals work together to achieve this
goal. Although geriatric rehabilitation is an important
topic, there has not been a single, easy-to-read clinical Jerris Hedges, MD, MS
handbook to guide practitioners in the care of their Professor and Dean, John A. Burns School
elderly patients. This Geriatric Rehabilitation Handbook of Medicine, University of Hawaii at Manoa
provides the fundamental knowledge that is required
to design and implement a practical rehabilitation Kamal Masaki, MD
program for elderly individuals over a wide functional Professor and Chair, Department
range. Exemplary chapters discuss the most common of Geriatric Medicine
issues in the elderly population, such as nutritional and John A. Burns School of Medicine,
swallowing problems, hearing impairment, osteoporo- University of Hawaii at Manoa
sis, sarcopenia, polypharmacy, deconditioning, as well
ix
List of Contributors
Editors Mooyeon Oh-Park, MD

Director of Geriatric Rehabilitation
David X. Cifu, MD Kessler Institute for Rehabilitation
Associate Dean of Innovation and System Integration Research Scientist
Virginia Commonwealth University School of Kessler Foundation
Medicine West Orange, NJ, United States
Richmond, VA, United States Professor
Herman J. Flax, MD Professor and Chair Vice Chair of Education
Department of PM&R Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Rutgers New Jersey Medical School
Medicine Newark, NJ, United States
Senior TBI Specialist
Principal Investigator, Chronic Effects of Neurotrauma Authors
Consortium
U.S. Department of Veterans Affairs Venu Akuthota, MD
Richmond, VA, United States Professor and Chair
Director, Sports Sciences Department of Physical Medicine and Rehabilitation
NHL Florida Panthers School of Medicine, University of Colorado
Richmond, VA, United States Aurora, CO, United States
Blessen C. Eapen, MD Matthew N. Bartels, MD, MPH

Section Chief, Polytrauma Rehabilitation Center Professor and Chairman of the Physical Medicine and
TBI/Polytrauma Fellowship Program Director Rehabilitation
Site Director, Defense and Veterans Brain Injury Albert Einstein College of Medicine
Center (DVBIC) Bronx, NY, United States
South Texas Veterans Health Care System Chairman
San Antonio, TX, United States Department of Rehabilitation Medicine
Associate Professor Montefiore Medical Center
Department of Rehabilitation Medicine Bronx, NY, United States
UT Health San Antonio
San Antonio, TX, United States Christina L. Bell, MD, PhD
Hawaii Permanente Medical Group
Henry L. Lew, MD Clinical Associate Professor
Tenured Professor and Chair Department of Geriatric Medicine
University of Hawai’i School of Medicine University of Hawaii John A. Burns School of
Department of Communication Sciences and Medicine
Disorders Honolulu, HI, United States
Honolulu, HI, United States
Adjunct Professor Jaewon Beom, MD, PhD
Virginia Commonwealth University School of Assistant Professor
Medicine Department of Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation Chung-Ang University Hospital
Richmond, VA, United States Seoul, South Korea
v
vi LIST OF CONTRIBUTORS
Shih-Ching Chen, MD, PhD Dennis D.J. Kim, MD

Professor Associate Professor,
Dean Department of Rehabilitation Medicine
College of Medicine Montefiore Medical Center
Taipei Medical University Albert Einstein College of Medicine
Taipei, Taiwan, Republic of China Bronx, NY, United States
Michelle Didesch, MD Jongmin Lee, MD, PhD

Traumatic Brain Injury Service Professor
Department of Physical Medicine and Rehabilitation Chair
University of Pittsburgh Medical Center Department of Rehabilitation of Medicine
Pittsburgh, PA, United States Konkuk University School of Medicine and Konkuk
University Medical Center
Walter R. Frontera, MD, PhD Seoul, Republic of Korea
Professor
Department of Physical Medicine, Rehabilitation, and Sang Y. Lee, MD, PhD
Sports Medicine Assistant Professor
Department of Physiology Department of Rehabilitation Medicine
University of Puerto Rico School of Medicine Seoul National University Boramae Medical Center
San Juan, PR, United States Seoul, Republic of Korea
Shari Goo-Yoshino, MS, CCC-SLP Sewon Lee, MD

Department of Communication Sciences and Associate Professor
Disorders Department of Rehabilitation Medicine
John A. Burns School of MedicineUniversity of Montefiore Medical Center
Hawai’i at Mānoa Albert Einstein College of Medicine
Honolulu, HI, United States Bronx, NY, United States
Kaiser Permanente Moanalua Medical Center
Honolulu, HI, United States Carol Li, MD
Department of Rehabilitation Medicine
Der-Sheng Han, MD, PhD University of Texas Health Science Center San Antonio
Medical Director San Antonio, TX, United States
National Taiwan University Hospital Beihu Branch,
Taipei, Taiwan, Republic of China Jae-Young Lim, MD, PhD
Assistant Professor Professor and Chair
College of Medicine Department of Rehabilitation Medicine
National Taiwan University Seoul National University College of Medicine
Taipei, Taiwan, Republic of China Seoul National University Bundang Hospital
Seongnam-si, Republic of Korea
Eric K. Holder, MD
Hospital for Special Surgery Adele Meron, MD
Department of Physiatry Physical Medicine and Rehabilitation
New York, NY, United States University of Colorado
Aurora, CO, United States
Carlos A. Jaramillo, MD, PhD
Staff Physician/Clinical Investigator William Micheo, MD
Polytrauma Rehabilitation Center Professor and Chair
South Texas Veterans Health Care System Sports Medicine Fellowship Director
San Antonio, TX, United States Physical Medicine, Rehabilitation and Sports
Assistant Professor Medicine Department
UT Health San Antonio University of Puerto Rico, School of Medicine
San Antonio, TX, United States San Juan, PR, United States
LIST OF CONTRIBUTORS vii
Peter J. Moley, MD Christopher K. Rogers, MPH

Assistant Attending Physiatrist, Research Associate
Hospital for Special Surgery Division of Geriatrics
Assistant Professor of Clinical Rehabilitation Medicine Hackensack University Medical Center
Weill Cornell Medical College Hackensack Meridian Health
New York, NY, United States Hackensack, NJ, United States
Yeonsil Moon, MD, PhD Luis A. Sánchez, MD

Clinical Assistant Professor Sports Medicine Fellow
Department of Neurology Physical Medicine, Rehabilitation and Sports
Konkuk University Medical Center Medicine Department
Seoul, Republic of Korea University of Puerto Rico, School of Medicine
San Juan, PR, United States
Jean Oh, PhD
Systems Scientist Chiemi Tanaka, PhD CCC-A
Robotics Institute Audiology Specialist
Carnegie Mellon University Audmet KK (Oticon Japan, DiaTec Company)
Pittsburgh, PA, United States Kawasaki-shi, Kanagawa, Japan
Adjunct Assistant Professor
Manisha S. Parulekar, MD, FACP, CMD Department of Communication Sciences & Disorders
Program Director University of Hawai’i at Mānoa, John A. Burns School
Geriatrics fellowship of Medicine
Assistant Professor Honolulu, HI, United States
Rutgers New Jersey Medical School
West Orange, NJ, United States Lisa D. Taniguchi, AuD
Associate Professor Department of Communication Sciences and
St. George’s Medical School, St. George’s, Grenada Disorders
Interim Chief John A. Burns School of Medicine
Division of Geriatrics University of Hawai’i at Mānoa
Hackensack University Medical Center Honolulu, HI, United States
Hackensack Meridian Health
Hackensack, NJ, United States Maria Vanushkina, MD
Department of Physical Medicine and Rehabilitation
Kanakadurga R. Poduri, MD, FAAPMR University of Rochester School of Medicine and
Professor and Chair of PM&R and Professor of Dentistry and Medical Center
Neurology Rochester, NY, United States
Department of Physical Medicine and Rehabilitation
University of Rochester School of Medicine and
Dentistry and Medical Center
Rochester, NY, United States
David Z. Prince, MD
Assistant Professor
Albert Einstein College of Medicine
Bronx, NY, United States
Director
Cardiopulmonary Rehabilitation
Montefiore Medical Center
Bronx, NY, United States
Preface
The world’s older population continues to grow at an medicine and rehabilitation interventions that can be
unprecedented rate. Longitudinal studies have revealed applied to both bolster the functional reserve of elders
the presence of multiple risk factors for disability, includ- and reverse many of the acute and even chronic disabil-
ing behavioral and individual characteristics (e.g., low ities seen. The geriatric population is diverse in its level
physical activity, alcohol consumption, increased age, of functional independence, ranging from elite athletes
reduced social contacts) and chronic conditions (e.g., to those totally dependent. The wide range of topics and
cardiovascular disease, osteoarthritis, cancer, diabetes conditions covered in this Geriatric Rehabilitation issue
mellitus). Although this is hardly surprising, what is provide the reader with the age-specific impacts com-
interesting and particularly pertinent to this Geriatric monly experienced, scientific background supporting
Rehabilitation handbook is that a substantial propor- the management strategies, and practical approaches
tion of individuals who are disabled report improve- to the assessments and interventions for this growing
ment on subsequent assessments. In effect, disability is a population. The authors have identified the key topics,
product of the disease or diseases, a sedentary lifestyle, delivered the information in a user-friendly style, and
and physiologic declines from normal aging or patho- highlighted the vital rehabilitation principles necessary
logic processes that are not specific diseases but instead to affect older adults with disability. In the fast-paced
result from factors such as inflammation or endocrine 21st century, awash in high technology and precision
changes. As these predisposing conditions change, they medicine, the core principles of rehabilitation medi-
have an impact on the initiation of disability and on cine offer proven treatments that are universal in their
changes in the status of already established disability. efficacy and that can provide durable and meaningful
These findings have especially significant implications outcomes. We hope that the readers of this important
on the role of rehabilitation efforts for older adults; work will find it an easy-to-use and practical resource
concerted efforts to optimize baseline and postdisabil- that will augment their skills and enable their patients.
ity physical, cognitive, and behavioral functioning can Many thanks to all who contributed and supported the
effectively “reverse the effects of time.” Disability and development and execution of this work.
aging are not inexorably linked. Although the impact
of degenerative and inflammatory processes on the David X. Cifu, MD
body’s systems will often be expressed in physical and Henry L. Lew, MD, PhD
cognitive limitations, there are a wide range of physical Mooyeon Oh-Park, MD
xi
CHAPTER 1
Epidemiology of Aging, Disability,

Frailty and Overall Role of Physiatry
KANAKADURGA R. PODURI, MD, FAAPMR • MARIA VANUSHKINA, MD
INTRODUCTION next 50 years, the trends associated with aging are

There is no agreement in the literature, practice, or largely predictable and amenable to interventions.
policymaking for considering an individual to be The future framework for global action should focus
truly “old.” Although not the most clinically relevant, on strengthening and preparing older adults to thrive
chronologic age is the commonly accepted criterion for in a turbulent and evolving environment.4 This chap-
categorization, with most Western societies arbitrarily ter provides an overview of aging demographics and
choosing 65 years as the cutoff to consider a person physiology, reviews emerging concepts and terminol-
as a member of the geriatric population.1 Terms fre- ogy in geriatric medical practice, and addresses current
quently used to describe this population are young practice models designed to compress morbidity and
old (60+), old old (75+), and oldest old (85+).1 When mortality in this complex population.␣
demographers mention “aging,” they are referring to
the increase in the proportion of the population in the
older age ranges.2 When life sciences experts discuss EPIDEMIOLOGY OF AGING:
“aging,” they are referring to the progressive changes DEMOGRAPHICS AND WHAT IS “NORMAL”
in functional properties at the cellular and tissue level Demographics
leading to decreased adaptability to stressors and an For the first time in recorded history, most individu-
overall vulnerability to morbidity and mortality.3 These als are expected to live beyond 60 years. Accordingly, all
changes are not linear or consistent, are sometimes current research predicts a steep increase in the aging
reversible, and correlate only loosely with chronologic population over the next 4 decades. In some countries
age. Some mechanisms of aging are random, whereas such as Brazil or Myanmar, a child born in 2015 can
others are strongly associated with biological, social, expect to live 20 years longer than one born 50 years
environmental, and behavioral factors intrinsic to the earlier.4 When combined with globally decreasing fer-
individual.4 tility trends, the increasing life expectancy is expected to
As we age our health is the predominant charac- have dramatic impacts on the structure of global popu-
teristic that affects the available opportunities and the lations.4 Worldwide, the 65+ years sector is projected to
ability to engage in meaningful activities. Individu- grow from 524 to 1.5 billion between 2010 and 2050.5
als with good health in their later years have very few In the United States the population of adults over the
limitations. However, if the extra years in later life are age of 65 years is expected to double between 2012 and
dominated by consequences of deteriorating physical 2050, reaching a projected maximum of 83.7 million.
and mental capacities, the implications for both the By 2030, more than 20.3% of US residents are pro-
society and the older individual are more detrimental. jected to be over 65 years old, compared with 13.7% in
Although it is often assumed that the trend of increased 2010 and 9.8% in 1970.2 This population is expected
longevity is accompanied by an extended period of to become more racially and ethnically diverse with a
good health and preserved function, the evidence that shift toward more equal gender distribution during this
older people today are “healthier” than their parents time.2 This accelerated growth is attributed to improve-
is not encouraging, especially for the American popu- ments in life expectancy over the past century.2,5 In
lation. Both demographic and biological “aging” have the United States, life expectancy at age 65 years was
tremendous implications for local and global health 15.2 years in 1972 and rose to 19.1 years in 2010.2 For
and healthcare, public policy, and economy.4 Unlike those turning 85 years in 1972, the average length of
most societal level changes that may occur over the life was 5.5 years, which increased to 6.5 years in 2010.2
1
2 Geriatric Rehabilitation
This oldest old population is expected to grow by 351% Chronic diseases are among the most common and
by 2050.5 Similar trends have been observed in almost costly of all the health problems but also the most
all developed nations.2,5␣ preventable. Chronic disease prevention, to be most
effective, must occur in multiple sectors and across
Changes Associated With “Normal” Aging individuals’ entire life spans. Prevention encompasses
Aging affects the physiologic function of multiple organ health promotion activities that encourage healthy
systems as summarized in Table 1.1.␣ living. Current research consistently associates many
adult-onset health problems and later-onset disability
to early life, or even in utero, socioeconomic condi-
CHRONIC CONDITIONS IN OLDER ADULTS tions, and associated health complications. Ensuring
Chronic Conditions at a Glance adequate living conditions, healthcare access, and
The life expectancy improvements discussed earlier are health literacy in childhood will reduce the future
reflections of multiple public health efforts in the 20th health burden of older populations.5 Studies repeat-
century, such as advances in living conditions, sanita- edly demonstrate that the onset of multimorbidity and
tion, and introduction of vaccination protocols. In its associated complications occurred between 10 and
fact, the global burden of morbidity and mortality has 15 years earlier in people living in the most deprived
shifted from infectious illnesses to chronic noncommu- areas compared with the most affluent, and socioeco-
nicable conditions, such as heart disease, stroke, diabe- nomic deprivation is particularly associated with multi-
tes, cancer, arthritis, obesity, and respiratory disease.2,5,6 morbidity.14 It is noteworthy that the scope and severity
In 2008 chronic conditions accounted for an estimated of the chronic disease problem in the United States has
86% of the burden of disease in developed countries.5 not escaped the attention of the public. More than two-
The prevalence of chronic conditions will continue to thirds of the adults believe that the healthcare system
increase in the future decades. In the United States, should place more emphasis on chronic disease pre-
almost half the general population is projected to have ventive care, and more than eighty percent Americans
at least one chronic condition by 2020.7 It has been favor public funding for such prevention programs.15␣
estimated that 20% of the Medicare beneficiaries have
five or more chronic conditions.8 It is important to note
that chronic conditions affect all age groups and the DISABILITY IN OLDER ADULTS
majority of persons with chronic conditions are not Comorbidity
disabled or “old.”9 The term “comorbidity” was introduced in 1970 by
Only about one-fourth of individuals with chronic Feinstein and refers to the combination of diseases
conditions have one or more daily activity limitations.10 beyond an index condition that may affect prognosis.16
Such individuals often require family or professional Many current inpatient and outpatient clinical practice
caregiver presence in the house. Caregivers are currently models continue to focus on an index condition and
present in only one of five US households.11 Most care- address comorbid conditions only as part of the risk
giving in United States is informal, provided by women factor modification for the index problem. “Comorbid-
(usually wives or daughters) on a daily basis, averaging ity” is also an important determinant in the formula
between 4 and 8 hours and lasting from weeks to mul- used for the rehabilitation prospective payment system
tiple decades. This type of informal care accounts for implemented in 2002 by the Centers for Medicare and
about 75% of all the care provided to the older popu- Medicaid services. It further defines and characterizes
lation in the United States.1 Access to and quantity of the burden of care.␣
social supports is positively correlated with happiness,
life satisfaction, physical health, lower mortality, and Multimorbidity
rates of institutionalization in the geriatric popula- The term “multimorbidity” was introduced in 2002 by
tion.12,13 Unfortunately, not everyone has equal access Bastra and colleagues and denotes the complex inter-
to social supports. Social dependency is more common play between multiple conditions in an individual.6,17
in women who are more likely to be widowed than age- This concept is slowly shifting the clinical practice
matched men. Older adult men are more likely to have models for providers caring for these individuals (see
the support of a spouse who is typically younger and in section on complex care teams for further discussion).
better health.1 The toll on caregivers’ health and well- Multimorbidity is most often defined as the coexis-
being is tremendous and accounts for significant costs tence of at least three chronic conditions over a span
to families, employers, and communities.11 of at least 1 year.6,18 Although the absolute number of
CHAPTER 1 Epidemiology of Aging, Disability, Frailty and Overall Role of Physiatry 3
TABLE 1.1
Physiologic Changes of Aging
Body System Change Consequences
Nervous ↓ Number of neurons ↓ Muscle innervation
↓ Action potential speed ↓ Fine motor control
↓ Axon/dendrite branches
Muscle Fibers shrink Tissue atrophies
↓ Type II (fast twitch) fibers ↓ Tone and contractility
↑ Lipofuscin and fat deposits ↓ Strength
Skin ↓ Thickness Loss of elasticity
↑ Collagen cross-links
Skeletal ↓ Bone density Movement slows and may become limited
Joints become stiffer, less flexible
Cardiovascular
Heart ↑ Left ventricular wall thickness Stressed heart is less able to respond
↑ Lipofuscin and fat deposits
Vasculature ↑ Stiffness
↓ Responsiveness to agents
Pulmonary ↓ Elastin fibers ↓ Effort-dependent and effort-independent
respiration (quiet and forced breathing)
↑ Collagen cross-links ↓ Exercise tolerance and pulmonary reserve
↓ Elastic recoil of the lung
↑ Residual volume
↓ Vital capacity, forced expiratory volume,
and forced vital capacity
Eyes ↑ Lipid infiltrates/deposits ↓ Transparency of the cornea
↑ Thickening of the lens Difficulty in focusing on near objects
↓ Pupil diameter ↓ Accommodation and dark adaptation
Ears ↑ Thickening of tympanic membrane ↑ Conductive deafness (low-frequency range)
↓ Elasticity and efficiency of ossicular ↑ Sensorineural hearing loss (high-frequency
articulation sounds)
↑ Organ atrophy
↓ Cochlear neurons
↓ Number of neurons in the utricle, saccule, ↓ Detection of gravity, changes in speed, and
and ampullae rotation
↓ Size and number of otoliths
Digestive ↑ Dysphagia
↑ Achlorhydria
Altered intestinal absorption ↓ Iron absorption
↑ Lipofuscin and fat deposition in pancreas ↓ B12 and calcium absorption
↑ Mucosal cell atrophy ↑ Incidence of diverticula, transit time, and
constipation
Urinary ↓ Kidney size, weight, and number of functional ↓ Ability to resorb glucose
glomeruli
↓ Number and length of functional renal tubules ↓ Concentrating ability of kidney
↓ Glomerular filtration rate
↓ Renal blood flow
Continued
TABLE 1.1
Physiologic Changes of Aging—cont’d
Body System Change Consequences
Immune ↓ Primary and secondary response ↓ Immune functioning
↑ Autoimmune antibodies
↓ T-cell function, fewer naive and more memory ↓ Response to new pathogens
T cells
Atrophy of thymus ↓ T lymphocytes, natural killer cells, cytokines
needed for growth and maturation of B cells
Endocrine ↑ Atrophy of certain glands (e.g., pituitary, Changes in target organ response, organ
thyroid, thymus) system homeostasis, response to stress,
functional capacity
↓ Growth hormone, dehydroepiandrosterone,
testosterone, estrogen
↑ Parathyroid hormone, atrial natriuretic peptide,
norepinephrine, baseline cortisol, erythropoietin
From Fedarko NS, McNabney MK. Biology. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatrics Review Syllabus: A Core Curriculum in
Geriatric Medicine. 9th ed. New York: American Geriatrics Society; 2016; with permission.
people with multimorbidity is higher for the below GERIATRIC SYNDROMES

65-year age ranges, the prevalence of multimorbid- One of the main challenges to traditional clinical
ity increases substantially with age.6,14 Coexistence of care and research models for the geriatric popula-
multiple chronic conditions is becoming the “normal” tion is the presence of multiple chronic conditions
in geriatric patients rather than the exception.6,14,18 The and geriatric syndromes that cross organ systems and
reported prevalence of multimorbidity in older persons discipline-based boundaries.14,18,23 The term “geri-
ranges from 55% to 98%.6,9,14,19 Chronic neuropsy- atric syndrome” is used to capture a clinical condi-
chiatric disorders, such as mental health disorders or tion affecting the geriatric population that does not
dementia, and lower socioeconomic status are strongly fit into a discrete disease category.23 “Geriatric syn-
associated with increased physical morbidities14 and dromes” are a valuable theoretical framework clini-
long-term care dependency.5,18 Chronic diseases can cally as well as an educational tool for patients and
exacerbate symptoms of depression, and depressive medical providers alike.24 The term “syndrome” may
disorders can themselves lead to chronic diseases. The be a misnomer.23,24 A syndrome is classically defined
correlation between multimorbidity and mortality as the “aggregate of symptoms and signs associated
is still a controversial topic in the literature. There is with any morbid process, and it constitutes together
strong evidence to suggest that multimorbid individu- the picture of the disease.”25 Geriatric syndromes are
als die earlier,18,20,21 are 99 times more likely to be more accurately conceptualized as “multifactorial
admitted to the hospital for ambulatory care sensitive health conditions that occur when the accumulated
conditions,19 have higher rates of functional decline effects of impairments in multiple systems render an
and disability,6,18 are more likely to be dependent for older person vulnerable to situation challenges.”26
long-term care at an younger age,18 report poorer qual- This definition emphasizes the nonlinear contribu-
ity of life,6,18,22 and have higher healthcare costs.6,9,18,19 tion of multiple etiologic factors and their varying
Persons with chronic conditions have greater health degrees of synergism to the observable characteristics
needs at any age and, not surprisingly, their costs are of a manifestation23 (Fig. 1.1). Many of the most com-
disproportionately higher.9 The direct healthcare costs mon conditions treated in geriatric patients across all
of US adults with more than one chronic condition is the care settings are classified as geriatric syndromes,
estimated to account for greater than three-fourth of including delirium, dizziness, syncope, urinary incon-
total annual healthcare expenditures, with 1990 costs tinence, pressure ulcers, falls, and frailty.23 There are
exceeding $659 billion per year.9 The per capita Medi- four shared risk factors consistently identified across
care expenditures are more than 66 times higher for all the geriatric syndromes suggesting a shared patho-
beneficiaries with multiple chronic conditions com- physiologic mechanism: older age, functional impair-
pared with their “healthy” counterparts.19␣ ment, cognitive impairment, and impaired mobility.
Linear Concentric Interactive Concentric

Risk Risk Risk Factor
Factor Factor Synergism Risk
B B Factor
Risk Risk Risk C
Risk Factor Factor Factor
Factor
A C A
Targeted
Early Disease Interventions
Advanced Disease
Risk Risk
Factor Factor
D D
Clinical Clinical
Phenotype Phenotype
A B C
FIG. 1.1 Concept models for geriatric syndrome pathophysiology. (A) The traditional linear model does
not adequately capture the multifactorial nature of geriatric syndromes. (B) The concentric model may
also not be suitable for geriatric syndromes because interventions targeting only one risk factor would
address only a small portion of the overall risk for such conditions, whereas multicomponent pharma-
ceutical interventions risk being unfocussed and could lead to adverse effects typically associated with
geriatric polypharmacy. (C) The interactive concentric model is a means of reconciling the need for
mechanistic research with the condition’s multifactorial complexity, by focusing on pathways associated
with risk factor synergisms, thus offering a locus for the design of targeted interventions. (From Inouye
SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. J Am Geriatr Soc. 2007;55(5):780–791; with permission.)
Excluding older age, the remaining risk factors (func- high rates (30%–40%) in the geriatric population.33
tional impairment, cognitive impairment, and impaired Gait instability accounts for approximately 20% of falls
mobility) are amenable to interventions, preventative in older adults.34 Although some physicians may worry
strategies to provide reorientation for cognitive impair- about falls, gait instability is in itself an indication for
ment, exercise, balance training, and mobilization.23 initiating an exercise program and can be improved sig-
There has been substantial progress in clarifying risk nificantly through strength and balance training.35 Falls
factors and intervention strategies for some common are associated with functional decline, hospitalization,
geriatric syndromes such as delirium and falls. Unfor- institutionalization, and increased healthcare costs.
tunately, these advances have failed to widely translate However, only 37% of primary care providers docu-
into the clinical implementation.23 Delirium is a very ment screening their older patients for falls.33,36 Based
common life-threatening geriatric syndrome for hos- on 2008 data, over 60 fall-reduction interventional tri-
pitalized older patients, occurring in 14%–56% and als have been conducted, with an approximated 30%
associated with in-hospital mortality of 22%–76%.27 relative risk reduction noted post intervention.33,37 The
Unfortunately, delirium is unrecognized in 66%–77% Connecticut Collaboration for Fall Prevention (CCFP)
of these patients and documented in only 3% of the program is an example of a local effort to translate
patients when it is present clinically. These factors pre- research into practice by providing targeted provid-
clude effective interventions.28,29 Up to 30%–40% of ers in emergency departments, primary care offices,
delirium may be preventable with appropriate inter- home care agencies, and rehabilitation centers with
ventions, such as the Hospital Elder Life Program the fall risk evaluation and management resources and
(HELP), which may also reduce delirium duration education.38
when it does occur, prevent functional decline and There are many challenges to the successful imple-
falls, and lead to higher rates of home discharge post mentation and sustainability of HELP, CCFP, and
hospitalization.30–32 similar programs, including the need for clinician lead-
Unintentional injury is the sixth most common ership and limited funding.39 The data collected as part
cause of death among older individuals. Falls are the of the CCFP project showed multiple barriers to dis-
leading cause of unintentional injury and occur at very semination, including lack of knowledge regarding the
importance and preventability of falls in providers and Multimorbidity is an etiologic risk for disability
patients alike, false perception that fall risk evaluation and is a potential outcome of frailty.41 Although frailty
and management were not allowed by Medicare, poor is poorly defined in the literature,40,42 broadly agreed
Medicare reimbursement for fall-related services, on- upon manifestations include accumulation of multi-
going healthcare focus on diseases rather than multidimensional loss of reserves across neuromuscular,
factorial geriatric syndromes, and competing demands metabolic, cognitive, and immune systems that give
for frequent clinical visits.38 As with most interven- rise to vulnerability.40,43,44 It is sometimes referred to
tions, a national-level shift of focus to prevention will as a loss of “functional homeostasis.”45 Frailty is asso-
be required for the geriatric population for optimal ciated with aging and increases in prevalence in older
results.␣ age groups, although exact estimates vary based on the
population studied. For example, among community-
dwelling adults in Canada 65–102 years old, 22.7%
FRAILTY were frail. Of the subgroup of individuals aged 85 years
The Concept of Frailty and older, frailty was noted in 40%.46 Other studies
“Frailty” can be thought of as one more example of mentioned rates as low as 6.9% in community-dwell-
a geriatric syndrome that overlaps with but is distinct ing American geriatric populations.41 Independent of
from disability, multimorbidity, and “normal” aging age, frailty is thought to be predictive of mortality,
(Fig. 1.2).40,41 Frailty as defined or rather described by hospitalization, institutionalization, falls, and worsen-
Walston et al. is“[Frailty is] a state of increased vulner- ing health status.40,41,44,46–50 Frailty is also thought of
ability to stressors due to age-related declines in physi- as bidirectional and can be reversed with appropriate
ologic reserve across neuromuscular, metabolic and interventions.51
immune systems.”43 It is a clinical syndrome presenting Both the high rates of associated morbidity and
the following symptoms: availability of “reversal” modalities for frailty make it a
• Self-reported exhaustion high-yield clinical construct for screening in the aging
• Low physical activity population. There are many operational definitions
• Unintentional weight loss (10 lbs or more than 5% and screening tools. These tools tend to be based on a
of body weight in past year) predefined set of rules, a summation of impairments,
• Weakness (grip strength in lowest 20th percentile) or reliant on clinical judgment.44 Each assessment has
• Slow walking speed (15 ft; lowest 20th percentile) associated drawbacks to clinical implementation, such
POOR
GERIATRIC OUTCOMES
SYNDROMES
Incontinence Disability-
SHARED Falls Dependence
RISK FRAILTY
FACTORS Pressure Ulcers Nursing Home
Delirium Death
Functional Decline
FIG. 1.2 Conceptual model of shared risks leading to geriatric syndromes. Conceptual model demon-
strating the interconnected nature with multiple feedback mechanisms of risk factors, geriatric syndromes,
frailty, and poor outcomes. These self-sustaining pathways hold important implications for elucidating
pathophysiologic mechanisms and designing effective intervention strategies for this patient population.
(From Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and policy implica-
tions of a core geriatric concept. J Am Geriatr Soc. 2007;55(5):780–791; with permission.)
as the need to consider a list of no fewer than 70 pos- DISABILITY IN OLDER ADULTS
sible disorders for models based on summation of It is important to differentiate disability from frailty,
impairments.44 Examples of validated assessment tools as patients may have one or both.54 Among disabled
used to determine frailty status include the Cardiovas- older patients only 28% are frail; nearly 75% of frail
cular Health Study Frailty Phenotype (CHSFP),41 the older patients can complete all their activities of daily
Frailty Index,48,49 and the Clinical Frailty Score (CFS).44 living (ADLs), and 40% do not have difficulty perform-
The CHSFP is an example of a rules-based approach ing all instrumental activities of daily living (IADLs).41
that diagnoses frailty based on the presence of at least Disability may be physical, emotional, or social or due
three of the criteria listed below: to disease-related changes. However, disability does
• Unintentional weight loss of 10 or more pounds not typically occur across multiple organ systems as
over a period of 1 year does frailty.55 The most common definition of disabil-
• Self-reported exhaustion ity focuses on physical limitations and is thought of as
• Grip strength weakness impairments in performance of ADLs and/or IADLs or
• Slow walking speed difficulty with independent mobility.
• Low physical activity.41 Disability is often used in research as a measure
The CFS is a seven-point system that may be the of health and function in the aging population.5 The
easiest to administer in clinical practice than the other increase in overall lifespan has raised an interesting
tools. It mixes items such as comorbidity, cognitive question: are individuals living healthier and longer,
impairment, and disability that some other groups or are the additional years spent in poor health and/
separate by focusing on physical manifestations of or chronic disability? Currently, there is a significant
frailty. Scores range from 1 (patient is in robust health) controversy surrounding the relationship between
to 7 (patient has complete functional dependence on increased life expectancy and overall health status in
others).44 The utilization of one of the many available part because this topic is difficult to research. Some
tools should be incorporated into clinical practice by researchers think there will be a decrease in the preva-
all providers dealing with this population.␣ lence of disability as life expectancy increases, termed
“compression of morbidity,” whereas others foretell an
Brief Note on Polypharmacy and “expansion of morbidity” as life expectancy increases.
Deprescribing Several studies of the US population have noted posi-
Although not a true “geriatric syndrome,” polyphar- tive trends suggesting that the healthcare system can
macy is a rampant problem in the older adults. Opti- affect not only the duration but also the quality of life
mizing pharmacotherapy is a critical aspect of geriatric in the aging population. Between 1982 and 2001, severe
care, as this population is at high risk for adverse drug disability decreased about 25% among those aged 65
events (ADEs). Polypharmacy is defined as the use of years or older, and life expectancy increased.5 Unfor-
multiple medications by a patient, with 5–10 medica- tunately, this positive trend may not persist because of
tions usually accepted as the cutoff.52 In the United alarmingly increasing rates of obesity among pediatric,
States, approximately 50% of Medicare beneficiaries adult, and geriatric populations alike. Several popu-
take five or more medications at the same time.8 Vari- lation-based studies from the late 2000s found stark
ous criteria exist to help identify medications that health differences between non-Hispanic white older
should be avoided or used with caution in this patient adults in the United States and the adults in England
population, although compliance with these medica- and 10 other European countries.5 Significantly higher
tion lists is suboptimal. A widely used example of such rates of chronic diseases and disability were reported
lists in the United States is Beers Criteria, which was for American adults aged 50–75 years compared with
revised in 2015.53 ADEs are associated with high rates their European counterparts. These discrepancies in
of hospitalization in older adults. Prescribing cascades health status were at all levels of wealth, educational
(when providers confuse ADEs with a new disease levels and behavioral risk factors.␣
process), drug-drug interactions, and inappropriate
drug doses are some of the most common causes of
preventable ADEs in this population. Evidence sug- THE CRITICAL IMPORTANCE OF PHYSICAL
gests that clinicians are consistently avoiding overpre- ACTIVITY
scribing of inappropriate drug therapies but are more There are numerous benefits to physical activity. It is
likely to underprescribe indicated drug therapies (e.g., often believed that the development and worsening of
statins).␣ chronic disease is part of normal aging. As discussed
earlier, this is not a valid conclusion. Regular physical meet recommended levels of weekly physical activity.62
activity has been shown to reduce both the development For the adult population, more than one-third do not
and worsening of chronic diseases.56 In addition, physi- meet the recommendations for aerobic physical activity
ologic changes associated with age should not preclude and 23% do not have leisure time physical activity for
an individual from engaging in exercises, even though several months.63 Only 51.7% of adults 18 years of age
the absolute gains are noted to be less in older adults.57 and over met the Physical Activity Guidelines for aero-
With very few exceptions, physical activity is rec- bic physical activity per the Centers for Disease Control
ommended and should be promoted for everyone and Prevention report (https://www.cdc.gov/nchs/fa
by healthcare providers. Lack of advice to exercise is stats/exercise.htm). For the geriatric population, 45%
often interpreted by patients as condoning a sedentary of the 65- to 74-year-old group and 51% of the 75+
lifestyle.58 The very few definitive contraindications to year-old group do not have any routine leisure time
exercise, such as unstable cardiovascular conditions, activity.64 Fortunately, the greatest impact of exercise in
are often transient.59 The risks of sedentary behavior far improving functional status occurs in sedentary indi-
outweigh the risks of a gentle exercise program.58 Many viduals who become active.58
physicians are hesitant to prescribe exercise for geriat- Regular physical exercise has been shown to reverse
ric patients with cardiovascular disease and may order some age-related decline in physiologic processes that
a preinitiation stress test.35 There are several guidelines occur with normal aging (such as improved body com-
about stress testing in this setting. It is worth noting position),56,65 reduce or reverse frailty,40 prevent onset
that more than 70% of patients over the age of 70 years of disability,66,67 improve recovery from mobility loss,68
will have abnormal stress tests with asymptomatic isch- prevent or mitigate physical dependency,69 reduce
emia.35 The American College of Sports Medicine rec- institutional placement,70 improve quality of life mea-
ommends “exercise stress testing for all sedentary or sures,71 and, of particular importance to older adults,
minimally active older adults who plan to begin exercis- reduce the risk of falls and injuries from falls.37,72
ing at a vigorous intensity.” However, most older adults Research and clinical practice guidelines promote phys-
can safely begin a moderate aerobic and resistance ical activity as a therapeutic modality for the manage-
training exercises if they can begin slowly and gradually ment of hypertension,73,74 coronary artery disease,74–76
increase their level of activity without stress testing.73 congestive heart failure,77 hyperlipidemia,74,78 periph-
Older adults with coronary artery disease with unstable eral vascular disease,79 type 2 diabetes mellitus,80,81
angina, uncontrolled hypertension, or dysrhythmia obesity,82 osteoporosis,83 osteoarthritis,84–86 colon can-
and a recent history of congestive heart failure must be cer,87 breast cancer,88 prostate cancer,89 and many other
evaluated with a stress test before starting any exercise common chronic conditions such as depression.71 Cog-
program. Fortunately, evidence suggests that risk for a nitive function is closely linked with physical activity;
recurrent coronary event and associated disability in this increased participation is shown to prevent or delay
population is actually reduced with exercise.35 Patients cognitive decline and dementia.90–92 Exercise improves
with intermittent claudication frequently avoid exercise, bone health and reduces the risk of falling.37␣
and their physicians often hesitate to recommend physi-
cal activity given their symptoms of pain. Intermittent The Geriatric Exercise Prescription
claudication is not a contraindication. These patients There is no consensus for the “optimal” exercise modal-
should be encouraged to exercise regularly, titrating the ity or frequency for geriatric patients. Innovative pro-
amount to pain tolerance with very gradual increase in grams such as Exergames have not been shown to be
duration and less emphasis on intensity.60 superior to standardized or self-regulated programs.70
Most evidence suggests that a multicomponent pro-
Benefits and Limitations gram inclusive of aerobic, resistance, balance, and flexi-
Despite the ample evidence supporting the critical role bility training is preferred.40 The key to success with any
of physical activity for the reduction of morbidity and program is involving the patient in the plan and the
mortality at all ages, many individuals in the United endorsement of physical activity by physicians.35 Par-
States avoid physical exercise. Based on the data from ticipants should be counseled to view their training as a
2015, up to 15% of adolescents did not participate long-term commitment because frail adults can rapidly
in at least 60 min of physical activity for a minimum lose fitness gains upon exercise cessation.93 Patients
of 5 days per week if it produced signs of moderate should directly be involved in creating an exercise plan
effort such as increased heart rate or breathing dif- because it seems to optimize safety and increase com-
ficulty.61 Up to 65.3% of adolescent students do not pliance.35 When assisting patients with goal setting,
focus on making choices that are SMART: specific, mea- supervision for safety during the initial learning phase of
surable, attainable, relevant, and time oriented.58 As an exercise routine.100 Some group therapy classes focus
an example, “Get more active, do the best you can” is on additional interventions, including nutritional educa-
not SMART. Adding specifics, such as “Start by walk- tion and psychosocial programs. These classes have been
ing 5 min every day and add 1 min daily to achieve a shown to have even greater success in the older popula-
30 min daily walk time,” is a more useful form of clini- tion compared with exercise alone, improving functional
cal endorsement and encouragement.58 status and reducing frailty.101 Physical activity, however,
In general, all programs should initially focus on is a crucial component, and educational programs alone
the patients’ current functional limitations and gradu- are not sufficient to show benefits in physical function.102␣
ally implement a more generalized fitness plan as func-
tion improves.35,94 The minimum suggested frequency Arthritis
for multicomponent training is two to three times per Arthritis is the most common cause of disability
week at a moderate intensity (12–14 Rating of Perceived in America, affecting one in every five adults.103 By
Exertion (RPE) or 3–4 on Borg CR10 point scale) for 60 years of age, 100% of individuals will have histo-
30–45 min in frail adults and 45–60 min in prefrail logic changes consistent with degeneration. Data from
adults.40,93,95 For patients with severe clinical frailty, it the beginning of this century suggested that 40% of US
is recommended that up to half of their training time adults reported having arthritis by age 60 years, and
should be spent on aerobic exercises.40 Clinicians 10% had limitations in activity associated with arthritis
should actively work on progressing exercise prescrip- symptoms.104 As the US population ages, the number
tions toward the upper end of the recommended range of adults with doctor-diagnosed arthritis is projected
of intensity and frequency to facilitate longer-term exer- to increase from 46 to 67 million by 2030, and 25 mil-
cise adherence and progression.96 Resistance training lion of these individuals will have limited activity as
exercise should include a variety of upper and lower a result.105 The disabling effects of arthritis are dispro-
body exercises that attempt to simulate functional portionately prevalent in racial and ethnic minority
tasks.93 An emphasis should be placed on lower body populations. For example, compared with the white
muscles contributing to gross mobility (e.g., knee flexors population, a higher proportion of African Americans
and extensors, gluteal muscles), as these are necessary reported severe pain as well as activity and work limi-
in maintaining physical independence and compensat- tations attributable to arthritis.106 Reducing the risk of
ing for disproportional age-related loss of strength in functional dependency is the main focus of arthritis
the lower extremities compared with the upper body.97 management.35 The literature suggests that appropriate
Intensity is initially established based on an individu- exercise programs can prevent and treat some arthritic
al’s one repetition maximum weight, starting light at disabilities and do not exacerbate pain or acceler-
approximately 50%–60% and progressing to heavier ate disease progression (which is contrary to popu-
loads.40 Resistance exercise helps counteract neuromus- lar belief).94,107,108 Aerobic exercises, such as aquatics
cular changes associated with age-related weakness. or walking, have been shown to increase the aerobic
With training, increases in voluntary muscle activation capacity and gait speed while improving symptoms of
and antagonist muscle coactivation are noted. These depression and anxiety in patients with osteoarthritis
changes are associated with overall strength gains in and rheumatoid arthritis when compared with sim-
older adults.98 Some evidence suggests that high-inten- ple range of motion exercises alone.109 In addition to
sity progressive resistance strength training is safe and aerobics and resistance programs focusing on quadri-
may improve lower-extremity strength more than lower- ceps training, a variety of nonpharmaceutical interven-
intensity programs but is not required to improve functions have proven effective in managing osteoarthritis,
tional performance.99 As in resistance training, the key including education, social support, well-cushioned
focus of balance training is improvement of daily func- customized shoes (e.g., extra depth, custom inserts
tion. Tandem foot stance, line walking, and single leg to distribute plantar weight-bearing surfaces, toe box
stance should be performed after completion of resis- adjustments), canes, assistive devices, icing, and heat-
tance training as part of a cool down.100 Patients should ing pads.104 Proper footwear and skin care is especially
be instructed on proper technique before initiation of critical in patients with diabetes. Obesity is one of the
training and monitored carefully to reduce fall risk. strongest risk factors for knee arthritis, second only to
Group therapy programs have been shown to be increasing age. Reducing body weight by 4.5 kg reduces
effective for this population when combined with the risk of developing symptomatic osteoarthritis by
home therapy, allowing for peer interaction and some approximately 50%.35 When specifically targeting
weight loss in the geriatric population, calorie restric- or enhancing residual functional capability in older peo-
tion combined with resistance training may have ben- ple with disabling impairments and improving quality
efits over aerobic training by attenuating loss of hip and of life.45,112 Frailty and other geriatric syndromes as well
femoral neck bone mineral density.110␣ as multimorbidity make the medical management and
rehabilitation of older adult care very complex.45 Phys-
iatrists receive targeted training and education to care
THE EMERGING ROLE OF for the many complex needs of this patient population,
MULTIDISCIPLINARY CARE TEAMS allowing them to provide improved care that addresses
The Problem age-specific differences and manages multimorbidity in
The growth of the aging population carries a special sig- the context of disability.1,113 Physiatrists are skilled in
nificance because of its implications for disability and its managing patients across multiple care settings, includ-
impact on those who provide preventative or restorative ing acute inpatient rehab facilities; skilled nursing
care. The geriatric patient can present with a complex set facilities, which are highly regulated by the Centers for
of issues and associated disability. They may have health, Medicare and Medicaid Services; and in ambulatory clin-
financial, and psychosocial issues resulting from one or ics in the continuum of care of the growing geriatric pop-
more disabling conditions. On-going public interest ulation. Physiatrists may act as primary care physicians
in aging, multimorbidity, and geriatric syndromes has providing direct management of the medically complex
helped establish risk factors and effective intervention conditions and their complications, coordinate the care,
strategies for several age-related conditions. Unfortu- maximize function, lead interdisciplinary teams, or act
nately, much of this evidence has not been disseminated as consultants. In the above-mentioned roles, physiat-
into clinical practice to date.111 This can be attributed to: rists have been able to contribute to cost savings for the
1. Lack of commonly accepted definitions for the healthcare system by minimizing functional decline,
recognition, diagnosis, and coding of geriatric syn- reducing hospital length of stays and readmissions, and
dromes. reducing functional dependency.114
2. Lack of simple, measurable interventions for some Rehabilitation medicine has embraced the princi-
geriatric syndromes. ples of “improving care of older patients” as set forth
3. Need for substantial provider time and longitudinal by the American Geriatrics Society.115,116 Principles of
follow-up to intervene and assess effectiveness. rehabilitation practice emphasize a holistic assessment
4. The fact that available interventions often require of patients, including the review of medical status,
new behaviors or attitude shifts for patients and functional impairments, societal constraints, and the
physicians. Examples include working as part of an utility of adaptive equipment.117 This comprehensive
interdisciplinary team and often requiring system- approach has been shown to improve outcomes in
wide changes across extended systems of care with geriatric patients, and several practice models, such as
coordination across multiple disciplines. the CGA, have been adapted to incorporate this holistic
5. Lack of champions for these interventions, particu- approach.118 Interdisciplinary team work is the corner-
larly in the face of many other competing clinical stone of rehabilitation medicine. Many medical settings
demands and mandates. incorporate a variety of professionals; however, few are
The multifactorial nature of the geriatric syndromes able to develop a truly interdisciplinary team process
requiring a coordinated, multifaceted approach does that often results in better outcomes than that provided
not adhere to the traditional disease model that drives by the traditional multidisciplinary methods.117 For
most of the medical practice.23 A more detailed assess- example, interdisciplinary treatment improves func-
ment, such as an evaluation by a physiatry team or the tional outcomes and decreases nursing home place-
Comprehensive Geriatric Assessment (CGA), can be ment.118 The interdisciplinary approach differs from
most beneficial.␣ the multidisciplinary approach by focusing on the
common patient and team goals, compared with a dis-
The Role of Physiatrists cipline-specific focus. It emphasizes regular and effec-
Physiatrists play an important role in the care of older tive communication, coordination, and integration
adults. They incorporate the biopsychosocial model of of care.117 The interdisciplinary model is ingrained in
intervention with a goal-oriented team approach. Geri- the Physical Medicine and Rehabilitation specialty as
atric rehabilitation is an important emerging field, with a fundamental component of their training. Learning
a focus on evaluative, diagnostic, and therapeutic inter- to work with and leading a team are the core clinical
ventions with the purpose of restoring functional ability competencies of physiatrists.117
Inevitably, rehabilitation services in the inpatient drivers.122 Physiatrists are an excellent resource for
and/or outpatient setting are required for older adults other physicians for this specific problem. A tactful but
to facilitate independent living in communities. Phys- candid discussion with the patient and the family about
iatrists may act as team leaders, primary care givers, the risks of driving is critical and may render reporting
or consultants to help provide the best available care unnecessary, unless otherwise mandated by state regu-
for this complex population. Many questions arise in lations. The loss of driving privileges can be devastat-
primary practices that are often difficult to manage or ing to the patient and may place additional burden on
outside the providers’ expertise, prompting referrals to their caregivers. Physiatrists are well equipped to reduce
physiatrists. For example, some key barriers to physi- caregiver burden by providing psychological support,
cal activity guideline implementation among primary education, and resources for respite care. In turn, on-
care physicians include limitations in the knowledge going informal care can prolong a person’s community
of where to refer and what to recommend, access to living. Social supports are a complex network of pro-
pragmatic programs or resources, competing priori- grams, services, funding, and people that serve several
ties for physician time, and/or lack of incentives.119 needs of this population.1
These patients can be referred to physiatric practices to Other common issues addressed by physiatrists
address their concerns. include return to work issues as well as recommenda-
Hospitalization is a risk for disability leading to tions for recreational and leisure time activities. Phys-
decreased ability to live independently after discharge iatrists, and all healthcare providers, also play a critical
from the hospital. Physiatrists play a critical role in role in patient advocacy. In the geriatric population,
efficient and safe care transitions by determining the ageism is a major societal-level concern. Ageism is a
appropriate level of care required based on the intensity negative societal belief that increasing chronologic
of services. Regardless of the setting, social integration age is synonymous with dementia, depression, depen-
is an important goal of a comprehensive rehabilita- dence, isolation, and debility. Ageist views may lead to
tion program and requires in-depth knowledge of discrimination in the workplace, social settings, and
patient-related factors as well as available community medical care. Healthcare professionals must combat
resources.120 negative attitudes in providing care to older individuals,
Successful integration in community living has mea- such as the common erroneous belief that decreased
surable positive physical, cognitive, and psychosocial function is inevitable with aging.1 Ageist’s self-per-
effects for older adults and disabled populations lead- ception of some individuals can have a very negative
ing to increased awareness, new legislative efforts, and impact on their own health and function. Modifying
development of adaptive equipment and products.120 these negative stereotypes can have positive functional
However, this is often a complicated process that benefits; some common age-related gait changes were
requires specific knowledge and training to navigate. shown to be reversible with exposure of elders to posi-
Dwelling modifications that match functional needs tive images of aging.123␣
are an important step in returning to the community.
These often require significant out-of-pocket expense, The Comprehensive Geriatric Assessment
as they are not routinely covered through Medicare.120 The CGA is an interdisciplinary diagnostic and treat-
Physiatrists and their interdisciplinary teams are often ment protocol similar to physiatric assessments that
able to assist patients with these issues. Some infor- is designed to identify biomedical, functional, envi-
mation on housing resources can be found at the US ronmental, and psychosocial limitations of older
Housing and Urban Development website. For the adults with the goal of developing a coordinated and
older adults, transportation is a vital link to “out of personalized plan to maximize health and assist in
home” activities for work and pleasure. The US Divi- clinical decision making.124,125 In general, the interdis-
sion of Transportation is the designated agency with ciplinary team consists of a physician (usually a geri-
regulatory and enforcement responsibility for people atrician), nurse, social worker, and neuropsychologist
with impairments. The risk of motor vehicle accidents and may draw on the expertise of physical and occupa-
increases significantly as individuals become older. Fre- tional therapists, nutritionists, pharmacists, podiatrists,
quently, impaired older adult drivers voluntarily stop opticians, and other medical personnel. It is impera-
driving or adjust their driving to compensate for limita- tive to consider the relevant social, spiritual, and eco-
tions.121 Many physicians have poor knowledge on cur- nomic domains when addressing geriatric syndromes
rent licensing policies, the state-specific driving laws, in addition to the traditional biological framework for
and actions to be taken against potentially ineligible diseases.23 There are six key steps in the assessment
process, including data gathering, frequent team-based 3. Holliday R. The multiple and irreversible causes of aging.
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https://doi.org/10.1016/j.jamda.2016.11.004.
CHAPTER 2
Sarcopenia
WALTER R. FRONTERA, MD, PHD
INTRODUCTION motor performance, and the loss of the capacity of

The World Health Organization has recognized the skeletal muscle to recover from injury. It is interest-
aging of the population in countries around the world ing that the qualitative nature of these changes is very
as one of the most significant challenges of the 21st similar to those experienced during the inactivity that
century.1 These demographic changes were discussed in follows injury or hospitalization, underlining the
more detail in Chapter 1 of this volume. In many coun- contribution of a sedentary life, inactivity, and immo-
tries, particularly in Asia and Europe, average life expec- bilization to the age-associated loss of function and
tancy has already exceeded 80 years, especially among independence.␣
women, and aging of the population is happening very
quickly. In 2015, Japan is the only country in the world,
more than 30% of the population was aged 60 years or DEFINITION OF SARCOPENIA
older. It has been projected that by the year 2050, this The term sarcopenia was initially used by Rosenberg
will be the case in more than 25 countries including to describe the loss of lean body mass with aging.4,5
nations in the Americas, Asia, and Europe.1,2 It has been For several years, it was used by scientists to refer only
estimated that by the year 2025, the number of people to the loss of skeletal muscle mass. More recently, in
above age 60 years in the planet will exceed 1 and 2 bil- 2010, the European Working Group on Sarcopenia in
lion by the year 2050. Furthermore, a large proportion Older People (EWGSOP) expanded the definition to
will be older than 80 years, some will be centenarians, include the presence of impaired performance mea-
and the majority will live in low- to middle-income sured by walking speed and/or muscle weakness in
countries. Not surprisingly, these changes in the age- handgrip strength testing and proposed an algorithm
group composition of the population have significant (see Fig. 2.1) for a systematic evaluation of persons
social, economic, political, and health implications. with possible sarcopenia.6 This first consensus rep-
Thus, understanding age-related changes in human resented a significant development because it went
physiology and their functional consequences is of sig- beyond the static evaluation of muscle mass and
nificant interest and relevance and has been identified underscored the physiologic and functional con-
as a research priority by the US National Institutes of sequences of muscle atrophy with advanced adult
Health.3 age. In fact, from a functional and rehabilitative per-
Aging is a continuum characterized by its signifi- spective, the addition of walking speed makes sense
cant variability. The source of this variability is mul- because this measurement correlates very well with
tidimensional and includes a combination of factors the prevalence of limitations in activities of daily liv-
such as individual genotype, environmental factors, ing, mobility, and survival.7,8 It has been reported that
health behaviors, and access to healthcare. Some of in many countries around the world, the prevalence
the most important contributors to the functional of limitations in activities of daily living is higher in
loss leading to impairment and disability are the mul- older age-groups.9
tiple changes in the structure and function of the neu- The proposal by the EWGSOP was followed by simi-
romuscular system. If not identified and addressed lar efforts by the International Working Group on Sar-
early, life-threatening complications, such as falls copenia,10 the American Foundation for the National
and bone fractures associated with muscle weakness, Institutes of Health,11 and the Asian Working Group on
can occur. Many physiologic changes associated with Sarcopenia (AWGS).12 The latter group updated their
advanced adult age contribute to a decline in skeletal criteria in a more recent publication.13 There are some
muscle strength and mass, alterations in cellular and differences among these proposals but many more sim-
molecular processes within muscle fibers, impaired ilarities and agreement.␣
19
FIG. 2.1 EWGSOP-suggested algorithm for sarcopenia case finding in older individuals. (From Cruz-
Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis:
report of the European Working Group on Sarcopenia in older people. Age Ageing. 2010;39(4):420; with
permission.)
MAKING THE DIAGNOSIS normal values and the adjustment of measurements

In 2016, the 10th version of International Classification of muscle mass for differences in height. Several tests
of Diseases (ICD-10-CM codes) added a code for the have been accepted for the testing of performance,
diagnosis of sarcopenia (M62.84) that could be used muscle strength, and muscle mass. In the case of per-
for reimbursement purposes under the general category formance, most studies recommend the measurement
of diseases of the musculoskeletal system and the spe- of gait speed in a 6-m course. All study groups have
cific group of disorders of muscle. Thus, an important recommended that a gait speed of ≤0.8 m/s be consid-
question from a clinical practice point of view is who ered low and a justification for proceeding to testing
should be tested for sarcopenia. In general, the work- muscle strength and mass. Static (isometric) strength
ing groups mentioned above have recommended that is measured using a handgrip dynamometer. In gen-
community-dwelling individuals aged 65 years and eral, normal values for men range between 26 and
older should be routinely screened. In addition, those 30 kg and for women between 16 and 20 kg. It should
who have experienced recent functional decline (i.e., be noted that handgrip strength by itself is associated
repeated falls, unintentional weight loss, self-reported with lower limb muscle power and mobility and is a
mobility difficulties, weakness, or self-reported slow good predictor of clinical outcomes.14 In the case of
walking speed) are good candidates for evaluation. It muscle mass, both dual-energy X-ray absorptiometry
is likely that as we come to understand this condition and bioelectrical impedance (BIA) have been used. A
better, indications for screening and testing will evolve skeletal muscle index is calculated as the sum of mus-
and become more specific. cle mass of the four limbs divided by the square of
Since 2010, several groups have established criteria the height. A measurement of 2 SD below the mean
for the diagnosis of sarcopenia (see Table 2.1). This proof a young reference group or in the lower quintile
cess requires the establishment of population-specific is considered abnormally low. In general, it is the
CHAPTER 2 Sarcopenia 21
TABLE 2.1
Recommended Tests and Range of Normal Values for the Diagnosis of Sarcopenia
Variable Specific Test Recommended Value
Physical performance 6 m walking speed ≤0.8 m/s
Muscle strength Handgrip <30 and 20 kg for men and women,
respectively
Muscle mass Mass measured using DXA (absorptiometry) 7.2 and 5.6 kg/m2 by DXA in men and
or BIA (bioelectrical impedance) and adjusted women, respectively
for height; 2 SD below the mean for a young or
control or the lowest quintile 8.9 and 6.4 kg/m2 using BIA in men
and women, respectively
DXA, dual-energy X-ray absorptiometry.

Data from Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis. Age Ageing.
2010;39:412–423, Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: an undiagnosed condition in older adults. Current consensus defini-
tion: prevalence, etiology, and consequences. International Working Group on Sarcopenia. J Am Med Dir Assoc. 2011;12:249–256, Studenski
SA, Peters KW, Alley DE, et al. The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates.
J Gerontol A Biol Sci Med Sci. 2014;69:547–558, Chen LK, Liu LK, Woo J, et al. Sarcopenia in Asia: consensus report of the Asian Work-
ing Group for Sarcopenia. J Am Med Dir Assoc. 2014;15:95–101, and Chen LK, Lee W-J, Peng L-N, et al. Recent advances in sarcopenia
research in Asia: 2016 update from the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2016;17:767.e1–767.e7.
combination of the three tests that helps make the was proposed by Japanese investigators who found
diagnosis. According to the EWGSOP, if two measure- that an algorithm not including the measurement of
ments are abnormally low, sarcopenia is present, and gait speed, as proposed by the EWGSOP,6 was equally
if all measurements are below the criteria, the condi- useful in identifying sarcopenic individuals.16 In other
tion is severe sarcopenia. The recommendations of the words, in this algorithm, a low measurement of hand-
different working groups are very similar, but there grip strength is an indication to measure muscle mass,
are some important differences. For example, accord- and only these two tests are the required measurements
ing to the EWGSOP, if gait speed is normal (>0.8 m/s), for the diagnosis of sarcopenia.
handgrip strength is not measured and the next step The importance of making the diagnosis early is
is to measure muscle mass. In the case of the recom- that sarcopenia leads to many negative outcomes,
mendations made by the AWGS, both gait speed and such as reduced physical capacity, poorer quality of
handgrip strength are measured at the beginning of life, impaired cardiopulmonary performance, unfavor-
the evaluation process. If one of these measurements able metabolic effects, falls, disability, higher all-cause
is low, then muscle mass is measured. mortality, high healthcare expenditure, and poorer out-
It is interesting that at least two other approaches comes of medical or surgical treatment of cancer.12,17
have been suggested to simplify the testing and screen- An early diagnosis may enhance the effectiveness of the
ing process. A rapid questionnaire has been designed interventions (see below).␣
to diagnose sarcopenia quickly, including five ques-
tions about the difficulty of performing certain tasks as
reported by the patient (difficulty in lifting and carrying PREVALENCE OF SARCOPENIA
10 pounds, walking across the room, transferring from The prevalence of sarcopenia varies significantly
a chair or bed, and climbing a flight of 10 stairs) and among countries.13 It could be argued that biologic
the number of falls in the past year.15 Each question is and cultural differences explain, at least partially, this
scored between 0 (no difficulty or no falls) and 2 (a lot variability. However, it is reasonable to conclude that
or unable and 4 or more falls). The scores range from variations in testing procedures and diagnostic criteria
0 to 10 and the authors suggested that a score equal have also contributed to this. The prevalence of sar-
or greater than 4 is predictive of sarcopenia and poor copenia has been reported to vary between 4.0 and
outcomes. This approach has obvious advantages in 27.1 and 2.5 and 22.1 in men and women of differ-
a clinical setting where more sophisticated resources ent nationalities, respectively. A high level of physi-
may not be available. A second simplified approach cal activity is associated with a lower prevalence of
sarcopenia even in obese people.18 It should be kept and an increase in mortality rate. Furthermore, muscles
in mind that the prevalence of sarcopenia increases produce myokines (i.e., growth factors and cytokines
with age, and older groups may require more atten- secreted by muscle cells) that may improve metabolic
tion and careful evaluation. Finally, those living in homeostasis, increase stress resistance, and delay age-
long-term facilities have a higher prevalence probably related functional decline in other tissues.21 Thus, a loss
due to a higher level of disability and the additional of muscle mass that reduces the production and secre-
deleterious effect of inactivity.19␣ tion of these myokines facilitates physiologic deteriora-
tion of tissues other than skeletal muscle. Many studies
have been conducted in the last 10 years to understand
PHYSIOLOGICAL CHANGES ASSOCIATED the physiologic and cellular basis of the clinical mani-
WITH SARCOPENIA festations of sarcopenia that can be measured in a
Fig. 2.2 summarizes many of the physiologic changes clinical setting: impaired performance, weakness, and
with advanced adult age that may contribute to the atrophy. In fact, the number of scientific manuscripts
development of sarcopenia.20 It can be seen that dys- published and identifiable in PubMed on the topic of
function or negative adaptations in multiple organs sarcopenia has increased by a factor of 9 (to almost
and systems that under normal conditions favor an 900 in 2016) in the same period. Several biomarkers of
anabolic state contribute directly or indirectly to sarco- aging have been studied in detail. We will briefly sum-
penia. Understanding sarcopenia is important because marize important observations regarding age-related
a reduction in skeletal muscle mass is associated with alterations in muscle strength, muscle size, and muscle
loss of functional capacity, many age-related diseases, function or performance.
FIG. 2.2 Factors contributing to the development of sarcopenia. (Adapted from Joseph AM, Adhihetty
PJ, Leeuwenburgh C. Beneficial effects of exercise on age-related mitochondrial dysfunction and oxidative
stress in skeletal muscle. J Physiol. 2016;594(18):5107; with permission.)
Muscle Strength Muscle Function and Performance

The most important function of skeletal muscle is the The loss of muscle function and performance typi-
production of force and generation of power. This is cal of aging has been reported by many investiga-
how movement and mobility become possible. The tors. Tests of gait speed that correlate with leg muscle
cellular elements that contribute to force generation strength and power show a reduction in gait speed
change with advanced adult age, and this combina- with age that predicts limitations in activities of daily
tion of changes results in muscle weakness. Both living.7,27 Other tests of functional performance,
cross-sectional (comparison among age groups) and such as the Short Physical Performance Battery that
longitudinal (follow-up of the same population over not only includes gait speed but also tests for bal-
the course of several years) studies show a decline in ance and muscle power,23,28 also show a significant
the strength of many muscle groups in both upper decline with age. Finally, muscle power (a parameter
and lower limbs that ranges between 0.5% and 1.5% that combines muscle strength and speed or rate of
per year depending on the study design.22,23 This force development) is lost at a faster rate than mus-
reduction is less in the upper limbs (elbow flexors cle strength.23,25 This is important because power
and extensors) particularly in women. The variability strongly correlates with functional performance, and
of this process is illustrated by the fact that approxi- its restoration may require a different rehabilitative
mately 10% of the older adults in one study showed approach (see below).␣
no change or even an increase in the strength of the
knee extensors and flexors over a 10-year follow-up.24
This increase was even higher (32%) in the case of the THE CELLULAR AND MOLECULAR BASIS
elbow extensors and flexors in women. Differences in OF MUSCLE WEAKNESS AND ATROPHY
levels of physical activity, genetic influence, and hor- Although activation of the neuromuscular system
monal factors may have contributed to the preserva- by central impulses contributes to muscle weakness
tion of strength in some individuals. In another study, in vivo, the ability of older muscle and muscle fibers
mobility-impaired older volunteers show a more sig- to generate force is impaired even when maximal acti-
nificant decline in strength and muscle power over a vation is achieved with maximal calcium concentra-
3-year period compared with healthy older adults.25 tions in vitro. Furthermore, when force is adjusted for
The clinical importance of muscle strength is demon- differences in muscle size (in vivo and in vitro), dif-
strated by the fact that baseline muscle strength lev- ferences in strength between age-groups persist.29–31
els predict outcomes after falls with fractures and is These two observations suggest that the intrinsic qual-
associated with lower age-adjusted death rates from ity of muscle to generate force is impaired in the older
all causes and cancer in older patients. This loss of muscle.
muscle strength makes the performance of activities Like in many other cell types, several basic pro-
of daily life more difficult and leads to the loss of cesses inside muscle fibers become dysfunctional
independence.␣ with advanced adult age. Several general hallmarks
underlying this dysfunction have been identified and
Muscle Size include genomic instability, telomere shortening,
It has been repeatedly shown that the loss of muscle epigenetic alterations, loss of proteostasis, and stem
tissue explains, at least partially, the age-related loss of cell exhaustion.32 Of note is a reduction in the num-
muscle strength. In one longitudinal study, the reduc- ber of satellite cells (stem cells of skeletal muscle),
tion in cross-sectional area over 12 years was 16.1% in particularly those associated with type II fibers, and
the quadriceps and 14.9% in the knee flexor muscle in the capacity of satellite cells to become activated
group.22 This loss of tissue is due to the loss of motor in the presence of a stimulus that activates regener-
units and their muscle fibers, particularly type II (fast, ating pathways.33,34 This is relevant because it is an
glycolytic) fibers, in combination with atrophy of type adaptation that reduces the regenerative capacity of
I and II individual fibers. Muscle atrophy and accumu- older muscle at the same time that muscle fibers are
lation of intermuscular fat are known to occur at the being lost. With regard to telomeres, it is interesting
same time in many muscles of the body. Several studies to note that telomere shortening has been reported
using imaging techniques, such as magnetic resonance to be related more to physical inactivity than to
and ultrasonography, have shown that fat replacement chronological age.35
increases with age and includes limb muscles as well as During the last 20 years, many studies have
the paraspinal muscle group.26␣ explored cellular and molecular alterations that may
result in abnormal formation and function of the stopped, some of the changes in skeletal muscle dis-
basic unit of force generation in muscle cells, the cussed above may be due to the presence of factors
myosin-actin cross-bridge. For example, fragmenta- such as the lack of physical activity or exercise and
tion of the excitation-contraction coupling system inappropriate nutritional practices and not to inevi-
formed by t-tubules and the sarcoplasmic reticulum table consequences of the aging process.35,44 This idea
has been reported by Weisleder and collaborators.36 has stimulated many investigators to examine the
This impairs the calcium homeostasis that is needed beneficial effects of exercise on muscle strength and
to activate cross-bridge formation. Changes in gene mass in older men and women. Cross-sectional stud-
expression, including the upregulation of some ies have shown that the prevalence of sarcopenia is
genes and the downregulation of others, have been lower in older men and women with a higher level of
associated with an aging “signature.”37,38 It has been habitual physical activity.18 In addition, many exer-
suggested that some of these alterations in gene tran- cise training studies have shown that strength train-
scription may be due to DNA methylation and may ing (i.e., resistance training, weightlifting) results in
have an impact on the quantity and quality of pro- significant gains in strength and muscle mass in older
teins needed for muscle function, such as oxidative people. In general, based on multiple studies, it can
enzymes and contractile proteins.39 Because physi- be concluded that the use of free weights or strength
ological traits such as muscle strength and muscle training devices (type of exercise), to perform three
size are partially regulated by genes, the possible to four sets of 8–10 repetitions each (duration of
contributions to sarcopenia of genotypes must be training), two to three times per week (frequency of
understood.40 training), at 60%–80% of the one repetition maxi-
Finally, several authors have reported chemical alter- mum (intensity), results in significant physiologic
ations, such as glycation and oxidation of the myosin and functional gains.19,45 Considering that many
molecule, that may interfere with cross-bridge kinet- activities of daily living do not require maximal force
ics.41,42 Taken together, these studies strongly suggest (strength) but rather the development of submaxi-
that multiple alterations at the level of the cell itself mal level of force quickly, several investigators have
contribute to muscle dysfunction in the elderly. The developed exercise training programs that include
importance of changes in muscle quality at the level a high-velocity component, particularly during the
of the muscle cells was demonstrated in a very com- concentric actions of the exercise.46,47 These exer-
prehensive study by Brocca and collaborators.43 These cise programs have resulted in significant gains in
investigators combined the assessment of in vivo mus- strength, increases in muscle power, and functional
cle function with in vitro analysis of isolated single improvements.
muscle fibers with proteomic analysis. They concluded Another important question relates to the use of
that qualitative adaptations in muscle proteins due to additional interventions that, in combination with
phosphorylation and/or oxidation contribute signifi- exercise, may optimize the benefits of exercise train-
cantly to muscle aging. It is important to note that their ing. Although anabolic agents such as testosterone
subjects were healthy volunteers with the same level of and human growth hormone have been shown to be
physical activity.␣ effective in short-duration studies, its long-term use in
the older population cannot be recommended because
it is not clear that prolonged administration of these
EXERCISE AND NUTRITIONAL agents is safe. On the other hand, many studies have
SUPPLEMENTATION AS demonstrated that nutritional interventions, such as
COUNTERMEASURES amino acid and protein supplementation, effectively
A comprehensive discussion of the effects of exercise increases muscle protein synthesis and can act syner-
training on sarcopenia is beyond the scope of this chap- gistically to enhance the benefits of exercise training.48
ter, and the exercise recommendations for older adults In fact, these beneficial effects on strength and mobility
are discussed in Chapter 14 in this volume. However, it can persist even several years after the intervention has
is appropriate to make some comments about the role been stopped.49␣
of exercise in preventing and slowing down the devel-
opment of sarcopenia.
One of the main goals of a geriatric rehabilitation CONCLUDING STATEMENT
program is to correct the impairments in the muscu- Aging and associated processes such as the develop-
loskeletal system associated with advanced adult age. ment of sarcopenia represent important challenges for
Although aging cannot be completely reversed or rehabilitation professionals. Our understanding of the
underlying mechanisms has improved significantly and 17. Landi F, Cruz-Jentoft AJ, Liperoti R, et al. Sarcopenia
our diagnostic approach has been enhanced consider- and mortality risk in frail older persons aged 80 years
ably. It is important to educate health professionals and older: results from ilSIRENTE study. Age Ageing.
working with older populations on the benefits of exer- 2013;42:203–209.
18. Ryu M, Jo J, Lee Y, Chung Y-S, Kim K-M, Baek W-C. Asso-
cise training in this population.
ciation of physical activity with sarcopenia and sarcopenic
obesity in community-dwelling older adults: the Fourth
Korea National Health and Nutrition Examination Survey.
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skeletal muscle. Aging Cell. 2014;13:360–366. trition to target protein synthesis impairments in aging
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CHAPTER 3
Osteoporosis and Fragility Fracture

JAE-YOUNG LIM, MD, PHD • JAEWON BEOM, MD, PHD •
SANG Y. LEE, MD, PHD
INTRODUCTION setting. However, as up to 80% of bone strength is

As elderly subjects increase in number, the physical attributable to bone density, measurement of bone
impairments and disability associated with falls and density is useful for diagnosing osteoporosis. There-
fragility fractures constitute major threats to health fore, diagnosis of osteoporosis is currently achieved
in older age and increase healthcare and socioeco- by assessment of bone density (in g/cm2) as measured
nomic burdens.1 Osteoporotic fractures or fragility by dual-energy X-ray absorptiometry. The standard
fractures have been recognized as geriatric conditions criterion defining and diagnosing osteoporosis is a
associated with various and complex problems that T-score of ≤−2.5 at the lumbar spine, femoral neck, or
significantly compromise whole-body conditions total hip as revealed by bone mineral density (BMD)
and functions in addition to the musculoskeletal measurements3 (Table 3.1).
problems due to fracture per se.2 If a fracture is not The T-score as a reference standard of the World
treated early, the fracture may trigger serious condi- Health Organization (WHO) criteria was calculated
tions leading to death. using the young normal mean (white females aged
The most common cause of osteoporotic fracture is 20–29 years). The WHO definition may be applied
a fall-related injury. Epidemiologic data and the health- properly to postmenopausal females but was not devel-
care systems regarding the occurrence of falls, risk fac- oped for males or premenopausal females.4 In terms
tors for falls, and postfall outcomes in older adults show of a reference standard for males, controversy exists
that such problems are already of major international as to whether it is appropriate to use BMD data from
concern. Comprehensive and systematic rehabilitation young healthy males (a sex-specific T-score) or young
can minimize complications and increase the success healthy females. However, the accumulated evidence
of medical and surgical treatments, thereby lowering suggests that both bone strength and the relative risks
the extent of impairment. of fracture at the same femoral neck BMD are similar
This chapter focuses on the rehabilitative manage- between males and females.5,6 The 2013 update from
ment of hip and vertebral fractures, which are the most the International Society for Clinical Densitometry
common fragility fractures causing severe dysfunction
in the very elderly (who are at greatest risk).␣
TABLE 3.1
World Health Organization Criteria for Clinical
OSTEOPOROSIS
Diagnosis of Osteoporosis
Definition and Diagnosis of Osteoporosis in
the Geriatric Population BMD T-Score Diagnosis
Osteoporosis is defined as “a disease characterized T-score ≥ −1 Normal
by low bone mass and structural deterioration of −1 > T-score > −2.5 Low bone mass
bone tissue that increase the risk of fracture due to
weakened bone strength” by the National Institutes T-score ≤ −2.5 Osteoporosis
of Health Consensus Development Panel.3 Bone T-score ≤ −2.5 with existing Severe osteoporosis
strength is determined by bone density and quality. fracture
Bone quality is determined by the bone turnover rate,
BMD, bone mineral density.
bone microarchitecture and mineralization, etc., but From NIH Consensus Development Panel on Osteoporosis Prevention,
these are rarely used to diagnose osteoporosis because Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and
it is difficult to measure bone quality in a clinical therapy. JAMA. 2001;285(6):785–795; with permission.
27
recommends the use of a uniform Caucasian (non–

TABLE 3.2
race adjusted) female reference for males of all ethnic
Commonly Prescribed Medications Lowering
groups. In addition, if local reference data are available,
Bone Mineral Density and Possible Mechanisms
they should be used to calculate only Z-scores but not
T-scores.7␣ Drug Class Mechanism of Action
Glucocorticoids Decreased bone
Epidemiology and Risk Factors formation and increased
With advancing age, BMD decreases and the preva- bone resorption
lence of osteoporosis increases. It is estimated that over Proton pump Unknown but may be due
200 million subjects worldwide suffer from the disease.8 inhibitors to decreased intestinal
It is estimated that the annual number of osteoporotic absorption of calcium
hip fractures worldwide will rise from 1.66 million to Anticonvulsants Uncertain but may include
6.26 million by the year 2050. Approximately 30% of (phenytoin, carbam- inactivation of vitamin D
all postmenopausal females in the United States and azepine, phenobarbital,
Europe have osteoporosis.9 In Sweden 6.3% of males valproic acid)
and 21.2% of females aged 50–80 years have been clas- Levothyroxine Increase in both the number
sified as osteoporotic.10 Currently, in Asian countries, (oversupplementation) and turnover rate of bone
the incidence of osteoporosis is relatively low com- turnover units
pared with that in Western countries. However, accord-
Aromatase inhibitors Reduced estrogen produc-
ing to projections by the WHO, the Asian population tion leading to increased
will consist of 900 million males and females aged bone resorption
≥65 years by the year 2050. As a result, although only
GnRH agonists Prevent the production of LH
30% of all hip fractures worldwide occurred in Asia in
and FSH, thereby decreasing
1990, this figure will be more than 50% by 2050.11 testosterone and estradiol
Osteoporosis in aging societies experiencing pro- and leading to increased
longed life spans has already attracted a great deal bone resorption
of interest in terms of risks and management; many
Serotonin selective Uncertain
research and clinical reports have appeared. In par- reuptake inhibitors
ticular, the consequences of osteoporosis are worse
Thiazolidinediones Decreased bone formation
for older adults; the number of osteoporotic frac-
tures increases with age, as do the risks of fracture- Heparin Osteoblast inhibition with
related morbidity and mortality.12 The rate of bone decreased bone formation;
loss is approximately 1% per year after 30s and higher increased bone resorption
during the perimenopausal period (bone loss com-
FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing
mences before menopause). In approximately, 50% of hormone agonist; LH, luteinizing hormone.
subjects aged 65–69 years, the bone mineral content
falls below the fracture threshold, which is the 90th
percentile for proximal femoral BMD for hip fractures and a sedentary lifestyle. Secondary osteoporosis may
and that of the spine for vertebral fractures, respec- be the consequence of endocrine and metabolism dis-
tively. Almost all individuals aged ≥85 years exhibit orders (e.g., hypogonadism, hypercortisolism, hyper-
bone mineral contents that have reached the fracture parathyroidism, hyperthyroidism, and/or anorexia),
thresholds, and most elderly females are at risk of lymphoproliferative disorders, intestinal malabsorp-
fracture. Osteoporosis causes approximately 9 mil- tion, rheumatoid arthritis, renal failure, and/or certain
lion fractures annually worldwide, of which more drugs (e.g., corticosteroids, selective serotonin reuptake
than 4.5 million occur in the Americas and Europe. inhibitors, anticoagulants, antidiabetic medications,
The estimated lifetime risk for a wrist, hip, or verte- anticonvulsants, and proton pump inhibitors). For
bral fracture is approximately 30%–40% in developed example, the main culprits in male drug-induced osteo-
countries. porosis are glucocorticoids and androgen deprivation
Primary osteoporosis has been known to be asso- therapy (ADT).13
ciated with major risk factors including advanced age, Commonly prescribed medications that decrease
female sex, low body weight/body mass index, early BMD and the potential associated mechanisms of
menopause, low calcium and/or vitamin D intake, action are summarized in Table 3.2.
CHAPTER 3 Osteoporosis and Fragility Fracture 29
TABLE 3.3
Common Laboratory Findings in Primary and Secondary Osteoporosis
Calcium Phosphate PTH ALP
Primary osteoporosis NC NC NC NC
Primary hyperparathyroidism Inc Dec Inc Inc
Malignant hypercalcemia Inc NC Dec Inc
Vitamin D insufficiency Dec or NC Dec or NC Inc or NC Inc or NC
Osteomalacia Dec Dec Inc Inc
ALP, alkaline phosphatase; Dec, decreased; Inc, increased; NC, not changed; PTH, parathyroid hormone.
Recently, fracture risk prediction algorithms, such TABLE 3.4

as the fracture risk assessment tool (FRAX), have been Bone Turnover Markers in Osteoporosis
widely used to predict osteoporotic fractures. FRAX is
used diagnostically to evaluate the 10-year probability Bone Resorption Bone Formation
of bone fracture (www.sheffield.ac.uk/FRAX).14 The Markers Markers
FRAX tool was developed in 2008 by the WHO to cal- Hydroxyproline Bone-specific alkaline
culate the overall risk of fracture (in both females and phosphatase
males) by reference to several clinical risk factors, with Pyridinolines Osteocalcin
or without the measurement of BMD. The clinical risk
N-terminal cross-linking C-terminal propeptide of
factors included in the FRAX algorithm are age, sex, telopeptide type I collagen
weight, height, a previous fracture, a parental hip frac-
C-terminal cross-linking Procollagen type I
ture, current smoking status, glucocorticoid use, rheu-
telopeptide N-terminal propeptide
matoid arthritis, secondary osteoporosis, and alcohol
intake (≥3 units/day).␣
Workup and Management of Osteoporosis reflect an underlying malignancy or hyperparathy-

Approaches roidism; hypocalcemia can contribute to osteopo-
Clinical history taking of patient’s complaints, any rosis. Inadequate vitamin D levels can predispose to
medical history relevant to bone metabolism, accom- osteoporosis. Liver function tests and measurements
panying diseases, medication use, and family history of the levels of thyroid-stimulating hormone, para-
(osteoporosis, breast cancer) are obtained from the thyroid hormone, luteinizing hormone, and follicle-
patient. Physical examination should begin with an stimulating hormone are also need to be checked.
inspection of the patient. Thoracic kyphosis, a dowager Elevated parathyroid hormone levels and sex hor-
hump, and a history of height loss increase the suspi- mone deficiencies are secondary causes of osteopo-
cion of vertebral fracture. In addition, examination of rosis (Table 3.3).
active and passive range of motion (ROM) is necessary Bone-specific alkaline phosphatase, osteocalcin,
to determine whether bone and/or joint pathology urine hydroxyproline have all been evaluated as pos-
may also be present.3,15␣ sible markers of bone turnover16,17 (Table 3.4). Such
markers may be useful to monitor patients and aid in
Laboratory studies decision-making as to when therapy should be recom-
Laboratory studies are performed to establish base- menced, but they still have limited clinical utility.18 The
line conditions or to exclude secondary causes of International Osteoporosis Foundation and the Inter-
osteoporosis. A complete blood count and serum national Federation of Clinical Chemistry and Labora-
levels of calcium, phosphate, alkaline phosphatase, tory Medicine Working Group recommend the use of
25(OH)-vitamin D, and creatine are measured at one bone formation marker (serum procollagen type I
baseline. The serum levels of calcium, phosphate, and N propeptide, s-PINP) and one bone resorption marker
alkaline phosphatase are usually normal in patients (serum C-terminal cross-linking telopeptide of type I
with primary osteoporosis. Severe hypercalcemia may collagen, s-CTX) as reference markers.19␣
Treatment of osteoporosis intravenous preparations affording high bioavaila-

Various pharmacologic and nonpharmacologic thera- bility are advantageous in terms of therapeutic effects
pies have been developed to prevent and delay osteo- in some geriatric patients with especially poor drug
porosis. Here, we will review the latest trends in bioavailability and poor compliance. Both oral and
pharmacotherapy; rehabilitation and exercise manage- intravenous formulations of ibandronate are avail-
ment will be discussed in later parts of this chapter. The able.20 Zoledronate is frequently used as an intrave-
generic drug names, dosages, instructions for adminis- nous bisphosphonate administered once a year for
tration, precautions, and side effects are summarized the treatment of osteoporosis.21 Although this treat-
in Table 3.5. ment is well established, routine use of zoledronate
is limited because of the cost and concerns regarding
Bisphosphonates. Bisphosphonates are the most adverse effects such as nephrotoxicity and cardiotox-
common drugs to treat osteoporosis. All second- icity. In particular, zoledronate is contraindicated in
and third-generation bisphosphonates (alendronate, patients with creatinine clearance < 35 mL/min. Oral
risedronate, ibandronate, and zoledronate) with ni- ibandronate is relatively safe in geriatric patients
trogen-containing side chains are powerful antiresorp- with chronic kidney disease.␣
tive agents that effectively limit osteoclast-mediated
bone resorption, increasing BMD and reducing frac- Parathyroid hormone therapy. Anabolic agents stim-
ture rates.20 Oral bisphosphonates are minimally ulating bone formation are ideal therapies for patients
absorbed by the intestine (1% bioavailability) and with osteoporosis. The only anabolic agent currently
should thus be taken on an empty stomach and ac- approved by the Food and Drug Administration (FDA)
companied by sufficient calcium intake. Therefore, is teriparatide or PTH 1-34, which effectively treats
TABLE 3.5
Pharmacologic Treatment for Osteoporosis
Instructions for Administration
Medication Treatment Dosage and Precautions Side Effects
BISPHOSPHONATES
Alendronate 10 mg once daily, Take first thing in the morning Esophagitis, heartburn,
70 mg once weekly Take with full glass of plain water difficulty swallowing, headache,
Wait for >30 min to eat; take other fever, etc.
medications
Sit upright/stand for over 30 min
Caution with renal dysfunction
Risedronate 5 mg once daily, See above See above
35 mg once weekly
Ibandronate Oral: 2.5 mg once See above See above
daily, 150 mg once renal toxicity, injection site
monthly, 3 mg once reaction, ocular inflammation;
every 3 months rarely, osteonecrosis of jaw
Zoledronate 5 mg infused over Take Ca and Vitamin D if See above (alendronate)
15 min, yearly insufficient in diet Acute-phase reaction (headache,
Caution with renal dysfunction myalgias, fever)
HORMONE THERAPY
Teriparatide 20 mcg SQ everyday Contraindicated in hyperparathy- Muscle cramps, spasm,
roidism and open epiphyses dizziness, sore throat
MONOCLONAL ANTIBODY
Denosumab 60 mg SQ everyday Caution with patients with Eczema, flatulence; rarely,
impaired immune system cellulitis
osteoporosis, significantly reducing the fracture risk, and person-years. The incidence of falls in a cross-sectional
has excellent safety profiles. However, it can be incon- public survey was 13% among the community-dwell-
venient to administer, as daily subcutaneous injections ing elderly. Furthermore, approximately 20% of falls
are required.16␣ required medical attention, and approximately 10%
caused fractures.25 Among fragility fractures, hip frac-
Denosumab. Denosumab is an antiresorptive agent ture is the most catastrophic for patients and their fami-
limiting osteoclast-mediated bone resorption. The lies and the most expensive to treat. It is estimated that
FDA has approved the drug for the treatment of os- the incidence of hip fracture will rise from 1.66 million
teoporosis and to prevent bone loss in males on ADT worldwide in 1990 to 6.26 million by 2050.26 Vertebral
who are at high risk of fracture.22 Denosumab is a fracture is the most common fragility fracture, reducing
fully human monoclonal antibody that specifically health-related quality of life by causing back pain as
binds to receptor activator of nuclear factor κ-B ligand well as decreasing physical capabilities and perceived
(RANKL), the master regulatory molecule required general health and emotional status. The epidemio-
for osteoclast formation and activity, thereby prevent- logic data on vertebral fractures differ from report to
ing RANKL from binding to the osteoclast receptor, report largely because only one-quarter to one-third of
RANK. Thus, osteoclastogenesis and bone-resorbing vertebral fractures are clinically recognized at the time
activity are inhibited and bone resorption is markedly of occurrence and lateral spine imaging is required.27
suppressed. Freemantle et al. showed that denosum- Wrist fracture is more prevalent in younger old women.
ab was more effective at reducing the occurrence of Such fractures are not just fractures; they are warnings
vertebral fractures than were raloxifene, risedronate, of further fragility fractures in the future. Both vertebral
and alendronate. The long-term efficacy and toxicity fractures and nonhip nonvertebral fractures should
of denosumab need to be explored in studies that in- also be considered clinically important and financially
clude longer follow-up periods than those of previous significant.␣
works.23␣
Outcomes of Fragility Fractures
After hip fracture in-hospital mortality was 1.6%,
FALLS AND FRAGILITY FRACTURES 1-month mortality 9.6%, and 6-month mortality
Injuries caused by falls, the leading cause of nonfatal 13.5%, another 12.8% patients required constant
injuries and the third leading cause of fatal injuries in assistance to ambulate.28 The 1-year mortality rates
the United States, have increased in recent years. The were variable, ranging from 11.5% to 33% depending
WHO defines fragility fracture as a fracture occurring on the study design (prospective or retrospective) and
during an activity that would not normally injure a institutions and countries where the studies were con-
young healthy bone (i.e., a fall from standing height ducted.29–33 The most common postoperative com-
or less). Of all fragility fractures, the care and rehabili- plications were chest infection (9%) and heart failure
tation of patients with hip fractures pose critical chal- (5%).33 The risk factors for death after hip fracture
lenges in terms of functional outcomes and medical were increased age, male sex, multiple comorbidities,
costs in a superaged society. More attention must be and cognitive disorders.29,34–36 Functional outcomes
paid to mortality and morbidity profiles, loss of inde- such as mobility and living independence are criti-
pendence, and their resulting clinical and socioeco- cal when evaluating the success of geriatric rehabili-
nomic impacts. tation in patients experiencing fall-related fragility
fractures (Fig. 3.1). Individuals with hip fractures
Epidemiology suffer increased long-term disability and functional
Several epidemiologic studies have explored the inci- dependence; most older adults do not reattain their
dence of falls and fall-related injuries; the findings are preinjury functional levels. One Japanese study found
diverse. One study reported that one-third of subjects that the proportion of patients who could walk out-
aged >65 years fall at least once each year, as do half doors alone with or without an assistive device was
of those aged >80 years.24 A special supplement of 68% before the fracture and was reduced to 51% by
the NHIS (National Health Interview Survey), one of 120 days postfracture.37 Of patients hospitalized for
the largest health surveys in the United States, noted hip fractures, only 60% had recovered their prefrac-
that 12% of community-dwelling adults reported fall- ture walking ability 6 months later.38
ing in the previous year, yielding a total estimate of Recurrent or repeated fractures, a second or subse-
80 million falls per year and a rate of 37.2 falls per 100 quent fracture at any site after the initial fracture, are
Adult Life
Early Life Late life
Fall-related
fracture
Successful
Function
rehabilitation
Disability threshold
Functional decline
Death
Age
FIG. 3.1 Consequences of fall-related fracture.
associated with higher mortality and a greater risk of as computed tomography (CT). Therefore, emergency
admission to a nursing care facility, compared with CT scan should be used instead. Because they are older
the primary fracture events.39 The refracture rate of ver- patients, the presence of medical and neurologic disor-
tebral fractures was 16.6%, and the rate of refracture ders should be checked before surgery and appropri-
1 year after surgery in patients with hip fractures was ate measures be taken. To minimize complications,
3.19%–5.16%.40␣ such as muscle weakness and pressure ulcers, accurate
assessment is essential. Although the use of pretreat-
ment traction has been reported to reduce preoperative
ORTHOPEDIC TREATMENT pain and to reduce further fracture displacement, its
Of the various fragility fractures, the management effectiveness thereof remains unclear; traction has been
of hip fractures, which constitute major burdens on reported to increase the requirement for analgesic anti-
public health systems, and vertebral fractures causing inflammatory agents.41 Care should also be taken to
back pain and dysfunction is the principal topic of this prevent the development of pressure ulcers, deep vein
section.␣ thrombosis (DVT), and pneumonia. The optimal time
to surgery remains unclear, but surgical fixation should
Preoperative Care not be delayed very long to reduce complications asso-
Most patients with hip fractures are delivered to emer- ciated with the fracture.␣
gency rooms. The fracture should be diagnosed by
taking history and performing the necessary physical Perioperative Care Before and After Surgery
examination. With the patient supine, and the leg held Perioperative time (preoperative and postoperative
in external rotation and abduction, the leg appears to be time) is defined as the time from immediately before
shortened. Pain is elicited on gentle internal and exter- surgery to the end of postoperative medical stabiliza-
nal rotation of the lower leg and thigh. A fracture may tion. During this period, various surgical treatments,
be suspected if groin pain is elicited on axial loading prevention of early complications that may develop
and the patient is unable to perform an active straight after surgery, and medical treatment are important
leg raise. Ecchymosis is rarely present initially. Plain components of management.
X-rays are the most widely used imaging technique for
the diagnosis of hip fractures. To diagnose occult frac- Orthopedic management
tures, magnetic resonance imaging is the gold standard Hip fractures are classified as femur neck frac-
but is neither as readily available, nor as inexpensive tures, intertrochanteric fractures, or subtrochanteric
A B C D
FIG. 3.2 Various surgical treatments for hip fractures. (A) Total hip replacement arthroplasty, (B) bipolar
hemiarthroplasty, (C) proximal femoral nail antirotation, and (D) compression screw fixation.
fractures according to the fracture site. Femoral neck surgical procedure. When compression screw fixation
fractures are classified according to the anatomical is used to treat comminuted fractures, weight-bearing
location of the fracture and the extent of displace- is often not permitted for several days to weeks,
ment. Structurally, such fractures may be classified to allow adequate bone union. On the other hand,
as impacted, nondisplaced, or displaced fractures. replacement arthroplasty enables earlier mobilization
The Garden’s classification system is most commonly and provides superior functional outcomes, compared
used in clinical practice to assess the fracture type with those of internal fixation in elderly patients with
and severity. Fractures are divided into four types unstable fractures.
depending on the presence or absence of displace- Osteoporotic vertebral compression fractures
ment and the extent of displacement. Type 1 and 2 in the thoracic or lumbar spine cause serious acute
fractures are associated with good prognoses. Type 3 back pain, especially during postural changes. Bed
and 4 fractures (displaced fractures) potentially cause rest for longer than a few days is not recommended
complications such as avascular necrosis. Nonsurgical for those with stable fractures, because immobiliza-
treatment should be applied cautiously, because the tion can trigger muscular weakness in the spine and
patient cannot perform joint movement or tolerate lower extremities. Appropriate spinal orthoses and
weight-loading for a considerable period of time. In analgesics aid in reducing the pain induced by spi-
terms of surgical treatment, various methods are used nal motion. The efficacies of the various vertebral
depending on the patient’s condition, level of activ- augmentation techniques, including percutaneous
ity, combined disease status, age, and the preference vertebroplasty and balloon kyphoplasty, remain con-
of the surgeon. Of the surgical methods used for hip troversial, although they may relieve acute or chronic
fracture treatment, internal fixation using metal plates back pain in some patients.42–44 If no neurologic
or pins is widely used to treat nondisplaced fractures. deficit is apparent, early initiation of rehabilitation
Replacement arthroplasty is usually performed to program including balance training and strengthen-
treat femoral neck fractures. Intertrochanteric or extra- ing exercises can help accelerate functional recovery
capsular fractures associated with displacement may after compression fractures.
undergo replacement arthroplasty or internal fixa- Other fragility fractures of the wrist (mainly the
tion, but the optimum treatment remains controver- distal radius) and proximal humerus often require
sial (Fig. 3.2). Postoperative rehabilitation differs by reduction and internal fixation.␣
Postoperative complications with hip fractures was found to reduce the incidence of
Thromboembolic disease. The incidence of DVT deep infections and urinary tract infections.49␣
after hip fracture surgery is increasing. Proximal
thrombosis has been reported in up to 27% of pa- Delirium. Delirium is a relatively common problem
tients, and the incidence of fatal pulmonary embo- during hospitalization for hip fracture treatment and
lism during the first 3 months has increased from is one of the major factors prolonging hospitalization
1.4% to 7.5%.45 The lack of sufficient sensitivity as- and increasing the medical costs. Delirium is charac-
sociated with physical examination renders a diagno- terized by the sudden appearance of disturbance(s) in
sis of DVT difficult. If persistent edema is apparent, consciousness and changes in cognitive function, with
but there is no evidence of inflammation or pain in the symptoms rising and falling over a single day. It
the thigh or lower leg, combined with elevated D- is essential to identify and eliminate the cause of de-
dimer level, a diagnosis of DVT may be made by ul- lirium. Maintenance of O2 saturation (>95%), blood
trasound Doppler imaging or CT angiography.46 If pressure (systolic blood pressure > 90 mmHg), electro-
DVT is evident, low doses of heparin are more appro- lyte balance, postoperative pain control, and bladder
priate for minimizing bleeding side effects. The Na- and bowel functions; good nutrition; and early reha-
tional Institute for Health and Care Excellence guide- bilitation are important to prevent delirium. Nonphar-
line suggests that venous thromboembolism (VTE) macologic intervention is the mainstay of delirium
prophylaxis should be combined with mechanical treatment. Haloperidol is a recognized first-generation
and pharmacologic treatments when caring for pa- drug, and olanzapine, risperidone, and quetiapine fu-
tients undergoing hip fracture surgery. Mechanical marate are second-generation drugs.50 However, such
VTE prophylaxes include antiembolism stockings, medications should be final options, prescribed only
foot impulse devices, and intermittent pneumatic when patients may harm themselves or others. Further
compression devices. Mechanical VTE prophylaxis details of delirium appear in Chapter 13, Geriatric Psy-
should be continued until the patient’s mobility is chiatric and Cognitive Disorders: Depression, Demen-
no longer significantly reduced since admission. The tia, and Delirium.␣
guideline recommends the addition of pharmaco-
logic VTE prophylaxis for patients with a low risk of
bleeding, using either low molecular weight heparin REHABILITATION IN ACUTE CARE
or unfractionated heparin (for patients with severe Establishment of a Postoperative
renal impairment or established renal failure). Phar- Rehabilitation Program
macologic VTE prophylaxis is continued until the A specific and stepwise postoperative rehabilitation
patient no longer exhibits significantly reduced mo- program should be established by every institution
bility (generally 5–7 days).47 In some Asian countries engaged in geriatric interventions. An integrated
including Korea, VTEs are relatively uncommon, aris- rehabilitation program applied after hip fracture sur-
ing in only 5.1% of all cases in one study.48 Patients gery is essential for elderly patients, and such pro-
at an increased risk of bleeding are often treated via grams have recently become established in several
nonpharmacologic methods, such as early mobili- countries.
zation, antithrombotic stockings, or pump therapy, In the United Kingdom, models of orthogeriatric
without the prescription of prophylactic thrombo- care have become well established. Perioperative ortho-
lytic agents.␣ pedic management is followed by early postoperative
transfer to a geriatric orthopedic rehabilitation unit.
Infection. Infection is one of the most serious com- The identification of appropriate patients may be left
plications after fracture treatment. If a deep infection to orthopedic staff, specialist orthogeriatric liaison
develops, bone union may be impossible, and the in- nurses, or geriatricians on their rounds. The extent of
ternal fixator or artificial joint should be removed and orthopedic input to the rehabilitation ward depends on
the necrotic tissues be resected. Apart from infectious how soon patients are moved from acute wards; ready
symptoms such as fever and chills, persistent pain access to orthopedic advice is vital if the momentum of
around the hip joint, pain associated with joint mo- rehabilitation is to be maintained. A weekly visit by a
tion, and an increased erythrocyte sedimentation rate surgeon at a predictable time allows multidisciplinary
should raise a suspicion of infection, which must then team members to describe their concerns and problems
be investigated meticulously and treated with antibiot- and discuss X-rays with the specialist. Alternatively, an
ics. Prescription of prophylactic antibiotics for patients orthopedic liaison nurse may visit the rehabilitation
ward to give advice, adjust plaster casts, and liaise with living (ADL), quality-of-life scores, and frailty scores all
orthopedic surgeons.51 improved significantly.52␣
In Korea, a multidisciplinary fragility fracture care
program (particularly for those with hip fractures) Rehabilitation in the acute phase and
staffed by physiatrists, geriatricians, and orthopedic subacute phase
surgeons has been established since the mid-2000s. The goal of rehabilitation of patients in the acute and
Recently, a nationwide, multicenter fracture liaison subacute phases is to get them out of bed as soon as
service launched a standardized, fracture-integrated possible and to make them stand and walk using
rehabilitation management of the hip joint (FIRM- walking aids. At this stage, recovery of joint ROM and
HIP) program to aid the elderly. This is based on the strength, pain control, and training in ADLs are all
critical features of fragility fracture rehabilitation in required. In addition, planning for functional recovery
both hospital and community settings. Patients receive and discharge should commence.
FIRM-HIP care, which consisted of physical therapy The modified Barthel index can be used to assess
(lower limb strengthening and gait training using assis- competence in terms of ADLs. Screening tests detecting
tive device, twice daily), occupational therapy (several cognitive dysfunction and dementia should be applied.
sessions during admission), training in fall prevention, Elderly patients exhibit limitations in the performance
and discharge planning advice for 2–3 weeks after hip of daily activities because of comorbidities and cogni-
surgery (Table 3.6). No serious event has been reported tive decline. As comprehensive management is thus
among patients who received FIRM-HIP care. At an required, interest is growing in the formation of stan-
average of 6–7 days postoperatively, patients are trans- dardized protocols using team and multidisciplinary
ferred to the department of rehabilitation medicine. approaches.
After FIRM-HIP care, we found that mobility scores, Early mobilization (within 24 h after surgery) is
competence when engaged in the activities of daily required. Exercise is essential to prevent DVT, pressure
TABLE 3.6
An Example of Integrated Rehabilitation Management for Hip Fracture
Goal Items of Rehabilitation Management
Prevention of Delirium: pain management, cessation of medications aggravating delirium, and environmental
complications modification
Pressure ulcer: education for position change and prevention of shear stress (to caregiver)
Pneumonia: sputum expectoration and education of respiratory training
Cystitis: early removal of an indwelling catheter, evaluation of bladder function, and urinalysis
Evaluation of nutritional status and nutritional support
Mobility training Wheelchair ambulation: 1–2 days after operation
and exercise Tilt table training, standing frame, and parallel bar standing (if patients cannot walk premorbidly)
Gradual increase in weight-bearing and early initiation of walker gait (if patients can walk premorbidly)
Cane gait if mobility function improves
Hip range of motion exercise: careful for patients who underwent total hip arthroplasty or
hemiarthroplasty
Isotonic strengthening exercise using machine and rubber band—Stationary bicycle is not
applied for patients who underwent replacement arthroplasty
Balance training: using instrument and machine
Occupational Training for activities of daily living: bedside activity, transfer, sit-up and sit-to-stand, dressing,
therapy wearing shoes, toileting, etc.
Early supported Determination of transfer to other hospital or discharge to home
discharge Home exercise education
Architectural barrier removal when visiting home
Community liaison: providing information for community liaison, sharing patients’ information
with local hospitals, and regular functional evaluation after discharge
muscles is also beneficial, for example, by placing

objects under the knee. Such strengthening exer-
cises aid walking via muscular retraining. Vigorous
resistive exercise is not recommended at this phase.
During the early postoperative period, straight leg
raising exercises need to be avoided, because this
may increase the rotational torque on the internal
fixator of the replaced joint.␣
COMMUNITY CARE AND LONG-TERM

CARE
Loss of functional independence is a well-known
long-term sequela after a fragility fracture.53 Func-
tional outcomes are particularly poor for those who
FIG. 3.3 An example of right hip dislocation developed already live in nursing homes.54 However, deteriora-
3 weeks after bipolar hemiarthroplasty. tion in the health-related quality of life is common
in patients who have suffered fragility fractures.55
ulcers, and atelectasis. Patients may commence with Longitudinal studies have found that the functional
ankle pumping and then restore ROM via passive and status of such patients declined following the taper-
active assistive exercise. After the patient attains a standing of rehabilitation services.56 Relative immobility
ing posture and balance using a parallel bar, rehabilita- following discharge contributes to balance deteriora-
tion training features walking with a walker or cane. In tion and muscle weakness, increasing the likelihood
patients who underwent replacement arthroplasty via a of subsequent fractures. Recent clinical trials showed
posterolateral approach, internal rotation, adduction, that the long-term functional outcomes afforded by
and hyperflexion (>90 degrees) of the hip joint should geriatric rehabilitation services delivered after surgery
be avoided for 2–3 months after surgery to prevent dis- to treat fragility fractures included significantly better
location of the metallic femoral head (Fig. 3.3). Fur- mobility and ADL scores.57–59 However, the evidence
thermore, ADL training must continue in the home supporting long-term functional improvement after
or rehabilitation facility, and cognitive rehabilitation the regular rehabilitation period remains weak. A
may be required depending on the extent of cognitive metaanalysis of 11 studies failed to demonstrate any
decline. improvement in long-term functional outcomes after
It is essential that ADL training is subdivided the implementation of rehabilitation or orthogeriatric
into small manageable activities; application of the models of care.60 Therefore, a few months of geriatric
whole activities should be performed only after rehabilitation after fragility fracture surgery may not
training for each part is complete. The use of walk- be enough to achieve the previous levels of function;
ing aids is important for elderly patients because of continuous community-based rehabilitation services
poor balance, loss of muscle strength and endurance, are required.␣
and visual and sensory dysfunctions. For example,
a walker, cane, long-handled reacher to cope with Exercise
reduced ROM caused by surgery, handle in the Home-Based Exercise
bath, bath chair, and auxiliary chair to raise the toi- Notably, a prospective cohort study found that most
let seat height may all be helpful. It is necessary to (75%) patients receiving standard care for fractured
evaluate and remove architectural barriers at home hips did not even meet a very low target of return to
before discharge. Thresholds and stairs that compro- the prior level of function at 12 months postopera-
mise walking, lack of space between furniture, and tively.61 Therefore, home-based exercise is an essential
inappropriate lighting all need consideration and component of long-term care after fragility fractures. To
modification. this end, the ProMo Trial59 randomized 81 hip fracture
Early active, active assistive, and isometric exer- patients to standard care or a year-long home-based
cises are required for the hip extensors, flexors, and program including evaluation/modification of envi-
abductors. Isometric contraction of the quadriceps ronmental hazards, guidance in terms of safe walking,
pain management, progressive implementation of a fracture patients found that mobility and functional
multicomponent home exercise program, and physical outcomes improved in ≥60% of patients who were
activity counseling. The program reduced the overall malnourished on admission and then randomized
disability of the elderly after hip fracture. Orwig et al. to the experimental intervention.67 It is not surpris-
developed an exercise program featuring 12 months ing that such a modest intervention, without attention
of home-based aerobic and strength training after hip paid to the cause of malnutrition, changes to the resi-
fracture surgery.62 The program increased activity levels dential environment, or ongoing nutritional support,
and modestly improved bone density, compared with improved clinically relevant long-term outcomes and
usual care. However, in contrast to their hypotheses, even resulted in weight gain. Finally, a controlled trial
no significant changes in muscle mass, strength, ADL in the Netherlands evaluated the cost-effectiveness of
independence, or physical function were observed. a multicenter, randomized controlled trial of regular
Thus, there is as yet no evidence that such all-inclu- dietary counseling and oral nutritional supplementa-
sive programs are effective compared with shorter- tion for 3 months, postoperatively delivered to 152
term, robust strength training (as described earlier).54 patients with hip fracture.68 Cost-effectiveness was
Notably, the lack of supervision, the fact that multiple considered significant for weight gain but not quality-
exercise modalities are required, and the fact that the adjusted life years.
patients are at home likely reduce training intensity, In addition, a high-protein diet may impact bone
even if adherence is good, explaining the observed lack health positively via several mechanisms including
of efficacy.␣ increased intestinal calcium absorption, stimula-
tion of insulin-like growth factor-1, and enhanced
Community-based exercise lean body mass.69 Despite previous concerns that an
Interest is increasing in booster exercise program that increase in dietary protein triggers calcinuria to an
continue beyond the regular rehabilitation period extent impairing calcium balance or induces a shift in
for patients with hip fractures who are returning to systemic pH (thus increasing osteoclastic bone resorp-
the community. These programs can be divided into tion), the studies have consistently shown that higher
two groups: exercise training conducted at home and protein intake was associated with a higher bone
that conducted in the community. A systematic review density and lower fracture risk. Protein supplementa-
comparing home- and community-based programs63 tion after hip fracture increased the BMD and muscle
found that the effect sizes for community-based strength and decreased complications and the length
interventions were larger and were more likely to be of hospital stay. Increased protein intake (via diet or
statistically significant, explained by higher exercise supplements) may also be beneficial for the treatment
intensity and the availability of more sophisticated of sarcopenia (which is common in elderly cohort)70
equipment in community-based, extended exercise and, if given near the time of resistance training ses-
facilities. However, the subgroup comparisons should sions, may enhance anabolic adaptation to such
be interpreted with caution, as the differences between training. This was vital in a frail hip fracture cohort
the two groups might be due to confounding factors in whom standard application of resistance train-
rather than the interventional setting. It is true, how- ing, even at high intensity, may not result in muscle
ever, that group settings enhance social interaction hypertrophy.71␣
among patients sharing the same condition, which
may enhance participation in more intensive com- Vitamin D
munity-based programs, reduce costs, and improve All patients with fragility fractures should have their
motor learning skills.64,65␣ 25-hydroxy-vitamin D levels assessed and corrected
to a steady state of >32 ng/mL.72 Many oral supple-
Nutrition ments are available. There is no universal agreement
General malnutrition is both very prevalent (40%– on either the ideal supplement or the dosing schedule.
80% of hospitalized patients with hip fractures) and Vitamin D supplements come in two forms: ergocal-
one of the strongest predictors of poor outcomes ciferol (vitamin D2) (from plants and yeasts) and cho-
after fracture.66 Oral nutritional supplements can lecalciferol (vitamin D3) (from animal sources and
help elderly patients recover after hip fracture surgery production in the skin).73 After repletion of vitamin
and reduce perioperative complications. An inter- D levels, patients are advised to take 2000 IU chole-
disciplinary treatment program evaluating 162 hip calciferol (vitamin D3) daily for long term in addition
to any vitamin D contained in their multivitamin or is a risk factor for a future fracture; this risk is highest
calcium supplements. A metaanalysis of vitamin D3 immediately after the initial event and subsequently
regimens showed that 25-hydroxy-vitamin D levels decreases over time.2,79–81 This was well demonstrated
of 32–44 ng/mL afforded optimal health benefits and recently.79 The authors suggested that the risk of a
were achieved only when 1800–4000 IU vitamin D3 major osteoporotic fracture after the first major osteo-
were taken daily.74 Mean serum calcium levels were porotic fracture was 2.7-fold greater than the risk in the
not adversely affected by dosing regimens of up to general population at 1 year and decreased to 1.4-fold
10,000 IU vitamin D3 daily.75 after 10 years. The risk of a second major osteoporotic
fracture increased by 4% with each year of age. Further-
Mobile Outreach Program more, prior fractures continue to be an important pre-
At the University of Minnesota and Regions Hospital, dictor of fracture risk for up to 10 years, even in models
Geriatric Fracture Program was established in 2004 and adjusted for age, BMD, and other clinical risk factors.82
featured an in-hospital fracture liaison service, a bone Further studies are needed to define the determinants
health and secondary fracture prevention service, and an of imminent risk (e.g., whether the type of fracture
on-site orthopedic clinical service: “Mobile Outreach.” affects the future risk, and whether the risks identi-
This model shares decision-making via high-quality fied are responsive to medical intervention). To date,
communication with patients and their families, which a previous fracture is the strongest predictor of a future
is a cornerstone of the program. Orthopedic care is pro- fracture.
vided for the frailest patients, including those whose Clinicians can also perform more targeted assess-
orthopedic needs are often nonsurgical and for whom ments of balance and gait features that directly impact
public transport access is difficult. In the present era of the fall risk. The Timed Up and Go (TUG) test is
bundled payments and the growth of advanced prac- an extension of the comfortable gait speed test that
tice providers, Mobile Outreach afforded a new oppor- incorporates the additional components of rise from a
tunity to improve the care and outcomes of a growing chair and a turn. Prospective data gathered over 1 year
population of patients with fragility fractures.76 Further showed that the TUG was particularly sensitive when
investigations to reveal the cost-effectiveness of the pro- used to predict future falls in older women with a his-
gram should be needed.␣ tory of vertebral fractures.83 The Berg Balance Scale
(BBS) is a performance-based measure of the ability to
complete 14 mobility tasks that are thought to be rep-
FALL PREVENTION resentative of typical daily tasks. Each task is scored
The occurrence of falls is multifactorial in nature. It on a scale of 0 (unable to complete the task) to 4 (able
results from a combination of extrinsic factors related to do the task independently), with a maximum score
to the environment and intrinsic factors related to indi- of 56. The BBS has been useful for predicting falls in
vidual physical and cognitive conditions.77 Such intrin- the frail elderly.84 Measurement of the comfortable
sic factors include muscle strength, flexibility, balance, gait speed is a simple method to assess dynamic bal-
gait, and mobility, all of which are potentially modifi- ance that can be performed in any clinic, hallway, or
able by adequate and effective interventions. Geriatric room, and it has shown strong prediction of future
physiatrists should review their prescription of medi- disability, institutionalization, and even mortality.85
cations that may increase the risk of falls (antihista- Gait speed is also a significant predictor of falls;
mines or sleeping pills). Vitamin D is recommended 0.8 m/s was an optimal cutoff for identifying at-risk
for patients at risk of vitamin D deficiency. Physiatrists individuals.86 Gait speed measures typical aspects of
should also conduct a comprehensive geriatric assess- postural maintenance, required for basic upright bal-
ment to identify impaired mobility and dementia, both ance and simple ambulation. However, as is true of
of which contribute to the risk of falling. Further details single measure, critical information may be lost or
of fall are described in Chapter 4, Fall Prevention and overlooked if an inappropriate incorrect assessment
Intervention.␣ tool is chosen and a functionally impaired area is thus
not assessed.87␣
Fall Risk Measurements
Many possible predictors of fall-associated fractures are Interventions to Prevent Falls
known; the timing of the associations between these Physical exercise significantly prevents falls and
risk factors and the actual fracture remains unclear.78 fractures in the ambulatory elderly.88 Several sys-
It is evident that a previous fracture (at a different site) tematic reviews and metaanalyses have emphasized
and demonstrated the beneficial effects of physical assistance. When in bed, upper body resistance train-
exercise programs on falls and fracture prevention ing (arm curls or arm raises) was performed. Target
in community-dwelling older adults.89–91 Exercise goals were individually set and adjusted on a weekly
improves strength, endurance, muscle flexibility, basis. Although this intervention may seem too sim-
and postural balance. Therefore, exercise not only ple, the intervention group exhibited significantly
reduces physical disability and functional limita- better functional outcomes than those of the control
tions in older adults but also aids in the mainte- group (in terms of strength and mobility endurance)
nance of mechanisms that prevent imminent falls.92 and a 10% reduction in the incidence of acute condi-
In contrast, the effect of exercise on fall and fractions. Therefore, no matter how simple the exercises
ture prevention in long-term care residents remains are, it can positively work on fall prevention.␣
controversial. A recent Cochrane review suggested
that exercise was not effective in preventing falls in
long-term care residents.93 However, the review was CONCLUSION
limited in terms of the studies selected for the evalu- Those involved in rehabilitation for falls and osteo-
ation; these studies included not only specific exer- porotic fracture must have a good understanding of
cise interventions but also general fall prevention osteoporosis, falls, fragility fracture, and pre-, peri-,
programs in which exercise was just one component and postoperative care. Multidisciplinary integrated
of the entire program. This may affect the validity rehabilitation programs are paving the way by which
of conclusions drawn in terms of a specific role for practitioners to provide appropriate postoperative care
exercise in fall prevention (the primary outcome).92 and improve the quality of life after hip fracture sur-
A more recent systematic review suggested that com- gery. There is no easy path to fall prevention. However,
bined, frequent, and long-term exercise programs are the first step is clinical awareness and evaluation of the
effective to prevent falls in long-term care facilities, risk of falls. In addition, the risk can be minimized by
but no effect of exercise on fracture prevention was the exercise programs included in community-based
noted.92 It was also reported that exercise was more fall prevention programs.
effective when programs lasted for >6 months with
two to three exercise sessions weekly.
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CHAPTER 4
Fall Prevention and Intervention

MOOYEON OH-PARK, MD • MICHELLE DIDESCH, MD
INTRODUCTION Slips and trips are terms often used by older adults
Falls are highly prevalent1 and a significant concern as synonyms for falls. A slip is “sliding of the support
among older adults worldwide. Falls, however, are not leg” and a trip is an “impact of the swinging leg with
part of the normal aging process. Rather, they reflect an external object or a body part.”5 These events may
the combined effect of illness, medications, and envi- result in falls but are not synonymous with falls.
ronmental hazards.2 Falls in older adults can lead to A clear definition of falls must be used to improve
devastating consequences of additional morbidity, the effectiveness of screening high-risk individuals
loss of independence, institutionalization, and even and to improve the validity of fall research. A list of
death. Falls also affect self-esteem and confidence in International Statistical Classification of Diseases and
older adults, compromising their quality of life. The Related Health Problems (ICD)-10 codes is included
direct cost for fall injuries in the United States was esti- in Table 4.1; consistency in diagnostic coding will also
mated at around $31 billion in 2015.3,4 Literature has help improve clinical research.␣
shown that systematic fall risk assessment, targeted
intervention, exercise programs, and environmental
modifications can significantly reduce falls among EPIDEMIOLOGY OF FALLS
older adults. This chapter will provide an overview of Fall Rates and Risks
the epidemiology and risk factors of falls as well as A variety of methods are used to determine and
a practical guide for fall prevention and intervention report falls, which makes it challenging for health-
among older adults in community and institutional care providers to compare fall rates or risks among
settings.␣ different care settings. Rate of falls is defined as “the
total number of falls per unit of person time that
falls were monitored (e.g., falls per person year).”
DEFINITION OF FALLS Risk of falling is calculated as the number of fall-
Although falls can be easily recognized when they ers during a given time.7 It is important to recognize
occur, the term “fall” can hold different meanings for how the fall rate and risk are calculated to under-
older adults and healthcare providers. For example, stand the epidemiology of falls and the effectiveness
most older adults often associate falls with a physical of interventions.
loss of balance but rarely as a side effect of medications. Falling is a common problem for older adults.
In addition, both older adults and healthcare providers Approximately 30% of persons aged ≥65 years suf-
tend to focus on the consequences of falls, which can fer a fall each year.8,9 After 75 years of age, fall rates
result in dismissing noninjurious falls, thereby missing increase up to 50% per year with an increase in con-
an opportunity for early intervention.5 comitant injury and mortality.1,10,11 Unfortunately,
The World Health Organization defines a fall as after an initial fall, the risk of a repeat fall within a
an event that results in a person coming to rest inadver- year is 66%.9
tently on the ground or floor or other lower level.6 The Despite this high prevalence, older adults are often
Kellogg International Working Group on the Preven- reluctant to discuss falls with their healthcare provid-
tion of Falls by the Elderly includes this additional ers because of the fear of losing their independence.
phrase to the definition: other than as a consequence of In the community, women fall more frequently than
the following: sustaining a violent blow, loss of conscious- men. Although this may be related to physical factors
ness, sudden onset of paralysis, as in a stroke, an epileptic such as bone mineral density and lower-extremity
seizure.2 strength, this statistic is skewed because women are
43
TABLE 4.1 BOX 4.1

ICD-10 Codes for Falls 2014 Centers for Disease Control and
Z91.81 Prevention Statistics on Falling in the United
History of fallinga
States Among Noninstitutionalized Adults Aged
Repeated fallsb R29.6 65 Years and Older
Falls divided by etiology W00–W19c
• Falls are the leading cause of fatal and nonfatal
Ice and snow W00 injuries
Slipping, tripping, and stumbling W01 • Approximately 30% older adults reported falls in the
past year
Collision with another person W03
• 29 million total falls reported
While being carried or supported W04
• 7 million associated injuries and 27,000 fatalities due
by others
to falls
From nonmoving wheelchair, W05 • 2.8 million patients treated in emergency departments
nonmotorized scooter, and
• 800,000 hospitalized
motorized mobility scooterd
• Women reported more falls than men (30.3% vs.
From bed W06 26.5%, respectively)
From chair W07 • Women reported more fall-related injuries than men
From other furniture W08 (12.6% vs. 8.3%, respectively)
On/from playground equipment W09 Data from Bergen G, Stevens MR, Burns ER. Falls and fall injuries
On/from stairs, steps, curb, W10 among adults aged ≥65 years – United States, 2014. Morb Mortal
Wkly Rep. 2016;65(37):993–998.
incline, escalator
On/from ladder W11
On/from scaffolding W12 Fall risk and rates vary considerably among set-
tings, with a higher incidence of falls in long-term
From/out/through building, balcony, W13 care facilities. The fall rate for elderly individuals liv-
bridge, roof, floor, window
ing in the community is estimated at 20%–40% per
From tree W14 year (Box 4.1). This rate is at least twice as high in
From cliff W15 older adults living in long-term care, with a higher
Into water W16
incidence of serious complications. Interestingly,
in these facilities, male residents are reported to
Other specific etiologies including W17–W18 fall more frequently and sustain more injuries than
falling into hole, into well, in shower
female residents.7 This finding is in contrast to the sex
Unspecified W19 differences seen among community-dwelling adults.
aIndicates
Most falls in long-term care facilities occur in the
fall risk.
bCan be used for acute fall when etiology is still being explored.
resident’s room or bathroom, with 41% during trans-
cFurther specifications needed for initial encounter, subsequent fers and 36% while walking.7 These are theoretically
encounter, sequela, fall level, and secondary injury. preventable events.
dFall from powered moving wheelchair: V00.811; fall from moving
The higher rate of falls in institutionalized settings
motorized mobility scooter: V00.831; fall from nonmotorized scooter:
is multifactorial. Those living in a long-term care
V00.141.
From the Centers for Medicare & Medicaid Services. 2018 ICD-10 facility may have more risk factors for falling than
CM and GEMs. Available at: https://www.cms.gov/Medicare/Coding/ healthy older adults living in the community, such as
ICD10/2018-ICD-10-CM-and-GEMs.html; with permission. more medical comorbidities, difficulty sleeping, and
higher rates of delirium. Given the potential serious
more likely than men to report falls and seek medical complications of a fall, additional efforts should be
attention. Despite the higher reporting rates among made to prevent falls in long-term care facilities.␣
females, most falls are not reported in both men and
women, and fall prevention is discussed even less.12 Outcomes of Falls
Research on the incidence of falling is also affected by Fortunately, most falls do not result in serious physi-
recall bias, which likely underestimates the true scope cal injury. However, approximately 10%–25% result
of this issue. in serious injury.10,13 The risk of injury and mortality
CHAPTER 4 Fall Prevention and Intervention 45
from falls increases with age. Falls remain the leading Unfortunately, these orthopedic injuries result
cause of fatal injuries among older adults1; however, in significant morbidity and mortality. One-third
the majority of deaths secondary to falls are considered of patients with wrist fractures have persistently
preventable.10 Falls are also the most common cause decreased function for 6 months.16 The consequences
of trauma-related hospital admissions among older of hip fractures can be even more detrimental than
adults. The main reasons for hospitalization after falls those of other fractures. The mortality rate in the first
include traumatic brain injury (TBI) and orthopedic 6 months after a hip fracture is reportedly up to 20%.
injuries such as hip, forearm, and humerus fractures.8,11 In particular, the risk of mortality is associated with
Although a minority of falls result in serious physi- infections such as pneumonia or sepsis. Therefore,
cal injuries, even those that appear to have no physi- extra care should be taken to avoid these secondary
cal effects often have serious social and psychologic complications, including simple measures such as
consequences.␣ early mobilization and incentive spirometry.14,15 One
in four individuals end up in long-term care after a
Orthopedic Injuries hip fracture, and the majority are unable to return
Although the proportion of falls that result in frac- to their prior functional level.15 It is notable that the
ture is low, the absolute number of older people prognosis of older adults who suffer a hip fracture in
who suffer fractures is high and places heavy burdens the hospital is worse than that in the community.7
on the patient and the healthcare system. The acute Returning to baseline function after a fall requires a
management of fractures is complicated by severe multifactorial approach that includes improving psy-
pain, impaired mobility, and impaired function. Even chosocial well-being, effectively utilizing support sys-
after acute treatment of a fracture, persistent pain, tems, and maintaining medical stability and adequate
decreased function, avascular necrosis, delayed bone pain control.␣
healing, and osteoarthritis are a few of the possible
sequelae.14 Traumatic Brain Injury
Fracture patterns depend on fall mechanism and Falls are now the leading cause of TBI for all age-
intensity. Wrist fractures tend to be more prevalent in groups based on the recent Morbidity and Mortality
individuals aged 65–75 years, whereas hip fractures Weekly Report on 2013 surveillance data from the
are more prevalent after 75 years of age. This statis- Centers for Disease Control and Prevention (CDC).
tic may be due to the differing mechanisms of injury The highest rate of combined TBI-related emergency
depending on the age-group. When quick protective department visits, hospitalizations, and deaths was
reflexes are intact, individuals tend to brace them- observed among persons aged ≥75 years (2232.2
selves from the impact of the fall using their upper per 100,000) followed by those 0–4 years (1591.5)
extremities. This predisposes them to upper-extrem- and those 15–24 years (1080.7).17 The number and
ity fractures. However, delayed protective reflexes rate of TBI-related hospitalizations among individu-
result in falls to the side, predisposing individuals to als aged ≥75 years showed an increase of 27% from
hip fractures. These delayed protective reflexes may 2007 to 2013, primarily due to increasing falls. In the
be secondary to a combination of decreased strength, aging population, these findings support a significant
impaired balance and coordination, and cognitive increase in fall-related TBI that results in hospitaliza-
changes.10,14 tions and deaths. Increasing public health attention to
Low femoral bone mineral density and increased this issue is needed.17
fall energy are also associated with a higher risk of hip Common pathologies include traumatic subdu-
fracture. One hypothesis is that elderly individuals with ral hemorrhage, subarachnoid hemorrhage, and con-
an increased fear of falling tend to stiffen their mus- cussion. The use of antiplatelet and anticoagulant
cles while falling, which can increase the fall impact. A medications, cerebral atrophy, and chronic cerebrovas-
decrease in muscle mass and strength is associated with cular disease associated with aging all contribute to this
impaired balance, decreased soft tissue, and increased medically complex picture. Older age increases mor-
bone mineral density loss. Fragility fractures are fur- tality and morbidity after TBI. In an Australian study,
ther described in Chapter 3, Osteoporosis and Fragil- 13% of all hospitalizations in the elderly due to TBI
ity Fracture. Although factors such as osteoporosis are resulted in death; this was most commonly associated
considered risk factors for postfall fracture, falling itself with subdural hemorrhage.18 A cohort study using the
is considered a stronger risk factor.14,15 Therefore, fall National Study on the Costs and Outcomes of Trauma
prevention is a key first step to decreasing fracture rates. database showed that older adults (aged 75–84 years)
had a 32% increased risk of in-hospital death and more (MFES), which asks older adults to rate their confi-
than 2.3 times increased risk of withdrawal of therapy dence (0 being the lowest, 10 being the highest) in
compared with younger patients of the same injury performing 14 indoor and outdoor daily activities.
severity, comorbidities, and sex.19 Elderly patients, even The final score is the average confidence score across
those with less severe injuries, have lengthier hospital- these different activities (range, 0–10). The mean
izations than younger patients. In addition, there is a score (range) of the MFES for healthy older women
heightened concern about neurologic deterioration, is 9.8 (9.2–10).29,30␣
which is more often delayed in its clinical presentation,
and evidence of slower functional gains and increased
dependence compared with younger patients.20 One RISK FACTORS FOR FALLS
study showed that 1 year post-TBI, 70%–75% of those An older person may fall for different reasons
aged <50 years had good recovery, whereas only 20% depending on his/her age, health status, level of
of those aged ≥60 years had good recovery.21 Possible mobility, and residential setting (i.e., living in the
modifiable factors to explain these worse outcomes in community vs. a long-term care facility). Risk fac-
older adults include a lower intensity of care in older tors for falls in the elderly are frequently multifac-
patients with TBI and the lack of an organized multisys- torial. It is important to use a systematic approach
temic approach.19 Given the poorer outcome, elderly to identifying risk factors when assessing a patient
patients not surprisingly have higher rates of institu- who is at risk for falling (Box 4.2). In a survey, older
tionalization after TBI.22␣ adults reported balance impairments, weather, inat-
tention, medical conditions, and surface hazards as
Spinal Cord Injury their main risk factors for falls. Less than 3% of older
While motor vehicle accidents remain the leading cause adults thought that medications could put them at
of spinal cord injury (SCI), falls are the second lead- risk of falls and that education about medications
ing cause and are increasing in prevalence, especially would be warranted.5
among patients ≥60 years of age. There has been a sig- Risk factors for falls among older adults residing in
nificant increase in the incidence of SCI among those long-term care facilities include older age, higher care
≥65 years of age from 3.1% to 13.2% when comparing demands, incontinence, male sex, prior falls, slow reac-
data from 1970s to data from 2010–2014. In fact, falls tion times, and psychoactive medications. Risk factors
are the leading cause of SCI in individuals ≥50 years of for older adults in acute care hospitals include gait
age.23,24 SCI in the older adult from a fall tends to result difficulty, confusion with agitation, urinary inconti-
in incomplete tetraplegia. The most common mecha- nence, previous falls, and psychotropic medications.7
nism of injury is cervical hyperextension on an already A systematic review of falls among 1924 older adults
spondylotic spine, which can result in clinical central in rehabilitation facilities identified the following risk
cord syndrome. In central cord syndrome, the upper factors summarized in Box 4.3.31
extremities are more affected than the lower extremi-
ties. Falls resulting in SCI are most commonly from Intrinsic Risk Factors
the same level.25–27 As is the case with TBI, older adults First, there are intrinsic factors that place elderly indi-
who suffer an SCI tend to have longer and more com- viduals at higher risk for falls including changes in gait,
plicated hospital stays than younger patients.26␣ vision, hearing, cognition, and balance that are part of
the aging process.32 As mentioned earlier, females fall
Postfall Syndrome (“Postfall Anxiety more frequently in the community, whereas males have
Syndrome”) higher fall rates in long-term care facilities. In addition,
Postfall syndrome is a combination of fear of falling a history of falls is a strong risk factor for recurrent
again and fear of losing one’s independence. Unfor- falls.13,33
tunately, this combination may result in self-induced Many medical conditions increase one’s risk for
restraints in physical activity, which results in an falls. Cardiovascular instabilities, such as orthosta-
ongoing cycle of increasing frailty and unintentional sis, arrhythmias, and syncope, can result in sudden-
increases in fall risk. Activity restriction due to fear onset falls. Neurologic illnesses, including stroke,
of falling is an independent predictor for worsening peripheral neuropathies, radiculopathies, and move-
disability.28 ment disorders, affect gait and balance. Endocrino-
The presence and severity of fear of falling can logical and renal issues can result in hyponatremia
be assessed using the Modified Fall Efficacy Scale and hypoglycemia, which may acutely increase one’s
BOX 4.2
Risk Factors for Falls in Older Adults
Female sex (among community-dwelling adults) Renal/genitourinary
Previous fall Hypovolemia
Visual changes Urinary incontinence
Hearing loss Endocrine
Cognitive deficits Hypoglycemia
Alcohol/substance use Hyponatremia
Cardiovascular Hypothyroidism
Orthostasis Pharmacology
Arrhythmias Psychoactive medications
Syncope Antidepressants (e.g., SSRIs, TCAs)
Dizziness Antipsychotics
Low ejection fraction Sedatives, hypnotics (i.e., benzodiazepines, sleep
Coronary artery insufficiency/myocardial medications)
infarction Anticonvulsants
Carotid stenosis Antihypertensives
Neurologic injuries that can affect gait or balance, Antiarrhythmics
including: Pain medication
Stroke Polypharmacy
Parkinson’s disease Hematologic
Nervous system tumor Anemia
Postpolio syndrome Extrinsic factors
Multiple sclerosis Rugs
Spinal cord injury Cords
Neuropathies Lighting
Radiculopathies Stability of furniture and banisters
Vertebrobasilar insufficiency (drop attacks) Steps
Vestibular disturbance (peripheral or central) Wet surfaces
Seizure Lack of adaptive equipment such as hand rails, raised
Musculoskeletal toilet seats
Sarcopenia Footwear
Osteoarthritis SSRIs, selective serotonin reuptake inhibitors; TCAs,
Foot deformities tricyclic antidepressants.
BOX 4.3
Risk Factors for Falling Among Older Adults in Rehabilitation Facilities
• Carpet flooring • Anticonvulsants
• Vertigo • Tranquilizers
• Being an amputee • Antihypertensive medications
• Confusion • Previous falls
• Cognitive impairment • Need for transfer assistance
• Stroke • Age 71–80 years
• Sleep disturbance
From Vieira ER, Freund-Heritage R, da Costa BR. Risk factors for geriatric patient falls in rehabilitation hospital settings: a systematic review.
Clin Rehabil. 2011;25(9):788–799; with permission.
fall risk. Musculoskeletal disorders including osteo- British Geriatrics Society,37 and Stopping Elderly Acci-
arthritis and sarcopenia may affect gait and transfers. dents, Deaths, and Injuries (STEADI)44,45 developed
Over the past two decades, the role of cognition by the CDC are summarized in Fig. 4.1.␣
in locomotion and falls has been increasingly rec-
ognized. Poor performance during cognitive and
walking dual tasks predicts falls,34 and poor execu- INTERVENTIONS
tive function is predictive of increased fall risk in Older Community-Dwelling Adults
community-residing older adults.35 These findings It is ideal for health professionals to assess fall risk and
may have ramifications in the development of novel directly implement interventions or ensure that these
interventions to reduce the risk of falls in older interventions are provided by other qualified profes-
adults.␣ sionals (Box 4.6). Once the causes or risk factors of
falling are identified, interventions can be instituted.37
Extrinsic Risk Factors For example, if postural hypotension is noted, the
Medications affecting the nervous system and discontinuation of medication that excessively low-
muscles also increase fall risk.10 In particular, poly- ers the blood pressure and ensuring proper hydration
pharmacy and use of psychotropic medications are are important aspects of treatment. For older adults
associated with higher fall rates.36 They can affect with gait or balance abnormalities, investigation of the
balance and reaction time. Even antidepressants underlying neurologic or musculoskeletal etiologies is
previously considered safe in the elderly, such as essential before or in parallel with assessing the need
selective serotonin receptor inhibitors, are associ- for walking aids, orthoses, and gait and balance train-
ated with an increased risk of fall.15,37,38 In clinical ing. During the in-office gait and balance evaluation,
practice, some of these medications may be neces- rehabilitation specialists may identify specific impair-
sary; however, careful monitoring with gradual titra- ments including proximal lower-limb muscle weak-
tion would be recommended. Finally, other extrinsic ness from deconditioning, joint pain or instability, or
factors include home setup and footwear. Lighting, limb-length discrepancies. Physical therapy, shoe lifts,
rugs, cords, and steps should all be considered in the or bracing can effectively address modifiable factors in
assessment of fall risk. In addition, appropriate foot- many cases. The following are the commonly included
wear can provide increased stability.␣ components of multifactorial interventions. The subset
of these components can be used to target the iden-
tified risk factors. For practical purposes, the STEADI
SCREENING AND ASSESSMENT initiative stresses the completion of two interventions
FOR FALL RISK during a single patient visit: (1) review of medica-
Falls among older adults are largely preventable in tions with modifications to those that increase fall
30%–40% of cases, and healthcare providers includ- risk (anticonvulsants, antidepressant, antipsychotics,
ing physicians, nurses, therapists, and pharmacists can benzodiazepines, opioids, sedatives-hypnotics, anti-
play an important role by discussing falls with older cholinergics, antihistamines, muscle relaxants, blood
patients and providing appropriate interventions.39 pressure medications) and (2) the recommendation
Effective fall prevention has the potential to reduce of a daily vitamin D supplement with/without calcium
serious fall-related injuries, emergency department cosupplementation.1,45
visits, hospitalizations, nursing home placements,
and functional decline. Most effective fall reduction Interventions to reduce the fear of falling
programs start with a systematic fall risk assessment A Matter of Balance is an 8-week cognitive-behavioral
that can lead to targeted interventions. Healthcare program that works on strategies to decrease the fear
providers should be aware of underreporting of falls of falling and increase physical activity. Through the
by older adults, particularly older male patients in program, participants gradually learn to conceptual-
the community, and proactively ask about falls.12 A ize falls and fear of falling as controllable entities. They
multifactorial fall risk assessment is primarily rec- set manageable activity goals and engage in exercise to
ommended for older adults who are at high risk of improve overall balance and strength. In addition, they
falling during the initial screening process (Boxes 4.4 learn to modify their external environment to decrease
and 4.5). Considering the complex nature of falls, fall risk. A Matter of Balance program significantly
interdisciplinary collaboration may be initiated at improves functional performance (i.e., Timed Up and
the assessment and to guide interventions. The rec- Go, Performance-Oriented Mobility Assessment) and
ommendations from the American Geriatrics Society, reduces the physical risk of falls.47,48␣
BOX 4.4
Key Recommendations for the Initial Screening for Fall Risk in Community-Dwelling Adults ≥65 Years of Age
• All older individuals should be asked about: • gait or balance impairments
• whether they have fallen in the past year • poor performance on a standardized gait and
• whether they have difficulty with walking or balance balance tests
• whether they worry about falling • Gait and balance evaluation should be done for:
• Multifactorial fall assessment should be performed for • any older adult who falls
individuals with: Older individuals with only a single fall and no subjective
• repeated falls or objective difficulty on gait and balance evaluation DO
NOT require a multifactorial fall risk assessment.
• a fall requiring medical attention
BOX 4.5
Multifactorial Fall Risk Assessment for High-Risk Group
• Focused history • Timed Up and Go (TUG) Test40,41
• Fall frequency • Chair Stand Test42 (optional)
• Injuries and other consequences of falls • 4-Stage Balance Test43 (optional)
• Circumstances of fall(s): • Recommendation from American Geriatrics Society/
• sudden change in position from lying down or British Geriatrics Society (any of the following):
sitting, suggestive of orthostatic hypotension • TUG
• slip or trip from gait instability, balance impair- • Berg Balance Scale
ment, vision deficits, or environmental hazards • Performance-Oriented Mobility Assessment
• drop attack without loss of consciousness • Lower-extremity joint evaluation (range of motion,
(vertebrobasilar insufficiency, knee instability, instability, tenderness, effusions)
leg weakness) • Neurologic assessment (cognitive testing, extrapy-
• after looking sideways or up, suggestive of ramidal and cerebellar function, muscle strength,
vascular etiology such as carotid sinus or arte- sensation including proprioception, reflexes,
rial compression peripheral nerve evaluation)
• sudden loss of consciousness, such as from • Cardiovascular examination: Check for orthostatic
seizure or syncope hypotension and examine heart rate and rhythm
• Symptoms associated with falls: while assessing for murmurs
• dizziness (cardiovascular issue such as ortho- • Visual acuity
static hypotension or arrhythmia, vestibular • Inspection and evaluation of feet and footwear
etiology, medication side effect)
• Functional assessment
• palpitations (cardiac arrhythmia)
• Evaluation of gait and mobility with the use of
•Medication review: assistive devices as needed
• prescribed and over-the-counter medications • Assessment of activities of daily living perfor-
including supplements mance with the use of adaptive equipment as
• Risk factors: needed
• Medical history including osteoporosis, known • Individual’s own perception of functional ability
cardiovascular disease, acute or chronic urinary • Fear of falling (FOF): Impact of FOF and assessment
incontinence if fear is appropriate and beneficial or negative and
• Physical Examination contributing to lack of physical activity and poor
• Gait, mobility, and balance assessment (see quality of life
Table 4.2 for details) • Environmental assessment
• Recommendation from the Stopping Elderly • Home safety (i.e., area rugs or electrical cords on
Accidents, Deaths, and Injuries Initiative of the the floor)
Centers for Disease Control (CDC)
Data from Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated
American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc.
2011;59(1):148–157.
TABLE 4.2
Gait and Balance Evaluation Tools
Tools Description Mean Value (Range) Cutoff for High Risk of Falls
Timed Up Measures the time (s) that 7–11: older men ≥12 s
and Go Test a person takes to stand up 7–12: older women Check also for
from an arm chair, walk a living in the community • Slow tentative pace
distance of 3 m, turn, walk • Little or no arm swing
back, and sit down again • Steadying self on walls
in the chair (higher score • Shuffling
indicating worse balance) • En bloc turning
Time to complete: <5 min • Not using assistive device properly
30-Second Tests leg strength and Below the average Age (years) Men Women
Chair Stand endurance score on the right
60–64 <14 <12
Test Records the number of indicates a high risk
times the patient stands in for falls 65–69 <12 <11
30 s from a chair without 70–74 <12 <10
arm support
Time to complete: a few 75–79 <11 <10
minutes 80–84 <10 <9
85–89 <8 <8
90–94 <7 <4
4-Stage Assesses static balance An older adult who cannot hold the tandem
Balance Test Person is asked to stand stance ≥10 s is at risk of falling
in four progressively more
challenging positions
without using an assistive
device
• Stand with feet side by
side
• Place the instep of one
foot so it is touching the
big toe of the other foot
• Place one foot in front
of the other, heel
touching toe
• Stand on one foot
Time to complete: a few
minutes
Berg Balance Tests balance 50–55 for community- <45–49 indicates high risk for falls
Scale 14 items, each scored from dwelling older adults
0 to 4 (total score, 0–56)
Higher score indicates
better balance
Time to complete:
15–20 min
Performance- Total score range 0–28 with 25–27 for age 19–23 indicates moderate risk for falls
Oriented POMA-balance subscale 65–79 years <19 indicates high risk for falls
Mobility (12) and POMA-gait
Assessment subscale (16)
(POMA) Higher score indicates
better balance
Time to complete: 15 min
Screen for fall or fall risk with 3 questions

Yes to any of the 3 questions
1. ≥ 2 falls in prior 1 year?
2. Presents with acute fall?
3. Difficulty with walking or balance? 1. Obtain relevant medical history, physical
examination, cognitive, and Functional
assessment
No to all 3
2. Determine multifactorial fall risk
questions
o History of falls
o Medications
o Gait, balance, and mobility*
Does this person Evaluate o Visual acuity
Yes Abnormal
report a single fall gait and o Muscle strength
in the past 1 year? balance* o Other neurological impairment
o Heart rate and rhythm
o Postural hypotension
Normal o Foot problems and footwear
No
o Environmental hazards
Reassess annually
Initiate multifactorial intervention to address
identified risks:
• Minimize medications
• Provide tailored exercise program
• Treat vision impairment
*Timed UP and Go (TUG) Test
• Manage postural hypotension
Berge Balance Scale
• Manage foot and footwear problems
Performance Oriented Mobility Assessment
(see the text for details for these tests) • Modify home environment
• Supplement vitamin D 800 IU
• Fall education
FIG. 4.1 Algorithm for fall screening and intervention in community-dwelling older adults. (Adapted from
Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society.
Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline
for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):150; with permission.)
Older Adults in Long-Term Care • An exercise program should be implemented with

Facilities caution, considering the risk of injury in older
Fall incidence in long-term care facilities is three times adults with frailty.
higher than that in the community, with a rate of 1.5 • Vitamin D supplementation effectively reduces fall
falls (range: 0.2–3.6) per bed per year.7 rate for residents with low baseline vitamin D levels.7
• The level of evidence for interventions in this Vitamin D supplementation ≥800 IU daily should be
population is not as strong as that for older com- provided to individuals with proven or suspected vita-
munity-dwelling adults. The similar principle of min D deficiency and to those at increased risk of falls.
multifactorial intervention is considered to re- • Hip protector pads reportedly reduce hip fractures
ducefalls. by 60%, although compliance can be an issue.49␣
BOX 4.6
Components of Effective Interventions
• Recommended with good to fair evidence10: • Most effective exercise programs are imple-
• Adaptation or modification of the home environ- mented for >12 weeks
ment37 • Both group and individual (home) exercises are
• Assessment and intervention provided by a effective for fall prevention
healthcare professional • Exercise may be more effective in conjunction
• Elimination of home hazards (i.e., loose rugs or with other interventions
electrical cords) • Management of postural hypotension10,37:
• Sufficient lighting • Keeping head of bed raised at night to avoid
• Bathroom modifications (i.e., grab bars, raised orthostasis when rising
toilet seat) • Wearing elastic stockings to reduce lower-
• Secured banisters extremity venous pooling
• Working accessible alarm systems • Getting up slowly or sitting on the side of the
• US Consumer Product Safety Commission bed for a few minutes before standing
provides a Safety for Older Consumers–Home • Avoiding heavy meals or vigorous physical
Safety Checklist for further details43 activity in hot weather
• Withdrawal or minimization of psychoactive • Increasing blood volume by increasing dietary
medications (strongest evidence compared with salt if not medically contraindicated
reduction in other medications)37 • If above measures are not effective and no
• Sedative hypnotics and anxiolytics medical contraindications, fludrocortisone
• Antipsychotics and antidepressants 0.1 mg/day or α-1 agonist (midodrine 2.5 mg
three times a day) can be trialed
• Selective serotonin reuptake inhibitors affect fall risk
as much as tricyclic antidepressants • If cataract surgery is indicated, it should be expe-
dited to reduce fall risks in older women
• Exercise37,39,46
• Dual-chamber cardiac pacing in individuals with
• Overall, exercise reduces the rate of falls by cardioinhibitory carotid sinus hypersensitivity with
21%–40% with greater effects seen from repeated unexplained falls
exercise programs that challenge balance and
involve >3 h of exercise per week46 • Vitamin D 800 IU supplementation daily should
be provided for those with vitamin D deficiency or
• Exercise types: Combination of balance,
those at risk of falls
strength, and gait training
• Fair evidence but no recommendation for or against
• Flexibility and endurance training should the intervention
not be the only component of exercise
• Reduction in total number or doses of medications
program
• Vision intervention
• Strength training: Chair rise exercise by Stop-
ping Elderly Accidents, Deaths, and Injuries • Multifocal lenses should be avoided during
can be done at home and repeated 10–15 ambulation, especially when attempting stairs
times • Management of foot problems and footwear
• Balance training: Standing on one foot 10–15 • Trial footwear with a relatively low heel and high
times for 10 s for each leg. Safety tip: Have a surface contact area
sturdy chair or a person nearby to hold onto in • Education tailored to individual cognitive level and
case the patient feels unsteady. Walking heel language
to toe for 20 steps; performing back leg raises
• Education should NOT be provided as a single
10–15 times, side leg raises 10–15 times, and a intervention
balance (tandem) walk
Older Adults in Hospitals and Rehabilitation

BOX 4.7
Facilities
Centers for Medicare & Medicaid Services
A 2012 Cochrane review showed that multifactorial
Provides Incentives to Physicians to Implement
interventions in hospitals reduced the fall rate (num-
Fall Prevention Programs
ber of falls over a given time) by 31%.7 Risk of falling
(number of fallers during a given time) also showed a • Welcome to Medicare preventive visit: One-time
decreasing trend but no statistically significant differ- initial examination within the first year after Medi-
ence. Further studies are needed to confirm the effec- care enrollment. Coverage for fall screening, safety,
and functional evaluation
tiveness of multifactorial interventions in acute care
hospitals or rehabilitation facilities.␣ • Annual wellness visit: Preventive care service including
fall prevention
Older Individuals With Cognitive • Two quality measures for falls in the Physician Quality
Impairment37 Reporting System
There is insufficient evidence to provide recommen- • Fall risk assessment
dations regarding fall prevention techniques in older • Fall plan of care
adults with dementia.␣
Data from Bergen G, Stevens MR, Burns ER. Falls and fall injuries
among adults aged >65 years – United States, 2014. Morb Mortal
Implementing Fall Prevention Programs as a Wkly Rep. 2016;65(37):993–998.
Public Health Intervention
Although interventions targeting multiple fall risk
factors could reduce fall rates by up to 40%, only 8% Pennsylvania’s Department of Aging has offered a fall
of physicians implemented fall prevention screen- prevention program, entitled “Healthy Steps for Older
ings according to clinical practice guidelines.50 Adults,” since 2005; to date, 40,000 older adults have
The frequently reported barriers to implement- been screened for fall risk.53 This program was associ-
ing fall screening included time constraints during ated with a 17% reduction in fall rate after adjusting
visits, higher priority of other medical issues, lack for risk factors54 and a savings of $840 for the esti-
of educational materials, cost, and lack of referral mated hospitalization and emergency department
sources.50 In 2011, health department and health care costs per program participant53 relative to the
system partnerships in Oregon and New York used comparison group.␣
CDC funding to implement STEADI in their pri-
mary care practices. Before implementing STEADI, Technological Applications and Novel
healthcare providers rarely discussed falls with older Interventions for Fall Prevention
patients. After the implementation, approximately Compliant flooring is a promising strategy for
65% and 50% of all adult patients were screened preventing fall-related injuries. A recent review
and assessed for fall risk in New York and Oregon, showed that compliant flooring can reduce fall-
respectively.1 related impact forces but minimally affects stand-
To overcome the barriers to fall prevention program ing and walking balance. The findings from the
implementation, the Centers for Medicare & Medicaid pilot studies reported that compliant flooring may
Services offers incentives for healthcare providers to be a cost-effective strategy; however, it may result in
provide fall prevention activities and links fall preven- increased physical demands for healthcare workers
tion quality measures through the Physician Quality (i.e., increased force required for nurses to push a
Reporting System in the Merit-Based Incentive Program medication cart).55
(see Box 4.7).1,51␣ In hospitals and long-term care facilities, bed rails or
restraints have been used to prevent falls, particularly
Cost-Effectiveness of Fall Prevention among older patients with cognitive impairment. How-
Withdrawal of psychotropic medications and group ever, bed rails or restraints have shown to be ineffective
tai chi classes are the least costly and most effective in preventing falls and even harmful to older patients.
single interventions for the prevention of hip fractures. Fall prevention sensor systems (i.e., bed-exit alarms)
Home modifications also provide good value in fall have also been developed to alert patients, caregivers,
prevention for their cost.52 The use of a primary fall and healthcare professionals that a patient is leaving a
prevention program has been advocated at the state bed unassisted. However, a high false alarm rate can be
level using the existing aging service infrastructure. a burden. Details of fall prevention technology can be
found in Chapter 16, Assistive Technology for Geriatric 2. Gibson MJ, Andres RO, Isaacs B, Radebaugh T. The preven-
Population. tion of falls in later life. A report of the Kellogg International
Exercise interventions using video games are also Work Group on the prevention of falls by the elderly. Dan
used for fall prevention. Exercise-based video games Med Bull. 1987;34(suppl 4):1–24.
3. https://www.cdc.gov/homeandrecreationalsafety/falls/ad
aim to improve the compliance of exercise interven-
ultfalls.html.
tions by using recreation, social interactions, and per- 4. Burns ER, Stevens JA, Lee R. The direct costs of fatal and
formance feedback. Older fallers are more likely to take non-fatal falls among older adults – United States. J Saf
incorrect steps such as in the wrong direction, be slower Res. 2016;58:99–103.
to initiate stepping responses, and be distracted when 5. Zecevic AA, Salmoni AW, Speechley M, Vandervoort
stepping while doing other tasks.56 Dance Dance Revo- AA. Defining a fall and reasons for falling: comparisons
lution is an exercise game with repetitive stepping in all among the views of seniors, health care providers, and the
directions at varying speeds that requires balance, coor- research literature. Gerontologist. 2006;46(3):367–376.
dination, and attention.56 Two to three exercise game 6. World Health Organization Fact Sheet. http://www.who.int/
sessions of 15–20 min duration for 8 weeks showed mediacentre/factsheets/fs344/en/.
7. Cameron ID, Gillespie LD, Robertson MC, et al. In-
improvements in reaction time and physical function
terventions for preventing falls in older people in care
in community-dwelling older adults. facilities and hospitals. Cochrane Database Syst Rev.
Interventions to improve mobility and reduce falls 2012;12:CD005465.
among older adults have traditionally focused on the 8. Organization WH. WHO Global Report on Falls Prevention
physical domain. Researchers are currently investigat- in Older Age. Geneva: World Health Organization; 2008.
ing whether cognitive training as a complementary 9. Vieira ER, Palmer RC, Chaves PH. Prevention of falls in
intervention can improve mobility in older adults older people living in the community. BMJ (Clin Res Ed).
with promising preliminary findings.57,58 Considering 2016;353:i1419.
the low adherence to physical exercise programs, cog- 10. Rubenstein LZ. Falls in older people: epidemiology,
nitive remediation may serve as an attractive alterna- risk factors and strategies for prevention. Age Ageing.
2006;35(suppl 2):ii37–ii41.
tive or complementary intervention to the traditional
11. Finlayson ML, Peterson EW. Falls, aging, and disability.
approach.␣ Phys Med Rehabil Clin North Am. 2010;21(2):357–373.
12. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E,
Adler G. Gender differences in seeking care for falls in the
CONCLUSION aged Medicare population. Am J Prev Med. 2012;43(1):
Falls are highly prevalent, and fall rates are expected 59–62.
to increase as the global population ages. The conse- 13. Peel NM. Epidemiology of falls in older age. Can J Aging.
quences of falls include devastating injuries or death, 2011;30(1):7–19.
but in addition, falls can also trigger loss of confi- 14. Marks R, Allegrante JP, Ronald MacKenzie C, Lane JM.
dence, decreased independence, and reduced quality Hip fractures among the elderly: causes, consequences
and control. Ageing Res Rev. 2003;2(1):57–93.
of life among older adults. The systematic screening of
15. Cummings-Vaughn LA, Gammack JK. Falls, osteoporo-
fall risks using public guidelines should be routinely sis, and hip fractures. Med Clin North Am. 2011;95(3):
implemented in all primary and rehabilitation settings 495–506.
as the first step toward effective fall prevention. Mul- 16. Vergara I, Vrotsou K, Orive M, et al. Wrist fractures and
tifactorial fall interventions should be implemented their impact in daily living functionality on elderly people:
for individuals at high risk of falling with an empha- a prospective cohort study. BMC Geriatr. 2016;16:11.
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modifications. Communication among multiple dis- and deaths – United States, 2007 and 2013. Morb Mor-
ciplines, the patient, and the family about their roles tal Wkly Rep Surveill Summ. 2017;66(9):1–16. Centers for
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CHAPTER 5
Central Nervous System Disorders

Affecting Mobility in Older Adults
CAROL LI, MD • BLESSEN C. EAPEN, MD • CARLOS A. JARAMILLO, MD, PHD •
DAVID X. CIFU, MD
AGING AND CENTRAL NERVOUS SYSTEM level, and being able to select the correct motor reac-
A discussion of normal age-related changes in the cen- tion in the setting of the surrounding environment.
tral nervous system (CNS) system may be approached When these processes are altered at any level because
from an anatomic, physiologic, or functional perspec- of secondary factors that may be seen in older adults
tive. Anatomically, there is reduction of brain mass, such as chronic exposure to toxins, inadequate nutri-
dilation of ventricles, widening of sulci, and shrinkage tional status, or the burden of neurologic disease, there
of gyri, as well as decline and changes in cell number, may be a production of cumulative changes that result
size, structure, and degree of myelination of white matter in far greater functional deficits than those associated
over time that affects neurotransmission and efficiency with known normal age-related changes in CNS. Thus,
that affect the CNS in a nonuniform pattern, including as with all aspects of geriatric medicine and rehabilita-
selectively affecting certain brain regions.1,2 More specifi- tion, it is important to realize that the translation of
cally, brainstem nuclei have been shown to retain the full anatomy and physiology to function and disability is
complement of neurons, whereas neuronal loss in the not direct and a comprehensive approach is required to
substantia nigra and locus ceruleus has been identified to understand and address functional problems related to
correlate with age. An estimated decrease in conduction the complex nature of aging and the CNS.
velocities of 1–2 m per second per decade after the fifth
decade of sensory and motor nerves, as well as loss of Visual and Auditory Changes
myelin sheaths within the central and peripheral nervous The most rapid decline in visual acuity and incidence of
systems, has also been reported.3,4 Functionally, a com- ocular disease occurs after age 60 years.1 Both pathologic
bination of decreased core strength and tight hip flexors and normal aging of the eye arise from tissue changes
can affect overall posture and the ability to ambulate within the eye. Loss of accommodation ability and flex-
efficiently. Age-related changes in auditory and visual ibility, also known as presbyopia, owing to changes in
systems may lead to distortion in interpreting signals connection between the lens and ciliary body, is often
accurately, thus leading to inaccurate input to the CNS the first sign of an aging visual system. One may also
and impairment in balance and higher risk for falls. see loss of central vision from retinal aging and macu-
Current research suggests that the levels of physi- lar degeneration, visual field loss and glaucoma that
ologic and structural abnormalities in the CNS are not may result from optic nerve damage, cataracts forming
usually directly proportional to the amount of func- from lens degeneration, and poor night vision from
tional impairment observed in aging.1 In fact, despite overall decrease in visual clarity.5 Other comorbidities
the known CNS changes with aging, some individuals that commonly occur in the aging population, such as
may survive well into old age without much functional diabetes and hypertension, can also affect ocular health
loss, whereas others may not. It has been suggested and further compound visual deficits.
that neuroplasticity of CNS is one of the major driv- Hearing loss is also common in the aging popu-
ing forces that produce this variability in functional lation, and the rate of disabling hearing loss, either
performance, thus supporting the concept that aging of peripheral or central etiologies, can quadruple
is not a homogenous process.1 The appropriate reac- for adults aged 55–64 years when compared with
tion and function of a healthy aging adult requires a adults aged 45–54 years.3 The inner ear is composed
balancing act of sensory and motor input, processing of three major structures, semicircular canals, vesti-
this input intellectually or automatically at a motor bule, and cochlea, which all play an important role in
57
maintaining balance and equilibrium. In general, all has been shown to improve strength and function even
structures can be affected adversely with age. Dizziness in the very old.10 The process and details of sarcope-
is a commonly experienced condition and affects about nia are further discussed in Chapter 3. In addition to
a quarter of the US geriatric population.6 Peripheral ves- causing neuromuscular changes that contribute to
tibular dysfunction is one of the most frequent causes activity limitations, the decline in central processing
of dizziness and imbalance in older individuals, which of external stimuli may also affect motor planning and
leads to an increase in the risk of falls and subsequent performance. Motor system function involves complex
injuries. Similar to ocular health, abnormalities in met- interactions between the premotor and motor areas of
abolic, vascular, and renal systems, nutritional deficien- the frontal lobes, basal ganglia, cerebellum, brainstem,
cies, inflammations, infections, medications, and head and spinal cord. Loss of neuroplasticity may also be a
trauma, can secondarily affect the auditory system. limiting factor in the ability of an aging CNS to adapt,
The identification of changes in the visual and audi- learn, coordinate, and refine motor control. Studies
tory systems that accompany aging can help modify have shown that there is a decrease in the recruitment
and assist in the selection of the most appropriate of frontal brain regions and impaired modulation of
therapeutic interventions, as well as provide an under- corticospinal excitability that can lead to prolonged
standing regarding psychosocial implications of such reaction times and a delay in generation, anticipation,
deficits. For example, even though hearing loss does and preparation of motor responses.11␣
not directly cause motor deficits, if the eighth cranial
nerve is involved, the vestibular system will be affected Cognitive, Memory, and Behavioral Changes
and contribute to vertigo that can cause gait imbalance Cognitive abilities are highly variable among indi-
and increase the risk of falling. Furthermore, when the viduals, and this variability increases among older
processing of visual and auditory senses is altered, in adults.1,2,8,12 Although there are significant individual
combination with cognitive deficits, it may impair the differences, generally speaking, what is known as “fluid
utility of these systems as modalities for motor and intelligence” that involves problem solving, executive
procedural learning. From a psychosocial standpoint, functioning, multitasking, abstract reasoning, and epi-
hearing loss affects not only the function of the indi- sodic memory declines with age, whereas “crystallized
vidual but also communication with family members, intelligence” that includes procedural and semantic
thereby potentially isolating them from social and memory remains stable. It is also documented that a
occupational opportunities and relationships, which reduction in adrenergic function and deterioration of
can further diminish the quality of life.␣ excitatory neurotransmitters can lead to age-related
decline in working memory,13 whereas slower cogni-
Sensory and Motor Changes tive capabilities and impaired attentiveness have been
Age-associated degeneration of dorsal column nuclei associated with poorer oxygen supply.14 Although
has been demonstrated in some rodent studies,7 which there is an age-related decline in memory performance,
may explain the propensity of impairment in light disabling intellectual decline is not an inevitable or
touch sensation, vibration, and proprioception seen expected consequence of aging, and it should be con-
in older individuals. Demyelination of nerve fibers or sidered significant pathology. Dementia and depression
axonal loss can lead to generalized peripheral neuropa- are also common in the elderly population; however,
thy (PN), which has an overall prevalence of 1% in the they are not part of the normal aging process. Although
general population, but the prevalence increases to 7% the topic of neuropsychological and objective metrics
in the elderly.8 Older patients with PN are at a greater for formal cognitive evaluation is complex in general,
risk of falls, and more so in unfamiliar environments. the main challenge is the variable nature of cognitive
Individuals with other comorbidities in conjunction deficits seen in aging, in the setting of multiple medi-
with PN have worse baseline functioning than those cal comorbidities or variable neurologic recovery after
with similar comorbidities without PN. The details of a CNS insult.␣
peripheral nervous system disorders are described in
Chapter 6. Medication Metabolism Changes
It is well known that there is a loss of motor units Age-related changes in pharmacokinetics and pharma-
and muscle fibers during aging,9 resulting in a decrease codynamics can lead to more frequent and severe side
in overall muscle mass and loss of force per unit area, effects in the elderly population.5 Further details on
which causes a significant but not completely irrevers- this topic are described in Chapter 9 of this book. The
ible decrease in muscle strength, as resistance training key changes include (1) an increase in adipose tissue,
CHAPTER 5 Central Nervous System Disorders Affecting Mobility in Older Adults 59
(2) a decrease in total body water, and (3) a decrease fear of increased bleeding risk in elderly patients who
in hepatic and renal clearance, all of which can prolong are at a high fall risk requires the clinician to weigh the
a medication’s biologic half-life and increase serum risk and benefits of antithrombotic therapy, American
concentrations. In addition, there is an increase in sen- College of Chest Physicians guideline recommenda-
sitivity to several classes of medications, including psy- tions of initiating oral anticoagulation remains strong,
chotropics, anticoagulants, and cardiovascular drugs.15 especially given the increased thromboembolic and
This increase in sensitivity to medications, such as neu- stroke risk with age.20,21 Stroke risk stratification can
roleptics and other CNS altering medications, can fur- be assessed with scoring systems such as the CHADS2
ther increase the risk of falls and/or delirium among (congestive heart failure, hypertension, age ≥75 years,
vulnerable older adults.␣ diabetes, stroke [double weight]) for patients with
atrial fibrillation. It is also important to consider other
risk factors for bleeding and intracranial hemorrhage
EPIDEMIOLOGY OF NEUROLOGIC (ICH), such as hypertension, anticoagulation intensity,
DISORDERS IN GERIATRIC POPULATION previous cerebral ischemia, and advanced age,21 when
According to the most recent data from the Population weighing the risks of anticoagulation therapy. The
Reference Bureau, the elderly population comprises standard 3 months of anticoagulation treatment for
46.2 million in 2014 or 14.5% of the US population acute venous thromboembolism (VTE) is associated
and is anticipated to more than double by 2060. Neu- with a 2%–3% increase in major bleeding (defined by
rologic disorders, including neuropsychiatric, cerebro- episode of bleeding that requires transfusion or hos-
vascular disease, and infectious etiologies, contribute pitalization, stroke, myocardial infarction, or death)
to 6.3% of global burden of disease and are projected events per year, and the rate nearly doubles for popula-
to double by year 2030,16 which reflects an increasing tions over 65 years.22 However, in other studies, elderly
demand and the importance of addressing CNS disor- patients who were determined to be high fall risk who
ders in the geriatric population.␣ were being treated for VTE with anticoagulation were
not at an increased risk of bleeding when compared
with low fall risk groups23 but had an increased risk
CENTRAL NERVOUS SYSTEM DISORDERS for nonmajor bleeding and not major bleeding.24 Stud-
THAT AFFECT GERIATRIC POPULATIONS ies comparing the use of aspirin and warfarin showed
Cerebrovascular Disease (Stroke) comparable risk for ICH in elderly patients, and vigi-
According to the Centers for Disease Control and Pre- lant modification of other ICH risk factors can enhance
vention, an individual has a stroke every 40 s and a death the safety of anticoagulants, such as warfarin, in the
from stroke occurs every 4 min in the United States.17 elderly population.21 In addition to being aware of
Along with musculoskeletal disorders, stroke is a major these risks, physical activity should not be discouraged
cause of serious long-term disability and reduces mobil- for elderly patients on anticoagulants, as it has been
ity in more than half of the stroke survivors over age shown that moderate and even high vigorous level of
65 years.17 Risk factors are similar for both old and physical activity in this population is associated with a
young populations, including hypertension, hyperlipid- decreased risk of major bleeding when compared with
emia, diabetes, heart disease, family history of stroke, those who had low physical activity.25
and previous stroke or transient ischemic attack (TIA). Clinical presentation of a stroke varies depend-
Functional outcomes and prognosis are worse among ing on the location of lesion. The various stages of
older adults, because of the combination of comor- motor recovery post stroke have been well described
bidities and frailty. The 2-year survival rate is also lower by Brunnstrom, Sawner, and Lavigne and can facilitate
in the very old (85 years and above) with a history of appropriate therapeutic intervention. Clinical practice
recurrent stroke as compared with women and younger guidelines for stroke rehabilitation approaches have
males aged 65–69 years with a history of one stroke18; been described26; however, when considering stroke
however, access to advanced medical care and inpatient rehabilitation for the elderly population, the sever-
rehabilitation have been shown to be associated with ity of neurologic deficits, other medical comorbidities
significant functional gains and higher return to the that may affect overall endurance and participation
community for patients with stroke over 85 years.19 with therapies, and learning potential in the setting of
Most strokes are ischemic, and anticoagulant ther- superimposed cognitive deficits must be considered to
apy may be indicated in cases of cardiac emboli, TIA, determine the intensity of rehabilitation and develop
atrial fibrillation, or prothrombotic states. Although the a comprehensive and customized treatment program.␣
TABLE 5.1
Assessment Tools of Dementia and Mild Cognitive Impairment (MCI)
Assessment Tool Description Sensitivity, Specificity
Mini-mental status Measures cognitive function in areas of 55%–78% sensitivity,85–87 100% specificity77 for the
examination (MMSE) memory, attention and calculation, lan- detection of mild dementia (MMSE > 26)
guage, and visual construction. Score 18% sensitivity for the detection of MCI87
of 23–24 or less is abnormal
General practitio- 9-item cognitive questions and 6 Strong sensitivity and specificity over MMSE for
ner assessment of informant questions to assess change dementia screening in the primary care setting
cognition over time 81%–98% sensitivity and 72%–95% specificity88
Montreal cognitive Assesses attention/concentration, Sensitive and specific for MCI in the setting of nor-
assessment executive functions, conceptual mal MMSE scores
thinking, memory, language, calculation, 90% sensitivity for MCI87
and orientation on a 30-point scale. 100% sensitivity for mild Alzheimer dementia (AD)87
Score less than 25 is abnormal 87% specificity for both MCI and mild AD87
Memory impairment 4-item scale, does not include High construct validity for memory impairment, good
screen visuospatial and executive function sensitivity and specificity and positive predictive
evaluation value for AD and other dementias
42.9% sensitivity and 98% specificity for AD89
Data from Sheehan B. Assessment scales in dementia. Ther Adv Neurol Disord. 2012;5(6):349–358 and Ismail Z, Rajji TK, Shulman KI. Brief
cognitive screening instruments: an update. Int J Geriatr Psychiatry. 2010;25(2):111–120.
Neurodegenerative Disorders substantia nigra and locus coerulus. PD affects 1% of the

Dementia population older than 60 years.4 Diagnosis is based on
Dementia, also known as major neurocognitive dis- clinical criteria, and the etiology is currently unknown.
order, is defined as an irreversible global decline of a Parkinsonian features are commonly associated with
nonorganic etiology that interferes with functional medications32 (Table 5.2), but they are also associated
independence involving at least one or more cogni- with trauma-related degenerative issues (i.e., chronic
tive domains: (1) learning and memory, (2) language, traumatic encephalopathy), environmental toxins
(3) executive function, (4) complex attention, (5) per- (manganese, carbon monoxide), structural lesions in
ceptual motor, and (6) social cognition.27 A report by the basal ganglia, neurodegenerative disorders such as
the World Health Organization in 2012 documented dementia with Lewy bodies, progressive supranuclear
35.6 million people living with dementia worldwide, palsy, multiple system atrophy, cortical-basal gangli-
a number expected to double by 2030. Alzheimer onic degeneration, or brain iron accumulation.33
dementia is the most common type of dementia in Classic motor symptoms include tremor at rest,
older adults, representing 65% of dementia cases.28 rigidity, and bradykinesia, which often present uni-
Mild cognitive impairment (MCI), associated with cog- laterally before progressing to the other side of the
nitive decline abnormal for normal aging that does not body.33 The combination of rigidity and bradykinesia
interfere with daily functioning, has been described, may give patients with PD a sense of weakness even if
although not in all cases, as a risk factor for progression no weakness can be detected on physical examination.
to dementia.28–30 Several assessment tools are available Other parkinsonian signs include reduced arm swing,
for evaluating dementia and MCI (Table 5.1). The value impaired rapid limb movement, micrographia, reduced
of these assessment tools may differ depending on the voice, masked facies, and reduced spontaneous gestur-
population age and living setting (community, nursing ing. As the condition progresses, severe akinesia, pain,
home) and may require different cutoff scores for accu- freezing, falls, and signs of postural instability become
rate diagnosis of cognitive impairment.31 Further details more prominent, making it more difficult to distin-
of dementia are described in Chapter 13 of this book.␣ guish from other causes of parkinsonism. Although
there are several different diagnostic criteria described
Parkinson disease in the literature for PD, expert opinion is still consid-
Parkinson disease (PD) is a progressive neurodegen- ered the gold standard and guidelines have been pro-
erative disorder affecting the dopaminergic neurons of posed by the Movement Disorder Society to assist with
TABLE 5.2
Medications Associated With Parkinsonism
Medication Notes
Typical antipsychotics Phenothiazine • The most common cause of extrapyramidal symptoms (EPS)
Chlorpromazine • Frequently causes symptoms days to weeks after medication
Prochlorperazine initiation
Perphenazine
Fluphenazine
Promethazine
Haloperidol
Pimozide
Sulpiride
Atypical antipsychotics Risperidone • The risk of EPS and aggravation of parkinsonism are lower than
Olanzapine with typical antipsychotics
Ziprasidone • Selective serotonin-2A (S2A) activity more than on dopamine (D2)
Aripiprazole receptors
• Risperidone has high binding to S2A but fast dissociation with D2
receptors in a dose-dependent manner
• Of all atypical antipsychotics, clozapine and quetiapine have the
lowest risk of drug-induced parkinsonism
Dopamine antagonists Reserpine
Tetrabenazine
Antiemetics Metoclopramide • Blocks peripheral D2 receptors in the gut, area postrema, and
Levosulpiride central D2 receptors
Clebopride • Levosulpiride causes more parkinsonian features than other EPS
• Metoclopramide is frequently associated with tardive dyskinesia
Calcium channel blocker Flunarizine • The exact mechanism of inducing parkinsonism is unclear
Cinnarizine • May reduce dopamine neurotransmission directly by acting on
central D2 receptors
Antiepileptics Valproic acid • Parkinsonian features found in 5% of patients with long-term use
• Possible role in oxidative stress and mitochondrial dysfunction
Others: mood stabilizers, Lithium • Infrequent cause of parkinsonism
antidepressants Citalopram • Lithium can decrease dopamine in the striatum and increase
Sertraline cholinergic activity by inhibiting acetylcholinesterase
Paroxetine
Adapted from Shin HW, Chung SJ. Drug-induced Parkinsonism. J Clin Neurol. 2012;8(1):16; with permission.
diagnosis for both clinical and research settings.34 Gen- action dystonia, constipation, rapid eye movement
erally speaking, there is a consensus that presence of sleep behavior disorder, hyposmia, anosmia, and
rest tremor, improvement of symptoms with levodopa nonspecific limb weakness that can lead to extensive
lasting 5 years, levodopa-induced dyskinesia, progres- workup for neuropathy or radiculopathy.35–39 Demen-
sive disorder lasting 10 years, and absence of features tia related to Lewy body deposition may be seen in up
suggestive of other forms of parkinsonism is suggestive to one-third of patients with PD. Pathophysiology of
of PD. The neurodegenerative process of PD often is dementia in PD is not clearly understood, although
asymptomatic until dopamine depletion greater than studies have identified potential cerebrospinal fluid
50%, and as a result, many studies have described (CSF) biomarkers for cognitive impairment in PD.40,41
“preclinical” or “prodromal” symptoms that are vague The shuffling and festinating gait (FSG) patterns are
and nonspecific that can occur before the more classic classic and pathognomonic presentations of gait distur-
motor symptoms manifest.33 These nonspecific symp- bances in patients with PD. The mechanism to sustain
toms may include widespread pain involving muscles normal posture and locomotion involves activation of
and joints, hypertension, mood disorders, unilateral frontal and parahippocampal gyri providing input to
brainstem via the basal ganglia to initiate gait. It is a for falls, which may be a sign of disease progression.
complex interaction and delicate balance between cen- In later stages of PD, FOG becomes the most disabling
tral processing and sensory input modulation to pro- motor symptom; however, visual/sensory and mental
duce appropriate involuntary and voluntary muscle tricks have shown promising results in reducing these
movements. Functional magnetic resonance imaging episodes.44,45 The decrease in proprioception and
(MRI) findings show altered activities of these normal sensory feedback that results in FOG may lead to an
pathways and activation of less efficient pathways in increase in visual kinesthesia as a maladaptive compen-
PD. Balash et al.42 organized PD gait disturbance vari- sation for the loss of function and create a more exag-
ety by stages (see Table 5.3). gerated dependence on visual feedback and control to
Episodic gait patterns such as FSG and freezing of help with initiating movement. In other words, exter-
gait (FOG) are brief, involuntary movements that are nal cues may act as a way to replace and compensate for
present in later stages and frequently interfere with gait the lack of internal cues from the basal ganglia via the
synchronicity. FSG is defined as uncontrolled forward thalamus to the primary and supplementary motor cor-
propulsion with rapid small steps, with a sensation of tex.46 This can possibly explain the mechanism of why
“being pushed.”43 FOG is characterized by brief (last- visual cues may be beneficial. In advanced stages of PD,
ing less than 30 s)42 periods of inability to initiate or falls become the chief complaint of most patients and
maintain locomotion with tremor in legs. FOG also caregivers42 as a result of increasing postural instability
contributes to the overall postural instability, which in paired with decreased gait continuity. Other exacerbat-
combination with greater hesitancy for turning when ing factors include the presence of urge urinary incon-
changing direction of ambulation, can increase the risk tinence increasing the risk for falls by six times than in
those with PD without urge incontinence.47
Medications that promote dopamine action and
TABLE 5.3 decrease cholinergic effect are typically first line,
Clinical Staging of Parkinson Disease Gait although surgical options, such as deep brain stimula-
Patterns tion (DBS), are also available. It is important to note
Clinical Gait Features
that patients with PD with dementia or psychiatric/
behavioral symptoms are less likely candidates for
Stage 1 • Short step length DBS.4 Rehabilitation is primarily supportive in address-
• ⇣Gait speed, arm swing
ing deficits related to mobility, fall risk, fine motor
• ⇡Stride-to-stride variability
• Hesitancy with turning and initiation of
control, cognition, speech, swallowing, and mood,
movement particularly as the disease progresses. Physical exercise,
• Bradykinesia including resistance training, has been shown to slow
but not stop the disease progression5,48 and exercise-
Stage 2 • Shuffling with ⇡bradykinesia
• Weakness to hip flexion and ankle plan-
induced motor recovery due to an increase in dopamine
tarflexion affecting preswing and “toe transporters49 but not restoration of dopamine in the
off” in stance phase nigrostriatal pathway itself in animal models.50 Core
• Dual tasking derangement (i.e., unable strengthening exercises should be prioritized given
to talk while walking) that abdominal muscle weakness has been shown to
• ⇡⇡Stride-to-stride variability be more significant than other muscles in the body.51
Stage 3 • Freezing of gait Music-based movement therapy and dance, such as
• Festinating gait tango,52 have also shown positive effects.53␣
• ⇡⇡Hesitancy with turning and initiation of
movement, higher risk for falling Multiple sclerosis
Stage 4 • ⇡⇡Falls Multiple sclerosis (MS) is a chronic demyelinating,
• ␣⇣⇣Stride length due to poor toe clearance inflammatory, and immune-mediated CNS disorder
• Knee and ankle contractures causing that results in neurologic and neuropsychological dys-
excessive knee flexion in stance and function. MS can also mimic other neurologic, rheu-
“walking on toes” matologic, and vascular diseases, which makes MS
primarily a diagnosis of exclusion. The average age of
From Balash Y, Hausdorff JM, Gurevich T, et al. Gait disorders in
Parkinson’s disease. In: Pfeiffer RF, Wszolek ZK, Ebadi M, eds.
onset is 30 years, and it is considered one of the most
Parkinson’s Disease. 2nd ed. Boca Raton: CRC Press; 2013; with common disabling neurologic conditions of young and
permission. middle-aged adults, but the variable nature of clinical
presentation and disease course makes it challeng- Cognitive deficits occur in about 50%–60% of
ing to predict prognosis for the disease’s effect on the patients with MS; however, there is no direct correla-
aging population. Although onset is rare for adults over tion between cognitive deficits and physical disability,
50 years, about 10%–15% of people with MS who have disease duration, or course of the disease,59,60 although
the primary progressive type are typically over the age of a high baseline cognitive capacity may be protective.61
40 years,1 and a wide range of 5%–64% are categorized Pharmacologic options, such as donepezil, ginkgo
as having a “benign” course,54 which has been defined biloba, memantine, and rivastigmine, have been stud-
and described in different ways.55 Initial symptoms ied; however, they have limited efficacy in improving
may include motor, sensory or autonomic dysfunction, memory performance.62–66 MS-related cognitive dys-
ataxia, vision changes, optic neuritis, fatigue, bladder function is also highly individualized and variable,
incontinence, or mood disturbances. Because fatigue with memory and learning dysfunction and slowed
is one of the most common presenting symptoms and processing speed as the most common cognitive-
may often precede a relapse, it can be challenging to related deficits, which can affect multiple aspects of a
determine if fatigue is “normal” for aging or pathologic patient’s activities of daily living. Thus an individual-
in an older patient with MS. Fatigue can be due to sleep ized, comprehensive, and interdisciplinary approach
disturbances, depression, and heat intolerance. Depres- must be used when developing a rehabilitation regi-
sion is simultaneously the most common mental men for elderly patients with MS.␣
health issue in the aging population and the most com-
mon mood disturbance associated with MS. Patients Traumatic Brain Injury in the Elderly
with MS-related depression have a higher suicide risk Traumatic brain injury (TBI) in the elderly accounts
because of psychosocial issues rather than the sever- for 80,000 emergency department visits annually, and
ity or duration of MS.56 In addition, although patients over 50% of cases are due to falls. The highest rates of
with MS have a normal lifespan, medical comorbidities TBI-related hospitalizations, morbidity, and mortality
affect persons with MS earlier than their peers,57 which occur in adults older than 75 years, making geriatric
significantly decreases their overall quality of life. Aging TBI an important public health concern. Age-related
patients with MS are forced to consider nursing home biochemical and physiologic changes may predis-
placement with fear of caregiver strain burden and loss pose this demographic to a higher stress response and
of autonomous control at an earlier age compared with inflammation after TBI.67,68 Medical comorbidities,
other patients with long-term disability. such as cardiac disease, requiring anticoagulation and
Early in the disease course, MS is characterized by coagulopathies can further increase bleeding risk and
inflammation and relapses of episodic neurologic the development of ICHs after a fall, which can be
dysfunction with partial to total recovery, but the neu- related to syncope, gait imbalance, orthostatic hypo-
rodegenerative process is what leads to progression tension, PN, malnutrition, electrolyte disturbances, or
of disability over time. Diagnosis is based on objec- side effects from polypharmacy. Subdural hematomas
tive neurologic findings and at least one relapse, as resulting from trauma to bridging veins are most fre-
described by the McDonald Criteria.58 MRI findings and quent. The cost of immediate medical care and length
CSF studies (i.e., presence of oligoclonal bands) can be of rehabilitation required to achieve the same level of
supportive, but they have limited specificity and no outcomes rises above that of the general population,
gold standard to validate these tests and there may be a despite less favorable outcomes.67,69,70 Although older
tendency to overtreat and overdiagnose.54 In addition, age, medical comorbidities, gender, and preadmission
although the physiologic process of aging may also pro- functional ability have been identified as factors that
duce hyperintense signals in the subcortical region on negatively affect recovery and prognosis after TBI, these
MRI, knowing that MS lesions typically involve the ven- variables are not as well studied in the geriatric popula-
tricles, brainstem, corpus callosum, cerebellum, and tion.71 An integrated program to address both cognitive
spinal cord can be helpful in differentiating pathology and neuromuscular impairments within the context of
in the older adult with MS.1 Disease-modifying agents, premorbid functional status is the recommended reha-
such as interferons, can be used as long-term manage- bilitation approach for this population.␣
ment, but weighing the risk versus benefit is important
before prescribing these agents because of adverse side Normal Pressure Hydrocephalus
effects, such as flulike symptoms, blood and bone mar- Normal pressure hydrocephalus (NPH) is a disease of
row abnormalities, and thyroid dysfunction, that may the elderly, most commonly affecting adults 65 years and
further increase the risk of falls in older adults. older, and the prevalence increases after age 80 years.72
It is defined as a type of communicating hydrocepha- There is strong evidence that shunting improves all
lus with normal intracranial pressure. The etiology and aspects of NPH, although not all with equal efficacy,
pathogenesis for NPH can be idiopathic, but cerebro- including cognition.81–84 Common complications after
vascular disease, such as stroke, TBI, and cardiovascular shunting include shunt malfunction causing obstruc-
disease causing inflammatory changes in the CNS, have tion or overdrainage, infection, wound dehiscence near
also been proposed to alter the flow and absorption the abdomen, and subdural hematoma. Symptoms of
of CSF.73,74 The clinical triad of gait imbalance, altered overdrainage include “muffled” hearing and, on dedi-
mental status, and urinary incontinence is well described; cated imaging, evidence of thin subdural effusions.84
however, these symptoms can also be nonspecific and Headaches that worsen with sitting and standing, but
presentation may be more subtle, thus a high clinical that improves with lying down, are the most common
suspicion and ruling out other causes of dementia is symptom of overdrainage and can be corrected by rais-
necessary. ing the shunt setting.84 For this reason, periodic brain
Gait apraxia, most commonly seen as short stride, imaging is recommended in the first 6–12 months
low speed, and wide based, is the earliest and most pre- after surgery to monitor for changes.84 Shunt malfunc-
dominant symptom of NPH and has the greatest chance tion resulting in obstruction can occur in up to 30%
of improvement after shunting.75 Gait improves by of patients,84 and rarely an emergency if detected and
64% 3 months after shunting and by 26% at 3 years76; treated early on. Nearly half who have a shunt will
more specifically, the gait velocity increases by 20% require revision within 3 years secondary to infection
after CSF tapping.77 Thus gait improvement after tem- and shunt malfunction.76 In the elderly population,
porary removal of CSF is an important aspect of criteria transient worsening weeks to months after the initial
to meet for shunt surgery. It is interesting to note that shunt surgery may not always indicate shunt malfunc-
there are some similarities between gait disturbances tion and may require additional workup for other eti-
noted in PD and NPH. For example, both conditions ologies and comorbidities.␣
may have decreased steps, rigidity of lower extremities,
flexed posture, and impaired postural reflexes. How-
ever, comparative analysis between PD and NPH have CONCLUSION/SUMMARY
shown NPH to have significantly slower velocity and CNS disorders that affect the elderly population are
stride length and increased step width and outward complex clinical conditions and present with a wide
rotation of foot to contribute to a broad-based gait that variety of symptoms. To design an effective strategy to
is not seen in PD,77 although both conditions shared treat these conditions, the rehabilitation expert must
loss of balance, short stride, and slowness, with parkin- have a comprehensive understanding of the nervous
sonian features being the main distinguishing features system as well as the normal and abnormal aging pro-
between NPH and PD groups.78 In addition, although cess. With increasing global burden of CNS disorders
the NPH group did worse on the walk test, the symp- in the aging population, there is a growing need for the
tom duration was shorter than in patients with PD,77,78 development of treatment and rehabilitation programs
which is consistent with the progressive nature of PD that optimize function and assist with caregiver support.
as described in the previous section. In addition, exter-
nal sensory cues that help improve gait imbalances in
patients with PD have minimal to no effect on patients REFERENCES
with NPH.77 These overlaps in gait impairment and 1. Umphred DA, Lazaro RT. Aging and the central nervous
differences in response to therapeutic interventions in system. In: Kauffman TL, Barr JO, Moran M, eds. Geriatric
both the NPH and PD patient populations may chal- Rehabilitation Manual. Edinburgh: Churchill Livingstone
lenge the idea that gait alterations are isolated to basal Elsevier; 2008:21–30.
ganglia pathology. Radiographic findings of ventriculo- 2. Jiang X, et al. Individual differences in cognitive function
in older adults predicted by neuronal selectivity at corre-
megaly disproportionate to the amount of cerebral atro-
sponding brain regions. Front Aging Neurosci. 2017;9:103.
phy can be seen, without elevation in the CSF pressure. 3. Quick Statistics About Hearing. National Institute of Deaf-
Treatment involving surgical shunting in patients ness and Other Communication Disorders; 2017. https-
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CHAPTER 6
Peripheral Nervous System and

Vascular Disorders Affecting Mobility
in Older Adults
SEWON LEE, MD • DENNIS D.J. KIM, MD • MOOYEON OH-PARK, MD
Mobility is defined as the ability to move independently • What are the appropriate history components and
and safely from one location to another in a manner physical examinations in patients with PNSD and/
that requires intact physical and cognitive function.1 or PVD?
It is fundamental to healthy aging and quality of life.2 • How do we select an approach for patients with
Impaired mobility in older adults has been associated PNSD and/or PVD based on the clinical informa-
with cognitive decline, loss of independence, higher tion gathered from history and physical examina-
rates of depression, fear and anxiety,3 increased insti- tion?
tutionalization, and death.4,5 Etiologies for impaired • What diagnostic tests can enhance the evaluation
mobility in older adults can be roughly categorized into process of older adults with PNSD and/or PVD?
neurologic disorders (central nervous system disorders • What are the components of the multidisciplinary
and peripheral nervous system disorders [PNSD])6 management of PNSDs and/or PVDs?
and nonneurologic disorders such as musculoskeletal • What conservative treatment options are available
disorders and vascular disorders.7 PNSDs and periph- for patients with PNSD and/or PVD?
eral vascular disorders (PVDs) are underrecognized by
healthcare providers as causes of mobility impairment,
although both conditions are increasingly common HISTORY TAKING FOR OLDER ADULTS
in an aging population.8 The presenting symptoms of WITH MOBILITY IMPAIRMENT AND
these conditions are often interpreted as merely aspects SUSPECTED PNSD OR PVD
of the aging process by patients as well as by health- Questionnaires to screen impaired mobility in the
care providers, thereby disabling the opportunity to National Health Interview Survey include the catego-
be treated. It is important to recognize and manage ries of difficulty with walking three city blocks, walking
these conditions properly to maximize independent a quarter of a mile, walking 10 steps without rest-
mobility in older adults. A diagnosis of PNSD or PVD ing, and/or standing for approximately 20 min.9 The
is largely based on good history taking and physical responses should be interpreted with caution consid-
examination. Electrodiagnosis (Edx), imaging studies, ering the wide range of norms according to age and
and laboratory testing may confirm the clinical suspi- gender. Other questionnaires for impaired mobility
cion. Although definitive treatment may be available (or dysmobility) include the speed of gait (e.g., being
for some of these conditions, the majority of patients able to safely cross the street10), weight change (loss
with PNSD or PVD need to manage these conditions via of weight), muscle strength, history of falling, loss of
exercise programs, orthosis, and assistive devices. This balance, etc. As impaired mobility is often underrecog-
chapter reviews the practical approaches and physiatric nized by patients and clinicians alike, it is important
management of older patients with impaired mobility to consistently review the functional/mobility status
due to PNSD and PVD, focusing on the discussion of of older adult patients during clinic visits. Once the
the following questions: problem of impaired mobility is recognized, collecting
• How common are PNSDs and/or PVDs among old- information regarding the mode of onset, pattern of
er adults? progression, and precipitating, aggravating, and reliev-
• How do PNSDs and/or PVDs affect mobility in old- ing factors is useful with regard to addressing other
er adults? complaints. However, it can be challenging to obtain
69
information pertaining to exacerbating or relieving fac- (ataxic) gait is secondary to a loss of proprioception in
tors from the older adult population, and healthcare patients with peripheral polyneuropathy involving large
providers must cultivate the skill of effective communi- sensory nerve fibers or dorsal root ganglia.19 Impaired
cation with patience.␣ postural stability with increased body sway during the
stance phase and displacement of the center of mass
during walking was noted in patients with diabetic neu-
PERIPHERAL NERVOUS SYSTEM ropathy.20 Foot slapping, dragging, and steppage gait
DISORDERS can occur secondary to distal muscle weakness (ankle
Peripheral neuropathy is increasingly common among dorsiflexor). Proximal muscle weakness can manifest
older adults. According to the National Health and as a Trendelenburg gait (secondary to hip abductor
Nutrition Survey, 34.7% of that population complains weakness), hip lurching (secondary to hip extensor
of sensory impairment after the age of 80 years, as com- weakness), and knee buckling (knee extensor and hip
pared with 8.1% at the age of 40–49 years.11 The preva- extensor weakness), depending on the location of the
lence of chronic symmetrical peripheral neuropathy was involvement. Muscle fatigue can decrease the distance
reported to be approximately 3% among the elderly.12 of the gait and slow down the gait speed in addition to
Diabetic peripheral neuropathy is the most common compromising safety due to the increased risk of falls.
form of peripheral neuropathy, and its prevalence is Patients with neuropathic pain also report reduced
increasing in the aging population. Approximately 50% mobility due to pain.21␣
of diabetic patients older than 60 years of age show evi-
dence of diabetic neuropathy.13 Overall, myopathies and History and Physical Examination
neuromuscular junction disorders are less common than The patient’s complaints that accompany impaired
peripheral neuropathy among older adults. However, mobility provide valuable information and impor-
some myopathies including statin-associated myopa- tant clues as to the underlying etiologies. Symptoms
thy,14 inclusion body myositis (IBM),15 paraneoplastic mediated by sensory and motor nerve dysfunction
myopathy, and neuromuscular transmission disorders such as numbness, tingling, pins/needles sensation,
(especially presynaptic types) should be recognized and weakness are common manifestations indica-
as contributors to mobility impairment among older tive of peripheral neuropathy. Sensory nerve–medi-
adults. IBM is the most common form of inflammatory ated symptoms can be further classified into positive
myopathy in patients older than 50 years, and it leads to sensory symptoms such as paresthesia, pain, and
a faster rate of mobility deterioration among older adult pins/needle sensation, and negative sensory symp-
patients compared with younger patients. Older patients toms (loss of proprioception, numbness/anesthe-
(60–79 years of age) require a walker for locomotion sia), which are more closely associated with impaired
5.7 years after the onset of the disease compared with mobility. Negative sensory symptoms become more
younger patients who tend to need a walker more than prominent in advanced sensory neuropathy or gangli-
10 years after the onset.16 Risk of statin-induced myopa- onopathy. Autonomic symptoms such as orthostatic
thy is higher in patients older than 80 years, especially hypotension, dryness or excessive sweating, impo-
in those with multiple comorbidities, polypharmacy tence, sphincter disturbance, diarrhea, and constipa-
(especially with fibrates and cyclosporine), sarcopenia, tion may suggest the involvement of small myelinated
and impaired renal and liver function.17 or unmyelinated fibers. Based on the symptoms,
peripheral neuropathy can be classified into motor,
Mobility Disability Related to Peripheral sensory, autonomic, or combined neuropathy. An
Nervous Disorders absence of sensory symptoms narrows down the dif-
Peripheral neuropathy is a well-known risk factor for ferential diagnoses to motor neuron diseases, motor
mobility impairment that is associated with impaired neuropathies, neuromuscular junction disorders, and
gait, falls, fear of falls, and fall-related injuries.6 In addi- myopathies; however, clinicians should be aware of
tion, poor peripheral nerve function has been associ- the possibility of concomitant sensory neuropathy
ated with impaired activities of daily life and late-life with these conditions, which complicates the clinical
disability.18 The mechanism of mobility impairment picture (Fig. 6.1). Determining the location of involve-
in older adults with peripheral neuropathy is multi- ment (especially weakness) provides clues for further
factorial, including unsteadiness (ataxia), focal muscle differential diagnosis. Involvement of the proximal
weakness (foot dragging, slapping, or knee buckling), lower extremities can occur secondary to myopa-
fatigue, painful limitations, and/or fear of falls. Unsteady thy, lumbar plexopathy, radiculoplexus-neuropathy
CHAPTER 6 Peripheral Nervous System and Vascular Disorders Affecting Mobility in Older Adults 71
Impaired mobility from PNSDs
Weakness No weakness (isolated sensory

disturbance)
Presence of sensory Length-dependent

loss peripheral
neuropathy "dying
back": DM, HIV,
hereditary, etc
Sensory loss (sensorimotor No sensory loss
peripheral neuropathy)
Not length
Motor neuron disease dependent;
Mixed type; DM*, uremia, ganglionopathy,
paraproteinemic neuropathy immune-mediated
neuropathy
Neuromuscular
Axonal type: metabolic, toxic, transmission disorders
infectious, paraneoplastic,
AMSAN, HSMN
Myopathies
Demyelinating type; AIDP,

CLDP, MADSAM, DADS, HSMN
Motor neuropathy: MMN,
AMAN, pophyria
FIG. 6.1 Algorithmic approach to common peripheral nervous system disorders (PNSDs) affecting mobil-
ity. *Most common pattern of diabetic peripheral neuropathy. AIDP, acute inflammatory demyelinating
polyneuropathy; AMAN, acute motor axonal neuropathy; AMSAN, acute motor sensory axonal neuropathy;
CIDP, chronic inflammatory demyelinating polyneuropathy; DADS, distal acquired demyelinating symmetric
neuropathy; DM, diabetes mellitus; HIV, human immunodeficiency virus; HSMN, hereditary sensory motor
neuropathy (Charcot-Marie-Tooth disease); MADSAM, multifocal acquired demyelinating sensory and mo-
tor neuropathy.
(amyotrophy), or radiculopathy. Myopathies com- Information pertaining to the mode of onset and
monly involve proximal muscles with difficulty stand- progression of symptoms is useful to determine the
ing from sitting (especially from a lower chair) and underlying etiologies, with implications for the treat-
dressing (overhead activity), with the exception of ment plan:
several myopathies such as IBM, myotonic dystrophy, • Immediate onset: traumatic neuropathy after identifi-
and other distal myopathies. Motor neuron disease able trauma or neuropathy associated with vasculitis
such as amyotrophic lateral sclerosis can present with in patients with vascular risk factors.
asymmetric weakness in the distal extremities that • Acute onset: inflammatory process (such as Guillain-
mimics focal neuropathy in the initial stage and pro- Barré syndrome: acute inflammatory demyelinating
gresses to diffuse symmetric weakness. In later-stage neuropathy) over days or weeks. Iatrogenic nerve in-
mononeuropathy multiplex, the involvement of mul- jury (partial) after an invasive procedure.
tiple peripheral nerves in a separate and noncontigu- • Gradual onset: “dying back neuropathy,” symmetric
ous fashion can mimic diffuse symmetric peripheral or slowly progressive symptoms from the distal seg-
neuropathy (confluent mononeuritis multiplex). ment (most commonly due to diabetic peripheral
neuropathy), chronic inflammatory demyelinating involving a loss of ankle dorsiflexion of more than
polyneuropathy, and others. 13 degrees during knee extension from knee flexion
Rarely, patients with slowly progressive neuropa- indicates gastrocnemius tightness.23 Palpation of the
thy such as hereditary sensory motor neuropathy (e.g., cutaneous nerve with or without pain along the course
Charcot-Marie-Tooth disease) may not notice their of the nerve (Valleix’s phenomenon)24 can be a valu-
symptoms until later in life. able technique to identify the location of pathology for
If significant sensory symptoms present in the upper focal/regional neuropathic pain and can also be use-
extremity before they present in the lower extremity, ful in nerve conduction studies. Clinicians should be
sensory neuronopathy (ganglionopathy) should be aware of the distant source of neuropathic pain in the
considered. Common causes of ataxic neuropathy/gan- distal lower extremity (e.g., saphenous nerve lesion in
glionopathy include chemotherapy (e.g., vincristine the knee causing medial ankle and foot pain or soleal
and cisplatin), cobalamin deficiency, pyridoxine (vita- tunnel syndrome causing pain in the sole of the foot).
min B6) overdose or deficiency, Sjögren’s syndrome, An abnormal gait pattern should be noted as the
paraproteinemia, and subacute sensory neuropathy, patient walks in. The posture, speed of gait, asymmetry,
which may be autoimmune or paraneoplastic.20 and width and length of the steps should be observed,
Diurnal variation should alert clinicians to investi- often multiple times in both the frontal (front and
gate neuromuscular junction disorders, given a relevant behind) and sagittal planes (from the side). In addi-
clinical context such as facial and/or proximal muscle tion, various mobility tests including standing with
weakness. eye closed, tandem stance/gait, standing on one leg,
Long-standing diabetes mellitus, which is highly preva- and heel-and-toe walking can elucidate the degree of
lent in older adults, is one of the most common etiologies mobility impairment and the underlying etiologies.
of “dying back” length-dependent symmetrical neuropa- Neurologic examination including sensory, motor,
thy. Information on any history of systemic disease (e.g., and deep tendon reflexes is particularly important to
chronic kidney disease, HIV infection, and history of can- diagnose peripheral neuropathy and to delineate its type
cer) is valuable for the differential diagnosis, as it may be and severity. Observation of fasciculation and myokymia,
directly or indirectly attributable (e.g., increasing the risk although not sufficient to make the diagnosis by itself, can
of peripheral neuropathy) to impaired mobility. Multiple offer useful clues to certain PNSDs. Sensory examination
comorbidities are common in the older adult population, should include modalities mediated by large nerve fibers,
which often complicates the picture. Medications should such as light touch, proprioception, and vibration thresh-
be reviewed with an emphasis on the temporal relation- olds.25 Vibration thresholds (in the high frequency range)
ship between the medication and the onset of symptoms. in the distal lower extremity normally decrease with
It is important to recognize the typical neuromuscular aging, whereas proprioception and light touch decrease
dysfunction pattern and to evaluate its impact on mobil- to a lesser extent.26,27 Semiquantitative measurement of
ity in association with individual medications (Table 6.1). vibration sensitivity with a graduated tuning fork (Rydel
Gross deformity (atrophy of the muscle and joint and Seiffer) can be used as a screening tool with available
deformity) may indicate significant muscle weakness reference ranges based on age (cutoff of 4.0 [0–8 scale, 0
and secondary imbalance of the agonist/antagonist indicating inability to feel vibration] in ages 41–60 years
muscles, which suggests the underlying specific periph- and 3.5 in ages 61–85).28,29 However, sensory examina-
eral neuropathy including: tion can be challenging because of the variability of per-
• claw toe deformity secondary to the earlier involve- ception and reporting from patient to patient. In addition,
ment of foot intrinsic muscles with better preserved the cranial nerves/upper motor neuron syndrome, cogni-
foot extrinsic muscles in length-dependent periph- tion, and cardiopulmonary examinations are important
eral neuropathy; for differential diagnosis and to evaluate any concomitant
• pes cavus with forefoot varus secondary to peroneus lesions. Further examination can be conducted based on
brevis/tibialis anterior weakness with better pre- the clinical impression from the history taking.␣
served peroneus longus/tibialis posterior muscles.
Development of a tight gastrocnemius with ankle Diagnostic Workup for PNSD
plantarflexion contracture (ankle equinus) is more The diagnostic study is an extension of the history and
common in the aging population than most clinicians physical examination. Based on the clinical impression
realize and is highly prevalent in patients with periph- that is formed, several diagnostic tests can be considered
eral neuropathy (37.2% vs. 15.3% in a group without to confirm the diagnosis, evaluate the severity, and elu-
peripheral neuropathy).22 A positive Silfverskiold test cidate the underlying etiologies. Diagnostic tests should
TABLE 6.1
Medications Implicated in Neuromuscular Dysfunction
Neuromuscular Dysfunction Categories Common Medications
Peripheral neuropathy Sensory neuropathy/ Pyridoxine (vitamin B6)
neuronopathy Cisplatin, oxaliplatin, ixabepilone
Hydralazine
Metronidazole, chloramphenicol, ethambutol
Taxol and Taxotere (occasionally sensory and motor neuropathy)
Sensory and motor Indomethacin
Nitrofurantoin, penicillamine, isoniazid
Perhexiline
Gold
Disulfiram
Thalidomide
TNF-α antagonists (can cause multifocal motor neuropathy
as well)
Predominantly motor Dapsone
Imipramine
Certain sulfonamides
Myopathy Statin, clofibrate
Zidovudine (AZT), daptomycin
Imatinib, cyclosporin Emetine
Corticosteroid (affecting neuromuscular transmission as well)
Myopathy and neuropathy Colchicine, amiodarone, chloroquine, penicillamine,
(myoneuropathy) phenytoin, and vincristine
Neuromuscular transmission Aminoglycoside antibiotics, tetracycline, polymyxin,
disorder penicillamine
Lithium, phenothiazines
Magnesium-containing cathartics
Procainamide, quinidine/quinine
Data from Weimer LH. Update on medication-induced peripheral neuropathy. Curr Neurol Neurosci Rep. 2009;9(1):69–75, Vilholm OJ,
Christensen AA, Zedan AH, Itani M. Drug-induced peripheral neuropathy. Basic Clin Pharmacol Toxicol. 2014;115(2):185–192, Jones JD,
Kirsch HL, Wortmann RL, Pillinger MH. The causes of drug-induced muscle toxicity. Curr Opin Rheumatol. 2014;26(6):697–703, Grisold W,
Grisold A. Neuromuscular issues in systemic disease. Curr Neurol Neurosci Rep. 2015;15(7):48, and Krarup-Hansen A, Helweg-Larsen S,
Schmalbruch H, Rørth M, Krarup C. Neuronal involvement in cisplatin neuropathy: prospective clinical and neurophysiological studies. Brain.
2007;130(4):1076–1088.
not delay the initial management plan unless there are context. Edx can confirm the clinical diagnosis and
red flags for serious diagnoses or the nature of the treat- delineate the extent of peripheral neuropathy. It is
ment is invasive. Clinicians should be aware of the high particularly useful in evaluating subtle motor weak-
prevalence of abnormal imaging findings in asymptom- ness and fatigue; providing anatomical localization of
atic older adults, and therefore the findings should be these motor deficits to root, plexus, peripheral nerve,
interpreted in the context of the clinical presentation. neuromuscular junction, or muscle pathologies; and
in further classifying the lesions as axonal, demyelin-
Electrodiagnosis ating, or combined.
Edx is a useful test to evaluate the peripheral ner- It is important to understand the following limita-
vous system including anterior horn cells and the tions of the routine Edx:
distal segments, as well as to evaluate neuromuscular • Evaluation of isolated smaller fibers (autonomic
transmission and muscle disorders. As an extension nervous system and pain).
of the history and physical examination, testing and • Mild focal proximal lesion or focal proximal sen-
interpretations should be conducted in the clinical sory lesion (e.g., sensory radiculopathy or mild
plexus/root lesion only involving a focal myelin Creatine kinase elevation is common in several myopa-
segment). thies but is often not specific.31
• Sensory nerve conduction study in the lower limb in Based on the clinical and Edx evaluation, the follow-
older patients: often unobtainable in an asympto- ing additional tests can be ordered:
matic person. • Anti-Hu (antineuronal nuclear) Ab, anti-CV2 (col-
Edx can be useful in the evaluation of ataxia medi- lapsin response mediator protein-5), amphiphysin
ated by large sensory fiber dysfunction rather than Ab test for paraneoplastic neuropathy.32
postural instability secondary to autonomic neu- • Anti-MAG Ab, GM1 Ab, and other gangliosides anti-
ropathy. A normal sensory nerve conduction study body tests for demyelinating neuropathy.
of the lower extremities in older adults is useful, as it • HIV Ab test for HIV-associated neuropathy.33
is against the diagnosis of significant peripheral neu- • Enzyme-linked immunosorbent assay, IgM, or IgG
ropathy involving large sensory fibers. In addition, the immunoblots for Lyme disease–related peripheral
differential diagnosis can be narrowed down to motor neuropathy.34
system involvement (motor units) or a central ner- • Anti-GQ1b and anti-GAD antibody test for Miller
vous system lesion. Motor nerve conduction studies Fisher syndrome.35
can be useful in localizing focal demyelinating lesions • Rheumatologic panels for specific rheumatologic
with the findings of a conduction block or conduction disorder.
slowing across the lesion. Motor nerve conduction • Muscle biopsy for certain myopathies.
slowing/blockage can occur secondary to local entrap- • Genetic tests in hereditary disorders.
ment neuropathy (such as the peroneal nerve at the In this stage of the diagnostic workup, appropriate
fibular head or the tibial nerve at the tarsal tunnel), referral to a neuromuscular specialist should occur to
multifocal motor neuropathy, or other demyelinating permit a more comprehensive evaluation.␣
neuropathy (such as chronic inflammatory demyelin-
ating neuropathy or Lewis-Sumner syndrome).30 The Imaging study
duration and recruitment pattern of motor units can In contrast to the essential role of imaging in central
assist in the differentiation of neuropathic (long dura- nervous system disorders, imaging has been unde-
tion and reduced recruitment pattern) and myopathic rused in the evaluation of peripheral neuropathy.36
(short duration and increased recruitment pattern) With the increasing availability of in-office high-res-
processes, with some exceptions (e.g., mixed pattern olution ultrasonography, quick and reliable imaging
in IBM or other chronic myopathy or a myopathic of the peripheral nerve trunks and some branches is
pattern in severe/advanced neuropathic disease). possible, with the advantage of wide coverage (par-
Repetitive nerve stimulation (low and high rate) can ticularly useful for multifocal lesions) and dynamic
be useful in the evaluation of neuromuscular trans- examination. In addition, muscle pathologies (fatty
mission disorder with a variability of motor units on infiltration with denervation, atrophy), underlying
needle electromyography (EMG). The amplitude of structural pathologies surrounding the peripheral
the combined motor action potential and the motor nerves, and concomitant musculoskeletal disorders
units (e.g., discrete recruitment pattern or only distant can be evaluated. Magnetic resonance imaging (MRI)
motor units) on needle EMG also provides informa- is more advantageous for the evaluation of deeply sit-
tion on the lesion severity and limited prognostic uated or bone-encased nervous structures and offers
information. Needle EMG is limited to the evaluation better soft tissue characterization. MRI techniques that
of myopathies that involve type 2 fibers (such as ste- are optimized for nerve imaging include MR neurog-
roid-induced myopathy).␣ raphy, diffusion tractography, and the use of higher-
strength magnets. Typically, ultrasonography can be
Laboratory test used as a screening tool to detect nervous pathologies
Common serologic tests to evaluate the etiologies of as a complement to Edx when it is available, and then
peripheral neuropathy include blood glucose level, MRI can be used when ultrasonography is restricted
complete blood count, chemistry, urine analysis, thy- because of technical limitations.37␣
roid function test, serum and urine protein electro-
phoresis, erythrocyte sedimentation rate and C-reactive Rehabilitation Management of Peripheral
protein for diabetes mellitus, end-stage renal disease, Neuropathy
thyroid dysfunction, paraproteinemia (monoclo- Management of peripheral neuropathy focuses on the
nal gammopathy), inflammatory disease, cancer, etc. symptomatic management of clinical manifestations,
as a primary cure is not feasible for most peripheral addition to using two layers of socks and the roomier
neuropathies.38 In some neuropathies, systemic immu- footwear.
nomodulation with intravenous immunoglobulin or Symptomatic treatment for neuropathic pain can
immunosuppressant medication is effective; therefore, include gabapentin, pregabalin (calcium channel α2
it is important to identify the peripheral neuropathies ligand blocker), amitriptyline (tricyclic antidepres-
such as chronic inflammatory demyelinating polyneu- sant), duloxetine and venlafaxine (selective serotonin-
ropathy, the acute phase of Guillain-Barre syndrome, norepinephrine reuptake inhibitors), and others.41
multifocal motor neuropathy, exacerbated myasthenia Clinicians should be well aware of the adverse effects of
gravis, and steroid-resistant inflammatory myopathy39 these medications, and doses should be increased grad-
and to refer the patient to a neuromuscular specialist. ually. Opioid analgesics should be reserved for patients
Rehabilitation includes therapeutic exercise such as who fail both first-line treatment and nonpharmaco-
strengthening and stretching exercises, evaluation of logic management.42␣
orthotics, and pain management. Stretching of tight
muscles with range-of-motion exercises is commonly
used to decrease discomfort and increase joint mobil- PERIPHERAL VASCULAR DISORDERS
ity, and patients should be instructed to perform them Peripheral Arterial Disease
at least a few times daily.40 Early weight-bearing and Peripheral arterial disease (PAD) is most commonly
the early introduction of gait training, even in a patient caused by atherosclerosis with progressive obstruction
with severe neuromuscular dysfunction, are essential to of the arteries by plaque. Other less common etiologies
achieving optimal rehabilitation outcomes. The early include inflammatory disorders of the arterial walls
introduction of power wheelchairs and scooters should (vasculitis) or noninflammatory arteriopathies such
be discouraged. Gentle, low-impact aerobic exercises, as fibromuscular dysplasia.43 The prevalence of PAD
such as walking, swimming, and stationary bicycling, is 11%–16% in the population aged 55 years or older.
improve cardiovascular performance, increase muscle Atherosclerotic PAD is associated with high rates of
efficiency, and reduce fatigue. Moderate-resistance cardiovascular events and death. Risk factors for PAD
exercise (defined by repetitions at <30% of a 1-repeti- are similar to the risk factors for atherosclerosis, with
tion maximum) can be applied to muscles with anti- smoking and diabetes being most common. The overall
gravity strength and more. High-resistance training 5-year mortality rate for PAD patients is approximately
does not offer added benefit over moderate-resistance 15%–30%, more than 75% of which is attributable to
training, and because it can lead to the adverse effect cardiovascular causes.44
of overwork weakness, it is discouraged. Low-intensity
resistance exercise may be indicated if the patient’s Mobility disability related to peripheral arterial
muscle strength is equal to or lower than the antigrav- disease
ity strength. PAD is associated with mobility impairment including
Orthotics that are commonly used to improve poorer standing balance, slower walking speed, and
mobility in patients with peripheral neuropathy decreased walking distance.45 Mobility impairment
include ankle-foot orthotics (AFO), such as posterior is often associated with feelings of social isolation, a
leaf spring orthotics (PLSO), to assist ankle dorsiflex- sense of inadequacy, and a perception of being a bur-
ion. If the patient needs bilateral orthoses, some ankle den to friends and family in patients with PAD.46␣
joint range should be allowed using articulated AFO
or PLSO. Articulated AFO with plantarflexion stop or History and physical examination
dorsiflexion stop features may be preferred if partial Claudication is one of the most common presenting
knee control is desired (e.g., cases of knee recurvatum, symptoms accompanying mobility impairment sec-
knee buckling, or tight gastrocnemius muscle). As a ondary to PAD and/or spinal stenosis. Claudication can
tight shoe can aggravate the pain, the patient should be classified into vascular or neurogenic depending on
be advised to opt for a roomier shoe. Accommodative the underlying etiology, with different characteristics
devices such as a quarter-inch heel lifts may be help- (Table 6.2).
ful for the patients with signs of a tight gastrocnemius- Atypical leg pain and a subtle functional decline
related painful foot condition. Metatarsal pain may be without leg pain (perhaps the most common) are
remedied by adding soft metatarsal pads in the roomier not uncommon; therefore, clinical suspicion of
footwear. Donut-shaped pads can be applied to allevi- PAD is critical in patients with unexplained func-
ate the focal cutaneous nerve irritation from the shoe in tional decline and impaired mobility. Of those with
TABLE 6.2
Characteristics of Vascular Versus Neurogenic Claudication
Vascular Claudication Neurogenic Claudication
Pain type Tightness, cramping Vague cramping, aching, burning
Pain location/radiation Back, buttock, leg, radiation from proximal Commonly in calf but can be in the ankle
to distal or foot, buttock
No proximal to distal radiation
Unilateral versus bilateral Unilateral Often bilateral
Distance to walk to trigger pain Fixed Variable
Triggered/aggravated by Increased vascular demand/inadequate Lumbar extension/lateral flexion (sitting)
vascular supply
Relieved by Rest (immediately after stop walking) Lumbar flexion (lingering pain)
Time to pain relief Rapid/immediately after stopping walking Variable, often prolonged
Effect of walking on pain Pain occurs after fixed amount of exertion Pain after variable amount of exertion
Walking uphill versus downhill Symptoms aggravated by walking uphill Symptoms aggravated by walking
downhill
Neurologic examination Normal May be abnormal (often subtle and
asymmetric)
Pulses Diminished Normal
claudication, 20%–25% experience further clinical helpful to localize the site of stenosis or other vascular
deterioration over time. However, major amputation pathologies such as aneurysm. Limb temperature can
is rare and only 1%–3% of patients with intermittent also be measured. A full cardiovascular examination
claudication require major amputation in a 5-year is recommended to identify comorbid cardiovascular
period. In the event of severely compromised arte- disease.␣
rial flow (critical limb ischemia), the patient presents
with foot pain at rest that may worsen in the supine Diagnostic workup
position and improve with the leg in a dependent The ankle-brachial index (ABI) is the most commonly
position. used screening test for PAD. The ABI is calculated by the
Medical history provides useful clues for the diagno- ankle systolic pressure (the higher value of the dorsalis
sis. For example, a history of cardiovascular disorders pedis or tibialis posterior artery systolic blood pressure)
(smoking, hypertension, dyslipidemia, diabetes, etc.) divided by the brachial systolic pressure with the fol-
increases the risk of PAD by two to six times, whereas lowing interpretation:
its absence decreases the likelihood of atherosclerotic • ABI < 0.9: abnormal
peripheral arterial disorders.45 • ABI of 0.7–0.89: mild PAD
Undressing a patient is important for the inspection • ABI of 0.4–0.69: moderate PAD
of trophic changes (hair loss, atrophic nail changes), • ABI of <0.4: severe PAD
erythema, hyperemia, pallor, and/or wounds (ulcer • ABI > 1.3: calcified or noncompressible vessels (in
typically on the toes or on the lateral malleolus), patients with diabetes or chronic kidney disease)
although some of the findings could be observed in Other noninvasive physiologic tests include seg-
older adults without PAD. Elevating the leg immedi- mental limb pressures and pulse volume recordings,
ately followed by lowering the leg can aid differenti- Doppler tracing, and arterial duplex. Transcutaneous
ating hyperemia (Buerger’s sign: hyperemia when the oximetry is used to assess tissue oxygenation in patients
leg is dependent) versus persistent erythema depend- with severe PAD to evaluate the healing potential of
ing on the position of the leg. Palpation of the periph- ischemic wounds.
eral pulses (iliac, femoral, popliteal, dorsal pedal, and Computed tomography angiography (CTA) and
tibialis posterior arteries) can be challenging but also magnetic resonance angiography (MRA) are highly
sensitive and specific tools for PAD. Radiation exposure are preferred before the surgery if anatomically feasible
in CTA, contraindication with some metallic foreign (aortoiliac disease).␣
bodies, and the risk of nephrogenic systemic fibrosis in
advanced kidney disease in MRA may limit their use. Venous System Disorders
The gold standard imaging study is digital subtraction Common chronic venous disorders include varicose
arteriography; owing to its superior spatial resolution veins and chronic venous insufficiency (CVI). CVI is a
over CTA and MRA, it is often used during endovascular clinical spectrum ranging from cosmetic problems and
revascularization.␣ edema to severe symptoms including persistent pain
and ulceration caused by persistent venous hyperten-
Rehabilitation management of peripheral sion.51,52 While varicose veins represent the most com-
arterial disease mon venous disorder, CVI has a more significant impact
Modification of risk factors should be implemented on mobility in older adults and is generally underrec-
immediately. Smoking cessation reduces the progres- ognized by healthcare providers despite its increasing
sion of PAD to critical limb ischemia in addition to prevalence.53,54 Approximately 7 million people in the
reducing the risk of myocardial infarction and death United States have CVI.55 Although the underlying
from vascular causes.47 Blood pressure management, mechanism of CVI is not clearly understood, the dis-
optimal glucose control, and the lowering of low- order includes dysfunction of the calf and other lower-
density lipoprotein cholesterol are critical in patients limb muscle pump mechanisms leading to impaired
with hypertension, diabetes mellitus, or dyslipidemia. venous return, the development of venous hyperten-
Antiplatelet agents such as aspirin (75–325 mg/day) sion, and distension of capillary walls, eventually lead-
and/or clopidogrel (75 mg/day) are used to decrease ing to insufficient venous valves and the destruction
cardiovascular risk. and obstruction of the venous system.
Exercise training is an effective intervention for The pumping action of venous blood back to the
patients with claudication.48 The typical exercise pro- heart requires well-functioning calf muscles. Calf mus-
tocol includes specific treadmill walking three to five cle dysfunction is associated with decreased range of
times a week for 3–6 months, with reported improve- motion of the ankle and often with neuropathy.56 Calf
ments in walking distance of 35%–200%. This pro- muscle dysfunction may affect independent mobility57
tocol includes treadmill exercise to elicit a moderate in addition to contributing to venous insufficiency.
degree of claudication followed by a brief period of rest Risk factors include age, sex, obesity, pregnancy, phlebi-
to resolve the claudication symptom with repetition. tis, previous leg injury, and a family history of varicose
Alternatively, a bicycle ergometer can be used. Warm- veins.
ing up and cooling down before and after each session
is strongly recommended.49 Clinical presentation
Pharmacologic treatment to improve functional Symptoms of CVI include swelling, restlessness, limb
capacity50 includes cilostazol (100 mg, twice daily), a heaviness, fatigue, aching pain, throbbing sensation,
phosphodiesterase inhibitor that was shown to enable burning, tingling, and nocturnal leg cramps.58 On
modest improvement in walking distance by approxi- physical examination, varicose veins, hyperpigmenta-
mately 25% in the short term. Use of a lipid-lowering tion (deposits of hemosiderin), stasis dermatitis, atro-
agent, atorvastatin (80 mg daily for 12 months), was phic blanche (white scarring at the site of previous
shown to improve the pain-free walking time but did ulcerations with a paucity of capillaries), or lipoderma-
not result in an increased maximal walking time.43 tosclerosis can be observed with or without tenderness.
Revascularization is rarely indicated for patients with Differential diagnoses of calf pain and tenderness
claudication and is reserved only for patients who fail include:
conservative management, patients who have a reason- • Deep vein thrombosis
able likelihood of symptom improvement, or patients • Arterial ischemic claudication
with critical limb ischemia. Revascularization strate- • Ruptured Baker’s cyst
gies should be individualized based on the location • Radiculopathy
of the lesion, anatomical factors, and patients’ general • Tight gastrocnemius
medical conditions and preference. Common surgical Edema, typically pitting (or less pitting “brawny
procedures include endarterectomy for localized dis- edema” with a long-standing course), should be
ease, but bypass graft is more commonly performed. assessed, and the limb girth should be measured.
Endovascular procedures with angioplasty and stenting A tourniquet test can be done to determine the
distribution of venous insufficiency (superficial, deep, the pathologies. Successful management of PNSDs and
or both). In superficial venous insufficiency, the vari- PVDs requires a multidisciplinary approach including
cose vein will remain collapsed when the patient sits modification of risk factors, patient education, thera-
up after the vein is emptied, and a tourniquet is applied peutic exercises, home exercise program, and pharma-
in the Trendelenburg position. In deep (or combined) cologic management.
insufficiency, varicose veins will appear.
The diagnosis is largely clinical and based on history
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CHAPTER 7
Arthritis and Joint Replacement

PETER J. MOLEY, MD • ERIC K. HOLDER, MD
INTRODUCTION (posttraumatic), older age, metabolically associated

In this chapter, we present a comprehensive general conditions (obesity), genetics, gender, and iatrogenic
overview of osteoarthritis with special attention to (postsurgical) and anatomic factors. As a point of refer-
osteoarthritis as it pertains to the hip. We discuss the ence, we discuss the roles each of these risk factors play
epidemiology, etiology, pathogenesis, recommended in the development of hip osteoarthritis.␣
grading systems, treatment paradigms progressing from
“conservative” measures to joint replacement tech-
niques, postoperative care, and surgical outcomes rel- PATHOGENESIS OF OSTEOARTHRITIS
evant to the hip. The knee joint is often referenced as a Historically, osteoarthritis has been dismissed as a nor-
point of comparison, as there is frequent overlap in the mal and expected component of the natural course of
literature regarding the hip and the knee. aging. Frequently, it is colloquially referred to simply
Throughout the chapter, there are references made as “wear and tear,” falling under the category of degen-
to the knee interspersed within the main text, as well as erative joint disease. However, with an increased inter-
high-yield “Knee OA Clinical Pearls” noted separately. est in reducing morbidity and adding life to years and
Historically, much of our methodology for hip osteoar- not simply years to life in an aging population, there
thritis care has mimicked treatment algorithms formu- has been considerable research dedicated to furthering
lated based on investigations of the knee. However, as our understanding of not only the factors that predis-
our understanding of hip pathology has advanced, hip pose to osteoarthritis but also the actual underlying
osteoarthritis care has developed its own identity. This pathophysiologic mechanisms that drive joint tissue
is a vast and rapidly evolving subject matter. Thus, we destruction in osteoarthritis. With our ever-evolving
hope to provide you with the most pertinent scientific knowledge and understanding of the pathogenesis of
and clinical pearls in an interactive, interesting, and osteoarthritis, it has become clear that it is a complex,
succinct manner.␣ sophisticated process, and simply referring to it as
“wear and tear” is quite the understatement.
GENERAL OVERVIEW OF OSTEOARTHRITIS Inflammation and Primary Osteoarthritis

EPIDEMIOLOGY There are several factors that contribute to the patho-
According to the most recent data from the Centers for genesis of osteoarthritis, and it is now well established
Disease Control and Prevention, osteoarthritis affects that proinflammatory mediators play an important
over 30 million adults in the United States (US).1 role. The interplay among proinflammatory media-
Primary osteoarthritis ranks high among the most tors, proteases, and biomechanical factors is an active
common causes of pain and disability in the elderly area of investigation.2 Traditionally, an inflammatory
population. In fact, it is the most common form of arthropathy is diagnosed in part by the leukocyte count
arthritis. However, there is pronounced variability within the affected joint tissue and synovial fluid. In
among people with regards to the age of onset, disease this sense, classic cellular inflammation is not a signifi-
progression, associated pain, and functional limita- cant feature of osteoarthritis.2 Generally, the leukocyte
tions. The underlying cause precipitating the osteoar- count found within an osteoarthritic joint aspirate is
thritic cascade is also variable. Therefore, it is plausible low and rarely surpasses 2000 white blood cells per
to think of osteoarthritis as a spectrum of disease of milliliter.2 However, in the inflammatory arthropathies
variable phenotypic presentations rather than a singu- (i.e., rheumatoid arthritis, ankylosing spondylitis), it
lar disease process. Notable risk factors that predispose is generally expected that the leukocyte count of syno-
an individual to osteoarthritis are history of joint injury vial fluid aspirate will exceed 2000 white blood cells
81
per milliliter.2 There may be cases where the synovial

BOX 7.1
inflammatory cell count is equivocal, and the impor-
Potential Proinflammatory Mediators That
tance of a comprehensive clinical history and diagnos-
May Play a Role in the Inflammatory Cascade,
tic evaluation cannot be understated in determining the
Resulting in Osteoarthritis
primary arthritic process. A discussion of the inflamma-
tory arthropathies is beyond the scope of this chapter, Proinflammatory Mediators of Investigation
and our discussion remains focused on osteoarthritis.
Cytokine interleukin (IL)-1 “catabolin”
To understand the inflammatory component of
osteoarthritis, we must look at the molecular level, Tumor necrosis factor-α
where there is a fascinating interplay between cytokines Transforming growth factor-α
and chemokines acting as proinflammatory media- IL-6
tors2,3 (Box 7.1). These proinflammatory mediators
IL-7
play an integral role in the signaling pathway that leads
to the activation of proteolytic enzymes (proteases). IL-8
Once activated, these proteases function to break down Oncostatin M
the extracellular matrix joint tissue.2,4 Although this Growth-related oncogene-α
is still an area of active investigation, it is postulated
Chemokine (CdC motif) ligand (CCL19)
that excessive force or abnormal joint contact leads to
an innate immune response, whereby the joint tissue Macrophage inflammatory protein-1β
upregulates proinflammatory factors and proteases fur- Macrophage chemotactic protein-1
ther mediating destruction.2–4 Interferon-induced protein-10
When signaled by activated proinflammatory
Monokine induced by interferon
mediators, proteases begin the process of hydrolytic
degradation of cartilage extracellular matrix proteins. Alarmins (S100 proteins)
Several proteases have been implicated, including ser- Damage-associated molecular patterns
ine proteases, cysteine proteases (i.e., cathepsin K), Complement activation
and matrix metalloproteinases (MMPs).9 Specifically,
ADAMTS-4 (adistintegrin and metalloproteinase with Data from Loeser RF. Pathogenesis of Osteoarthritis. https://www.
thrombospondin motifs) and ADAMTS-5, and MMP- uptodate.com/contents/pathogenesis-of-osteoarthritis; Liu-Bryan
13 play a significant role in the breakdown of aggre- R, Terkeltaub R. Emerging regulators of the inflammatory process in
osteoarthritis. Nat Rev Rheumatol. 2015;11(1):35–44; Liu-Bryan R,
can and type II collagen, respectively.9,10 Aggrecan (also Terkeltaub R. The growing array of innate inflammatory ignition
known as cartilage-specific proteoglycan core protein switches in osteoarthritis. Arthritis Rheum. 2012;64(7):2055–2058;
or chondroitin sulfate proteoglycan 1) is a large, high- Loeser RF, Goldring SR, Scanzello CR, Goldring MB. Osteoarthritis:
molecular-weight proteoglycan that plays a crucial role a disease of the joint as an organ. Arthritis Rheum. 2012;64(6):1697–
1707; Sohn DH, Sokolove J, Sharpe O, et al. Plasma proteins present
in cartilage function and resiliency.2 Type II collagen is
in osteoarthritic synovial fluid can stimulate cytokine production
the most abundant collagen found in cartilage. As one via Toll-like receptor 4. Arthritis Res Ther. 2012;14(1):R7; Little CB,
can imagine, there is considerable interest in formulat- Fosang AJ. Is cartilage matrix breakdown an appropriate therapeutic
ing disease-modifying therapies targeted at inhibiting target in osteoarthritis–insights from studies of aggrecan and collagen
the activation of proteases that degrade aggrecan and proteolysis? Curr Drug Targets. 2010;11(5):561–575; and Wang Q,
Rozelle AL, Lepus CM, et al. Identification of a central role for com-
type II collagen.2,10␣ plement in osteoarthritis. Nat Med. 2011;17(12):1674–1679.
Individual Joint Components and Primary 4. Metabolically associated (obesity), and

Osteoarthritis 5. Anatomically or genetically predisposed.
The order in which joint tissue undergoes destructive There is often frequent overlap among these catego-
changes is variable and is determined in a large part by ries. Regardless of the underlying etiology, as osteoar-
the predisposing etiology. The primary generators for thritis progresses to end stage, it affects the entire joint
the development of osteoarthritis may be compartmen- to varying degrees. Thus, it is important that we review
talized into: the manner in which the osteoarthritic cascade affects
1. Age associated, each individual component of the joint, including the
2. Injury induced (posttraumatic), articular cartilage, synovium, adjacent bone, meniscus,
3. Iatrogenic (postsurgical), and extraarticular soft tissues.
CHAPTER 7 Arthritis and Joint Replacement 83
The joint space articular cartilage is frequently

referred to as the “shock absorber,” because of its abil-
ity to reduce the transference of forces felt by the sub-
chondral components of the joint. Although this may
be partially accurate, its primary function is to provide
a smooth, articulating surface to allow for the effi-
cient gliding motion of the joint. It is composed of a
tightly woven collagen network, which provides ten-
sile strength and contains hydrophilic proteoglycans.
Frequently, the earliest evidence of pathoanatomy in
osteoarthritis involves the articular cartilage, as noted
by fibrillations in focal areas of the joint subject to the
greatest load.2 Once the integrity of the articular car-
tilage is compromised, the collagen network unwinds
on a microscopic level, allowing the influx of water
drawn to the hydrophilic proteoglycans; consequently,
the cartilage expands.2 Chondrocytes are the only cell
type found within the cartilage and function to main-
tain the cartilage matrix. When damage to the cartilage
occurs, chondrocytes upregulate their activity, and it is
believed that some of the cells undergo a phenotypic FIG. 7.1 Anteroposterior (AP) right hip with crest view.
transformation to a hypertrophic chondrocyte produc- Demonstrates osteoarthritic changes notable for bone-
ing type X collagen and proteases, such as MMP-13. The on-bone apposition in the right hip. There is subchondral
activation of proteases results in further destruction of sclerosis and cystic changes. Of note, osseous structures
collagen via a proinflammatory signaling pathway. This about the right hip are relatively osteoporotic, attributed in
part to disuse.
results in a destructive feedback loop whereby chon-
drocyte activity is once again upregulated, leading to
the production of more cytokines and proteases.2 points of various muscles, tendons, and ligaments. In
Synovium is a form of connective tissue that lines advanced disease, bony cysts may also be visualized,
the inner capsular surface of diarthrodial joints and is although bony erosions would be an atypical finding
responsible for the production of synovial fluid. Syno- in primary osteoarthritis. In addition, with advanced
vial fluid is necessary to maintain a low-friction state imaging modalities such as magnetic resonance imag-
within the joint space and acts as a lubricant. Hyaluronic ing, bony marrow lesions indicative of localized bony
acid (HA) is a component of the synovial fluid that is edema, necrosis, and fibrosis are often visualized in
important for maintaining its viscosity. In the osteo- areas subjected to the greatest mechanical stress.2,13
arthritic cascade, most individuals demonstrate some Additional soft tissue structures that are important
degree of synovial membrane inflammation (synovitis) to discuss include the menisci (knee), labrum (hip),
with or without synovial hypertrophy.11,12 Synovitis can ligaments, joint capsule, periarticular muscles, and
be quite painful. It may also further the degeneration nerves. Each of these structures plays an important
of cartilage through the production of proinflamma- role in maintaining the stability and promoting proper
tory factors, such as damage-associated molecular pat- joint mechanics in the hip and knee. In addition to
terns.3,5 However, synovitis is not considered to be the the subchondral bone and periarticular musculature,
primary instigating factor in osteoarthritis. the menisci play a prominent load-bearing role in the
The subchondral bone, along with the periarticular knee. It has long been established that physiologic bio-
musculature, is responsible for bearing most of the joint mechanical loading is required for joint tissue homeo-
load. When excessive shear and load are placed upon the stasis. In the elderly population, it is common for tears
subchondral bone, thickening (bony sclerosis) develops to be visualized within the surrounding ligaments,
as a result of the enhanced production of improperly labrum, and menisci, often without a prior known
mineralized collagen2 (Fig. 7.1). In addition, bone spurs traumatic event. Meniscal tears can be an origin for
(osteophytes) develop at joint margins (Fig. 7.2A and proinflammatory mediators14 and an obvious source
B). These osteophytes frequently develop at the insertion of mechanical instability, igniting the degenerative
A B
FIG. 7.2 (A) AP pelvis with crest and (B) elongated frog-leg lateral right hip view. Severe hip osteoarthritis,
right greater than left. There is flattening of the superolateral aspect of the right femoral head attributed to
chronic impaction with subchondral sclerosis and lucencies. There are bony proliferative changes (osteo-
phytes) lateral to both acetabulae.
osteoarthritic cascade. Similarly, labral tears, muscle

imbalances, muscle weakness, or nerve injury can result
in instability, which greatly alters the joint biomechani-
cal homeostasis, thus generating enhanced shear stress
and load and igniting the osteoarthritic cascade.
Now that we have created a solid foundational
understanding of osteoarthritis, we will take a closer
look at osteoarthritis and its management as it pertains
to the hip (and knee) (Fig. 7.3A and B).␣
A
HIP OSTEOARTHRITIS
Epidemiology
The estimated overall prevalence of radiographic hip B
osteoarthritis in persons 45 years or older is 27.6%, of FIG. 7.3 (A) AP view of bilateral knees demonstrating os-
which 9.7% of individuals are estimated to be symp- teoarthritis preferentially affecting the medial compartments
tomatic.15 Generally, women are affected more so than with loss of the normal valgus alignment (yellow arrows).
men.1,15 The reported prevalence of hip osteoarthritis in (B) Merchant view of bilateral knees. Circles demonstrate
the literature varies greatly depending on the character- severe bilateral patellofemoral osteoarthritis.
istics of the cohort and the definition of osteoarthritis
applied (self-reported, radiologic, or clinical criteria).16
There is almost a 10% lifetime risk of undergoing a following in their editorial comments regarding the
total hip replacement for advanced osteoarthritis.17,18 2014 International Hip Society Proceedings: “Total hip
Within the US from 1992 to 2011, the rate of total hip replacement is currently one of the most successful pro-
replacements increased by 119% from 139.9 to 306.6 cedures surgeons perform. While this operation works
per 100,000 persons.19 In 2009, the estimated costs as well for patients 65 years of age and older, patients
a result of hospital expenditures for total hip replace- under the age of 50 do not appear to do as well. Avoid-
ments in the US were $13.7 billion .20 With rapidly ing, or at least delaying, the occurrence of osteoarthritis
evolving advances in medical care and a trend toward in the younger age group could make a substantial dif-
increasing life expectancy, it is inevitable that the preva- ference in the lives of our younger patients.”21 The role
lence of surgery in middle-aged to elderly adults with of the musculoskeletal specialist in identifying those
hip osteoarthritis will only continue to increase. Dr. patients who would be best served by joint replacement
Michael Leunig and Dr. Reinhold Ganz, renowned is crucial to optimizing surgical outcomes and health-
orthopedic experts in hip surgery, wisely stated the care expenditure.␣
Knee OA Clinical Pearl: In 2009, there were 620,192 cohort to maintain the static stability of the hip joint. If
US hospital discharges associated with total knee joint the static stability of the joint is compromised, further
replacements, corresponding to $28.5 billion dollars in degeneration is likely to occur, eventually inciting the
expenditures. From 2000 to 2006, total knee replace- osteoarthritic cascade.
ment procedures performed increased by 58%, from Layer III is described as the “contractile” layer of the
5.5 to 8.7 procedures performed per 1000 Medicare hip and hemipelvis.22 This layer is composed of the
beneficiaries.20 entire hemipelvis musculature, which extends from the
lumbosacral musculature to the pelvic floor. Through
muscular balance, layer III is responsible for promot-
Anatomy and Biomechanics of the Hip ing dynamic stability of not only the hip but also the
Thus far, we have discussed the basic anatomic makeup pelvis and trunk. Likewise, loss of hip motion, as seen
of a diarthrodial joint, the pathogenesis of osteoarthri- in osteoarthritis, may hinder motion throughout the
tis, and its effects on each individual joint component. entire kinetic chain, predisposing to injury elsewhere.
Now, we further describe the intraarticular and extraar- Layer IV is described as the “neurokinetic” layer and
ticular components of the hip and their biomechani- is composed of the thoracolumbar plexus, lumbopelvic
cal function. Through the “layered concept/approach,” tissue, and lower extremity structures.22 This layer pro-
we illustrate an algorithmic approach to understanding vides innervation to most of the hemipelvis muscula-
functional hip anatomy.22 ture, facilitates neuromechanical control and feedback,
The four-layer approach was originally described initiates physiologic muscular activation patterns, and
by Kelly et al. as a systematic means of discerning controls neuromuscular proprioception. In addition,
which hip-related structures are the source of pathol- this layer is crucial to orienting posture and position of
ogy and/or pain.22 It was fundamentally formatted as the pelvis over the femur. It is of upmost importance to
a means to investigate the young, painful, nonarthritic understand how the constituents of the osseous, inert,
hip, which historically has been figuratively regarded contractile, and neuromechanical layers work in unison
as a black box, proving to be a diagnostic quandary, to promote normal hip mechanics. Clearly, if there is an
even for the astute clinician. Although this approach insult to any one of the four layers that is not addressed
was not originally described as an assessment tool for in an appropriate and timely manner, it is only a mat-
the less diagnostically perplexing elderly osteoarthritic ter of time before the degenerative cascade begins and
hip, it remains a useful paradigm for methodically osteoarthritis ensues. We next investigate the effects of
evaluating the hip, regardless of age or pathology. It hip joint pathomorphologies.␣
involves compartmentalizing functional hip anatomy
into osteochondral, inert, contractile, and neurome- Hip Joint Pathomorphologies
chanical layers. In our general overview of osteoarthritis, we described
Layer I is the osteochondral layer, which is formed the theoretical interplay between supraphysiologic
by the pelvis, acetabulum, and femur. In the normal forces caused by abnormal joint contact that result in an
hip, this layer demonstrates normal joint congruence innate immune response, whereby joint tissue upregu-
and normal osteoarticular kinematics, which is greatly lates proinflammatory factors and proteases that further
altered in the osteoarthritic hip.22 Abnormalities within mediate destruction. This is an area of active investiga-
this layer have been classified into three categories: tion. It is fair to say that the literature regarding the hip
static overload, dynamic impingement, and dynamic is rapidly evolving. It was once believed that most hip
instability. Several factors may result in static overload, osteoarthritis were idiopathic. In the last 15–20 years,
including anterior or lateral acetabular undercoverage we have made tremendous strides in understanding hip
(dysplasia), femoral anteversion, or femoral valgus.22 osteoarthritis and its link with subtle developmental
Dynamic impingement may result from femoroac- hip pathomorphologies that result in prearthritic hip
etabular impingement (FAI), femoral retroversion, or disease and eventually osteoarthritis.17,23,24
femoral varus. Dynamic instability may occur when the The two areas of particular interest are FAI and
functional range-of-motion demands exceed the nor- developmental dysplasia of the hip (DDH). Develop-
mal motion parameters, resulting in the potential for mental hip conditions, such as slipped capital femo-
subluxation and intraarticular joint damage. ral epiphysis and Legg-Calve-Perthes disease, have also
Layer II is described as the “inert” layer and is com- been linked to FAI morphology but are believed to
posed of the labrum, joint capsule, ligamentous com- make up a small minority of hips with FAI.17 It is not
plex, and ligamentum teres.22 These structures work in yet well understood why certain individuals with FAI
morphology become symptomatic, given that only a

fraction of individuals with FAI morphology become
symptomatic. It is theorized that symptomatic FAI
develops because of labral and chondral injury that
occurs secondary to bony impingement.25,26 Symp-
toms are often described as groin or buttock pain that
is made worse with physical activity and is often associ-
ated with loss of end range of hip motion.
Nonoperative and operative hip preservation care
has grown exponentially, with the goal being to curtail
the onset of the osteoarthritic cascade and the need for
hip joint replacement surgery later in life. Hip preser-
vation care has become a subspecialty within orthope-
dic surgery with great promise. With this knowledge, FIG. 7.4 AP pelvis with crest view (reformatted with pelvis
there is consensus agreement among musculoskeletal cropped). The black arrow demonstrates mild joint space
narrowing with bony prominence of the head-neck junction,
practitioners that hip pathomorphology is a dominant
indicative of cam-type morphology.
player in hip osteoarthritis pathophysiology, supported
by thorough, well-studied mechanistic evidence.23,24
femoral neck offset usually occurs anterolaterally. It has
Femoroacetabular impingement syndrome been documented that FAI can occur anywhere within
The notion of hip “impingement” is not a new phe- the joint, although it tends to occur anterolaterally and
nomenon but has actually been described in the litera- is produced by internal rotation of the femur while in
ture dating back to at least 1936 by Smith-Petersen.27,28 flexion.24 This occurs as a result of abnormal contact
In 1965, Murray described a minor anatomic abnor- between the cam lesion and acetabulum, resulting in
mality, which he termed the “tilt deformity.”24,29,30 He cartilage injury. As the area of cartilage injury extends,
described the tilt deformity as a medial angulation of the femoral head resettles within the defect, resulting
the femoral head in relation to the femoral neck and in joint space narrowing (JSN). In addition, the cam
illustrated an association with the later development of lesion abuts the anterosuperior labrum of the hip. The
osteoarthritis of the hip.29,30 The insightful findings of summative result is separation of the acetabular carti-
Murray inspired many, and further investigation into lage from the labrum and delamination of the acetabu-
this theory was championed by the likes of Harris and lar cartilage from the subchondral bone.17,24,44 Over
colleagues in the US and Solomon and colleagues in time, subchondral cysts develop within the femoral
South Africa.24,31–40 In the early 2000s, Ganz and col- head or near the head-neck junction because of the
leagues described the concept of FAI and its association chronic effects of impingement of the femoral head
with osteoarthritis in further detail and also described a against the acetabulum.24,45 This deformity tends to be
new surgical technique to treat the disorder.28,41,42 The more prevalent in young athletic males.24,39 Hips with
literature provided by Ganz and the incorporation of cam FAI tend to fail over time as a result of anterosupe-
arthroscopic surgery in the early 2000s resulted in an rior osteoarthritis.24
upsurge of interest in the diagnosis and treatment of
FAI and a tremendous growth in the literature.24,28 Pincer-type morphology. The pincer-type morphol-
Two types of FAI have been characterized: the cam- ogy describes overcoverage of the femoral head by
type morphology and the pincer-type morphology. the acetabulum (Fig. 7.5). This results in linear im-
However, it is not uncommon to observe combined pact of the acetabular rim against the femoral head-
deformities.41 neck junction, which is normal in morphology in an
isolated pincer-type deformity. The area of impact
Cam-type morphology. The cam-type morphology is tends to be anterior.24 Unlike the isolated cam lesion,
caused by a loss of offset between the head and neck of the first structure to fail in the pincer-type deformity
the femur, resulting in an “outside-in” delamination of tends to be the labrum anterosuperiorly.24,28,46 Over
the acetabulum.24 “Offset” refers to the contour of the time, bone apposition develops on the bony rim next
head-neck junction, which should be concave as op- to the labrum, extending the margins of the labrum
posed to flat or convex (a prominence); this is referred and enhancing the impingement and secondary labral
to as a cam-type deformity28,43 (Fig. 7.4). The loss of degeneration.24 Likewise, the acetabular cartilage in
present to diagnose FAI syndrome, with the primary

symptom being pain, which is often motion or posi-
tion related.28,42 In addition, patients with FAI may
also report catching, locking, clicking, stiffness, or
give-way. Otherwise, isolated pathomorphology in
the asymptomatic patient should be referred to as
cam or pincer morphology.17,28
The appropriate management of the heterogeneous
patient population with FAI syndrome requires the
availability of all three of these resources.28
The goal of treatment for FAI syndrome is to allevi-
ate pain and functional limitations in the short term
and to potentially curtail the development or pro-
gression of osteoarthritis in the long term. Treatment
strategies typically fall into three categories: conserva-
tive care, rehabilitation, and surgery.17,28 It is recom-
mended that joint preserving surgery is considered
before the development of hip osteoarthritis or in very
mild cases of hip osteoarthritis, as these individuals
tend to obtain greater symptomatic benefit from the
procedure than those with advanced hip osteoarthri-
tis.17,53 Although there has been considerable research
to date regarding hip preservation care, there is cur-
FIG. 7.5 AP pelvis with crest view (reformatted with pelvis
rently no high-level evidence supporting a definitive
cropped). The lateral center-edge angle (also known as the
center-edge angle of Wiberg) is used to assess the supero- treatment choice for FAI syndrome28,48,50 (Table 7.1).
lateral coverage of the femoral head by the acetabulum.43 There is no definitive evidence that treating individuals
Values greater than 36 degrees may indicate overcoverage with cam or pincer morphology will reduce their risk of
of the femoral head (pincer-type morphology).47 developing FAI syndrome or osteoarthritis in the long
term. There is sufficient evidence that an association
does exist between cam morphology and hip osteoar-
proximity to the degenerated labrum begins to break thritis.28,54–57 However, whether an association exists
down, and the focal area of impact on the femoral neck between pincer morphology and hip osteoarthritis is
undergoes callus formation and ulcerations of the peri- not as clearly defined.28 Lastly, as hip preservation care
osteum. Late in the disease, the posteroinferior femoral is still in its infancy, there are no long-term prospective
head cartilage/acetabular cartilage wears down as well, outcome studies to determine whether treatment of FAI
which is referred to as a “contrecoup lesion.”44 This de- syndrome alters the development of osteoarthritis later
formity is more often seen in active women between in life. There are several ongoing randomized clinical
the ages of 30 and 40 years. Hips with pincer FAI tend trials comparing conservative, rehabilitation, and surgi-
to fail over time as a result of posteroinferior or central cal care options, with study outcomes expected to be
osteoarthritis.24 published within the next few years.28␣
Management of femoroacetabular impingement Developmental dysplasia of the hip

syndrome. In 2016, an international, multidisci- DDH refers to an underdeveloped, shallow, or
plinary group of experts was convened at the Uni- deformed (that may also be improperly oriented) ace-
versity of Warwick to format a consensus statement tabulum resulting in decreased acetabular coverage of
on the diagnosis and management of patients with the femoral head17,40,58,59 (Figs. 7.6 and 7.7). DDH pre-
FAI syndrome.17,28 The panel defined FAI syndrome disposes the labrum and articular cartilage to abnormal
as a “motion-related clinical disorder of the hip contact forces, resulting in early degeneration of the
with a triad of symptoms, clinical signs and imaging hip. It is recognized as a major cause of osteoarthritis in
findings. It represents symptomatic premature con- the young adult. Studies suggest that acetabular dyspla-
tact between the proximal femur and the acetabu- sia can lead to secondary osteoarthritis in 25%–50% of
lum.”17,28 The key point is that symptoms must be patients by the age of 52 years.40,58,59 The young adult
TABLE 7.1
Conservative, Rehabilitation, or Surgical Approaches for Treating Femoroacetabular Impingement (FAI)
Syndrome
Treatment Purpose Outcomes
Conservative care • Patient education • There are no reports of the outcomes that
• Activity modification conservative care alone has on symptoms of
• Lifestyle modification FAI syndrome28
• Nonsteroidal antiinflammatory drugs
• Intraarticular steroid injection
• Close follow-up
Structured physical • Hip stability assessment, treatment, • Physical therapy components have not been
therapy program and education well tested, and there is variation in treatment
• Neuromuscular control provided per institution and therapist
• Functional movement pattern • Physical therapy may be associated with
assessment and treatment improvement for at least 2 years28,48,49
• Lumbosacral range of motion
Surgery (arthroscopic • Goal is to correct hip morphology to • More studies have been published regarding
or open) allow for impingement-free motion surgical outcomes, but there are issues
• Debride cam lesion regarding poor design and sample size, and
• Trim and/or reorient acetabulum in thus risk for bias
pincer lesion. • Studies indicate that there may be
• ±Correct femoral torsion improvement in symptoms for up to at least
• ±Adjust femoral neck angle 5–10 years28,50–52
• Resect, repair, and reconstruct
labrum or cartilage if needed
FIG. 7.6 AP pelvis with crests. There is bilateral uncoverage of both femoral heads (dysplasia) with re-
spect to shallow acetabulae. The lateral center-edge angle is used to assess the superolateral coverage of
the femoral head by the acetabulum. Values less than 25 degrees may indicate inadequate coverage of the
femoral head (dysplasia).43
patient often reports pain in the hip region, owing to in severity and frequency over time.58 The young adult
overload of the acetabular rim (frequently anterosu- patient with DDH may also report snapping, locking,
periorly), which is referred to as acetabular rim syn- and clicking, which can be attributed to intraarticular
drome17,58 (Fig. 7.8). The patient often describes this (i.e., labral tear) and extraarticular processes (i.e., snap-
pain as sudden, sharp, localized to the groin region ping psoas tendon). A sensation of instability is also
associated with mechanical overload, and increasing quite common.
known as Bernese periacetabular osteotomy.58,60 Patients

with no or minimal osteoarthritis are the most appropri-
ate candidates for this surgery, and the goals are to allevi-
ate pain, restore function, and curtail the development or
progression of osteoarthritis of the hip.␣
ASSOCIATED RISK FACTORS FOR HIP

OSTEOARTHRITIS
Gender
Female sex has often been conferred as a risk factor
for the development of osteoarthritis in other joints,
although the relationship between gender and hip
FIG. 7.7 Anteroposterior view of pelvis with crest. There is osteoarthritis is less clear, with conflicting study results.
lateral uncoverage of both femoral heads (dysplasia) with bi- A large meta-analysis review of nine studies involving
lateral hip joint space narrowing. In addition, subtle features more than 14,000 participants determined that there
of underlying cam-type morphology are present. Of note,
were no significant sex differences in the severity of hip
this patient is 48 years old, and the osteoarthritic cascade
osteoarthritis. There was a higher incidence risk of hip
has already begun.
osteoarthritis for women but no significant gender dif-
ferences for the prevalence of hip osteoarthritis.61 The
Framingham Osteoarthritis Study found a higher prev-
alence of radiographic hip osteoarthritis in men than
in women. However, there was no significant difference
in the prevalence of symptomatic hip osteoarthritis in
men compared with women.62␣
Knee OA Clinical Pearl: Studies demonstrate that knee

osteoarthritis is significantly more prevalent in women as
compared with men.16
Genetics and Ethnicity

Genetic factors have been well established as predis-
posing factors for the development of hip osteoar-
thritis. A classic twin study, formulated to determine
the genetic contribution to radiographic hip osteoar-
thritis in women, determined that genetic factors play
FIG. 7.8 AP pelvis with crests (reformatted with pelvis a significant role in the development of osteoarthritis
cropped). Representation of areas of joint space narrowing. of the hip in women, accounting for up to 60% of the
Yellow: superior/lateral joint space; blue: axial joint space; risk.63 The heritability estimates reduced slightly when
orange: medial/inferior joint space. The joint space is well potential confounders such as age, hip bone density,
maintained in this image. and body mass index (BMI) were considered.63 As
noted previously, FAI has been established as a poten-
As with FAI syndrome, hip-preserving surgical tech- tial precursor to the development of osteoarthritis. Pol-
niques have been formulated to treat DDH. Once the lard et al. compared 96 siblings of 64 patients treated
diagnosis of dysplasia is made in the symptomatic patient, for primary impingement with a screening protocol
it should be determined whether the patient is an appro- for clinically and radiologic evidence of cam and pin-
priate candidate for hip-preserving surgery. The patient cer deformities and osteoarthritis.64 It was determined
should be fully educated on the indications, potential ben- that the siblings of patients with a cam deformity had
efits, risks, and literature regarding outcomes. The surgery a relative risk of 2.8 of having the same deformity, and
most commonly recommended to treat this condition is the siblings of patients with a pincer deformity had a
relative risk of 2.0 of having the same deformity. Like- selenium.17,69–71 For example, vitamin D has been proved
wise, bilateral deformity occurred more often in the sib- to be very important in maintaining bone health and
lings compared with controls.64 Pelt et al. determined bone metabolism. In a study evaluating serum vitamin D
that the relative risk of undergoing total hip arthroscopy and incident changes of radiographic hip osteoarthritis,
for osteoarthritis was increased in first-degree, second- it was determined that the risk of incident hip osteoar-
degree, and third-degree relatives.65 One study discuss- thritis (defined as definite JSN) was increased for subjects
ing the genetic epidemiologic scope of hip and knee who were in the lowest (8–22 ng/mL) or middle tertiles
osteoarthritis reported that the heritable component (23–29 ng/mL) for 25-hydroxy (OH) vitamin D com-
for primary osteoarthritis may account for 50% of sus- pared with subjects in the highest tertile (30–72 ng/mL).70
ceptibility. Thus far, at least 18 osteoarthritis-associated However, vitamin D levels were not associated with the
genetic loci have been established.66 Further studies are development of definite osteophytes or new disease.70 A
required to determine the exact genes, genetic muta- recently published meta-analysis evaluating the relation-
tions, and associated diagnostic biomarkers that are ship between 25-(OH) vitamin D serum levels and osteo-
necessary for the accurate screening of osteoarthritis arthritis determined that epidemiologic studies do not
before disease manifestation and the creation of tar- provide any clear evidence of an independent association
geted therapeutic disease protocols.66 between 25-(OH) vitamin D serum levels and hip osteo-
There is believed to be a genetic variation in the arthritis.71 Similar conflicting results have been published
prevalence of hip osteoarthritis based on ethnicity. One regarding the other aforementioned dietary factors.17,69␣
such example is a study conducted by Nevitt and col-
leagues comparing the prevalence of osteoarthritis of Obesity
the hip among elderly persons in the US and China.67 It has long been an established mantra within muscu-
It was determined that the crude prevalence of radio- loskeletal medicine that obesity is a modifiable risk
graphic hip osteoarthritis in Chinese adults (60– factor for the development or progression of osteoar-
89 years old) was 0.9% in women and 1.1% in men, thritis, especially in the weight-bearing joints. The evi-
and this did not increase with age. Chinese women had dence in the literature regarding the effects of obesity
a lower age-standardized prevalence of radiographic on hip osteoarthritis is not as clearly defined as the
hip osteoarthritis when compared with Caucasian effects of obesity on the development of knee osteoar-
women, and Chinese men had a lower prevalence of thritis.69,72–74 However, the evidence suggests that obe-
radiographic hip osteoarthritis when compared with sity promotes the development of hip osteoarthritis
age-matched Caucasian men, summating to an 80%– through both biomechanical factors and an upregula-
90% less frequent presentation of hip osteoarthritis in tion of proinflammatory mediators.17 Studies have dem-
Chinese study subjects compared with Caucasian study onstrated a correlation between BMI and bilateral hip
subjects.67 In a large community-based cohort study, osteoarthritis.72,75 In one study evaluating 568 women
which included both African Americans (AA) and who underwent total hip replacement because of pri-
Caucasians, it was determined that AA and Caucasians mary osteoarthritis, a higher BMI was associated with
exhibited similar baseline frequencies of radiographic an increased risk of hip replacement. Women with a
hip osteoarthritis, although differences in baseline hip BMI equal to or greater than 35 kg/m2 had a twofold
radiographic features were noted.68 After 6 years of fol- increased risk of hip replacement owing to osteoarthritis
low-up, AA had increased pain and disability, whereas compared with those with a BMI less than 22 kg/m2.76
Caucasians had more radiographic hip osteoarthritis.68 In a large systematic review and meta-analysis evaluating
It was deemed plausible that the worsening of disabil- 14 epidemiologic studies, it was determined that BMI
ity in AAs was due to an unmet need for hip osteoar- was strongly associated with an increase in the risk of hip
thritis management in this population.␣ osteoarthritis, which did not vary by sex, study design, or
osteoarthritis definition.77 Each 5-unit increase in BMI
Dietary Factors was associated with an 11% increase in the risk of hip
The literature regarding the association of dietary factors osteoarthritis.77 Contrarily, an epidemiologic study with
with osteoarthritis is not definitive, with studies dem- 10 years’ follow-up determined that a high BMI was sig-
onstrating conflicting results and lacking high-quality nificantly associated with knee osteoarthritis and hand
evidence.17,69 Many vitamins and minerals have been osteoarthritis but not with hip osteoarthritis.74 The asso-
implicated as being potentially protective against the ciation between obesity and hip osteoarthritis requires
development, progression, or minimization of osteo- refinement, and further investigation will prove useful in
arthritis. These include vitamins D, K, C, and E and better understanding this association.␣
Knee OA Clinical Pearl: The AAOS Treatment of Osteo- loading and shear stress leads to osteoarthritis; a simi-
arthritis of the Knee Evidence-Based Guideline, 2nd Edi- lar mechanism is observed in heavy manual laborers.
tion (2013), recommends weight loss for patients with The second concept relates to the higher prevalence
symptomatic osteoarthritis of the knee and a BMI ≥ 25 kg/ of the cam-type morphology, which may develop dur-
m2; moderate-level evidence.78 ing the crucial adolescent years, while osseous develop-
ment is still occurring and the youth is participating in
frequent cutting, rotational, and high-impact activity
Age through sports. It is believed that frequent exposure to
Older age is undeniably one of the strongest risk factors these forces through sporting activity during this criti-
for osteoarthritis in all joints. It is multifactorial and cal period of development results in a repetitive insult
likely related to the cumulative exposure to risk fac- to the proximal femoral physis, resulting in the cam-
tors and biologic decline, such as cellular senescence, type morphology.17,24,29,30,39,86
decreasing chondrocyte density resulting in cartilage Overall, although long-term participation in heavy-
thinning, weakening perimusculature support and duty manual labor or high-impact sports has been
diminishing proprioceptive feedback.17,69,76,79–82 The shown to predispose a person to hip osteoarthritis,
net effect is disequilibrium between joint synthesis and epidemiologic evidence is lacking to support the belief
degradation, promoting the osteoarthritic cascade.␣ that exercise or physical activity has a detrimental effect
on the hip in the general population.17␣
Occupation
It is believed that frequent high-impact activity through
occupation or long-term exposure to high-impact sports CLINICAL DIAGNOSTIC CRITERIA FOR HIP
predisposes an individual to the development of osteo- AND KNEE OSTEOARTHRITIS
arthritis of the hip (as well as other joints). The mecha- In 1981, the American Rheumatism Association
nism is due to long-term biomechanical stress resulting (now known as the American College of Rheumatol-
in shear forces and enhanced load, igniting the osteo- ogy [ACR]) requested that the Diagnostic and Thera-
arthritic cascade. Epidemiologic studies have demon- peutic Criteria Committee establish a subcommittee
strated a strong correlation between hip osteoarthritis focused on the development of criteria for classifica-
and heavy manual labor.83–85 A particularly high risk tion of osteoarthritis.87 Altman and colleagues pub-
has been documented in farmers.83,84 A study review- lished criteria for the classification of osteoarthritis
ing the literature cross-referencing hip osteoarthri- of the knee first in 1986 and subsequently the hip in
tis and heavy lifting, including farming, construction 1991.87,88 These studies rank among the most com-
work, and climbing stairs, concluded that moderate to monly cited articles in the musculoskeletal medical
strong evidence exists for a relationship between heavy literature and remain relevant. During the initial
lifting and hip osteoarthritis.84 Specifically, burdens study of the knee, it was believed that no single set
had to be at least 10–20 kg for 10–20 years to demon- of criteria could satisfy all circumstances to which
strate a definitively increased risk for hip osteoarthritis. the criteria for knee osteoarthritis would be applied.
It was noted that the risk of hip osteoarthritis doubled Thus, the subcommittee designed distinct sets of clas-
after 10 years of farming. However, the evidence of a sification criteria that can be used depending on the
relationship between hip osteoarthritis and construc- circumstances and tools that the diagnostician has
tion workers was limited, and there was insufficient evi- available (Table 7.2). The investigators determined
dence demonstrating a correlation between climbing that the presence of osteophytes seemed to best
stairs or ladders and hip osteoarthritis.84 Similarly, an differentiate osteoarthritis from non-osteoarthritis-
earlier study demonstrated a direct correlation between mediated knee pathology.87
hip osteoarthritis and the duration and heaviness of In 1991, ACR created the criteria for the classification
occupational lifting. This study also demonstrated a of osteoarthritis of the hip and determined that clinical
pattern implicating a causal relationship between fre- criteria without a radiographic evaluation were fairly
quent stair climbing and hip osteoarthritis.85 sensitive but not particularly specific (Table 7.3).17,88
It has also been noted that athletes participating in Notably, reduced internal rotation and hip flexion were
high-impact sports have a higher risk of developing of significant clinical importance. Similar to previous
hip osteoarthritis. Several mechanisms that generally studies, pain was noted to be the major symptom in
revolve around two concepts have been proposed. The hip osteoarthritis, although the distribution of pain
first concept is that high-impact biomechanical joint and characteristics of physical activities inducing pain
TABLE 7.2
American Rheumatism Association Criteria for the Classification and Reporting of Knee Osteoarthritis
Clinical + Laboratory Clinical + Radiographic ClinicalΦ
Knee pain and (at least 5 of 9): Knee pain, osteophytes, and (at least 1 of 3): Knee pain and (at least 3 of 6):
• Age >50 years • Age > 50 years • Age > 50 years
• Stiffness <30 min • Stiffness < 30 min • Stiffness < 30 min
• Crepitus • Crepitus • Crepitus
• Bony enlargement 91% Sensitive • Bony enlargement
• Bony tenderness 86% Specific • Bony tenderness
• No palpable warmth • No palpable warmth
• ESR < 40 mm/h 95% Sensitive
• RF < 1:40 69% Specific
• SF OA
92% Sensitive
75% Specific
ESR, erythrocyte sedimentation rate; RF, rheumatoid factor; SF OA, synovial fluid signs of osteoarthritis (clear, viscous, or white blood cell
count <2000 cells/mm3); Φ, option for clinical category would be 4 of 6, noted to be 84% sensitive and 89% specific.
Adapted from Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification
of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum.
1986;29(8):1047; with permission.
TABLE 7.3
American College of Rheumatology Criteria for the Classification and Reporting of Hip Osteoarthritis87
Clinical Criteria Group I Clinical Criteria Group II Clinical + Radiographic Criteria
Hip pain and Hip pain and Hip pain and at least two of the
Hip internal rotation < 15 degrees and Hip internal rotation ≥15 degrees and features below:
ESR ≤45 mm/h (If ESR is not available, Pain on hip internal rotation and ESR < 20 mm/h
replace with hip flexion ≤115 degrees) Morning stiffness of the hip ≤60 min and Radiographic femoral and/or
Age > 50 years acetabular osteophytes
Radiographic joint space narrowing
(superior, axial, and/or medial)
ESR, erythrocyte sedimentation rate.
were inconsistent among patients with hip osteoarthri-

tis and did not differ significantly from patients with TABLE 7.4
hip pain from other causes.87 Among radiographic fea- Tönnis and Heinecke Classification
tures, it was determined that osteophytes were the fea- Grade Characteristics
ture that best delineated patients with hip osteoarthritis 0 No signs of osteoarthritis
from those with hip pain due to other causes.87␣
1 Slight narrowing of joint space, slight lipping
at joint margin, slight sclerosis of femoral head
or acetabulum
GRADING OSTEOARTHRITIS OF THE HIP
AND KNEE 2 Small cysts in femoral head or acetabulum,
Several grading systems have been generated to describe increasing narrowing of joint spine, moderate
loss of sphericity of femoral head
the severity of osteoarthritis based on radiologic criteria.
Hip osteoarthritis is often evaluated by overall global 3 Large cysts, severe narrowing or obliteration
visual qualitative assessment tools89–91 or by analyz- of joint space, severe deformity of femoral
ing the joint space width (JSW)90,92–95 (Tables 7.4–7.5; head, avascular necrosis
Box 7.2; Table 7.6). Most commonly, the Tönnis and From Tönnis D, Heinecke A. Acetabular and femoral anteversion:
Heinecke classification system and Kellgren and Law- relationship with osteoarthritis of the hip. J Bone Joint Surg Am.
rence classification are used to grade hip osteoarthritis, 1999;81(12):1747–1770; with permission.
TABLE 7.5 TABLE 7.6

Kellgren and Lawrence Classification Overall Qualitative Assessment Tool for Hip
Osteoarthritis Formatted by Croft et al.
Grade Characteristics
Grade 0 No changes of osteoarthritis
None (0) Definite absence of x-ray changes of
osteoarthrosis Grade 1 Osteophytosis only
Doubtful (1) Doubtful joint space narrowing (JSN) and Grade 2 Joint space narrowing (JSN) only
possible osteophytic lipping
Grade 3 Two of osteophytosis, JSN, subchondral
Minimal (2) Definite osteophytes and possible sclerosis, and cyst formation
JSN on anteroposterior weight bearing
Grade 4 Three of osteophytosis, JSN, subchondral
radiograph
sclerosis, and cyst formation
Moderate (3) Multiple osteophytes, definite JSN,
Grade 5 As in grade 4, but with deformity of the
sclerosis, possible bony deformity
femoral head
Severe (4) Large osteophytes, marked JSN, severe
sclerosis, and definite bony deformity From Croft P, Cooper C, Wickham C, et al. Defining osteoarthritis of
the hip for epidemiologic studies. Am J Epidemiol. 1990;132(3):514–
Originally studied as a grading tool for the hand, wrist, spine, hip, 522; with permission.
and knee. Currently, it is more commonly used to grade osteoarthri-
tis of the hip and knee.
Data from Kellgren JH, Lawrence JS. Radiological assessment of global visual assessment tools have been criticized for
osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494–502s and O’Brien being somewhat subjective with nebulous distinctions
WM. In: Lawrence JS, ed. Rheumatism in Populations. London:
William Heinemann Medical Books; 1977:572 pp. Arthritis Rheum.
between grades that are often open to the interpreta-
1978;21(3):398. tion of the examiner.
In the often cited 1990 Croft et al. study, the authors
compared seven radiologic indices of hip osteoarthritis
BOX 7.2 in an effort to determine the best definition of the dis-
Radiologic Indices of Hip Osteoarthritis ease for epidemiologic purposes (Box 7.2; Table 7.6).
Compared by Croft et al. to Determine the Best In a subset of 759 men, minimal joint space and thick-
Definition of the Disease for Epidemiologic ness of the subchondral sclerosis were the radiologic
Purposes characteristics that were most predicative of hip pain.90
Minimal joint space is defined as the shortest distance
Lateral joint space from the margin of the femoral head to the acetabu-
Superior joint space lum.90 Lastly, Croft et al. concluded that “minimal joint
Medial joint space space is a simple, repeatable index of osteoarthritis of
the hip which relates to other radiologic features of
Minimal joint space
the disease and to symptoms and is suitable for use
Maximum thickness of subchondral sclerosis in epidemiologic studies. None of the other radio-
Size of the largest osteophyte logic indices that we examined performed as well by
Overall qualitative assessment (Refer to Table 7.6) these criteria”90 (Box 7.2). Thus, minimal joint space
demonstrated the best intraobserver and interobserver
From Croft P, Cooper C, Wickham C, et al. Defining osteoarthritis of repeatability. A major limitation of this study was that
the hip for epidemiologic studies. Am J Epidemiol. 1990;132(3):514– it included only men, aged 60–75 years old.90
522; with permission.
In 2004, Jacobsen et al. conducted a large cohort
study of 3807 subjects (1448 men and 2359 women)
whereas knee osteoarthritis is most commonly graded and determined that the average minimum JSW was
with the Kellgren and Lawrence classification system narrower in women than in men.95 In addition, they
(Tables 7.3–7.5). Regardless of the grading assessment determined that regardless of sex, the minimum JSW
tool, it is important that intraobserver and interobserver decreased after the fourth decade of life, but even more
agreement is maintained. Often within an institution, it so in women.95 Lastly, when the cutoff value of 2.0 mm
is recommended that all musculoskeletal practitioners for JSW was used, regardless of other radiologic features
are trained to use the same grading system, so that there of osteoarthritis, the prevalence of hip osteoarthritis
is strong intraobserver and interobserver reliability. The ranged from 4.4% to 5.3% in participants older than
60 years, and a minimum JSW less than 2.0 mm held colleagues, “This is despite the growing consensus that
the strongest association with self-reported hip pain.95 osteoarthritis is not a single disease affecting the joints,
In a study comparing the minimum JSW method, Kell- but rather a number of distinct conditions, each with
gren and Lawrence grading system, and Croft grading unique etiological factors and possible treatments,
system, Terjesen et al. determined that the minimum which share a common final pathway.”17
JSW method (defined in this study as less than 2.0 mm)
was the simplest, most reliable, and reproducible clas- Patient Education on Osteoarthritis
sification when grading hip osteoarthritis in patients A crucial component of the treatment algorithm
with DDH.93 for elderly patients with osteoarthritis is to lay the
In everyday practice, there is often discordance groundwork through patient education. Consider-
between symptoms and imaging findings. It is not able effort should be made to explain the underly-
uncommon for patients with evidence of osteoarthri- ing pathology causing their symptoms through an
tis by radiologic criteria to be asymptomatic and for individualized patient-centered approach using con-
patients complaining of joint pain to lack radiologic cise and easy-to-understand terminology. There are
evidence of osteoarthritis.96 Thus, a fundamental several different delivery modes that can be used,
understanding of the anatomy and biomechanics of including a discussion with the physician or physical
the hip, along with the clinical and radiographic diag- therapist involved in the patient’s care, written hand-
nostic criteria, is crucial to direct care. Lastly, it is worth outs, self-management programs, support groups,
mentioning that magnetic resonance imaging is more and approved websites.16,99 It is important that the
helpful than radiographs for detecting early structural patient plays an active rather a passive role in the
changes of osteoarthritis.␣ care plan, incorporating a shared decision-making
paradigm based on preferences and goals. The cur-
rent standard of care for patients with symptomatic
CARING FOR THE ELDERLY osteoarthritis involves activity and lifestyle modi-
OSTEOARTHRITIC HIP AND KNEE JOINT fications, assistive devices as deemed appropriate,
Osteoarthritis in the elderly is an onerous burden for physical therapy, oral and topical medications, and
the elderly patient who was once highly functional, intraarticular injections. If the symptoms remain
active, and independent. Thus, the perceptive prac- refractory to conservative measures, then surgical
titioner should be aware of the physical and psy- intervention may be necessary.16,17,53,69,99
chological encumbrance this places on the elderly
patient seeking his/her counsel. A crucial part of Activity and Lifestyle Modification
the clinical evaluation should be focused on assess- The conservative management of osteoarthritis is aimed
ing for confounding psychosocial factors, including at preserving the remaining joint integrity, providing
mood disorders, sleep disturbances, family, relation- pain relief and maintaining the patient’s overall func-
ship, or employment stressors. A comprehensive, tionality. With that being stated, weight loss and exer-
holistic approach to managing the patient should be cise have long been considered as cornerstone pillars
formatted, taking into account the patient’s comor- in the nonpharmacologic management of joint osteo-
bidities, social support, activities of daily living, and arthritis.16,17,69,97–104 Weight loss is generally recom-
functional goals. mended for those with lower limb osteoarthritis who
Historically, clinical guidelines for the management are classified as overweight or obese by a BMI criteria of
of hip and knee osteoarthritis have been combined, >25 kg/m2.16,97,100 Historically, the recommendations
attributable to a lack of research specific to the hip. regarding the benefits of weight loss and exercise for
The literature specific to knee osteoarthritis has been osteoarthritis have been based on research dedicated to
more robust, possibly because of the higher prevalence the knee and have been assumed to be adaptable to
of knee osteoarthritis and greater ease with which the the hip.16,98,99 In general, the research on conservative
knee joint can be evaluated and accessed for clinical care of patients with hip osteoarthritis is lacking high-
interventions.17,97,98 Although there is overlap, based quality evidence.16,97–104
on our discussion of the spectral pathogenesis of osteo- However, as one may intuitively expect, the recent
arthritis and pathomorphologies specific to the hip, it literature demonstrates preliminary evidence that
is clear that this generalized grouping of care is funda- improvements in self-reported physical function
mentally flawed. As eloquently stated by Hunter and and pain of overweight or obese patients with hip
osteoarthritis can be achieved through the combination Physical Therapy Program

of exercise, weight loss, and dietary modifications.99 An integral part of the care paradigm for the osteoar-
However, this study is considered preliminary, and thritic hip or knee is the determination of the utility
there are no randomized trials of weight loss interven- of enrolling a patient in a physical therapy program
tions in individuals with hip osteoarthritis.16 Similarly, to enhance function and overall well-being. Aerobic
although exercise is widely recommended in guidelines and strengthening exercises are the most frequently
for the treatment of hip osteoarthritis, the studies are reported interventions in the nonoperative manage-
limited and demonstrate a small to moderate benefit ment of hip or knee osteoarthritis.98,105 A structured
in minimizing pain and improving function. In con- therapy program in the geriatric patient with hip or
trast, the literature for the knee is more robust and knee osteoarthritis is of particular importance, as
convincing.16,17,99,102–104 comorbidities frequently play a confounding role in
A randomized study evaluated the efficacy of exer- adherence and tolerance to exercise. In addition, the
cise therapy and patient education versus patient edu- challenge of formulating a therapy program to stimu-
cation alone (control) on the 6-year survival of the late improvements in pain, stiffness, and functional-
mild to moderate symptomatic osteoarthritic hip.104 ity without inducing pain and motivating the patient
Patients (n = 109) were randomized evenly to exercise/ to maintain long-term adherence to the program can
patient education and control groups (patient educa- prove to be formidable.
tion). It was determined that only 22 of 55 patients Surprisingly, before 2010, it has been argued that
in the exercise/patient education group compared no exercise programs formatted specifically for hip
with 31 of 54 patients in the patient education group osteoarthritis were found in the literature.98 A targeted
underwent total hip replacement. The median time assessment of the patient’s range of motion, strength,
to total hip replacement was 3.5 years in the control endurance, motor control, and function should be
group versus 5.4 years in the exercise/patient educa- completed during the initial clinical encounter before
tion group. There were no significant differences in prescribing a physical therapy program.106,107 In gen-
pain or stiffness between groups, although the exer- eral, a target therapeutic exercise program for hip or
cise therapy group reported better hip function before knee osteoarthritis should include warm-up, strength
the end of the study or before undergoing total hip training, functional exercises, and flexibility/stretch-
replacement. The author noted that this could indi- ing. The frequency, total number of visits, and par-
cate that hip function may play a bigger role than hip ticipatory precautions should be noted, along with
pain in delaying the need to undergo total hip replace- the patients’ comorbidities and functional and pain
ment.104 The exercise therapy program was designed limitations.98
specifically for individuals with hip osteoarthritis and The warm-up should be individualized based on
involved supervised sessions at least once weekly for the patient but frequently involves light walking on a
3 months, as well as home exercises 2–3 times a week. treadmill or the use of a stationery or recumbent bike.
However, along with other limitations, no data were If walking is tolerated, special attention should be
obtained on the continuation of the exercise therapy paid to the gait mechanics, including symmetry and
program after 12 weeks.104 cadence, with an assessment for improvements with
Further investigation is necessary to conclusively assistive devices if needed. In the warm-up, manual
determine the long-term effects of exercise and therapy and modalities should be used at the discre-
weight loss as conservative measures for managing tion of the physical therapist, based on the individual
hip osteoarthritis and postponing hip replacement.99 needs of the patient. Strength training has numerous
Further specifications regarding the type, frequency, potential benefits. Case-control studies have demon-
mode of delivery (i.e., land or aqua based), and strated decreased muscle strength and muscle hypot-
length of exercise regimens are required.16 Regard- rophy in patients with hip osteoarthritis.108,109 As
less, the Ottawa Panel guidelines recommend that expected, randomized controlled trials have shown
weight loss in overweight or obese patients should benefits from strengthening and functional exer-
be considered before instituting weight-bearing exercises in both the young and elderly.98 Strengthening
cises to avoid further joint destruction.16,101 Over- exercises for both the core musculature and the hip
all, it is recommended that the exercise, dietary, periarticular supporting musculature should be incor-
and weight loss programs should be specific to the porated as hip muscle activation during the perfor-
unique requirements of each patient. mance of core exercises.98,108
Functional therapeutic exercises that imitate the Knee OA Clinical Pearl: AAOS Treatment of Osteo-
individualistic demands of the patient’s daily activi- arthritis of the Knee Evidence-Based Guideline, 2nd
ties should also be incorporated. One goal of the Edition (2013), strongly recommends that patients with
therapy program is to increase the degree of diffi- symptomatic knee osteoarthritis participate in self-
culty of the functional exercises by adding dynamic management programs, strengthening, low-impact
movements, reducing the base of support, and/or aerobic exercises, and neuromuscular education, as well
potentially increasing the range through which a as engage in physical activity consistent with national
movement is performed.110 The stretching/flexibility guidelines. They were unable to provide a recommenda-
tion for or against manual therapy or modalities.78
program should involve passive relaxed motions that
are mechanically initiated by the physical therapist,
as well as patient-initiated active static and dynamic
stretches.98 It is important that the therapist is attune Assistive Devices: The Formidable Cane
to range-of-motion limitations that are truly muscula- The cane is interlaced in the history of mankind. The
ture and not structural (i.e., hip ball and socket con- staff was illustrated in the Egyptian tombs of the Sixth
figuration), as this is integral to increasing functional Dynasty (2830 BC).115 Historically, the cane was a sym-
range of motion without exacerbating pain related to bol of style and nobility. As the population has aged
underlying osteoarthritis. over time, the cane has become associated with debility
There are several caveats that should be mentioned and diminished vitality. However, Blount’s statements
in regards to hip osteoarthritis and physical therapy. in his sentinel article published in 1956 (“Don’t Throw
First, within the musculoskeletal community, there Away The Cane”) remain pertinent and valuable. He
is some contention as to the value of physical therapy keenly stated, “Gradually, we are coming to look upon
in the management of hip osteoarthritis.17,111–114 Some eye glasses, hearing devices, and dentures as welcome
investigators have debated that therapy offers mini- aids to gracious living rather than as the stigmata of
mal benefit beyond that expected of a self-guided exer- senility. They should be accepted as components of a
cise program.17,112 Bennell and colleagues completed richer life. The cane, too, should be restored to favor as
a randomized, placebo-controlled, participant-and- a means of preventing fatigue and a halting gait, rather
assessor-blinded study comparing physical therapy–led than maligned as a sign of deterioration.”115
management with sham therapy and did not find dif- An antalgic (limping) gait, which is often associ-
ferences in pain or function between groups.114 In con- ated with a lurch, is fatiguing, frequently places undo
trast, several studies have demonstrated an increased strain on the lumbar spine, and may result in undo
survival time of the native hip, improved physical func- pressure on the femoral head (up to four times the
tion, and reduced pain in patients receiving exercise body weight), potentiating further deterioration of
therapy.103,104 the hip.115 The use of a cane in the opposite hand of
Furthermore, the optimal exercise dosage (i.e., num- the arthritic hip (i.e., right hand, left hip) reduces the
ber of exercise sets, repetitions, and duration of each forces across the hip and decreases the pull required
session and therapy program) for patients with hip of the ipsilateral hip abductor muscles (i.e., left hip)
osteoarthritis is not clear, with limited studies compar- needed to support the body weight in a single-support
ing exercise regimen parameters.112 The current best (i.e., left leg) stance phase.115,116 Thus, the cane should
available evidence from several randomized controlled be advanced with the affected limb in what is referred
trials and systematic reviews have demonstrated that to as a three-point gait pattern.116 A cane is capable of
manual therapies (i.e., joint manipulation and mobi- offloading up to 20% of the patient’s body weight from
lization techniques, muscle stretching, soft tissue mas- the affected limb.116
sage) are unlikely to provide any additional benefit as The cane is an effective, supportive device and pro-
an adjunct treatment to an exercise program in patients prioceptive aid that has the potential to prolong the
with hip and knee osteoarthritis in terms of improving lifespan of the native osteoarthritic hip while enhanc-
physical function, range of motion, and participant- ing well-being and functionality. An informed discus-
assessed improvement.17,111–113 Further high-quality sion with the patient regarding the utility of the cane
research is required to definitively state which sub- should be held, and this discussion should include
group of patients with hip osteoarthritis will respond a realistic assessment of the patient’s current limita-
best to physical therapy, as well as the optimal therapy tions, degree of osteoarthritis, pain, comorbidities, and
approach, timing, frequency, and duration.␣ functional goals, as a cane may not be the appropriate
adjunct in every case. The goal is to provide the patient

BOX 7.3
with all the information and tools needed to be an
American College of Rheumatology (ACR)
active participant in their care plan.
2012 Recommendations for Pharmacologic
Management of Hip Osteoarthritis
Knee OA Clinical Pearl: AAOS Treatment of Osteo-
arthritis of the Knee Evidence-Based Guideline, 2nd ACR Pharmacologic Recommendations for Hip
Edition (2013), was unable to provide a recommenda- Osteoarthritis Management (2012)
tion for or against a valgus-directing force brace (medial Conditionally recommend the following:
compartment unloader). Similarly, based on moderate • Acetaminophen
evidence, the committee could not suggest that lateral • Oral nonsteroidal anti-inflammatory drugs (NSAIDs)
wedge insoles be used for patients with symptomatic • Intraarticular corticosteroid injections
medial compartment osteoarthritis of the knee.78 • Tramadol
Conditionally do NOT recommend the following:
• Chondroitin sulfate
Pharmacologic Management • Glucosamine
Historically, pharmacologic management of osteoar- No recommendations regarding:
• Topical NSAIDs
thritis has been palliative and focused on symptomatic
• Intraarticular hyaluronate injections
relief. Alternatively, there have been several disease-mod-
• Duloxetine
ifying osteoarthritic agents that have demonstrated great • Opioid analgesics
promise in preclinical trials but unfortunately have not
Please note that these are the most current published
demonstrated the same promise in clinical studies.17 A
recommendations by the ACR and are based on the evi-
brief overview of the more commonly used pharmaco-
dence available through the end of 2010. Please refer
logic treatments is provided. To date, few trials have been to the ACR website (http://www.rheumatology.org/) peri-
performed in patients with hip osteoarthritis. Often, odically for any revisions or updates. The information in
patients with hip osteoarthritis are treated in a manner this table may predate many of the studies referenced
similar to patients with knee osteoarthritis.97 within this chapter.
The authors of this chapter recommend referring to
clinical guidelines created by the American Academy Adapted from Hochberg MC, Altman RD, April KT, et al. Ameri-
can College of Rheumatology 2012 recommendations for the use
of Orthopaedic Surgeons (AAOS), ACR, Osteoarthritis of nonpharmacologic and pharmacologic therapies in osteoar-
Research Society International, and National Institute thritis of the hand, hip, and knee. Arthritis Care Res (Hoboken).
for Health and Care Excellence “Osteoarthritis: Care and 2012;64(4):471; with permission.
Management in Adults” for the most up-to-date infor-
mation regarding recommendations in osteoarthritis from “nutrition” and “pharmaceutical” and essentially
treatment. When considering medical management of describes “a food that has health benefits including the
patients with osteoarthritis, there is not one singular prevention and/or treatment of a disease.”117 Frequently
“cookbook” algorithmic approach to care. Each patient described supplements for osteoarthritis include glu-
should undergo an individualized assessment based cosamine sulfate, chondroitin, diacerein, avocado,
upon the patient’s functional level, pain, comorbidities, soybean unsaponifiables, and turmeric.17,117–119 The
values, and goals. Thus, the guidelines should be used literature regarding the efficacy of these supplements
as a tool and are not intended to be absolute, as there is in the treatment of osteoarthritis is highly heteroge-
variability in patient symptoms and responses to treat- neous, in part because of variations in study param-
ments provided. Please refer to Box 7.3 and Table 7.7 eters, sponsorship bias, lack of adequate long-term
for a summary of the ACR and AAOS recommendations follow-up time, and the subjectivity of measuring
regarding the management of hip osteoarthritis. Please pain as a primary outcome. However, based on the
also refer to “Knee OA Clinical Pearls” for a summary body of literature, it is fair to say that there is no
of high-yield recommendations regarding the manage- definitive evidence that supplements alter the natural
ment of knee osteoarthritis by the ACR and AAOS. progression of osteoarthritis. However, they generally
have a low side-effect profile and are well tolerated.
Supplements In certain cases, some of the supplements have dem-
“Supplement” is often used interchangeably with onstrated benefit in reducing pain and enhancing
“nutraceuticals,” which is a term that originated function.118␣
TABLE 7.7
Excerpts of Recommendations From the 2017 American Academy of Orthopaedic Surgeons (AAOS)
Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guidelines
AAOS Evidence-Based Clinical
Practice Guideline for Management
of Osteoarthritis of the Hip (2017) Recommendations
Nonnarcotic management Strong evidence supports nonsteroidal anti-inflammatory drugs in improving short-
term pain, function, or both in patients with symptomatic osteoarthritis of the hip
Glucosamine sulfate Moderate evidence does not support the use of glucosamine sulfate because
it does not perform better than placebo for improving function, reducing stiff-
ness, and decreasing pain for patients with symptomatic osteoarthritis of the hip
Intraarticular corticosteroids Strong evidence supports the use of intraarticular corticosteroids to improve
function and reduce pain in the short term for patients with symptomatic osteo-
arthritis of the hip
Intraarticular hyaluronic acid (HA) Strong evidence does not support the use of intraarticular HA because it does
not perform better than placebo for function, stiffness, and pain in patients with
symptomatic osteoarthritis of the hip
Physical therapy as a conservative Strong evidence supports the use of physical therapy as a treatment to
treatment improve function and reduce pain for patients with osteoarthritis of the hip and
mild to moderate symptoms
Preoperative physical therapy Limited evidence supports the use of preoperative physical therapy to improve
early function in patients with symptomatic osteoarthritis of the hip following
total hip arthroplasty
Special note: biological injectables There were no high-quality randomized controlled trials comparing the perfor-
mance of intraarticular injections of stem cells or prolotherapy with placebo at
the time these guidelines were prepared. Three studies139–141 compared intraar-
ticular injections of platelet-rich plasma (PRP) with HA or a combination of PRP
or HA, but there were no high-quality studies comparing PRP with placebo for
inclusion in this analysis
Endorsed by the Pediatric Orthopaedic Society of North America (POSNA), American Physical Therapy Association (APTA), and the American
College of Radiology (ACR).
Data from American Academy of Orthopaedic Surgeons Board of Directors. Management of Osteoarthritis of the Hip: Evidence-Based Clinical
Practice Guideline; 2017. Available at: https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/OA%20Hip%20C
PG_5.22.17.pdf.
Knee OA Clinical Pearl: The ACR (2012) conditionally with placebo in osteoarthritis.120–124 There is high-
recommends that practitioners avoid using nutritional quality evidence that acetaminophen has a significant
supplements (i.e., chondroitin sulfate, glucosamine).97 but small short-term benefit in patients with hip or
AAOS Treatment of Osteoarthritis of the Knee Evidence- knee osteoarthritis when compared with placebo.120
Based Guideline, 2nd Edition (2013), strongly does not Also, high-quality evidence demonstrates that fre-
recommend using glucosamine and chondroitin for
quent acetaminophen use increases the risk of having
patients with symptomatic osteoarthritis of the knee.78
abnormal values on liver function tests, although the
clinical relevance of this is unclear.120 The ACR con-
Acetaminophen ditionally recommends that patients with hip osteo-
For safety reasons, guidelines frequently recommend arthritis use acetaminophen.97 If acetaminophen is
the prescription of acetaminophen as the first-line used, the authors of this chapter recommend using
pharmacologic agent for the treatment of osteoar- the lowest effective dose for the shortest time frame
thritic conditions.97,120,121 However, this is highly possible for pain relief. As per the US Food and Drug
controversial, as several studies have demonstrated Administration, the maximum daily dose recom-
limited effects of acetaminophen when compared mended is 4000 mg.97,120␣
Knee OA Clinical Pearl: The ACR (2012) conditionally If all other measures fail or are contraindicated,
recommends that practitioners use acetaminophen in tramadol is a weak opioid that may be considered for
patients with symptomatic knee osteoarthritis.97 AAOS judicious use. However, careful evaluation of the side-
Treatment of Osteoarthritis of the Knee Evidence-Based effect profile should be made and discussed with the
Guideline, 2nd Edition (2013), was unable to provide rec- patient.17,97 As noted in the ACR 2012 recommenda-
ommendations for or against the use of acetaminophen tions, tramadol is considered separate from other opi-
for symptomatic knee osteoarthritis.78 oids because of its central analgesic effect, which “is
thought to be mediated not only by a weak opioid
receptor agonist effect but also through modulation
Nonsteroidal Antiinflammatory Medications of serotonin and norepinephrine levels.”129 Opioids
Nonsteroidal antiinflammatory drugs (NSAIDs) are are otherwise not generally recommended for the
generally considered to be the main form of treatment treatment of knee or hip osteoarthritis, as the adverse
for osteoarthritis (124). In the US, approximately 65% effects frequently outweigh the benefit in the geriatric
of patients with osteoarthritis are prescribed NSAIDs population.17
as the pharmacologic agent of choice.124 NSAIDs have
been well studied and validated for the symptomatic
Knee OA Clinical Pearl: AAOS Treatment of Osteoar-
relief of osteoarthritis.17,121–125 However, only certain thritis of the Knee Evidence-Based Guideline, 2nd Edi-
NSAIDs have consistently demonstrated clinically sub- tion (2013), was unable to provide a recommendation for
stantiated benefit in osteoarthritic pain.124 Regardless, or against the use of opioids or pain patches for symp-
when choosing prescribed NSAIDs, a careful risk versus tomatic knee osteoarthritis.78
benefit analysis should be contemplated. In the geriatric
population in particular, the patient’s comorbidities and
current medications should be meticulously evaluated
before selecting the NSAID of choice, as there are varia- Intraarticular Injections
tions in side-effect profiles. Regardless, in light of the Intraarticular injection options for osteoarthritis are an
well-established cardiovascular, renal, and gastrointesti- area of much interest because of the direct action within
nal adverse effects of NSAIDs, they should be prescribed the joint and relative lack of systemic effects.129–132
only as needed for short, limited time frames using Injection options are usually considered in patients
the minimally effective dose with detailed instructions who fail to experience relief with nonpharmacologic
provided to the patient regarding the optimal method and oral pharmacologic treatment measures. Often,
of intake (i.e., with food and water). In addition, the these patients are not quite yet eligible for a joint
patient should be educated on potential side effects of replacement because of various factors or are eligible
the medication. Lastly, NSAIDs can be administered but choose to defer. Regardless, the authors of this
orally or topically. Topical NSAIDs have been proved to chapter recommend that all hip intraarticular injec-
be beneficial in relief of knee osteoarthritis, but there are tions be performed under either ultrasound or fluoro-
no recommendations for their use in hip osteoarthritis scopic guidance.
because of the depth of the hip joint.17,97,126␣
Corticosteroid Injections. International guidelines
Alternative Oral Agents are in favor of intraarticular steroid injections (IASIs)
In patients who fail to demonstrate an adequate in the management of hip osteoarthritis, although
response to initial therapy options, alternative options these recommendations have generally been assumed
may be considered. Duloxetine is a centrally acting to be applicable based on studies of knee osteoar-
selective norepinephrine and serotonin reuptake inhib- thritis.129 Historically, there have been studies dem-
itor that has demonstrated efficacy in osteoarthritis- onstrating the transient efficacy of corticosteroids in
related knee pain.127–129 One published study that knee osteoarthritis, and the ACR guidelines condition-
included a very small subset of patients with hip osteo- ally recommend that healthcare providers use knee
arthritis along with a much larger cohort of patients IASIs as a treatment option.96 However, the recent
with knee osteoarthritis also demonstrated favorable literature regarding the use of IASIs in knee osteoar-
results of duloxetine for the management of chronic thritis has been conflicting, raising concerns regard-
pain due to osteoarthritis.129 Further studies dedicated ing the risk versus benefit of IASIs for the knee (refer
to evaluating the efficacy of duloxetine in alleviating to the following Knee OA Clinical Pearl for further
hip osteoarthritis pain are necessary. details).
A large systematic review of the literature suggested The rationale for “viscosupplementation” is to
that “hip IASI may be efficacious in delivering short replace the properties lost by a reduction in intrinsic
term but clinically significant, pain reduction in those HA production and quality that occurs with osteoar-
with hip osteoarthritis, and may also lead to transient thritis.132 Although considerable effort has been dedi-
improvement in function.”129 However, it is impor- cated to investigating the method by which HA exerts
tant to restate that the number of studies performed in its potential therapeutic benefit, it remains unclear
patients with symptomatic hip osteoarthritis are few, and significant evidence for “restoration of rheological
and the quality of evidence is relatively poor, with few properties is lacking.”132 Simply stated, it is believed
participants overall in comparison to studies of the that two stages may be involved: an initial mechani-
knee.129 Therefore, it is possible to “overestimate treat- cal stage and a secondary physiologic stage. The benefit
ment effect size or report significant effect when none is for the initial mechanical stage is believed to be due
present.”129 Once more, in the studies evaluated, most to the injected HA restoring elastoviscosity, thus pro-
of the participants were awaiting or candidates for total viding lubrication and shock-absorbing capabilities
hip replacement, indicating severe end-stage hip osteo- of the synovial fluid. The physiologic benefit refers to
arthritis. Thus, these results cannot be generalized to the longer sustained benefit of injected HA that per-
patients with a lesser grade of hip osteoarthritis.129 Fur- sists beyond the residence time (hours to days) of HA,
ther studies are required to determine the ideal candi- which is largely based on preclinical studies.132 Over-
dates, evaluate the best steroid preparation and dose, all, the literature regarding the efficacy of HA for hip
and confirm both the efficacy and safety of IASIs in the osteoarthritis demonstrates large heterogeneity and is
management of hip osteoarthritis.129,132␣ conflicting.132–137 Currently, clinical guidelines do not
recommend HA injections for the management of hip
osteoarthritis.17,97,132,138␣
Knee OA Clinical Pearl: A recent randomized, placebo-
controlled, double-blinded 2-year trial of an intraar-
ticular injection of 40 mg triamcinolone every 3 months Knee OA Clinical Pearl: The ACR (2012) recommen-
versus saline for symptomatic knee osteoarthritis with dations regarding the pharmacologic management of
ultrasound features of synovitis was conducted in 140 knee osteoarthritis state “we have no recommendations
patients. Intraarticular triamcinolone injections resulted regarding the use of intraarticular hyaluronates” (along
in significantly greater cartilage volume loss than saline, with duloxetine and opioid analgesics).97 The AAOS
and there was no significant difference in knee pain Treatment of Osteoarthritis of the Knee Evidence-Based
between groups.130 These results contradicted a previ- Guideline, 2nd Edition (2013), could not recommend
ous smaller, but highly cited, study that found no differ- using HA for patients with symptomatic osteoarthritis of
ence in the rate of radiographic joint space loss with a the knee.78
detected benefit on knee pain.131 AAOS Treatment of
Osteoarthritis of the Knee Evidence-Based Guideline,
2nd Edition (2013), was unable to provide recommen-
Biologic Injectables. The literature regarding the use
dations for or against the use of IASIs for symptomatic
of cellular-based therapies, such as platelet-rich plasma
knee osteoarthritis.78
(PRP) and mesenchymal stem cells (MSCs), to treat
hip osteoarthritis is very limited, and it is too early to
make any definitive conclusion regarding efficacy and
Hyaluronans. Endogenous hyaluronan (HA, also outcomes.139–142 By comparison, there have been sev-
known as hyaluronic acid) is described as a linear, large eral prospective, randomized controlled clinical studies
glycosaminoglycan found in synovial fluid and is made evaluating biological interventions for knee osteoar-
in the lining layer cells of the joint. It is sequestered thritis and symptom modulation, some of which have
from the joint through the lymphatic circulation and shown some benefits.142–153 However, there is large
is broken down by hepatic endothelial cells.132 Its pri- heterogeneity in treatment protocols, biologic injec-
mary function is to provide lubrication, viscoelasticity, tate preparation, study length, severity of knee osteoar-
and tissue hydration. It maintains protein homeostasis thritis treated, baseline patient characteristics, control
by acting as an osmotic buffer, thus preventing large groups used, and primary outcomes measured, making
fluid shifts.132 Commercial HA was first isolated from it difficult to formulate a consensus statement.142–153
roosters’ combs and umbilical cord tissue in the 1960s As a result, there is no US Food and Drug Adminis-
for the treatment of arthritis and use in ophthalmic tration (FDA)-licensed or FDA-approved biological
surgery.132 therapy or procedure that halts the degenerative
cascade of osteoarthritic joints.143 In general, results

TABLE 7.8
have demonstrated that PRP use is safe and that bone
Estimated Prevalence of Total Hip (THR) and
marrow aspirate concentrate is a safe and feasible
Total Knee Replacements (TKR) by Age in 2010
source of MSCs.141–152 Both treatments may have the
potential to provide symptomatic benefit for osteoar- US Prevalence of US Prevalence of
thritis in at least the short term.142,143 Age THR (%) TKR (%)
Further high-quality studies are necessary to deter- 50 years old 0.58 0.68
mine the optimal patient population, biologic prepa- 60 years old 1.49 2.92
ration protocols, and mechanism of action before
70 years old 3.25 7.29
clinical efficacy and cost-effectiveness can be fully rec-
ognized.142,154 An expert consensus statement on the 80 years old 5.26 10.38
minimum reporting requirements for clinical studies 90 years old 5.87 8.48
evaluating PRP and MSCs was published in an attempt
to address the limitations in reporting of scientific data Please note these data do not include individuals who have un-
critical to outcomes and to create more stringent study dergone joint replacement techniques other than total hip or knee
replacement (i.e., partial hip or partial knee replacement).
parameters to improve research regarding biologics.154␣␣␣ Adapted from Maradit Kremers H, Larson DR, Crowson CS, et al.
Prevalence of total hip and knee replacement in the United States.
J Bone Joint Surg Am. 2015;97(17):1387; with permission.
Knee OA Clinical Pearl: The ACR (2012) guidelines
regarding pharmacologic management of knee osteo- the US.156 As of 2010, it is estimated that the preva-
arthritis did not make any recommendations regarding lence of total hip replacements and total knee replace-
biologics.97 This is understandable, as the overwhelming ments among the entire US population was 0.83% and
majority of randomized controlled clinical studies inves-
1.52%, respectively.156 This equates to 2% of the US
tigating biologics (PRP, MSCs for knee osteoarthritis)
occurred after the publication date. Likewise, the AAOS
population living with a total hip or total knee replace-
Treatment of OA of the Knee Evidence-Based Guideline, ment, corresponding to an estimated 7 million people,
2nd Edition (2013), was unable to provide recommen- of which 620,000 underwent both procedures.156 For
dations for or against growth factor injections and/or both procedures, the prevalence is noted to increase
PRP for patients with symptomatic osteoarthritis of the with age and more steadily for total knee replacements
knee.78 than for total hip replacements (Table 7.8). For both
procedures, the prevalence is higher in women than
in men.156 Given the overall success of hip and knee
replacement procedures in improving quality of life
TOTAL JOINT REPLACEMENT and functionality, it is anticipated that the incidence
(ARTHROPLASTY) and prevalence rates of total hip and knee replacement
In the patient with severe osteoarthritis that remains procedures will continue to increase in the years to
painful, functionally limiting, and refractory to all come (Figs. 7.9–7.11).␣
conservative measures, total joint replacement surgery
should be considered.155 Total hip replacement has Hip Arthroplasty Patient and Implant
evolved from a procedure with poor outcomes reserved Selection
for the most debilitated patients to one of the most Optimal surgical outcomes are maximized through care-
successful orthopedic surgeries available.17,21,156,157 ful patient selection. Obesity, advanced age, and medi-
Studies in the US and United Kingdom show greater cal comorbidities are not absolute contraindications,
than 95% implant survivorship at the 10-year follow- although a careful risk-to-benefit assessment should be
up and greater than 80% implant survivorship at considered.78,138,157 According to the 2017 AAOS hip
the 25-year follow-up.157–159 Approximately 65% of clinical practice guidelines, moderate-strength evidence
total hip replacements occur in patients 65 years and supports that when obese patients are compared with
older.157 nonobese patients with symptomatic osteoarthritis
of the hip, they may achieve lower absolute outcome
Incidence and Prevalence scores but have a similar level of patient satisfaction
The overall incidence of joint replacement procedures and relative improvement in pain and function after
is quite high, with over 1 million total hip and total total hip replacement. Moderate-strength evidence also
knee replacement procedures performed annually in suggests that increased age is associated with lower
A B
FIG. 7.11 (A) AP and (B) lateral views status post-total
FIG. 7.9 AP with crests view (reformatted with crests right knee replacement.
cropped) image of noncemented left hip total replacement
in anatomic alignment. There is also joint space narrowing
and minimal osteophytes of the right hip.
polyethylene wear, metallic wear debris resulting in
increased serum levels of chromium and cobalt, frac-
ture of the ceramic components).157,160 Cemented or
noncemented components (or a hybrid of the two) may
be used for total hip replacement. Cementless stems
are more commonly used and with good results. In the
US, 60%–90% of total hip replacement procedures use
cementless stems.157 One of the theoretical benefits of
cementless fixation is remodeling of the bone-implant
interface.157 Resurfacing is considered to be a bone-
conserving option that is most often recommended
for younger, active patients, and its use is controversial.
It is technically more demanding, with a potentially
increased risk of aseptic loosening and revision surgery
compared with total hip replacement.157,162
FIG. 7.10 AP with crests view (reformatted with crests Currently, AAOS guidelines indicate that moder-
cropped) status post-anatomically aligned left and right
ate-strength evidence supports no clinically signifi-
total hip replacement with noncemented femoral and ac-
cant differences in patient-oriented outcomes related
etabular components.
to the surgical approach for patients undergoing total
hip replacement for symptomatic osteoarthritis.138
function and quality of life in patients with hip osteoar- National registries have revolutionized our abil-
thritis undergoing total hip replacement. Lastly, moder- ity to assess patient outcomes, surgical techniques,
ate-strength evidence demonstrates that mental health and implant survivorship on a national and global
disorders, such as depression, anxiety, and psychosis, scale.157␣
are associated with decreased function, pain relief, and
quality of life status post-total hip replacement.138 Total Hip Replacement Complications
A comprehensive assessment of the patient is Although total hip replacement surgery is usually
required to identify which implant design or surgi- quite successful, complications may occur. Despite
cal techniques will provide the best benefit. There are advances in total hip replacement surgical techniques
several bearing surfaces available, including metal on and implant designs, revision rates have remained
polyethylene, metal on metal, ceramic on ceramic, unchanged over the past several decades.157 The most
and metal on ceramic, and there are also resurfacing common reasons for revision surgery are instabil-
techniques.157,160,161 However, each of the bearing ity (22%), mechanical loosening (20%), infection
surfaces has certain associated benefits and risks (i.e., (15%), implant failure (10%), osteolysis (7%), and
TABLE 7.9
Excerpts of Recommendations From the Evidence-Based Clinical Practice Guidelines for Surgical
Management of Knee Osteoarthritis
American Academy of Orthopaedic Surgeons
Evidence-Based Clinical Practice Guidelines for
Surgical Management of Knee Osteoarthritis (2015) Recommendations
Obesity Strong evidence supports that obese patients have less
improvement in outcomes with total knee arthroplasty (TKA)
Preoperative physical therapy Limited evidence supports that supervised exercise before
TKA might improve pain and physical function after surgery
Polyethylene tibial component Strong evidence supports use of either all-polyethylene or
modular tibial components in knee arthroplasty (KA), because
of no difference in outcomes
Cemented versus cementless tibial components Strong evidence supports the use of tibial component fixation
that is cemented or cementless in TKA because of similar func-
tional outcomes and rates of complications and reoperations
Cemented femoral and tibial components versus Moderate evidence supports the use of either cemented
cementless femoral and tibial components femoral and tibial components or cementless femoral and tibial
components in KA because of similar rates of complications
and reoperations
Continuous passive motion (CPM) Strong evidence supports that CPM after KA does not im-
prove outcomes
Postoperative mobilization and length of stay Strong evidence supports that rehabilitation started on the
day of the TKA reduces length of hospital stay
Postoperative mobilization and pain/function Moderate evidence supports that rehabilitation started on the
day of the TKA compared with rehabilitation started on postop-
erative day 1 reduces pain and improves function
Early-stage supervised exercise program and function Moderate evidence supports that a supervised exercise
and pain program during the first 2 months after TKA improves physical
function. Limited evidence supports a decrease in pain.
Supported by the American Society of Anesthesiologists. Endorsed by The Knee Society, American Association of Hip and Knee Surgeons,
American College of Radiology, Arthroscopy Association of North America, and AGS Geriatric Healthcare Professionals. Please refer to the
AAOS guidelines for a complete list of recommendations. Overall, the AAOS guidelines and recommendations regarding knee osteoarthritis
are more comprehensive than those provided for the hip.
Data from American Academy of Orthopaedic Surgeons Board of Directors. Surgical Management of Osteoarthritis of the Knee: Evidence-
Based Clinical Practice Guideline; 2015. Available at: https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/
guidelines/SMOAK%20CPG_4.22.2016.pdf.
periprosthetic fracture (6%). The most common causes postoperative physical therapy may improve early
of failure after revision include infection (30%), insta- function to a greater extent than no physical therapy
bility (25%), and loosening (19%).157 management.138 Please refer to Table 7.9 for data
Limited-strength evidence supports that patients regarding total knee replacement guidelines for com-
who are obese or use tobacco products are at an parison (Table 7.9).␣
increased risk for complications after total hip replace-
ment.138 Also, limited-strength evidence supports Total Hip Replacement Survivorship
an association between increased age and mortality Regardless of the prosthetic component used, the sur-
risk in patients with symptomatic hip osteoarthritis vivorship of the artificial hip is quite good. There have
receiving total hip replacement.138 Regardless, mod- been several revisions and upgrades in surgical tech-
erate-level evidence supports the use of postop- nique and implant design over the years. It is believed
erative physical therapy. It is generally believed that that patients can expect their prosthesis to last well
over 20 years.157 Although complications may occur, 6. Sohn DH, Sokolove J, Sharpe O, et al. Plasma proteins
the great majority of patients do not experience these present in osteoarthritic synovial fluid can stimulate cy-
complications.157␣ tokine production via Toll-like receptor 4. Arthritis Res
Ther. 2012;14(1):R7.
7. Little CB, Fosang AJ. Is cartilage matrix breakdown an
appropriate therapeutic target in osteoarthritis–insights
FUTURE CONSIDERATIONS
from studies of aggrecan and collagen proteolysis? Curr
The science of joint preservation care is rapidly evolv- Drug Targets. 2010;11(5):561–575.
ing. It is likely inevitable that the trend toward shifting 8. Wang Q, Rozelle AL, Lepus CM, et al. Identification of a
the care paradigm from palliative management of end- central role for complement in osteoarthritis. Nat Med.
stage osteoarthritis toward a focus on the earliest stages 2011;17(12):1674–1679.
of the condition’s precursors will continue to be fine 9. Troeberg L, Nagase H. Proteases involved in cartilage
tuned. In just the last 15–20 years, there have been con- matrix degradation in osteoarthritis. Biochim Biophys
siderable advances in our understanding of the role that Acta. 2012;1824(1):133–145.
abnormal hip morphology, specifically FAI and DDH, 10. Tonge DP, Pearson MJ, Jones SW. The hallmarks of os-
teoarthritis and the potential to develop personalised
plays in developing hip osteoarthritis later in life. Hip
disease-modifying pharmacological therapeutics. Osteo-
arthroscopy is increasingly used to correct joint patho- arthr Cartil. 2014;22(5):609–621.
morphologies in hopes of curtailing the osteoarthritic 11. Loeuille D, Chary-Valckenaere I, Champigneulle J, et al.
cascade. However, further clinical trials and long-term, Macroscopic and microscopic features of synovial mem-
prospective, observational studies remain crucial for us brane inflammation in the osteoarthritic knee: correlat-
to truly understand the efficacy of hip arthroscopy ver- ing magnetic resonance imaging findings with disease
sus conservative care measures in curtailing hip osteo- severity. Arthritis Rheum. 2005;52(11):3492–3501.
arthritis risk. Hip and knee total joint replacements 12. Baker K, Grainger A, Niu J, et al. Relation of synovitis
have proved to be highly successful surgeries, and it is to knee pain using contrast-enhanced MRIs. Ann Rheum
to be expected that surgical techniques and componen- Dis. 2010;69(10):1779–1783.
13. Taljanovic MS, Graham AR, Benjamin JB, et al. Bone
try will only continue to improve.
marrow edema pattern in advanced hip osteoarthri-
The literature regarding the use of biologic treatment tis: quantitative assessment with magnetic resonance
options in knee osteoarthritis is rapidly expanding, and imaging and correlation with clinical examination, ra-
similar studies are increasingly being formatted for the diographic findings, and histopathology. Skeletal Radiol.
hip. Recently and for the first time, a consensus statement 2008;37(5):423–431.
on the minimum reporting requirements for clinical 14. Brophy RH, Rai MF, Zhang Z, Torgomyan A, Sandell LJ.
studies evaluating PRP and MSCs has been created, and Molecular analysis of age and sex-related gene expres-
it is anticipated that the consensus parameters will only sion in meniscal tears with and without a concomitant
improve the quality of research into biologics. It is also anterior cruciate ligament tear. J Bone Joint Surg Am.
likely that further research into the role genetics plays in 2012;94(5):385–393.
15. Jordan JM, Helmick CG, Renner JB, et al. Prevalence of
the development of osteoarthritis will continue with the
hip symptoms and radiographic and symptomatic hip
formulation of gene-specific targeted treatments. osteoarthritis in African Americans and Caucasians:
the Johnston county osteoarthritis project. J Rheumatol.
2009;36(4):809–815.
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149. Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A. of primary and revision hip and knee arthroplasty in the
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150. Campbell KA, Saltzman BM, Mascarenhas R, et al. Does 160. Varnum C. Outcomes of different bearings in total hip
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151. Sanchez M, Fiz N, Azofra J, et al. A randomized clinical 2014;96(suppl 1):79–97.
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152. Simental-Mendia M, Vilchez-Cavazos JF, Pena-Martinez 163. Surgical Management of Osteoarthritis of the Knee: Evi-
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Trauma Surg. 2016;136(12):1723–1732.
CHAPTER 8
Prevention of Hospital-Acquired
Deconditioning
DER-SHENG HAN, MD, PHD • SHIH-CHING CHEN, MD, PHD
EPIDEMIOLOGY AND EFFECT OF IMPACT OF BED REST AND IMMOBILITY

DECONDITIONING Musculoskeletal System
Unnecessary bed rest often occurs in hospitals or There are three main effects of bed rest on the muscu-
institutions, resulting in deconditioning.1 The diag- loskeletal system:
nosis of debility (deconditioning) is coded as R53.81 1. sarcopenia (muscle atrophy and weakness)
in the International Statistical Classification of Dis- 2. joint contracture
eases and Related Health Problems, 10th revision 3. osteoporosis
(ICD-10).2 The concept of deconditioning has been
discussed in many articles, and synonyms for the Sarcopenia
term include debility, generalized weakness, asthenia, Activity-related sarcopenia resulting from bed rest,
and immobilization syndrome. What does the above deconditioning, or zero-gravity conditions is one type
definition of functional decline refer to? Functional of secondary sarcopenia. According to the diagnos-
status represents the ability to perform basic activi- tic criteria proposed by the European Working Group
ties of daily living (ADLs), such as bathing, dressing, on Sarcopenia in Older People, sarcopenia is defined
transferring from bed to chair, using the toilet, and as low muscle mass plus low muscle strength or low
sphincter control. It is estimated that 34%–50% of physical performance. Low grip strength is deemed as
older adult patients experience functional decline in low muscle strength, and usual gait speed is employed
at least one basic ADL during hospitalization.3 Preva- for physical function evaluation.7 The muscle mass
lent losses occurred in the ability to perform bathing can be easily measured with bioimpedance analyzer or
and dressing skills, and the onset of decline occurs as dual-energy X-ray absorptiometry (DXA). The DXA cut-
early as day 3 of the hospital stay.4 Those patients with off value for low muscle mass is below 7.23 kg/m2 for
hospital-associated deconditioning have a higher risk the male and 5.67 kg/m2 for the female.8 The cause of
of mortality and nursing home institutionalization. activity-related sarcopenia is multifactorial, including
It is absolutely important for healthcare workers to decreased cardiovascular function, muscle atrophy, and
pay attention proactively to avoid unnecessary bed motor neuron loss. Berg et al.9 carried out a classic study
rest. on young healthy men and found that after 6 weeks of
The causes of deconditioning are multifactorial and bed rest, maximum voluntary isometric and concen-
include a low premorbid functional status, immobility, tric knee extensor torque was decreased by 25%–30%
iatrogenic complications, generalized inflammation, and the cross-sectional area of the quadriceps femoris
compromised nutrition, anemia, pain, sleep depriva- muscle was decreased by 14%. The decline in muscle
tion, fatigue, and depression.5 strength was more significant than the decrease in the
Immobility results in adverse consequences in cross-sectional area of muscles, showing that changes
multiple organ systems (Table 8.1). In the musculo- in neural control efficiency or neurotransmitter secre-
skeletal system, it results in a decline in strength/endur- tion and other factors can similarly cause a decline
ance, muscle atrophy, and decreases in metabolism in muscle strength. Another study on young healthy
and oxygen utilization rate. In the circulatory system, men found that bed rest for 29 days resulted in a 10%
immobility results in a decrease in functional capacity decrease in the volume of the quadriceps femoris mus-
(including cardiac output and workload), orthostatic cle and a 16% decrease in the volume of the gastrocne-
hypotension, and deep vein thrombosis. Osteoporosis mius/soleus muscle complex.10 Immobility and muscle
is one of the complications of immobility.6␣ disuse cause muscle atrophy, which leads to weakness
111
(responsible for rapid movement) decreases by 46%,

TABLE 8.1
while the average cross-sectional area of type I muscle
Complications of Immobility
fibers (responsible for slow movement) decreases by
System Complication 69%. At the same time, the size and number of mito-
Musculoskeletal Sarcopenia (muscle atrophy and chondria decrease, leading to decreases in aerobic
weakness), joint contracture, os- respiration.14
teoporosis, hypercalcemia Regarding metabolism, the main source of energy
Circulatory and Body fluid accumulation, orthostat- at rest is derived from carbohydrates and fat, and nitro-
respiratory ic hypotension, decreased cardiac gen loss increases during immobility. The main cause is
output, deep vein thrombosis, decreased muscular activity, resulting in decreased pro-
impaired lung function, pneumonia tein synthesis and consequently in a decrease in blood
Metabolic and Electrolyte imbalance, glucose proteins. This is exacerbated by poor appetite, poor gas-
endocrine intolerance, endocrine dysfunction, trointestinal absorption of proteins, constipation, and
hyperparathyroidism other digestive tract factors. During immobility, a nor-
Others Urolithiasis, urinary tract infec- mal human loses 2 g of nitrogen daily, whereas a mal-
tion, low appetite, constipation, nourished patient loses 12 g daily, and a patient with
sensation deprivation, anxiety/ a long bone fracture loses 8 g daily. On day 5 or 6 of
depression, confusion, impaired bed rest, nitrogen loss is increased, reaching the highest
cognition, balance, and coordina- amount in week 2. The nitrogen loss is accompanied by
tion disorders decreases in muscle blood flow, metabolic activity, and
muscle endurance.15
The main reason for decreased muscle endurance
and functional defects. A study in the elderly found that is decreased oxidative enzyme activity in the muscles,
10 days of bed rest caused a decrease in muscle protein resulting in decreased oxygen utilization efficiency and
synthesis, total lean mass, and appendicular lean mass. lactic acid tolerance in the blood, followed by changes
The effects observed were more severe than the effects in the size and shape of the end plate. In addition,
found in young people who had 28 days of bed rest.11 decreases in intramuscular glycogen storage and lipid
Early termination of immobility can reduce the length utilization and changes in the function of acetylcholine
of stay, expense, and incidence of complications due to receptors also result in decreased muscle endurance.
immobility. As the relative concentration of collagen increases,
Overall, under conditions of complete rest, the muscle tightness and myogenic contracture occurs,
decrease in muscle mass in the first 2 days is not sig- which particularly affects type I fibers in the lower
nificant but accelerates in the following 10 days, with limbs. When the quadriceps femoris muscle is con-
large decreases on days 8–10, followed by even further tinuously in a state of contraction, large histochemical
decreases. Approximately 10%–15% of muscle strength changes occur in the vastus intermedius muscle con-
will be lost per week (1%–3% per day). After 3–5 weeks, sisting mainly of type I muscle fibers. When muscles
only half of the original muscle strength remains. Muscle are maintained in a shortened state, muscle fibers lose
atrophy is mainly caused by a decrease in protein syn- 40% of their sarcomeres, and decrease in serially con-
thesis rather than an increase in degradation. Myostatin, nected sarcomeres results in a shortening of length at
a negative muscle growth regulator, expresses more rest. Stretching exercises for just half an hour a day
actively in catabolic state. The serum myostatin peptide prevents sarcomere loss, showing that stretching is an
concentration increased during immobilization and in important factor for maintaining function. The rate of
the patient receiving hemodialysis.12,13 Although colla- muscle atrophy varies according to the muscle, with
gen synthesis also decreases, the speed of this decrease the quadriceps femoris muscle, hip joint extensors,
is relatively slower, and therefore there is a comparative and back extensors undergoing rapid atrophy, further
increase in the collagen ratio. In normal urine, creatinine decreasing walking tolerance and inducing back pain.16␣
levels are low, but in an immobile and zero-gravitational
environment, creatinine excretion increases. Joint Contracture
Histologic changes accompany muscle weakness, Contracture refers to a clinical condition caused by
but it is seldom performed in a clinical scenario. After restriction of passive or active range of motion (ROM)
4 weeks of immobility, muscle mass decreases by 69%. in joints, muscles, or soft tissues. Reasons for the
The average cross-sectional area of type II muscle fibers restricted ROM include joint pain, paresis, and fibrosis,
CHAPTER 8 Prevention of Hospital-Acquired Deconditioning 113
The main clinical effects of contracture are decreased

mobility, ADL dependence, and increased difficulty
with respect to skin care. Hip joint flexion contracture
restricts hip joint extension, affects gait, and increases
energy consumption by 60% during ambulation. From
a biophysical perspective, hip joint flexion contrac-
ture causes hamstring muscle shortening, which fur-
ther results in knee joint and ankle joint contracture.
Ankle joint plantarflexion contracture will prevent heel
strike during the gait cycle and increase walking energy
consumption. Hip joint extension contracture is rarely
A B seen but causes difficulty in using a wheelchair. Knee
FIG. 8.1 (A) Elbow joint and (B) hip joint heterotopic os-
joint flexion contracture will cause difficulty in getting
sification in the nursing home residents. in and out of cars. Multiple joint contractures will hin-
der positioning in the bed, standing, mobility, perineal
hygiene, and skin care.
but the most important single factor is lack of joint Complete assessment of contracture is helpful to
movement. Other contracture-inducing factors include design a treatment plan. The main points of complete
inappropriate limb positioning, length of immobility, assessment are:
preexisting etiology, peri-joint edema, hematoma, and 1. analyzing the causes of contracture and identifying
ischemia. the actual contracture location and
Connective tissue is a complicated and dynamic 2. carefully measuring passive and active ROM.
structure. This tissue is important for structure stabil- When passive and active ROM differs, there is a need
ity and movement, and external mechanical stress will to distinguish whether muscle weakness or an increase
result in changes to connective tissue. When damage or in spasticity is present, since rapid joint movement can
inflammation occurs in connective tissue, the damaged induce spasticity. Nerve blockade can be used to assist
area will be repaired, and reassembly will be carried in determination if there is no other way of distinguish-
out according to the strength and direction of stretching between these conditions.␣
ing exercises. Collagen is the most abundant protein
in the body, and the synthesis and decomposition of Osteoporosis
collagen occurs in dynamic balance. Trauma, inflam- Bone mass increases because of stress loading and
mation, ischemia, and degeneration increase collagen decreases because of zero gravitation or low muscle
synthesis. When compounded by lack of stretching, activity. Normal bone mass begins to decrease around
this results in fibrosis, which affects normal function. the ages of 31–50 years and accelerates 5–7 years after
Collagen in muscles can fix muscle fibers, and its syn- menopause. Because of low physical activity, patients
thesis increases with activity and increased stretching with spinal cord injury have significant bone loss.
but decreases because of immobility. The main cause of Immobility results in decreased bone density. Osteo-
myogenic contracture is shortening of the sarcolemma porosis is defined as T-score below −2.5 when com-
and muscle fiber length.17 pared with young healthy women.19 The cause of this
Heterotopic ossification refers to an abnormal patho- type of osteoporosis is increased osteoclast activity,
logic condition of bone accumulation in soft tissue. This resulting in obvious calcium and hydroxyproline loss
is most commonly observed after joint surgery (espe- of cancellous bone in the epiphyses and metaphyses
cially hip joints), trauma, and spinal cord injury, and of long bones and an increase in the excretion of cal-
in patients with a central nervous system injury. The cium in the urine and stool.20 After 12 weeks of bed
cause for this disease is unknown but may involve local rest, bone density is reduced by almost 50%. The
metabolism, blood flow changes, and abnormalities in causes of bone absorption are unclear, and osteope-
systemic calcium metabolism (Fig. 8.1). Preventive care nia is a risk factor of hip joint fracture. In addition,
measures mainly include getting off bed rest early. Treat- under non-weight-bearing conditions, bone mineral-
ment must maintain joint ROM, and surgical resection ization becomes poorer, easily resulting in fractures.
can be carried out only if the ossification process is com- In osteopenia, because of immobility, bone mineral-
plete. A larger area of bone accumulation will result if ization continues to decrease for 5–8 weeks, even after
the surgery is performed too early.18 resumption of activity.␣
CIRCULATORY AND RESPIRATORY pneumonia if accompanied by a decrease in secretion

SYSTEM discharge ability in the upper lungs (due to weaknesses
Effects on the Circulatory System in the abdominal muscles or ciliary dysfunction caus-
Every 2 days of immobility results in an increase in ing a decrease in coughing ability).
the resting heart rate of one beat per minute, lead-
ing to tachycardia. Stroke volume decreases by 15% Orthostatic Hypotension
(possibly caused by a decrease in blood volume) after After a few days of bed rest in normal humans, 500 mL
2 weeks of bed rest. Although heart rate is increased, of blood will flow from the thoracic cavity to the lower
cardiac output decreases under normal workload con- limbs once they stand up and ankle venous pres-
ditions. The resting heart rate increases 10–12 beats sure increases from 15 to 120 cm H2O. Decreases in
after 3 weeks of bed rest. Walking on a 10% slope for intravascular volume, changes in the compliance of
half an hour at 5.6 km/h will increase heart rate by a venous walls, and intravenous retention will cause a
further 35–45 beats than the normal response if an decreased stroke volume and cardiac output, resulting
individual is subjected to a 3-week bed rest before the in a decrease in systolic blood pressure. Under nor-
exercise. Increased peripheral vessel resistance will mal circumstances, activation of the sympathetic ner-
cause an increase in systolic pressure, whereas cardiac vous system will increase the heart rate and maintain
ejection and refill time are both decreased, resulting blood pressure stability and prevent decreases in blood
in a decreased stroke volume and a further decrease in pressure. After bed rest, normal sympathetic nervous
total work capacity.21 responses cannot be induced, resulting in orthostatic
Immobility can also cause body fluid redistribution. hypotension.
Under normal circumstances, 20% of blood volume is Orthostatic hypotension is defined as a decrease
in the arteries, 5% is in the capillaries, and 75% is in in systolic pressure by 20 mmHg or a decrease in dia-
the veins. Compared with the sitting or standing posi- stolic blood pressure by 10 mmHg within 3 min in a
tion, when a person is lying down, 500 mL of blood will standing posture compared with a lying position.24
rush to the thoracic cavity and heart rate will decrease, The presentation includes dizziness, light-headed-
increasing cardiac output by 24%. During bed rest, the ness, vertigo, and a burning sensation in the lower
most significant decrease in blood volume occurs on extremities. Patients with a history of heart disease
day 14. As the decrease in plasma volume is more sig- may even experience angina because of insufficient
nificant than the decrease in red blood cells, this causes coronary circulation. This regulatory mechanism
increased blood viscosity and an increased tendency to is totally lost in normal humans who were bedrid-
cause thromboembolism. Plasma volume will decrease den for 3 weeks, and complete recovery requires
by 5% after a day of bed rest and it will further decrease 20–72 days (even longer in the elderly). Patients
by 10% after 6 days and by 20% after 14 days. Perform- with quadriplegia are more prone to orthostatic
ing exercises can decrease the loss in plasma volume in hypotension.25
normal people.22␣
Deep Vein Thrombosis
Effects on the Respiratory System Immobility clearly results in venous stasis and
Respiratory system complications induced by immo- increases coagulation. The probability of thrombosis
bility can be lethal. The primary changes include (1) is increased if vascular wall injury is present. Paresis,
a supine position restricting thoracic cage movement bed rest, and trauma increase the risk of deep vein
and (2) gravitation-induced changes in perfusion as thrombosis. The probability of stroke patients devel-
lying down increases venous pressure and pulmonary oping deep vein thrombosis in the ipsilateral side
perfusion. When changing from a standing to a supine is 10 times that of the contralateral side. The risk of
position, vital capacity decreases by 2% and total lung thrombosis in patients who are unable to walk is five
capacity decreases by 7%. After prolonged bed rest, times that of patients who can walk 50 ft. Deep vein
vital capacity and total lung capacity decrease by 25%– thrombosis readily occurs in the first week of immo-
50%, with probable mechanisms, including decreased bility. Thrombi are often hidden in deep veins, with
diaphragmatic excursion, decreased rib cage ROM, and the most common site of occurrence being the calf
fast and shallow breathing.23 vein, and 20% will extend up to the knee and thigh
A decrease in gaseous exchange and an increase in veins, of which half of them will result in a life-
perfusion will cause significant arteriovenous shunt- threatening pulmonary embolism. Blood stasis causes
ing. This can easily result in alveolar atelectasis and embolus formation, resulting in platelet aggregation
and thrombosis. The risk factors of blood stasis are or affinity of insulin receptors or changes in the down-
decreased calf muscle contraction strength for venous stream receptor of target organs.
return, recent surgery, old age, obesity, heart failure, After bed rest, parathyroid hormone levels increase,
and other coagulation-prone conditions, such as can- causing hypercalcemia of unknown etiology. Other
cer or high blood viscosity.26 accompanying endocrine changes include increased
Deep vein thrombosis may be lethal. First-line urine cortisol levels, a decreased ACTH response in the
medical staff should observe clinical symptoms, such adrenal glands, increased blood hydrocortisone lev-
as edema, tenderness, erythema, and venous dilation. els, and decreased norepinephrine levels. Bed rest for
The presentation of deep vein thrombosis is similar to 1 month will increase ACTH levels threefold, which
cellulitis, and it is not easy to distinguish between the requires 20 days of exercise to return to normal. In
two. Pulmonary embolism is a serious complication. It addition, total cholesterol levels do not increase.29␣
is difficult to diagnose, and the symptoms include dys-
pnea, tachycardia, bradypnea, and chest pain. Diagno-
sis requires sampling arterial blood gas, a radionuclide OTHER ORGAN SYSTEMS
breathing scan, and angiography. Immobility clearly results in bladder or kidney stone and
The commonly used clinical diagnostic tools urinary tract infection. The etiology of stone formation
include: is hypercalciuria, hyperphosphaturia, and high postvoid
1. Doppler ultrasonography, which is highly accurate residue (the main cause of which is difficulty in urination
and the most commonly used; in the supine position). Kidney stones cause bacterial
2. radionuclide venous scan, which has high sensitiv- growth and affect the efficacy of antibiotics. Stimulation
ity and specificity with respect to large blood vessels of the bladder mucosa predisposes the patient to infec-
but cannot detect calf emboli; and tions. Urea-decomposing bacteria can alkalinize urine
3. angiography, which is considered the gold standard; and further precipitate calcium and magnesium ions.30
however, its utilization is limited because of high in- Functional incontinence is an inability to reach the toilet
vasiveness, time consumption, and low accessibility.␣ in time because of the difficulties caused by physical or
mental illness. Bed rest–induced delirium or immobility
is the common cause.31
METABOLIC AND ENDOCRINE SYSTEM Bed rest decreases intestinal peristalsis, lowers appe-
Immobility induces changes in body composition. tite, and decreases blood protein levels, resulting in mal-
Total lean mass decreases and is substituted by fat mass, nutrition. Food intake in the supine position will increase
and bone mass insufficiency is observed. Low total lean the time taken for food to pass through the digestive
mass further results in a low metabolic rate, decreased system, whereas a standing posture can increase esopha-
maximal oxygen consumption, and impaired musculo- geal peristalsis speed and shorten the time of esophageal
skeletal function. expansion; therefore, increasing the height at the head of
Immobility results in a sodium, calcium, potas- the bed can prevent and treat gastroesophageal reflux.32
sium, and phosphate ion imbalance. Bed rest leads to The etiologies of constipation include (1) immobility
hyponatremia and diuresis. The symptoms of hypo- increasing adrenal gland activity, inhibiting peristalsis,
natremia include drowsiness, confusion, disorienta- and increasing sphincter contractility; (2) dehydration
tion, poor appetite, and even convulsion. The elderly and desiccation of stool; and (3) the stool pan causing
are especially vulnerable. In the first few weeks of bed awkwardness, resulting in patients not defecating.
rest, potassium levels may also decrease, but this rarely Social isolation results in emotional disorders and
results in serious complications.27 anxiety. Combined with immobility, social isolation
Abnormal glucose tolerance appears on the third results in disorientation to person, time, and place;
day of immobility, and tissue glucose uptake decreases confusion and delusion; and even pain, hostility,
by 50% after 14 days, which worsens with increasing insomnia, depression, and irritability. Bed rest and iso-
length of bed rest. This form of abnormal glucose tol- lation for 2 weeks can incur the abovementioned symp-
erance can show improvement with isotonic exercises toms. These symptoms further affect functional status
in large muscle groups, but isometric exercise is inef- and independence, resulting in a vicious cycle. The bal-
fective.28 This form of abnormal glucose tolerance is ance and coordination disorders caused by immobility
not due to insufficient insulin but increased insulin could be caused by changes in nervous control rather
resistance. Therefore, hyperglycemia or hyperinsu- than muscle weakness.33
linemia could be due to the decrease in the quantity
Cognitive function may deteriorate with hospital- prompted voiding, and physical training in combina-
ization. Up to 50%–60% of hospitalized older adults tion with ADL practicing.35 In addition, environmental
may develop delirium during hospitalization. Delir- factors should be modified to improve accessibility. For
ium is described further in detail in Chapter 13, Geri- example, the route from the patient to the toilet should
atric Psychiatric and Cognitive Disorders: Depression, be easily accessible and uncluttered to avoid delay or
Dementia, and Delirium.␣ falls.␣
Joint Contracture
ASSESSMENT Bed positioning with posture change is essential.
Comprehensive geriatric assessment (CGA) is used to Stretching is an important factor for maintaining func-
create a plan of care for hospitalized elderly patients. A tion. To realize and eliminate the factors inducing
specific goal of the CGA is early identification of elder increased muscle tone or rigidity is the key for some
care needs to provide interventions to minimize high- specific groups with neurologic disorders. Orthoses can
risk events including deconditioning. A CGA should be considered in some cases.␣
include assessment of ADL and instrumental ADL per-
formance, as well as assessment of cognition, vision Pressure Injury (Ulcer)
and hearing, social support, and psychologic well- Prevention of pressure injury (ulcer) is one of the minimal
being. A number of geriatric assessment tools can be requirements of nursing care especially for the subjects
used to make initial and ongoing evaluations of hospi- with consciousness change or with sensory impairment.
talized elderly patients.34␣ Pressure ulcers occur at areas with bony prominence or
thin skin. The areas around the sacrum, ischial tuberos-
ity, femoral greater trochanter, fibular head, lateral mal-
PREVENTION OF COMPLICATION OF BED leolus, retro-calcaneus, and occiput are vulnerable sites.
REST IN ACUTE HOSPITALIZATION Bed positioning with proper pillows and cushions,
For the hospitalized patients, general conditions deterio- changing position every 2 h, preventing shearing force
rate not only caused by diseases but also by consequential on the skin, supplying nutrition to prevent anemia or
effects of diseases and subsequent limitation of activities. hypoalbuminemia are all important for pressure ulcer
All of the following aspects require attention and com- prevention.␣
prehensive intervention to prevent hospital-acquired
deconditioning. At the acute stage of hospitalization, it is Orthostatic Hypotension
most important to prevent complications including pneu- Since bed rest is the main factor resulting in orthostatic
monia, urinary tract infection, joint contracture, pressure hypotension, uprighting the trunk on the bed or tilting
ulcer, orthostatic hypotension, and deep vein thrombosis. table should be applied once it is permitted. Patients
with extensive paralysis, diabetic mellitus, cardiovas-
Pneumonia cular disorders, autonomic nervous disorders, who are
Breathing exercise should be instructed for the cases prone to orthostatic hypotension, should be managed
before surgery related with the chest or abdomen, or for for high risk of falls.␣
cases with pulmonary disorders. Chest percussion and
posture drainage should be applied once pneumonia Deep Vein Thrombosis
is noted. Proper food texture and specific swallowing To prevent deep vein thrombosis, lower limb pumping
skills to prevent aspiration should be considered for the exercise with intermittent foot and calf muscle contrac-
subjects with potential swallowing disorders.␣ tion is most important. Early and frequent walking and
graduated compression stockings are also effective. For
Urinary Tract Infection and Functional the high-risk patients, using an intermittent pneumatic
Incontinence compression device to improve circulation is indicated.
Adequate and proper fluid intake is essential. For the Anticoagulation is the standard treatment if there are
patients using diapers or urinary catheters, appropri- no contraindications.␣
ate perineum and catheter cleaning is important. For
seniors with functional incontinence, nonpharmaco-
logic conservative treatment should be emphasized INTENSIVE CARE UNIT REHABILITATION
first. Behavior therapies include attention training, Thanks to the advances in critical care medicine, more
bladder training, pelvic muscle exercises, scheduled and patients survive from serious illness. However, many
survivors experience new or worse impairments of mechanics. Since muscle power decays very quickly
physical, cognitive, or psychologic functions known as once patients become immobilized, the limb muscle
post–intensive care syndrome.36 Early rehabilitation training should be started as a bedside training. How-
and mobilization play important roles in preventing ever, introduction of selective isotonic or isometric
neuromuscular complications, reducing delirium, and exercise for a variety of disease types at appropriate
shortening hospital length of stay, hence improving timing will require consultation from a rehabilitation
the quality of life.37,38 Early rehabilitation and mobi- specialist.
lization are safe and feasible and should be initiated
immediately after stabilization of physiologic disorder, Cognition Rehabilitation and Psychologic
which may include the patients on mechanical venti- Support
lation.39 The program starts with proper positioning, It is especially important for patients with stroke,
passive ROM exercises, breathing exercises, active arm traumatic brain injury, or other pathology of the
and leg exercises, sitting on the edge of the bed, transfer central nervous system. It can be provided by reha-
to chair, mobilization out of bed, including ambula- bilitation professionals with specific training. Anxiety
tion.38 Early intervention also decreases the negative and depression are frequently noted in hospitalized
effects of immobilization, such as pressure ulcer, deep patients, especially in cases with disease-related disabil-
vein thrombosis, heterotopic ossification, pulmonary ity. These are known negative predictors that interfere
complications, joint contracture, and physical decon- with treatment and outcomes. Anxiety and depression
ditioning. The ICU healthcare team may include a can be effectively eliminated by psychologic support by
variety of professionals, including physiatrists, primary the rehabilitation team and family prior to considering
care physicians, neurologists, surgeons, nurse practi- pharmacologic interventions. The details of cognitive
tioners, psychiatrists, pharmacists, dietitians, physical impairment, depression, and delirium are described in
therapists, occupational therapists, speech language Chapter 13, Geriatric Psychiatric and Cognitive Disor-
pathologists, and social workers. Early mobilization at ders: Depression, Dementia, and Delirium.
ICU setting has shown to reduce morbidity and mortal- Family and social support have an amazing power,
ity, and active involvement of physiatrists in this inter- which can heal the body and mind. One recent study
vention is highly recommended.␣ in China stated that both family and friend support
are essential factors for the emotional well-being of
the elderly. Family support had greater influence on
RECONDITIONING REHABILITATION AT reducing older people’s negative affects, such as being
SUBACUTE STAGE frustrated, depressed, hostile, anxious, or impatient.
At the subacute stage, the medical conditions become Compared with family support, friend support, includ-
stable progressively. It is the optimal time for patients ing colleagues or neighbors, played an important role
to start comprehensive rehabilitation. The aims of in increasing positive effects, for example, being happy,
rehabilitation are to recondition the deteriorated gen- friendly, and competent.40
eral status and restore functions for independence.
The tasks of reconditioning rehabilitation include Activity of Daily Living Training
integrated motor function training, cognition rehabili- A concept “give a chance for him or her to do activi-
tation, activity of daily living training, assistive technol- ties independently as much as possible” needs to be
ogy, and devices implementation. promoted for disability prevention. ADL training is
the most direct way of achieving an independent life,
Motor Function Training which requires rehabilitation professionals with special
For the patients with extensive paralysis, motor func- skills. Assistive technology and devices can assist the
tion training is the core strategy to prevent disability functions of patients with deconditioning for improv-
or to restore functions with adequate and appropri- ing mobility and ADL. The details of assistive technol-
ate exercise. Physical therapy to maintain a range of ogy are described in Chapter 16, Assistive Technologies
joint motion and to keep muscle strength and endur- for Geriatric Population.
ance should be applied for the trunk and upper and
lower limbs. Training of trunk muscles, including Nutrition and Metabolic Disorders
respiratory muscles and core muscles surrounding A chronic illness is usually accompanied with nutrition
the abdomen, can keep patients with a good pul- deficiency and metabolic disorders. Anemia, hypoal-
monary function and ensure good trunk supporting buminemia, and electrolyte imbalance are the most
common problems. The diseases and all of the related 12. Zimmers TA, Davies MV, Koniaris LG, et al. Induction of
problems would cause a debilitated vicious cycle. Sup- cachexia in mice by systemically administered myostatin.
plements of nutrition and correction of imbalanced Science. 2002;296:1486–1488.
conditions are important. Chewing and swallowing 13. Han DS, Chen YM, Lin SY, et al. Serum myostatin levels and
grip strength in normal subjects and patients on mainte-
difficulty is highly prevalent among older adults, which
nance hemodialysis. Clin Endocrinol. 2011;75(6):857–863.
may interfere with consuming sufficient nutrition. 14. Ohira Y, Yoshinaga T, Ohara M, et al. Myonuclear domain
The details of nutritional support and dysphagia are and myosin phenotype in human soleus after bed rest with
described in Chapter 10, Nutritional Issues and Swal- or without loading. J Appl Physiol. 1999;87(5):1776–1785.
lowing in the Geriatric Population.␣␣ 15. Mack PB, Montgomery KB. Study of nitrogen balance and
creatine and creatinine excretion during recumbency and
ambulation of five young adult human males. Aerosp Med.
CONCLUSION 1973;44(7):739–746.
Physical activity can maintain and enhance the function 16. Funato K, Matsuo A, Yata Y, et al. Changes in force-veloc-
ity and power output of upper and lower extremity mus-
of various body systems of human beings. Bed rest in
culature in young subjects following 20 days bed rest. J
a supine position results in dysfunction and deteriora- Gravit Physiol. 1997;4(1):S22–S30.
tion of multiple systems. Early mobilization is the cor- 17. Karpakka J, Vaananen K, Orava S, et al. The effects of
nerstone of prevention of deconditioning. As medical preimmobilization training and immobilization on col-
professionals, we should avoid bed rest and promote lagen synthesis in rat skeletal muscle. Int J Sports Med.
mobilization in patients in hospitals or institutions. 1990;11(6):484–488.
18. Cipriano CA, Pill SG, Keenan MA. Heterotopic ossifica-
tion following traumatic brain injury and spinal cord in-
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1997;82(1):182–188. of men under hypokinesia. J Environ Pathol Toxicol Oncol.
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cle atrophy during 29-day bed rest. Acta Physiol Scand. during bed rest with isotonic and isometric exercise. J Appl
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11. Kortebein P, Ferrando A, Lombeida J, et al. Effect of 10 29. Lerman S, Canterbury JM, Reiss JE. Parathyroid hormone
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30. Anderson RL, Lefever FR, Francis WR, et al. Urinary and acute respiratory failure. Crit Care Med. 2008;36(8):2238–
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Chem Toxicol. 1990;28(8):543–545. 39. Parker A, Needham DM, Society of Critical Medicine. The
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34. Li CM, Chen CY, Li CY, Wang WD, Wu SC. The effective-
ness of a comprehensive geriatric assessment intervention
program for frailty in community-dwelling older peo- FURTHER READING
ple: a randomized, controlled trial. Arch Gerontol Geriatr.
1. Brown CJ, Friedkin RJ, Inouye SK. Prevalence and out-
2010;50(suppl 1):S39–S42. comes of low mobility in hospitalized older patients. J Am
35. Meyer P. Algorithms and urinary incontinence in the el- Geriatr Soc. 2004;52:1263–1270.
derly. Assessment, treatment, recommendations and lev-
2. Halar EM, Bell KR. Physical inactivity: physiological and
els of evidence. Review. Prog Urol. 2017;27(3):111. functional impairments and their treatment. In: Frontera
36. Needham DM, Davidson J, Cohen H, et al. Improving WR, ed. DeLisa’s Physical Medicine & Rehabilitation. 5th ed.
long-term outcomes after discharge from intensive care
Lippincott Williams & Wilkins; 2010.
unit: report from a stakeholders’ conference. Crit Care 3. Inouye SK, Bogardus ST, Baker DI, Leo-Summers L, Cooney
Med. 2012;40(2):502–509. LM. The hospital elder life program: a model of care to pre-
37. Tipping C, Harrold M, Holland A, Romero L, Nisbet T,
vent cognitive and functional decline in older hospitalized
Hodgson C. The effects of active mobilisation and reha- patients. J Am Geriatr Soc. 2000;48:1697–1706.
bilitation in ICU on mortality and function: a systematic 4. Bartels, Prince. Acute medical conditions. In: Cifu DX, ed.
review. Intensive Care Med. 2017;43:171–183.
Braddom’s Physical Medicine and Rehabilitation. 5th ed. Saun-
38. Morris PE, Goad A, Thompson C, Taylor K, et al. Early ders; 2016.
intensive care unit mobility therapy in the treatment of
CHAPTER 9
Polypharmacy and Mobility

MANISHA S. PARULEKAR, MD, FACP, CMD • CHRISTOPHER K. ROGERS, MPH
Polypharmacy is defined as the simultaneous use of population, and they use 33% of prescription drugs.2
multiple drugs to treat a single ailment or condition, By 2040, this will increase to 25% of population,
or the simultaneous use of multiple drugs by a single using 50% of prescription medications2 (Fig. 9.2).
patient, for one or more conditions. As the population Approximately, 82% of adults living in the United
is aging, polypharmacy has become an important risk States take at least one medication in a given week.4
factor for poor outcomes in the elderly.1,2 Generally, The prevalence of polypharmacy in the elderly across
polypharmacy in the elderly occurs because of three various healthcare settings has been reported in the
factors: demographic factors, health factors, and access literature (Table 9.1).5–7 Among the elderly, 87.7%
to healthcare.3 Important risk factors for polypharmacy use at least one medication.8 The prevalence of poly-
are presented in Fig. 9.1. With advances in medicine, pharmacy among the elderly in the United States is
we have more medications available as prescriptions 35.8%.8 Patients over 65 years of age take on average
and over the counter. In addition, there is a surge in 2–6 prescribed medications and 1–3.4 nonprescribed
various nutritional and antiaging supplements, lead- medications.9 Polypharmacy and associated adverse
ing to increases in the incidence of polypharmacy and outcomes were recognized as a safety concern in the
adverse events related to it. Box 9.1 provides facts on Healthy People 2000 Final Review (National Center for
adverse drug events (ADEs) resulting from polyphar- Health Statistics, 2001).1
macy in the United States. Elderly patients are at an increased risk for ADEs
and drug interactions.10–12 ADEs account for nearly
700,000 emergency department visits and 100,000
EPIDEMIOLOGY hospitalizations each year.13 Nearly 5% of hospital-
Polypharmacy is an important health issue among ized patients experience an ADE.13 Table 9.2 presents
the US population, especially the elderly. Currently, the rate and percentage of ADEs for certain diseases.14
people aged 65 years and older make up 13% of US Many factors contribute to ADEs in the elderly (Fig.
9.3), one such factor being the number of medications
Age:
risk increases BOX 9.1
with age Facts on Adverse Drug Events (ADEs) Resulting
From Polypharmacy in the United States
Multiple Increase in number
• 82% of American adults take at least one medica-
providers: of medications
tion.
more the number moving from
of providers, prescription to • 25% of American adults take five or more medica-
higher the risk over the counter tions.
• ADEs cause more than 1 million emergency depart-
Polypharmacy
ment visits and 280,000 hospitalizations each year.
• $3.5 billion is spent on excess medical costs of
Recent and/or ADEs annually.
multiple Increase in
herbals and • 40% of costs related to ambulatory (nonhospital)
hospitalizations or ADEs can be saved.
emergency room alternative
visits therapies
Data from Centers for Disease Control and Prevention (CDC). Medi-
cation Safety Basics. Available at: https://www.cdc.gov/medication
FIG. 9.1 Risk factors for polypharmacy in older adults. safety/basics.html.
121
60
50 47.6 48.3
46.2 46.8
43.5
40
31.1 30.9 31.2

Percent
30 28.6
25.4
20
10.2 10.1 10.7

10 8.3
6.3
0
1999-2000 2001-2002 2003-2004 2005-2006 2007-2008
Year
Use of one or more drugs Use of two or more drugs Use of five or more drugs
FIG. 9.2 Trends in the percentage of persons using prescription drugs in the United States, 1999–2008.
(Adapted from Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug
data for 2007-2008. NCHS Data Brief. 2010;(42):1.)
TABLE 9.1
Notable Studies of Polypharmacy Impacting Elderly Patients
Degree of
Setting References Target Population Polypharmacy Primary Outcomes
Hospital Flaherty et al.5 64 years of age and older 5 or more Hospitalized patients were signifi-
7 or more cantly more likely to take 7 or more
10 or more medications and 10 or more medica-
tions, respectively, compared with
nonhospitalized patients
Ambulatory Kaufman et al.3 18 years of age and older 1 or more Prescription drug use is higher in
5 or more elderly women compared with men,
10 or more of whom 23% took at least five in the
preceding week compared with 19%
in men
Comorbidities were the most common
reason for polypharmacy
Nursing home Morin et al.6 42 years of age and older 12 or more The mean number of medications
(mean age 82.5 years) prescribed was 12.7 (range 0–30)
Nursing home Beers et al.7 65 years of age and older 7 or more The mean number of total medications
(mean age 84 years) among nursing home patients was 7.2
CHAPTER 9 Polypharmacy and Mobility 123
TABLE 9.2
Causes of Drug-Related Adverse Outcomes in US Hospital Inpatient Settings, 32 States, 2011
ADEs on Admission ADEs During Hospitalization
General Causes of Drug-Related Number of ADEs per 10,000 Number of ADEs per 10,000
Adverse Outcomes Discharges Discharges
Antibiotics and antiinfectives 90.9 28.0
Systemic agents 52.8 8.5
Hormones 46.3 20.7
Analgesics 45.5 16.2
All other general drugs and nonspe- 215.1 64.7
cific ADE causes
Any ADE cause 388.0 128.7
ADEs, adverse drug events. Of an approximate total of 20.2 million discharges in 32 states, an estimated 782,800 ADEs were present on
admission and 259,700 ADEs originated during the hospital stay.
Number of
drugs taken
Inappropriate Inappropriate
Adverse drug
combinations prescribed
event
of drugs drugs
Inappropriate
dosages of
drugs
FIG. 9.3 Geropharmacological factors contributing to adverse drug events. (Data from Gallagher LP. The
potential for adverse drug reactions in elderly patients. Appl Nurs Res. 2001;14(4):220–224.)
prescribed.15 An estimated one-third of elderly persons compared with 50% for patients prescribed with five
will experience an adverse reaction to medication for a drugs and 100% for patients prescribed with eight
given year.16 Furthermore, past research has confirmed or more drugs.18 One such adverse event among the
an association between polypharmacy and ADEs and elderly that results from polypharmacy is impaired
drug interactions.17 The potential for an adverse event mobility.19,20
increases as the number of prescribed drugs increases. Mobility, the ability to move around in one’s envi-
Elderly patients prescribed with two medications ronment, is the essential capacity for his or her survival.
have a 6% chance of experiencing an adverse event, Mobility problems are most common among older
adults, and the likelihood of reduced mobility and related • Gait changes: Shorter stride length, decreased
consequences increase with polypharmacy. Consequences arm swing, slower gait.
of reduced mobility resulting from polypharmacy are • Volume status changes: Decreased ability to
shown in Box 9.2. Elderly patients are especially vulner- maintain homeostasis, increased risk for dehy-
able to adverse mobility events due to age-related physio- dration and volume depletion, increased risk for
logic changes resulting from the absorption, distribution, orthostasis.
metabolism, and elimination of drugs. Montiel-Luque • Autonomic changes: Diminished beat-to-beat
et al. examined polypharmacy effects on health-related variation of heart in response to postural change,
quality-of-life variables in older patients and found that reduced vasoconstrictor response to cooling,
mobility was affected in 54.9% of the patients.21 Herr more pronounced orthostasis.
et al. reported that having polypharmacy, in addition to • Central nervous system changes: Decrease in dopa-
frailty, markedly increases the risk of mortality. This study mine receptors, increase in α-adrenergic response
showed that frail people with excessive polypharmacy and muscarinic parasympathetic response—in-
of 10 drugs or more were six times more likely to die.22 creased tendency for Parkinsonism.
This emphasizes the importance of polypharmacy among • Hearing: High-frequency hearing loss causing re-
those with impaired mobility for the rehabilitation team.␣ duced ability to recognize speech, presbycusis—
decreased sensory input for the mobility.
• Vision: Decreased lens flexibility, increased time
AGE-RELATED PHYSIOLOGIC CHANGES
for pupillary reflex, decreased tear production
AFFECTING MOBILITY
causing presbyopia, increased glare, difficulty ad-
Physiologic changes of aging can impact gait and justing to changes in lighting, decreased contrast
mobility adversely and make the elderly especially sus- sensitivity—decreased sensory input for the gait.
ceptible to adverse outcomes including falls.␣
BOX 9.2
Consequences of Polypharmacy by System Affecting Mobility
MUSCULOSKELETAL INTEGUMENTARY
Muscle stiffness Decubitus ulcer
Muscle soreness Decreased peripheral arterial circulation
Muscle apathy
Contractures GASTROINTESTINAL
Joint pain or stiffness Loss of appetite
Osteoporosis Risk of heartburn, indigestion
Disability Malnutrition and weight loss
Constipation
RESPIRATORY Increased aspiration due to position and inability to
Atelectasis sit-up or stand after a meal
Increased risk for pneumonia
Pulmonary embolism GENITOURINARY
Poor cough reflex, increased risk for aspiration Urinary incontinence
Urinary tract infection
CIRCULATORY
Decreased blood pressure when standing up MENTAL/PSYCHOSOCIAL
Decreased sympathetic response, poor response of Confusion, irritability, or disorientation, delirium
heart rate, and blood pressure changes Depression
Cardiac arrhythmia Forgetfulness, cognitive decline
Hypotension Anxiety
Hypertension Decreased social interaction
Deep venous thrombosis Decreased self-dependence
Increased caregiver stress/burden
NERVOUS Increased cost of care, both health-related and custodial
Delirium care
PHARMACOKINETIC CHANGES WITH MEDICATION CLASSES AND MOBILITY

AGING23 IMPAIRMENT
• Absorption: Decreased acid and pepsin secretion in Medications can affect mobility by various mecha-
stomach and decreased absorption area in small in- nisms, and various classes of medications are com-
testine may lead to impaired absorption, especially monly associated with impaired mobility. Table 9.3
of vitamin B12, calcium, and iron. presents common high-risk medications associated
• Distribution: Increased body fat percentage, de- with impaired mobility. Benzodiazepines are com-
creased lean body mass and total body water. monly associated with decreased mobility.24 They work
• Effect: Prolonged duration of action for the fat- on the central nervous system by selectively increasing
soluble medications (e.g., opioids, benzodiaz- the inhibitory effects of γ-aminobutyric acid.
epines). In addition, antipsychotics have been reported as
• Recommendation: Decrease dose and fre- a contributing factor to drug-induced mobility prob-
quency (longer interval between medications) lems.25 Antipsychotics are widely used to care for elderly
when prescribing opioids and benzodiaz- patients with psychiatric disorders. The use of antipsy-
epines. chotic drugs has been reported to be 50%–75% for
• Reduced albumin leading to increased availabil- elderly patients in long-term care facilities.26 Antipsy-
ity of the active form of protein-binding medica- chotics work by blocking specific dopamine receptors in
tions (e.g., propranolol). the brain to help normalize dopaminergic substances or
• Reduced extracellular fluid volume allows small- actions, which in turn causes side effects such as mobil-
er volume of distribution for the water-soluble ity disorders, including Parkinsonism, loss of move-
medications (e.g., digoxin, gentamycin, cimeti- ment, akathisia, muscle spasms, and tardive dyskinesia.
dine). Elderly adults simultaneously taking one or more of the
• Excretion: Impaired renal function (decreased glo- drugs outlined in Table 9.3 are at an increased risk of
merular filtration rate, tubular secretion, and blood developing symptoms leading to mobility problems. It
flow). is important that the rehabilitation team pay attention
• Effect: Delayed excretion of the drugs requiring to high-risk medications as per Beers criteria to prevent
need for dose adjustment. A significant number mobility impairment in patients.
of medications are excreted via kidney. Furthermore, certain classes of medications are
• Recommendation: Adjustment of the dose more commonly associated with delirium and can
when prescribing antibiotics. lead to decreased mobility (Table 9.3). The rehabilita-
• Liver metabolism: Although volume and blood tion team should become familiar with the medication
supply is decreased, drug metabolism may not be classes that decrease mobility and avoid polypharmacy
affected.␣ and functional decline.␣
PHARMACODYNAMIC CHANGES WITH EVALUATION OF PATIENTS FOR

AGING23 POLYPHARMACY AND MOBILITY
Impaired homeostatic capacity, which is part of IMPAIRMENT
physiology of aging and changes in liver and kidney The patient assessment begins with a comprehensive
metabolism, translates into increased sensitivity to medical history review. A detailed medication his-
various medications in the elderly. Important classes tory is an important part of the evaluation for poly-
of medications include anticoagulants, antihyperten- pharmacy. Any new medications, both prescription
sive medications, antipsychotics, and sedatives. The and over-the-counter ones, should be assessed and
above changes in mobility, pharmacokinetics, and addressed. Recent hospitalization or emergency room
pharmacodynamics are exacerbated by chronic con- visits are important events and can increase the risk for
ditions and medications taken for the management polypharmacy. Medication reconciliation during dis-
of chronic conditions. These translate into increased charge from the hospital and at home can help mini-
risk for impaired mobility and falls. Impaired mobil- mize inappropriate medication, wrong dosage, and
ity and polypharmacy are independent risk factors for duplication of medications. Recent healthcare provider
the disability; however, coexistence of both has much visits and number of healthcare providers in the care
profound impact on disability.␣ team can also increase this risk by either duplication of
TABLE 9.3
Medications May Affect Mobility in Older Adults
Mechanisms Affecting
Category Generic Name Trade Name Symptoms Mobility
Benzodiazepines Lorazepam Ativan Confusion Disequilibrium
Alprazolam Xanax Dizziness and sedation
Diazepam Valium Lack of coordination
Antipsychotics Haloperidol Haldol Confusion/delirium Poor insight and judgment,
Risperidone Risperdal poor balance, unsteady
Quetiapine Seroquel gait and sedation
Opioids Morphine sulfate Many trade names Confusion/delirium Poor insight and judgment,
Oxycodone OxyContin, and others poor balance, unsteady
Hydrocodone gait and sedation
Vasodilators Nitroglycerin Light-headedness Disequilibrium
Hydralazine Dizziness and orthostasis
Calcium channel
blockers
First-generation Diphenhydramine Lethargy, delirium Decreased awareness
antihistamines Chlorpheniramine
Diuretics Chlorothiazide Diuril Orthostatic hypoten- Poor balance and
Bumetanide Bumex sion unsteady gait
Eplerenone Inspra
medications or drug-to-drug interaction. Special atten- medication review for all drugs taken. Before seeing the
tion should also be given to the spouse or other fam- patient, the rehabilitation team should ask the patient
ily member medications, as medication sharing would to bring his/her “brown bag” to the visit for review. The
increase the risk of adverse events. In addition, collat- “brown bag” medication review is a method of encour-
eral history from the family and or a caregiver can help aging patients to bring to the visit all their medica-
identify acute or chronic changes in mental status and tions and supplements in a bag for review.27 For each
mobility. medication contained within the bag, the clinician can
A physical assessment conducted by the rehabilita- determine potential adverse effects on mobility and
tion team can identify polypharmacy and drugs that consult with the patient’s physician for possible alter-
impact mobility. A gait assessment along with a special native medications.
attention to mental status, heart rate, blood pressure, When conducting the comprehensive medication
and checking for orthostatic blood pressure changes review, the clinician, if needed, should begin by briefly
can provide important clues to possible medication- explaining to the patient the purpose of the medica-
associated adverse events and its impact on mobility. tion assessment. Medical jargon should be avoided
Postural changes have been associated with syncopal to ensure that the patient does not underreport his/
episodes and can contribute to falls and impaired her medication history. Open-ended questions should
mobility.␣ be used, such as, “What do you take for your blood
clots?” and “What do you use for your heartburn?”
Open-ended questions do not restrict the dimension
INTERVENTION along which the elderly answers but encourages the
Preserving Mobility Reducing Polypharmacy patient to give a full, meaningful answer using his/
Comprehensive medication review her knowledge, beliefs, and/or feelings concerning
A comprehensive medication review is the initial the medications. The clinician should encourage the
step that will help the rehabilitation team to pro- patient to ask questions and when responding discuss
mote mobility and patient safety. Box 9.3 presents any drug interactions and their adverse impact on
details of the information needed in a comprehensive mobility.
what were the patient’s signs and symptoms, and how

BOX 9.3
it was treated. Prevention is the key in this situation,
Components of Comprehensive Medication
and information gathered should be used to reduce
Review
polypharmacy, assess the probability of future adverse
• Medication names events affecting the patient’s mobility, and initiate
• Strength, dosage, form, frequency, and number of interventions as needed.␣
tablets for all medications
• Route of administration Promoting safe drug use
• Disease associated with each medication The goal of the rehabilitation team is to educate elderly
• Contraindication for each medication patients in the safe use of drugs to prevent mobility
• Side effects for each medication impairment resulting from polypharmacy. The reha-
• Initiation of medication
bilitation team can play an important role in helping
the patient to understand the effect of medications on
• Last titration date
physical functions. To the extent permitted, the reha-
• Prescriber name
bilitation clinician should involve the elderly patient’s
• Last date and time each medication was taken
caretaker and family members in the education session.
• Determining if the patient is currently taking the
Together, the rehabilitation team, patient, and caretaker
medication
can collaboratively manage medication administration
• History of allergies, interactions, and adverse
reactions
with careful attention to signs and symptoms of immo-
bility resulting from polypharmacy.
• Use of over-the-counter products
Educating patients and their caretakers about their
• Use of vitamins, herbal, and nutritional products
medications and the potential adverse effects on
• Use of topicals, liquids, injectables, and inhalants
mobility requires the rehabilitation clinician to review
• Name, address, website, and phone numbers of
some basic, yet important, questions about their level
pharmacy used to fill prescriptions
of understanding concerning their medication history
• Ability to pay
(Box 9.4). Patients must have a basic understanding of
• Ability to obtain medications (e.g., transportation,
the risks and benefits of their medications and how to
pharmacy delivery service)
communicate with their doctor when they believe they
• Missed dose of each medication
are unsure of the reasons for medications or feel they
• Use of recreational drugs such as alcohol or
are taking too many drugs. The rehabilitation team
illicit drugs
should help the patient to identify drugs that have
the potential to adversely impact his/her mobility. For
example, multiple research studies have demonstrated
that benzodiazepines increase the risk of self-reported
Another component of the comprehensive medi- mobility problems and loss of physical function.28–30
cation review is to determine the strength, dosage, In addition, the rehabilitation team should encour-
form, frequency, and number of tablets for all medi- age elderly patients to use the “brown bag” technique
cations. It is important to accurately record all medi- as a way of providing their physician and pharmacist
cations, indications and side effects. This will help with a complete list of all drugs they take to prevent
in minimizing medication use to treat side effect of polypharmacy and assess the risk for impaired mobil-
another medication, an important factor in polyphar- ity. Empowering elderly patients and their caregivers
macy. The clinician should focus on any side effects, to proactively monitor medications prescribed and
specifically those that have the potential to impact the supplements consumed and to communicate their
patient’s mobility, for example, muscle weakness or questions and concerns to their physician or pharma-
pain, changes in mental status, drowsiness, blurred cist can help prevent mobility problems and physical
vision, hypotension, or dizziness. In addition, the limitations.␣
review includes obtaining information about the
patient’s history of allergies, interactions, and adverse
reactions. If the patient reports a history of allergies, SUMMARY
interactions, and/or adverse reactions, the clinician Once polypharmacy is identified it is essential to cre-
should document when the patient had it, how long ate an interdisciplinary plan to minimize its impact
it lasted, what medications the patient was taking, on mobility. Identifying all the members of the care
medication management. The following are the steps

BOX 9.4
rehabilitation team may implement for patients with
What Elderly Patients and Their Caretakers
polypharmacy:
Should Ask and Know About Their Medications
1. Appointment with primary care provider: Ar-
What is the name of each drug? ranging a phone call or visit with primary care
What is the purpose of each drug? provider for medication review can be an im-
portant step in streamlining the medication list.
How to administer each drug?
Encouraging patients to bring the “brown bag
What are the risks of each drug?
of medications” for the visit can be extremely
What are the benefits of each drug?
helpful.
Ask pharmacist for written information about the side 2. Pharmacy consultation can help in monitoring
effects of each drug.
drug-to-drug interactions, duplication of medica-
What foods, drinks, or activities should you avoid tions, and patient and family education.
while taking each medicine?
3. Visiting nurse visit, when appropriate, can help
What should you do if a dose is missed? with ongoing monitoring for compliance with
How should medication be stored? drugs, dosage, and any new adverse events.
Have there been any safety problems associated with 4. Social worker referral, if appropriate, can aid pa-
each drug reported to the US Federal and Drug tients and families to comply with medical treat-
Administration? ment regimens, including identifying financial bur-
Routinely check the expiration dates for each mediand den and health literacy for patient and family.
supplement. 5. Patient and caregiver education is a vital component
If you have multiple prescribing physicians, bring all in preventing polypharmacy. Education material
your medicines and supplements to your doctor for patient and family that helps them understand
visits—“brown bag.”
prescribed medications, polypharmacy, common
If you have multiple pharmacist, bring all your mediand side effects, and drug-to-drug interaction can be an
supplements to the pharmacy while filling your
immense help in preventing ADEs leading to immo-
prescriptions—“brown bag.”
bility.
Make sure your doctor knows about any medicines
that have impacted your mobility in the past.
If taking more than one drug, ask your doctor to REFERENCES
review the drugs you are taking and how your medi-
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bmed/16190007.
CHAPTER 10
Nutritional Issues and Swallowing in

the Geriatric Population
CHRISTINA L. BELL, MD, PHD • SHARI GOO-YOSHINO, MS, CCC-SLP
INTRODUCTION among hospitalized older adults has been reported to

Nutritional issues in older adults can cause and com- range from 23% to 60%.2 In the long-term-care setting,
pound functional decline, leading to increased mor- the prevalence of malnutrition varied depending on
bidity and mortality. It is vital to identify and treat how it was measured and was as high as 77% in some
potentially reversible causes of weight loss and malnu- studies. Older adults with dementia are at particular
trition/undernutrition as early as possible to improve risk of malnutrition.
outcomes. A systematic interdisciplinary approach to The consequences of nutritional issues in older
older adults with possible nutritional issues will ensure adults include higher rates of disability, morbid-
that important contributing factors are recognized and ity, mortality, reduced quality of life, and increased
appropriately managed. healthcare costs. In the Cardiovascular Health Study,
We will examine the issue of weight loss and weight loss of as little as 5% over 3 years in community-
malnutrition in older adults using a hypothetical dwelling geriatric patients was an independent predic-
patient case, Ms. Robinson.␣ tor of mortality, regardless of patients’ starting weight.␣
Case Study—Initial Clinical Presentation: Ms. Robinson

Case Study—Weight Loss Presentation: Ms. Robinson
is 85 years old who was recently widowed and now lives
tells the nurse at the medical clinic that she often skips
alone. Last year, she was diagnosed with mild cogni-
meals and lost 10 pounds in the last 4 months. She notices
tive impairment and macular degeneration. She stopped
more fatigue and has lost her appetite. She explains to
driving because of her visual impairment. She also has
her doctor that her favorite foods just are not appetizing
a history of knee osteoarthritis and uses a walker inter-
anymore and she feels full faster.
mittently “when her knees are giving her a hard time.”
She is independent in ADLs (activities of daily living) but
relies on neighbors for rides to the market once a week,
something she feels ashamed to do. IS WEIGHT LOSS PART OF NORMAL
AGING?
Some healthcare professionals might be tempted
HOW COMMON IS MALNUTRITION IN to think that malnutrition or weight loss is part of
OLDER ADULTS? the normal aging process. Lean body mass normally
Malnutrition and undernutrition are synonyms and starts to decline around the age of 30 years, whereas
can be defined as “a state resulting from lack of intake body fat increases until at least 65–70 years of age.
or uptake of nutrition that leads to altered body com- However, malnutrition is not a normal part of aging.
position (decreased fat free mass) and body cell mass Similarly, the sense of smells declines with aging and
leading to diminished physical and mental function older adults may have decreased sense of taste. How-
and impaired clinical outcome from disease.”1 Weight ever, older adults still have the ability to enjoy food
loss does not always go with malnutrition, but an that is well prepared and nicely presented. The stom-
assessment of weight loss should consider the risk of ach has less ability to distend and older adults may
malnutrition. The prevalence of malnutrition among have some earlier satiety, but not to the degree that
ambulatory outpatient older adults has been reported would cause malnutrition in the absence of a disease
to range from 5% to 30%, whereas the prevalence process.3␣
131
Case Study—Identification of Malnutrition: Ms. a single meal. Some laboratory tests, such as albumin,
Robinson has moderate muscle wasting, generalized particularly in dementia patients, lack specificity for
weakness, and chronic arthritic changes. Her labora- malnutrition, as inflammatory processes can cause the
tory testing reveals low albumin, low cholesterol, and albumin to be elevated. Skinfold measurements and
hypothyroidism. other anthropometric measures are also less helpful
in older adults because of risk of inaccurate measure-
ment, variation in different groups, and lack of clear-
cut points for the elderly.␣
WHAT IS THE BEST WAY TO IDENTIFY
MALNUTRITION IN OLDER ADULTS? Case Study—Evaluation and Management of Mal-
Multiple measures can identify malnutrition in older nutrition: Ms. Robinson continues to experience slow
adults. A body mass index (BMI; calculated as weight involuntary weight loss and has now lost 16 pounds in
[kg] divided by height [m] squared or wt/[ht]2) is a 7 months. She discloses to the dietician that she tries to
eat but does not have the energy to cook. Her current
quick way to identify an older adults as undernour-
diet consists of canned soups, crackers, cereal, and cof-
ished (BMI < 18.5 kg/m2), normal (18.5–24.9 kg/m2),
fee. Once a week she looks forward to company with her
overweight (25–29.9 kg/m2), or obese (30 kg/m2 or neighbor who brings fast food for their lunch. She enjoys
higher).4 In the outpatient and hospital setting, BMI the prepared meal but usually eats only 50% of servings.
is a good way to identify undernourished older adults. Ms. Robinson has a son who calls her weekly and
Another useful and commonly used criterion for drives 2 h to visit her every other week. She relies on
malnutrition is weight loss. In the long-term-care set- him for decision-making in areas that her husband was
ting, the Medicare-mandated minimum data set defines responsible for such as personal finances and home
significant weight loss as 5% body weight or more in maintenance problems. She prefers to be as indepen-
the preceding month or 10% body weight or more in dent as possible to avoid being a burden.
the preceding 6 months. This is considered to be one
of the best measures for malnutrition in the long-term-
care setting. In the outpatient setting, unintentional WHAT IS THE BEST APPROACH TO
weight loss can also be used to raise concern for mal- MALNUTRITION?
nutrition, particularly if more than 10 pounds.3 It is An interdisciplinary approach to malnutrition in older
recommended that every outpatient medical visit for adults is shown in Fig. 10.1.5
a community-dwelling older adult includes a screen- The first step in assessing malnutrition in older
ing for malnutrition and measurement of weight and adults is to determine whether caloric intake is ade-
BMI. In long-term-care facilities, it is recommended quate. Some medical conditions cause increased
to check for weight loss every month. Graphing an metabolism or catabolism resulting in malnutrition
older patient’s weight over time is a very effective way despite adequate oral intake, including cancer, thyroid
to identify worrisome downward trends. The Euro- problems, or infections, noted in Box 10.1.
pean Society of Clinical Nutrition and Metabolism If caloric intake is inadequate, the second step is
recently developed diagnostic criteria for malnutrition to assess the older adult’s access to food. Strategies for
of either BMI < 18.5 kg/m2 or a combination of (1) improving access to food for older adults, especially
unintentional weight loss (>10% of weight or >5% over those who live alone, are summarized in Box 10.2.
3 months) and (2) BMI under 22 kg/m2 in adults over Bringing isolated older adults to community centers or
70 years or low fat-free mass index. Several question- adult day-care centers to eat with other people improves
naires also assess risk of malnutrition. The most widely nutrition, especially when combined with activities and
used is the Mini-Nutritional Assessment or MNA. For exercise strategies. It is essential to identify and remove
community-dwelling elders, screening using the MNA dietary restrictions in older adults with malnutrition or
has been shown to identify the risk of hospitalization who are at risk of malnutrition. The American Dietetic
and poor outcomes. Association recommends removing restrictive, therapeu-
There are some measures that are less helpful to tic diets in long-term-care patients as a way of improving
identify malnutrition in older adults. For example, intake, weight gain, and quality of life.6 Supplements can
the percentage of oral intake is often inaccurate and sometimes be helpful, but studies have had mixed con-
is not as helpful as weight loss. Trends in percentages clusions and the mortality benefit is small. Other strate-
(such as a person suddenly eating less than half or his gies include providing favorite foods and making sure
or her food compared with usually eating all of the the food is served at the appropriate temperature (soups
food) are usually more helpful than percent eaten at and hot meals should be hot or warm, not lukewarm,
CHAPTER 10 Nutritional Issues and Swallowing in the Geriatric Population 133
Assess caloric intake:

Malnutrition despite adequate caloric intake (Box 10.1)
• Altered metabolism/ catabolism - endocrine, cancer, infection, heart or
lung disease (physician, nursing, dietary)
Assess access to food: Inadequate access to food (Box 10.2 for strategies to improve access)
• Restrictive diets (dietary, physician)
• Sensory or functional impairments (nursing, PT, OT, physician)
• Social factors (social work)
• Financial needs (social work, case management)
Assess dental problems:
Dental issues
• Dental/ denture care (dental and nursing)
Assess anorexia: Important causes of anorexia (specialist)

• Medications or alcohol overuse (physician, pharmacy, nursing)
• Mood disorder (physician, mental health)
• Dysguesia - “bad taste in mouth” – i.e., zinc deficiency (physician)
• Dementia - feeding strategies, no “food wars” (nursing, dietary)
• Avoid appetite stimulants without addressing causes

Assess dysphagia problems:
Dysphagia
• Swallow evaluation (speech language pathology)
FIG. 10.1 Overview of interdisciplinary evaluation and management of nutritional issues in older adults.
(Data from Omran ML, Salem P. Diagnosing undernutrition. Clin Geriatr Med. 2002;18(4):719–736.)
and ice cream and frozen items should be cold). Home-

BOX 10.1
made milk shakes, gravy, and sauces are other great ways
Medical Conditions Associated With to increase caloric intake. Increasing protein intake,
Malnutrition in Older Adults especially with foods such as eggs, tofu, fish, or beans,
can also improve nutrition. Finally, it is important to
Cardiac/pulmonary diseases (i.e., congestive heart consider cultural factors, such as preferred foods, or cul-
failure, cardiomyopathy, chronic emphysema) tural practices, that may be missing in an assisted living
Cancer or nursing home setting, which can have a profound
impact on an older adults’ nutritional status.
Infections/AIDS
Functional issues can also affect access to food by
Rheumatoid arthritis impairing an older adult’s ability to feed himself or her-
Helicobacter pylori self. Poor dexterity and arthritis can make using uten-
Gallbladder disease sils difficult and result in reduced oral intake. Specially
adapted devices and utensils can enhance the ease of
Malabsorption (i.e., Crohn’s disease, short gut syndrome)
self-feeding. Similarly, for patients with tremors, uten-
Hypothyroidism or hyperthyroidism sils can be modified and diet can be changed slightly
Alcoholism to reduce frustration from spilling. Occupational thera-
Parkinson’s disease pists can provide expertise in adaptive equipment to
enhance a patient’s ability to eat. As much as possible,
Pressure ulcers
meals in bed should be avoided, as the positioning in
bed tends to increase intraabdominal pressure and be
Adapted from Omran ML, Salem P. Diagnosing undernutrition. Clin
uncomfortable for eating, and it is recommended to
Geriatr Med. 2002;18(4):720; with permission.
have patients sit up in a chair for meals. Completely
medical team to reduce or stop any medications that

BOX 10.2
may be affecting appetite. Depression, substance abuse,
Strategies for Improving Access to Food for
and other psychologic disorders need to be identified
Older Adults
and treated if present. Mirtazapine for depression can
Meal programs/Meals on Wheels stimulate appetite and improve the mood and can be
a good choice if an older adult has depression, malnu-
Senior centers or adult day care if home-dwelling
trition, and trouble sleeping. Appetite stimulants such
Serve food attractively and at the correct temperature as megestrol have potentially dangerous side effects in
Companionship and congregate dining older adults, including risk of thromboembolism, and
Comfortable seating, warm lighting, ambient music, are generally not recommended as an initial treatment
and use of china plates for malnutrition or weight loss for most older adults.
Family-style or cafeteria-style meals better than fixed-
Artificial nutrition and hydration can be considered in
portion trays appropriate clinical situations, such as reversible post-
operative malnourished states where clinical improve-
Special utensils if arthritis impairs the use of utensils
ment is expected. Use of long-term artificial nutrition
Assist or enable self-feeding if tremors impair feeding and hydration in end-stage dementia or terminal
Cues for hearing and visual impairment cancer is generally not recommended in the geriatric
Positioning if bed-bound (upright, alert, comfortable, population. Discussions about artificial nutrition and
able to see the plate) hydration in frail older adults should be approached by
the team using sensitivity, high-level communication
Make diet as liberal as possible (remove restrictive
therapeutic diets) skills, and a careful appraisal of risks versus benefits. A
detailed discussion of artificial nutrition and hydration
Smaller more frequent meals and snacks
in the geriatric population is beyond the scope of this
Provide favorite foods, milk shakes, gravy, and sauces chapter, but training programs to enhance communica-
to increase calories tion skills in this area can be very helpful.
Older adults with dementia have additional factors
that need to be considered in addressing malnutri-
bed-bound patients need to be carefully positioned tion. Mood disorders, adjustment to new care settings,
to be able to see what they are eating, control foods understimulation or overstimulation, misperceptions,
and liquids in their mouths, and remain comfortable paranoia, and other behavioral issues can contribute
throughout a meal. to feeding difficulties in older adults with dementia.
The third step in evaluating and managing malnutri- The Edinburgh Feeding Evaluation in Dementia can
tion in older adults is to assess for dental problems. The help identify challenging behaviors related to feeding
dental team is an integral part of the management of in older adults with dementia. There are some feeding
malnutrition, as carefully assessing and treating broken strategies that can be particularly helpful in older adults
or rotten teeth, poorly fitting dentures, dry mouth, oral with dementia (Box 10.3).7
lesions, and candidiasis can improve oral intake and
quality of life. Ongoing oral care improves dysgeusia Case study—New Concern: Ms. Robinson calls her
(bad taste in the mouth) and dry mouth, and family neighbor after awakening and feeling “too weak” to get
and/or caregivers may need to help older adults with out of bed. Her neighbor calls 911 for emergency care.
monitoring, cleaning, and rinsing out the teeth, mouth, She is taken to a hospital and admitted for a stroke.
and dentures. Edentulousness is an independent risk During the review of her history, involuntary weight loss,
factor for weight loss; therefore evaluating community- reduced appetite, and fatigue over the past 7 months
dwelling and more functional nursing home patients were noted. Her admitting team wonders if the stroke
for dentures may help improve nutrition. In addition, may have affected her swallowing as well.
oral care is one of the best methods for preventing
pneumonia among nursing home patients.
The fourth step is to assess for anorexia. Anorexia Swallowing problems (dysphagia) are particularly
is not a normal part of aging. It is common for health important to recognize and address in older adults,
professionals to wonder if appetite stimulants may be especially when evaluating and managing malnutri-
an option for older malnourished adults with anorexia. tion. Oropharyngeal dysphagia is defined as a swal-
Before considering an appetite stimulant, it is impor- lowing difficulty that affects the transport of foods and
tant to first work closely with the pharmacist and liquids from the mouth to the esophagus. According
As a result, the prevalence of swallowing impairment

BOX 10.3
increases with age. As older adults are the fastest-grow-
Strategies to Optimize Feeding and Pleasurable
ing segment of the overall population, oropharyngeal
Mealtime With Adults With Dementia
dysphagia is becoming a critical healthcare issue.
Maintain meal routines (e.g., time, after/before medica- Complications resulting from dysphagia include
tions, sitting at dining table) aspiration pneumonia, chronic lung disease, malnu-
trition and dehydration, and compromised general
Establish calm dining environment
health prompting treatment with possible hospitaliza-
Remove distractions that could interrupt mealtime tion. Choking and death are also morbid outcomes.
(e.g., reduce noise, turn off television, limit number
Furthermore, dysphagia can disrupt quality of life for
of items on the meal tray or table setting)
affected individuals with diminished satisfaction of
Arrange seating by individual needs and personalities eating and drinking and in activities surrounding meals
Use visual contrast: plate, food, and place setting such as grocery shopping, cooking, and social engage-
Provide finger foods if person has trouble with utensils ments. Collectively, these complications extend beyond
the patient by adding to caregiver burden.␣
Offer preferred food and liquid choices
Present foods that look, smell, and taste appealing
Serve meals promptly to maintain optimum temperatures HOW DOES AGING AFFECT SWALLOWING?
No force-feeding The swallowing process has four phases that occur in a
controlled, timed, and overlapping sequence of events
Encourage self-feeding or assist person to feed him/
herself as needed requiring central and peripheral sensory-motor activity.
Any compromise in this dynamic process can result in
oropharyngeal or esophageal dysphagia:
• First phase: Oral preparation phase consists of chew-
to a position document developed by the Dysphagia ing and mixing food with saliva. Foods and liquids
Working Group, oropharyngeal dysphagia is included (i.e., bolus) are then gathered and controlled on the
in the World Health Organization’s classification of tongue (Fig. 10.2A).12
diseases and meets the criteria of a geriatric syndrome • Second phase: Oral phase is the transfer of bolus
including high frequency of occurrence in older adults, from anterior to posterior of the tongue (Fig. 10.2B
multiple causal factors, poor outcomes, and multidis- and C).
ciplinary treatment.8 The processes and methods for • Third phase: Pharyngeal phase starts when the bo-
management of oropharyngeal dysphagia in the geri- lus enters and then passes through the pharynx (Fig.
atric population are discussed in this section and are 10.2C–E).
aimed to support interprofessional practice in preven- • Fourth phase: Esophageal phase refers to passage of
tion, early identification and diagnosis, and interven- the bolus through the esophagus and lower esopha-
tion of dysphagia to reduce consequences that are both geal sphincter (Fig. 10.2F).
costly and compromise health and quality of life.␣ Presbyphagia refers to changes in the swallowing
process of healthy adults related to a natural course
of aging that includes alteration in the central ner-
HOW COMMON IS DYSPHAGIA IN OLDER vous system, head and neck anatomy, physiology, and
ADULTS? sensory-motor function.13,14 Swallowing in older adults
Oropharyngeal dysphagia is a clinical symptom of an may be slower in all phases and result in pooling in the
underlying disease process that affects 1 in 25 adults.9 pharynx but is not considered a disorder.13–16 However,
In a systemic review by Takizawa et al.,10 the prevalence these differences reduce functional reserve and can
of oropharyngeal dysphagia was high in patients with compromise safe and efficient swallowing when a vul-
a history of stroke (8%–80%), Parkinson’s disease nerable system is challenged with “physical exertion,
(11%–81%), traumatic brain injury (27%–30%), and injury, infection, starvation, and dehydration.”17␣
community-acquired pneumonia (92%). A systematic
review by Alagiakrishnan, Bhanji, and Kurian indicated
13%–57% of persons with dementia also have dys- WHAT ARE CAUSES OF DYSPHAGIA IN
phagia.11 Although aging is not a disease, age-related OLDER ADULTS?
diseases such as these exacerbate, predispose, and Although aging is not a disorder, adults are at risk for
increase the risk of dysphagia in the elderly population. comorbid conditions related to aging that increase
A B C
D E F
FIG. 10.2 (A–F) Phases of swallowing with videofluoroscopic swallow study. (From Goldsmith TA, Holman
AS, Nunn D. Videofluoroscopic evaluation of oropharyngeal swallowing. In: Som PM, Curtin HD, eds. Head
and Neck Imaging. 5th ed. St. Louis: Mosby, Inc.; 2011; with permission.)
their risk for dysphagia and aspiration pneumonia. The HOW IS DYSPHAGIA IDENTIFIED?
most common causes of dysphagia in adults include A swallow screen is a pass/fail procedure that identi-
neurologic, medical, and surgical conditions and head fies individuals who require a comprehensive swallow
and neck cancer treatment.18 Although it may be diffi- assessment or a referral for other professional and/
cult to identify the main cause of dysphagia in an older or medical services. Although systematic reviews did
adult with a complex history, it is critical to the evalu- not result in agreement on the best screening tool for
ation and management of oropharyngeal dysphagia. oropharyngeal dysphagia, instruments developed for
Box 10.4 lists medical conditions that may contribute diverse age groups were identified. Because the absence
to dysphagia.␣ of consensus does not mean screening should not be
performed, it is imperative that professionals select a
process that is appropriate for their patient population
Case Study—Identification of Swallowing Difficul-
ties: Ms. Robinson is alert for a swallow screening by
and reliable in identifying or ruling out dysphagia.19
the nurse. After the final swallow of water, she coughs. If a screening is positive, a follow-up comprehensive
This is considered a failed screening test at this hospital, swallow assessment is warranted. Fig. 10.3 shows a
triggering a referral for a clinical swallow evaluation. workup process from identification to treatment of
dysphagia.␣
BOX 10.4 worsened. He was mostly concerned about his mother’s

Medical Conditions That May Contribute to weakened state and ability to continue independent living.
Dysphagia in Older Adults Ms. Robinson is alert to participate in the intake and
examination. Her speech is understood although mildly
Alzheimer’s disease imprecise in articulation. Her son indicates no communi-
cation changes with the exception of slurred speech that
Cardiothoracic surgery significantly improved over the past 24 h.
Cognitive decline—other dementias An oral motor examination reveals reduced tongue
strength and control. Dentition is compromised for chew-
Deconditioning
ing with no opposing molars. Ms. Robinson acknowl-
Delirium edges having dentures but prefers not to wear them.
Dentition absent or in poor condition To evaluate swallow function, Ms. Robinson is offered
various liquids and foods. Using a systematic approach,
Developmental disabilities (e.g., cerebral palsy)
texture and bolus size are increased to safely challenge
Frailty her swallow. She exhibits both oral preparation and oral
Gastroesophageal reflux phase dysphagia with prolonged chewing and food resi-
due on her tongue. After successive liquid swallows, her
Head and neck cancer or cancer treatment voice changes to a wet quality. She also coughs when
Lung disease—respiratory compromise swallowing liquids with preexisting food in her mouth
and reports sensation of food sticking in her throat.
Medication related
Therapeutic intervention trials and training are intro-
Multiple sclerosis duced in the session. Wet vocal quality and cough
Parkinson’s disease decreases with compensatory strategies (individual sips
of liquid to improve bolus control, two swallows per tea-
Post–polio syndrome
spoon of food to eliminate oral and sensation of pha-
Pulmonary diseases ryngeal residue), postural adjustments (chin tuck), and
Sarcopenia texture modification (nectar-thick liquid).
Ms. Robinson and her son, speech-language pathol-
Stroke ogist, physician, nurse, and dietician collaborate in
Traumatic brain injury developing a plan of care that includes the following:
1. Modify the diet order to cohesive, moist, minced
foods, requiring minimal chewing. Meals will include
personal preferences of coffee, soup, oatmeal,
mashed potato, and cottage cheese.
WHAT ARE SYMPTOMS AND SIGNS OF
2. Initiate dysphagia intervention to establish compen-
DYSPHAGIA? satory strategies (individual sips and two swallows
Although symptoms and signs of dysphagia can be per teaspoon of food).
present, problems may still go undetected. Elders may 3. Assess barriers to oral care and wearing dentures.
be unaware of or unable to report difficulties. For these 4. Continue nutrition therapy to optimize oral intake to
reasons, a caregiver report of changes in food prepara- meet nutrition and hydration needs with an addition
tion or preferences (e.g., soft, moist over dense, chewy of healthy and calorie-dense snacks.
foods), eating habits (e.g., chewing foods well and 5. Perform an instrumental swallow examination to
frequent sips of liquid), and extended mealtime and evaluate oral and pharyngeal phases of swallow and
effort level can be revealing. It is essential to consider assess effectiveness of therapeutic interventions to
symptoms and signs of dysphagia in the context of improve swallow efficiency and safety.
other clinical indicators, rather than relying on a single
symptom or sign. Refer to Table 10.1 for a list of com-
mon symptoms and signs of dysphagia in the elderly.␣ HOW IS DYSPHAGIA DIAGNOSED?
Evaluation and management of dysphagia is a com-
plex and multidimensional process that is best accom-
Case study—Evaluation: A speech-language patholo-
gist conducts a clinical swallow evaluation. Although plished with an interprofessional approach. The team
Ms. Robinson attributed coughing to “just old age,” includes the patient, their support network, speech-lan-
she acknowledged some fear when swallowing. Her guage pathologist, physician, nurse, dietician, radiolo-
son noted problems about a year ago that gradually gist, gastroenterologist, otolaryngologist, neurologist,
and others depending on the patient’s needs.
Swallow screen Outcomes

Examples of protocols: • Pass
SLP, team • Interview • Rescreen
member • Questionnaire • Refer for other examinations or
• Observation of the presence of services
oropharyngeal or esophageal • Fail -> Refer for clinical swallow
dysphagia evaluation
Clinical swallow evaluation Outcomes

• Case history • Diagnosis of a swallowing
• Oral, pharyngeal, laryngeal disorder (oral prep/oral dysphagia)
examination and the degree of severity
SLP • Physical, social, behavioral, • Relate signs of dysphagia to
speech-language-cognition anatomy and physiology
assessment
• Prognosis for improvement
• Swallow function assessment with
oral intake trials (if indicated) • Recommendations for the safest
• and most efficient route (oral vs.
Therapeutic intervention trials and
nonoral) to meet nutrition and
training
hydration needs
• Patient and family education
• Determination of food and liquid
textures and other compensatory
approaches to optimize safe and
efficient swallowing
Intervention Instrumental • Develop individualized plan of

for oral swallow care
prep/oral evaluation • Counseling, education and training
phase • VFSS
for the patient and caregi,vers
dysphagia • FEES
• Indications for instrumental
swallow evaluation
• Referral for other services or
professionals
Intervention for
pharyngeal phase
dysphagia
FIG. 10.3 Dysphagia workup. FEES, fiberoptic endoscopic evaluation of swallow; VFSS, videofluoro-
scopic swallow study.
Based on the primary symptoms, the initial step may • an assessment of alertness, speech, language, and
be a referral to the speech-language pathologist for an cognitive abilities;
evaluation of oral and pharyngeal phases of swallow- • an examination of oral structures and function in-
ing or gastroenterologist for gastrointestinal concerns. volved in swallowing;
This section focuses on the evaluation of oropharyn- • a systematic evaluation of swallow during intake of
geal dysphagia. various food and liquid textures based on swallow
safety and patient’s acceptance; and
Clinical (or Bedside) Swallow Evaluation • a trial of compensatory strategies to reduce or elimi-
If signs and symptoms are more consistent with an nate symptoms or clinical signs of swallowing dif-
oropharyngeal dysphagia (vs. esophageal dysphagia), ficulty.
the first step in diagnosis is a clinical swallow evalua- To gather accurate and relevant information from
tion conducted by a speech-language pathologist spe- older adults, it is important for healthcare providers
cializing in swallowing. Critical elements involve: to be mindful of their patients’ communication needs
• a review of medical records and interview with without ageist assumptions. The following can enhance
patient, family, and caregivers; engagement and evaluation results20:
TABLE 10.1
Symptoms and Signs of Dysphagia
GENERAL SYMPTOMS AND SIGNS OF DYSPHAGIA
Coughing
Choking
Hoarse voice
Globus sensation
Complaints of pain with swallowing
Repeated swallows per sip of liquid or teaspoon of food
Involuntary weight loss and difficulty gaining weight
Recurring pneumonia, respiratory infection or fever
Symptoms and Signs of Oropharyngeal Dysphagia Symptoms and Signs of Esophageal Dysphagia
• Coughing during or shortly after eating and drinking • Chronic coughing
• Complaints of food “sticking” in the pharynx • Complaints of food “sticking” in the throat or chest
• Reduced mouth opening or labial seal around spoon or • Pressure or burning in chest
cup • Progressive difficulty in swallowing solids to liquids
• Holding food or liquid in mouth • Vomiting
• Prolonged chewing • Hiccups
• Spill of food or liquid from the lips or nasal cavity • Bone pain
• Food or liquid residue in the mouth • Black stool
• Fear of eating or swallowing • Anemia
• Drooling or extra secretions • Fatigue
• Dysarthria
• Wet voice during or after swallow
• Difficulty coordinating breathing and swallowing
• optimize sensory information (e.g., placement of sensation of slow clearance through the esophagus, a
glasses or hearing aids as needed); referral to a gastroenterologist should be considered.␣
• focus attention (e.g., greet the older adult using
his/her name, establish eye contact, reduce distrac- Case Study—Instrumental Swallow Examination:
tions); A videofluoroscopic swallow study (VFSS) is selected
• encourage autonomy (e.g., include the older adult based on clinical questions (e.g., Is cough related to
in conversation, share decision-making); and aspiration? If yes, is it resulting from oral impairment,
pharyngeal impairment, or both? What impact do strate-
• support participation (e.g., provide simple direc-
gies have on bolus flow through oropharynx?) and Ms.
tions; allow additional time for processing, compre- Robinson’s preference. Before the study, Ms. Robinson’s
hension, and expression; ask open-ended questions; son and a nursing assistant helped with the placement
model or use visual aids; and verify exchanges). of her dentures with adhesive. She was encouraged to
Reports and observations are integrated to deter- wear them as tolerated during meals. A speech-lan-
mine the presence of oral preparation and oral phase guage pathologist provided education and training to
dysphagia, symptoms or clinical signs of pharyngeal establish individual sips of liquid, two swallows per tea-
phase dysphagia, nature of impairment, and etiology of spoon of food, and coordinate chin tuck with swallows.
the disorder. Outcomes also include recommendations The speech-language pathologist and radiologist
for an oral diet (if indicated), support and interven- conducted the VFSS. Radiographic visualization of the
oral, pharyngeal, and laryngeal structures and function
tion to improve swallow safety and efficiency, patient
confirmed oral phase dysphagia with residual of food
and family education, and direction of next steps such on her tongue. Visualization also showed entrance of
as an instrumental swallow examination. In addition, liquids into the airway and trace aspiration before the
a referral and consultation with other specialists and swallow. These signs are related to reduced tongue
follow-up for dysphagia may be indicated based on movement and strength. Pharyngeal phase dysphagia is
presentation. For example, if a patient complains of
characterized by liquid and food residue in the vallecula TABLE 10.2

related to reduced tongue base retraction. Ms. Rob- Indications and Contraindications for an
inson is aware of this residue to swallow again. Swal- Instrumental Swallow Evaluation
lows evaluated with compensatory strategies improved
safety and efficiency of swallow. The chin tuck in par- Indications Contraindications
ticular reduced the spill of liquids deep into the pharynx History of medical conditions Medical instability
and eliminated aspiration and residue in the vallecula. associated with high risk for
Results of the study are discussed with the medical dysphagia and aspiration
team. Based on her history, it is determined that dys-
phagia is likely resulting from a combination of preexist- Uncertainty in safety and Unable to participate
ing sarcopenia exacerbated by malnutrition before this efficiency of swallowing or cooperate
admission and further impaired by the stroke. Differential diagnosis of dys- Outcome would not
Additional recommendations included: phagia to guide management change management
1. resumption of thin liquids with chin tuck; and treatment or treatment
2. continuation of therapy for dysphagia with explora- Symptoms or signs are
tion of restorative treatment; inconsistent with clinical
3. occupational therapy for assessment and as- presentation
sistance with ADL training including increasing
independence in oral care and denture placement;
4. physical therapy to support safe and independent viewed in the lateral and anterior-posterior planes
mobility within her home and community settings. as foods and liquids (mixed with barium or water-
soluble contrast medium) are swallowed.
• FEES (Fig. 10.4)
Instrumental Swallow Examination • A procedure conducted by a speech-language
An instrumental swallow examination is used to evalu- pathologist, frequently in collaboration with an
ate all phases of swallowing. The aim is to clarify the otolaryngologist. It is an examination that can
nature of the disorder with related anatomic and physi- be performed at bedside with portable equip-
ologic impairment. Unlike a clinical swallow evaluation, ment. The examiner passes a flexible endoscope
an instrumental swallow examination provides direct through the nasal pharynx for direct visualiza-
visualization of the pharyngeal and laryngeal structures tion of the anatomy of the larynx and pharynx at
to determine the presence, severity, and characteristics of rest and with swallowing tasks.
pharyngeal phase dysphagia. It is also sensitive to identi- Both procedures result in diagnosis, understanding
fying aspiration, which is critical because approximately of the nature and severity of the problem, and assess-
40% of patients who aspirate do so without cough ment of the effect of strategies on swallow safety and
response.21 This is called silent aspiration. efficiency. Given the availability of both evaluations
Guidelines for the appropriate use of instrumental within a facility, refer to Table 10.3 for the benefits of
procedures have been developed with consensus.22 VFSS versus FEES.␣
Refer to Table 10.2 for indications and contraindica-
tions for an instrumental swallow evaluation. Case Study—Intervention: Ms. Robinson is now con-
Instrumental swallow evaluations consist of two suming about 75%–90% of minced foods and nectar-
primary procedures that allow the provider to view thick liquid meals, more than her intake at home. After
the anatomy and physiology of swallowing structures being cleared to drink thin liquids with chin tuck, she
to determine the nature and severity of oropharyngeal often accepts sips of water throughout the day with
dysphagia and aspiration. In hospital and clinical set- snacks.
tings, common options include VFSS also known as Although Ms. Robinson does not mind modified diet
modified barium swallow study (MBSS) and fiberoptic textures, she expressed a desire to eat “regular” foods
such as grilled ham and cheese sandwich and stew.
endoscopic evaluation of swallow (FEES):
Meals are liberalized with inclusion of soft filled sand-
• VFSS or MBSS (Fig. 10.2)
wiches and other soft, moist foods as her risk of chok-
• A radiographic procedure conducted by a speech- ing has decreased with two swallows to clear residual of
language pathologist, frequently in collaboration food from her tongue.
with a radiologist performed in a radiology suite. She agrees to start a restoration program with exer-
Images of the oral, laryngeal, pharyngeal, and cises intended to improve and maintain muscle function
upper esophageal structures and movement are
for swallowing. Oral and pharyngeal motor exercises are TABLE 10.3
selected based on impairments noted on the swallow Comparison of Videofluoroscopic Swallow
evaluation. Ms. Robinson responds well to models and Study (VFSS) Versus Fiberoptic Endoscopic
brief written instructions to optimize her accuracy and
Evaluation of Swallow (FEES)
independence in demonstrating exercises. The speech-
language pathologist’s role of coaching Ms. Robinson Clinical Indications VFSS FEES
through exercises is gradually transferred to her son to
Can be performed in patients with +
optimize follow-through at home.
• Movement disorder
• Bleeding disorder or recent
epistaxis
• Recent craniofacial trauma
• Bilateral nasal obstruction
Poor tolerance for nasal endoscopy +
Global complaints +
Evaluate oral preparation and oral +
phases
Screen esophageal phase +
Evaluate pharyngeal phase + +
Identify aspiration + +
Evaluate swallow of secretions (high +
risk of aspiration)
Real-time patient and family educa- +
tion, strategy training, and biofeed-
back without radiation exposure
Barium allergy or intolerance +
Claustrophobia +
FIG. 10.4 Fiberoptic endoscopic evaluation of swallow-
Imaging equipment cannot accom- +
ing. Liquid residue in the vallecula and pyriform sinuses. modate patient’s size or posture
(From Leder SB, Murray JT. Fiberoptic endoscopic evalu- limitations
ation of swallowing. Phys Med Rehabil Clin North Am.
2008;19(4):792; with permission.)
HOW IS DYSPHAGIA TREATED? swallowing, the nature and the consequences of dys-
Effective treatment of dysphagia is guided by compre- phagia, and intervention options are shared with
hensive evaluation results and ongoing assessment of patients (and their families and caregivers). Discus-
the individual’s interest and response to intervention. sions also include feeding and swallowing guidelines,
In older adults, developing and executing an individu- instructions for thickening liquids (if recommended),
alized patient-centered plan of care must consider pri- and suggestions to incorporate palate preferences to
mary condition(s) related to the dysphagia and their optimize adherence.␣
goals, priorities, and resources.
Key treatment goals of intervention are to minimize Compensatory Approaches
related consequences of oropharyngeal dysphagia. This Strategies used to offset impairment improve swallow
includes a safe and efficient oral intake of a least restric- safety without altering physiology. Simple and quick
tive diet (textures) to meet nutrition and hydration strategies include smaller bites of foods or sips of liq-
needs. Treatment includes education and compensa- uid to improve bolus control or follow-up dry or liq-
tory and rehabilitative approaches. uid swallows to clear oral and pharyngeal residue. In
a review of these types of compensatory strategies, Laza-
Education and Counseling rus reported positive outcomes with reduction in medi-
Within an interdisciplinary process, information about cal consequences of oropharyngeal dysphagia such
conditions and diseases likely affecting nutrition and as aspiration pneumonia and enhanced nutritional
BOX 10.5 Case Study—Ongoing Assessment and Support:

General Strategies to Optimize Safe Oral Intake Ms. Robinson reports feeling “good” and “ready to go
home.” Her laboratory testing reveals improvement in
Offer meals when individual is alert and ready prealbumin level along with an increase in her appetite,
weight, and energy level. Her son agrees with plans for
Place dentures (that fit comfortably) her discharge to home with home care rehabilitation (OT,
Sit upright during and after eating and drinking PT, and speech-language pathology). Social work will
Mouth should be clear of food before next bite or sip continue to assist her in identification and utilization of
community resources such as transportation for medi-
Swallow food and liquid before talking or next bite of cal appointments and meal deliveries while she contem-
food or sip of liquid plates a move to an assisted living center.
Allow more time to swallow and complete meals Nutrition recommendations include more frequent
smaller meals (i.e., 4–6 meals a day), making sure to get
After meal, clear mouth of residual food
sources of protein and fluids in her diet, and keeping
Maintain healthy oral care and hygiene meals social by eating with others and limiting isolation.
Speech-language pathology recommendations
include follow-up for (1) swallow reassessment including
status.23 Refer to Box 10.5 for general strategies to opti- a repeat VFSS and (2) initiating cognitive-communication
mize safe oral intake. assessment and intervention for mild cognitive impair-
ment to optimize cognitive function.
Diet modification, such as thickening liquids and
downgrading food textures, is frequently used during
the acute phase of an illness and adjusted as swallow
function improves or other compensatory strategies Rehabilitative Approaches
are established.24 In the context of progressive dis- The principles of neuroplasticity—use it or lose it; use
ease with a decline in cognitive and swallow function, it and improve it; and repetition, intensity, and saliency
diet modifications may be used long term. Systematic matter—are applied to improve swallow physiology.15
reviews of oropharyngeal dysphagia management Swallow function exercises are selected based on the
concluded that the use of thickened liquids may be underlying impairment. For example, resistance and
advantageous in addressing dysphagia and reducing range-of-motion exercises for labial and lingual weak-
aspiration.11,24 Although supported in research, tex- ness or swallowing with “effort” to increase posterior
ture changes may not be well accepted by individuals, tongue base movement may be prescribed. Exercises
particularly in elders who may already have appetite can take weeks to months to take effect.
changes from reduced sense of smell and taste. Older In approaching swallowing issues in older adults, it
adults often have poor compliance with thickened is important to broaden the focus beyond the act of
liquids because of dissatisfaction and inaccessibility. swallowing. Physical therapy and occupational therapy
With this in mind, it is important to determine if the are crucial in enhancing a patient’s ability to sit upright,
benefits outweigh the risks such as refusal to eat and use utensils, and feed oneself. Nursing, dental, phar-
drink, anxiety, and social isolation that can add to fur- macy and medical professionals need to review and
ther functional decline. manage oral care, medications and reversible medical
Other compensatory strategies include postures conditions affecting the mouth, swallowing, or mental
and maneuvers that can also be helpful in the man- alertness, which may contribute to eating or swallowing
agement of dysphagia. Although chin-tuck and air- problems. Dietary specialists should continue to moni-
way-protection maneuvers (e.g., supraglottic swallow) tor the nutritional quality of the older adult’s diet. In
may improve swallow function, effects in preventing addition, as the older adult’s condition stabilizes and
aspiration are variable. In addition, these intentional swallowing improves, ongoing monitoring for malnu-
modifications may be difficult to execute consistently trition and weight loss remains essential.
in individuals with memory and endurance chal- The most common reversible causes of malnutrition
lenges. For individuals who demonstrate the ability in older adults are summarized with the mnemonic
to promptly and consistently follow instructions and “Meals on Wheels” in Fig. 10.5.25 Healthcare profes-
retain new information, it may be reasonable to pro- sionals need to work as a team to identify and treat
vide them with training opportunities to support their factors contributing to malnutrition, weight loss, and
independence in using behavioral strategies as a first dysphagia in older adults. A continued team approach
option rather than thickened fluids.␣ toward the older adult, with attention to the medical,
Medication (digoxin, theophylline, Wandering (dementia/ behavior) 11. Alagiakrishnan K, Bhanji RA, Kurian M. Evaluation and
psychotropics) Hyperthyroidism/ hyperparathyroidism management of oropharyngeal dysphagia in different
Emotional (depression) Enteric problems (malabsorption) types of dementia: a systematic review. Arch Gerontol Geri-
Anorexia/ alcoholism Eating problems atr. 2013;56:1–9.
Late-life paranoia Low-salt or restricted diets 12. Goldsmith TA, Holman AS, Nunn D. Videofluoroscopic
Swallowing disorders Social/ shopping/ food prep problems evaluation of oropharyngeal swallowing. In: Som PM,
Curtin HD, eds. Head and Neck Imaging. 5th ed. St. Louis:
Oral and dental disease Mosby, Inc.; 2011.
No money 13. Humbert IA, Robbins J. Dysphagia in the elderly. Phys Med
Rehabil Clin North Am. 2008;19:853.
FIG. 10.5 Reversible causes of malnutrition: “Meals on
14. McCullough GH. Normal swallowing in the geriatric pop-
Wheels.” (Adapted from Morley JE, Silver AJ. Nutritional issues
ulation. Perspect Swal Swal Dis (Dysph). 2001;10(1):14–18.
in nursing home care. Ann Intern Med. 1995;123(11):850–859;
https://doi.org/10.1044/sasd10.1.14.
with permission.)
15. Robbins J, Butler SG, Daniels SK, et al. Swallowing and
dysphagia rehabilitation: translating principles of neural
functional, and social aspects of eating and nutrition,
plasticity into clinically oriented evidence. J Speech Lang
is necessary to maintain gains made in nutrition and
Hear Res. 2008;51(1):S276–S300. https://doi.org/10.1044/
weight. A clear, stepwise approach, such as the one out- 1092-4388(2008/021).
lined in this chapter, will help to ensure that important 16. Ortega O, Martín A, Clavé P. Diagnosis and management
factors are not missed and that the team is able to work of oropharyngeal dysphagia among older persons, state of
together to improve quality of life for our older adults. the art. J Am Med Dir Assoc. 2017;18:576–582.
17. Murray J. Frailty, functional reserve, and sarcopenia in the
geriatric dysphagic patient. Perspect Swal Swal Dis (Dysph).
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1. Cederholm T, Barazzoni R, Austin P, et al. ESPEN guide- 18. American Speech-Language-Hearing Association. Roles of
lines on definitions and terminology of clinical nutrition. Speech-Language Pathologists in Swallowing and Feeding Dis-
Clin Nutr. 2017;36(1):49–64. https://doi.org/10.1016/j. orders [Technical Report]; 2001. Available from: www.asha
clnu.2016.09.004. .org/policy.
2. Agarwal E, Miller M, Yaxley A, Isenring E. Malnu- 19. Etges CL, Scheeren B, Gomes E, Barbosa LDR. Screening
trition in the elderly: a narrative review. Maturitas. tools for dysphagia: a systematic review. CoDAS. 2014;26(5):
2013;76(4):296–302. https://doi.org/10.1016/j.maturi- 343–349.
tas.2013.07.013. PMID: 23958435. 20. Harwood, et al. https://changeagents365.org/resources/
3. Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatrics Re- ways-to-stay-engaged/the-gerontological-society-of-
view Syllabus: A Core Curriculum in Geriatric Medicine. 9th ed. america/Communicating%20with%20Older%20Adults
New York: American Geriatrics Society; 2016. %20Low_GSA.pdf; 2017.
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bmi/index.html. piration in rehabilitation patients: videofluoroscopy
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6. Alzheimer’s Association Website. http://www.alz.org/nati 22. American Speech-Language-Hearing Association. Guide-
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7. Niedert KC. Position of the American Dietetic Association: Dysphagia. Rockville, MD: American Speech-Language-
liberalization of the diet prescription improves quality of Hearing Association; 2000.
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2005;105(12):1955–1965. tory strategies in management of swallowing disorders.
8. Baijens LW, Clavé P, Cras P, et al. European Society for Dysphagia. 2017;32:3–10.
Swallowing Disorders – European Union Geriatric Medi- 24. Anderson UT, Beck AM, et al. Systematic review and evi-
cine Society white paper: oropharyngeal dysphagia as a dence based recommendations on texture modified foods
geriatric syndrome. Clin Interv Aging. 2016;11:1403–1428. and thickened fluids for adults (≥18 years) with oro-
9. Bhattacharyya N. The prevalence of dysphagia among pharyngeal dysphagia. e-SPEN J. 2013;8(4):e127–e134.
adults in the United States. Otolaryngol Head Neck Surg. 25. Morley JE, Silver AJ. Nutritional issues in nursing home
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jury, and pneumonia. Dysphagia. 2016;31:434–441.
CHAPTER 11
Diagnosis and Rehabilitation of

Hearing Disorders in the Elderly
CHIEMI TANAKA, PHD • LISA D. TANIGUCHI, AUD • HENRY L. LEW, MD, PHD
INTRODUCTION of hearing loss is sensorineural. High frequencies

According to the National Institute on Deafness and are usually affected most, and then the hearing loss
Other Communication Disorders,1 disabled hear- gradually progresses to the low frequencies. Despite
ing loss was reported by about 8.5% of adults aged the high-frequency hearing loss being a prevalent
55–64 years, increasing to about 25% of the popula- form, some individuals with ARHL can exhibit other
tion in the 65- to 74-year-old range and 50% of those hearing configurations, such as flat hearing loss (all
who are 75 years and older. With increasing longevity, frequencies are affected by the similar degree).12–14
the number of older adults who suffer from hearing Typical complaints of the patient with hearing impair-
impairment is expected to increase tremendously. In ment are summarized in Box 11.1. Patients with ARHL
this chapter, the authors will briefly describe the diag- report the same complaints as younger ones with hear-
nosis and rehabilitation of age-related hearing loss ing loss. However, more difficulty understanding with
(ARHL). Accumulation of research studies indicated speech, especially in noisy environment, is observed
that audiologic management of ARHL is more crucial in older adults with ARHL.
than what we used to think because untreated ARHL The fact that some patients with ARHL may be
could result in negative consequences, such as depres- unaware of the presence of hearing loss is notewor-
sion, anxiety, lethargy, social dissatisfaction, poor social thy. This may be, in part, due to an asymptomatic
interaction,2–7 and, more importantly, dementia.8,9 condition and/or self-denial/indifference of hearing
Besides ARHL, this chapter will briefly cover informa- loss. Some patients, especially Asian older adults with
tion about other ear disorders that may be commonly ARHL, may not seek a medical attention because they
observed in the elderly population (e.g., cerumen accept hearing loss as part of natural aging. In addi-
impaction and ear infection). For those who need basic tion, others may view hearing aids as a stigma of old
audiologic knowledge, please refer to the book chapter age, leading to delay in treating their hearing loss. Basi-
by Lew et al.10␣ cally, the lack of understanding of the impact of hear-
ing loss in general could increase the population of
untreated hearing loss and consequently impair one’s
AGE-RELATED HEARING LOSS quality of life (QOL).
Definition of Age-Related Hearing Loss The impact of hearing loss in older adults has been
ARHL, also known as presbycusis, is an age-related described well in literature: depression, anxiety, leth-
degeneration of the auditory function without any argy, social dissatisfaction/isolation, poor social inter-
effects of other ear diseases. Therefore, ARHL is a diag- action, loss of independence, reduced emotional and
nosis of exclusion and “an umbrella term for mul- social well-being, and cognitive dysfunction. 2–7 Nega-
tiple forms of auditory pathology manifest in aging tive effects, such as social deprivation, on the spouse
individuals.”11␣ and caregivers of individuals with ARHL were also
reported.15–17 Moreover, various studies revealed a
Symptoms and Impact of Age-Related link between hearing impairment in older adults and
Hearing Loss dementia,6 and recent studies found that hearing loss
ARHL exhibits a slow onset and is normally bilateral, is associated with incident all-cause dementia and an
symmetrical, progressive, and permanent because increased risk of developing dementia in the elderly.8,9
aging of the auditory system affects both ears simul- Even more, longitudinal studies reported an associa-
taneously and at a similar rate. Typically, the type tion between hearing loss and cognitive decline.18,19␣
145
alcohol use, renal failure, diabetes, cardiovascular dis-

BOX 11.1
eases, bone mineral density, head trauma, immune
Typical Complaints of the Patient With Hearing
system, diet, hormones, and socioeconomic status.
Impairments
Fig. 11.1 shows the complexity of ARHL.␣
• Difficulty understanding speech in background
noise (e.g., restaurant) Evaluation of Age-Related Hearing Loss
• Difficulty understanding speech in a group setting Clinical evaluation for an elderly patient with hearing
(e.g., meeting) impairment is performed with case history intake, oto-
• Able to hear speech but do not understand what is scopic examination, and audiologic testing. Physicians
said or audiologists take case history and examine the ears,
• Sounds like people are mumbling depending on types of practice, and audiologic testing
• Talk too loud (sensorineural hearing loss) or too soft is almost always performed by audiologists. Diagnosis
(conductive hearing loss) of ARHL is given by the physicians such as an otolar-
• Turn up volume on TV and/or difficulty using a yngologist and otologist who also perform a head and
phone neck examination.
• Difficulty understanding accent and/or unclear
speech Case history
• Difficulty learning foreign language Questioning about hearing loss (onset, ear, severity,
• Tinnitus and/or dizziness progression, previous hearing test results) and other
• Difficulty following a conversation related symptoms, such as otalgia (ear pain), otorrhea
• Family members or friends complain about hearing (ear drainage), tinnitus, vertigo, dizziness, and facial
loss nerve dysfunction, is necessary to rule out other oto-
Some people may have no symptoms at all, if hear- logic disorders. Inquiring about past and present oto-
ing loss progresses slowly overtime. logic disorders, such as ear infections (acute/chronic),
impacted cerumen (accumulation of excessive ear
From Lew HL et al. Auditory, vestibular, and visual impairments. In: wax), Eustachian tube dysfunction, and ear trauma, is
Cifu DX, Kaelin DL, Kowalske KJ, et al., eds. Braddom’s Physical helpful. Information about medical and occupational
Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier; 2016;
with permission.
history, history of noise exposure, prior ear surgery,
ototoxic medication/chemical intake, and a family
history of hearing loss can be used to determine the
Pathology, Etiology, and Contributing contributing factors to ARHL and aid in differential
Factors of Age-Related Hearing Loss diagnosis. Questions about previous experience in
ARHL is known to show the variability in its pathology. amplification and psychosocial impact of hearing loss,
Human temporal bone examination revealed degen- such as activity limitation due to hearing loss, are also
eration and/or damage to different structural elements important to understand the patient’s psychologic
in the auditory pathway, such as hair cells, especially status, feeling about hearing aid use, and any effects
in the basal end of the cochlea, neurons, and cochlear that hearing loss might have caused on individuals.
lateral wall tissues including stria vascularis.12,13 What Information on the patient’s cognitive status is also
makes ARHL complex is that these pathologies can important because hearing loss and cognitive dysfunc-
occur in different elements simultaneously. Genetic tion have similar manifestation sometimes. Warning
susceptibility modified by environmental effects (e.g., signs that physicians should note regarding possible
noise exposure, diseases, and lifestyle) was consid- hearing impairments during hearing evaluation are
ered to be contributing to the observed variability.11 shown in Box 11.2.␣
Recently, the free radical, mitochondrial dysfunction,
and oxidative stress were reported to be in association Otoscopic examination
with ARHL.20 During the otoscopic examination, external and inter-
Exact etiology of ARHL is still under investiga- nal ear structures are inspected to detect the presence of
tion. However, Van Eyken21 proposed that ARHL is a any anomalies with pinna, ear canal, tympanic mem-
complex sensory disorder caused by the interaction brane, ossicular landmarks, and middle ear space. The
of a variety of factors, including genetic and nonge- otoscopic examination is useful to note the evidence
netic factors (environmental and medical) such as of impacted cerumen, ear infection, and structural
noise exposure, exposure to ototoxic agents, smoking, anomaly. For external ear structures, such as pinna, any
CHAPTER 11 Diagnosis and Rehabilitation of Hearing Disorders in the Elderly 147
??? Free radical,

Aging
mitochondrial
dysfunction,
oxidative stress
Genetic factors
Health comorbidities
(renal failure,
Exposure to diabetes,
noise/ototoxic agents cardiovascular
diseases, bone
mineral densities,
Life style head trauma, immune
(diet, smoking, alcohol, system, hormones)
socioeconomic status)
Changes in auditory system

(cellular, molecular, structural)
Degeneration of auditory function
FIG. 11.1 Complexity of age-related hearing loss.
abnormalities (atresia, anotia, microtia), set (position) excessive cerumen) should be checked with an oto-
of the ears, skin tags, nodule (possible carcinoma) or scope because severe blockage can elevate air-conduc-
sinuses, tenderness, redness, signs of drainage, or ceru- tion thresholds, causing a conductive or mixed hearing
men buildup are detected. For internal ear structures, loss. Excessive cerumen needs to be removed before the
the presence of an obstruction, drainage or blood, ste- audiometric testing to ensure accurate results. Health-
nosis, damage, and signs of inflammation in the ear care providers routinely use different techniques such
canal are examined. Normal landmarks (cone of light, as irrigation, suction, cerumen-removal ear drops, and
translucent/pearly gray tympanic membrane, handle of curettage to remove cerumen. In case of severe cerumen
malleus), signs of inflammation (red/bulging), retrac- impaction, the patient needs to be referred to an oto-
tion, perforation, and bubbles behind the tympanic laryngologist to avoid serious side effects of cerumen
membrane are noted during the examination of the removal (e.g., bleeding of the ear canal, damaging the
tympanic membrane. tympanic membrane).
Normal ear examination or age-appropriate changes Besides cerumen impaction, collapsed ear canal is
in the ear structures is expected in the older adults with another popular functional condition in the elderly
ARHL. Normal age-related changes in the outer ear population. This is due to the decreased elasticity in
and tympanic membrane include enlargement of the the cartilaginous portion of the ear canal. It is com-
pinna, loss of elasticity and strength in the ear canal, mon practice to use insert earphones in the older
loss of secretory ability in the sebaceous and cerumen adults for an audiometric testing to avoid pressure
glands in the ear canal, and excessive hair growth along from the headphones that may cause the ear canal
the edge of the helix and at the tragus (mostly seen in to collapse resulting in an inaccurate audiogram.
elderly males). Moreover, owing to less effective immune system
Beyond ARHL, owing to the changes in the glands in the elderly population,23 indicative of ear infec-
in the ear canal, hardening or impaction of cerumen is tions, such as red tympanic membranes and/or ear
commonly observed in the older adults.22 Before audio- canal, bubbles behind the tympanic membrane, may
metric evaluation, a blockage of the ear canal (e.g., be found commonly in the elderly population. The
BOX 11.2 BOX 11.3

Signs That Physicians Should Note Regarding Red Flags: Warnings of Ear Disease
Possible Hearing Impairments
1. Hearing loss with a positive history of ear infec-
• Cannot hear or understand you when you ask them tions, noise exposure, familial hearing loss, TB,
to enter your office for the appointment syphilis, HIV, Meniere’s disease, autoimmune
• Not very talkative disorder, ototoxic medication use, otosclerosis,
von Recklinghausen’s neurofibromatosis, Paget’s
• Does not reply when spoken to
disease of bone, ear or head trauma related to
• Does not respond appropriately to the questions onset.
you are asking
2. A history of pain, active drainage, or bleeding from
• Does not understand you when you speak with an ear.
them on the telephone
3. Sudden onset or rapidly progressive hearing loss.
• Looks closely at your face or lips when you speak
4. Acute, chronic, or recurrent episodes of dizziness.
• May appear confused when giving an inappropriate
5. Evidence of congenital or traumatic deformity of
response
the ear.
• May have a hearing aid but does not use it
6. Visualization of blood, pus, cerumen plug, a foreign
• May strain to understand or place the hand behind body, or other materials in the ear canal.
the ear in an attempt to amplify your voice
7. An unexplained conductive hearing loss or abnor-
• Needs occasional repetition or a louder speaking mal tympanogram.
voice to understand
8. Unilateral or asymmetric hearing loss (a difference
• Needs frequent prompting multiple repetitions or of greater than 15 dB pure-tone average between
restatement of what was said ears) or bilateral hearing loss > 30 dB.
• Not able to understand what is being said; asks you to 9. Unilateral or pulsatile tinnitus.
write the message down to facilitate understanding
10. Unilateral or asymmetrically poor speech discrimi-
• Appears to have difficulty understanding fast nation scores (a difference of greater than 15%
speech and accented speech between ears) or bilateral speech discrimination
scores < 80%.
From Weinstein BE. Primary care physicians and audiologists: part-
ners in care. In: Weinstein BE, ed. Geriatric Audiology. 2nd ed. New The red flags do not include all indications for a
York: Thieme Medical Publishers, Inc.; 2013; with permission. medical referral and are not intended to replace clinical
judgment in determining the need for consultation with
an ENT physician (otolaryngologist).
American Academy of Otolaryngology–Head and
Neck Surgery or Foundation (AAO-HNS/F) provides Reprinted with permission. Copyright © 2017 American Academy of
the position statement regarding the medical refer- Otolaryngology–Head and Neck Surgery. Reproduction or republi-
cation strictly prohibited without prior written permission.
ral recommendation to a specialist for possible ear
diseases (Box 11.3). It is recommended that patients
who show these warning signs be referred to an speech, are determined in air- and bone-conduction
otolaryngologist.␣ pathways, using headphones/insert earphones and
bone conductor, respectively. Occasionally, pure-tone
Standard audiologic evaluation average (PTA) is calculated by simply averaging air-con-
The standard audiologic evaluation is composed of duction hearing thresholds at 500, 1000, and 2000 Hz.
pure-tone (air and bone conduction) and speech The AAO-HNS/F listed unilateral or asymmetrical hear-
audiometry. ing loss as a red flag of ear diseases, if a difference of
greater than 15 dB PTA between ears or bilateral hearing
Pure-tone audiometry. The pure-tone audiometry, loss >30 dB is detected (Box 11.3).
including air- and bone-conduction testing, is conduct- Three types of hearing loss are conductive, senso-
ed to characterize type, degree (severity), and sided- rineural, and mixed. Conductive hearing loss results
ness (unilateral or bilateral) of hearing loss. Clinically, because of obstruction, damage, or infection of the
pure-tone hearing thresholds (lowest decibel hearing outer ear (ear canal) and/or middle ear (tympanic
level [dB HL] at which the patient detects the pure tone membrane, ossicular chain, middle ear space), which
at least 50% of the time) at frequencies from 250 to can be seen as 15 dB or more of air-bone gap in an
8000 Hz, important frequency range to understand audiogram (elevated air-conduction thresholds with
TABLE 11.1 TABLE 11.2

Examples of Drugs Known to Be Associated Examples of Industrial Chemicals and Solvents
With Ototoxicity Known to Be Associated With Ototoxicity
Type/Group Subclass of Drug Examples Type/Group Examples
Chemother- Platinum complex Cisplatin, Chemical Carbon monoxide, cyanide
apeutics carboplatin asphyxiants
Vinca alkaloids Vinblastine,
Metals Lead, mercury, manganese
vincristine,
vinorelbine Organic solvents Styrene, toluene, ethyl benzene,
Difluoromethylornithine Eflornithine xylene, trichloroethylene, n-hexane
Antibiotics Aminoglycosides Gentamicin, Acrylonitrile

kanamycin,
neomycin, This list is not all-inclusive, and ototoxicity depends on various fac-
tors, such as dose (daily/life time), duration of intake, kidney func-
streptomycin,
tion, age, drug interactions, preexisting hearing loss, and genetic
tobramycin, susceptibility.
amikacin, From Campbell KCM, ed. Pharmacology and Ototoxicity for Audi-
netilmicin ologists. 1st ed. New York: Cengage Learning; 2007.
Macrolides Erythromycin,
azithromycin,
clarithromycin thresholds with an air-bone gap of 15 dB or greater.
Others Vancomycin Examples of otologic disorders that can cause a con-
Diuretics Loop diuretics Ethacrynic acid, ductive or mixed hearing loss in the older adults are
furosemide, cerumen impaction, perforation of the tympanic
bumetanide membrane, Eustachian tube dysfunction, ear infec-
tions, and otosclerosis. The patient with unexplained
Nonnarcotic NSAIDs Salicylates (as-
analgesics pirin), ibuprofen conductive hearing loss may need a medical referral
to an otolaryngologist based on the AAO-HNS/F rec-
Antimalarials Quinine, chlo-
ommendation (Box 11.3).
roquine
Severity of hearing impairment is described by a
NSAIDs, nonsteroidal antiinflammatory drugs. degree of hearing loss (mild, moderate, moderately
This list is not all-inclusive, and ototoxicity depends on various fac- severe, severe, profound), and there is no uniform clas-
tors, such as dose (daily/life time), duration of intake, kidney func- sification system. However, hearing threshold of 25 dB
tion, age, drug interactions, preexisting hearing loss, and genetic HL or better is commonly considered normal hearing
susceptibility.
From Campbell KCM, ed. Pharmacology and Ototoxicity for Audi-
in adults, followed by mild (26–40 dB HL), moder-
ologists. 1st ed. New York: Cengage Learning. ate (41–55 dB HL), moderately severe (56–70 dB HL),
severe (71–90 dB HL), and profound (>90 dB HL) hear-
ing losses.24 Fig. 11.2 shows age-related changes in
hearing thresholds in different age-groups. Note that
normal bone-conduction thresholds). On the other elderly males exhibit greater hearing loss than females,
hand, sensorineural hearing loss (SNHL) is charac- and high-frequency hearing is mostly affected, continu-
terized by elevated air- and bone-conduction thresh- ing to progress following aging. Auditory rehabilitation
olds with 10 dB or less of air-bone gap. This type of is considered for a patient with any degree of hearing
hearing loss results because of damage/deterioration impairment based on healthcare professional’s clinical
of the cochlea and/or in the retrocochlear pathway. judgment and the patient’s needs.␣
Almost all patients with ARHL, drug-induced hearing
loss, and noise-induced hearing loss exhibit high- Speech audiometry. Speech audiometry is per-
frequency SNHL. Therefore, it is important to find formed to obtain the speech recognition (reception)
out about a history of ototoxic medication intake threshold (SRT) or speech detection (awareness)
(Tables 11.1 and 11.2) and traumatic noise exposure thresholds (SDTs) using spondee (bisyllabic) words
for differential diagnosis. Lastly, mixed hearing loss and suprathreshold speech recognition. The SRT meas-
is a mixture of conductive hearing loss and SNHL, ures the lowest dB HL at which a patient can correctly
characterized by elevated air- and bone-conduction repeat or identify spondee 50% of the time, while the
Mean threshold by 5-year age-groups—men

0
dB HL (ANSI – 1969) 20
40 Better ear
Age (N)
60 65–69 (224)
70–74 (170)
75–79 (103)
80
80–84 (59)
85–89 (26)
100
.25 .5 1.0 2.0 4.0 8.0
A Frequency (kHz)
Mean threshold by 5-year age-groups—women

0
dB HL (ANSI – 1969)
20
40 Better ear
Age (N)
60 65–69 (279)
70–74 (261)
75–79 (191)
80
80–84 (75)
85–89 (47)
100
.25 .5 1.0 2.0 4.0 8.0
B Frequency (kHz)
FIG. 11.2 Age-related changes in hearing thresholds in different age-groups. (A) Men; and (B) women.
(From Gates et al. Hearing in the elderly: the Framingham cohort, 1983-1985 Part I. Basic audiometric test
results. Ear Hear 11:247-56, 1990; Lew HL et al. Auditory, vestibular, and visual impairments. In: Cifu DX,
Kaelin DL, Kowalske KJ, et al., eds. Braddom’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia:
Elsevier; 2016; with permission.)
SDT assesses the lowest dB HL at which a patient can there is no consensus about the categorization of
correctly detect the presence of speech. The SDT is the speech recognition scores, 90%–100% is typi-
used when the SRT cannot be obtained owing to the cally considered as excellent or within normal limits.
patient’s inability to repeat or identify words. The SRT According to the AAO-HNS/F, a medical referral to an
or SDT is used to cross-check the accuracy of the pure- otolaryngologist is recommended to rule out ear diseas-
tone thresholds and determine the presentation level es if unilateral or asymmetrically poor speech discrimi-
of the speech recognition (discrimination) scores that nation scores (a difference of greater than 15% between
are typically obtained at suprathreshold level (40 dB ears) are observed or bilateral speech discrimination
above the SRT). For speech discrimination, an audi- scores are < 80% (Box 11.3).␣
ologist scores the percentage of words that are correct-
ly repeated or identified from phonetically balanced Immittance audiometry
word lists (25 or 50 words), such as Northwestern Immittance audiometry includes tympanometry and
University Auditory Test No. 6 (NU-6) and the Central acoustic reflexes. Tympanometry assesses the volume
Institute for the Deaf Auditory Test W-22. Although of the ear canal, integrity of the tympanic membrane,
and the middle ear pressure, while the acoustic reflexes

BOX 11.4
examines the presence of retrocochlear and facial nerve
Compensatory Communication Strategies
pathology by using the reflexive contraction of the stape-
dius muscle in the middle ear in response to loud sound. 1. Address the person with hearing loss.
Compared with the acoustic reflexes, tympanometry, in • Get the person’s attention before starting to
most cases, is ordered more often when clinically indi- communicate. His/her brain must be alerted to
cated a condition that cannot be explained solely by age- be ready to focus and listen.
related changes (e.g., presence of a conductive or mixed 2. Have face-to-face communication.
hearing loss and any signs of ear infection mostly detected • The more important high-pitched sounds of speech
by the otoscopic examination, or higher risks indicated are very directional (only propagate well in the
by the case history). It is important for clinicians to keep direction the speaker is facing) and the production
in mind that the elderly population is susceptible to ear of the high-pitched sounds is visible on the mouth.
infection owing to less efficient immune system.␣ • Do not obscure the lips with hands or other
objects.
Other auditory testing and questionnaires • Make certain that light shines directly on the
Other auditory testing such as otoacoustic emissions speaker’s face, not from behind the speaker.
and auditory brain stem response test may be per- 3. Start with the topic.
formed for the purpose of differential diagnosis. For • It is easier for the listener to fill in missed infor-
testing details, please refer to Lew et al.10␣ mation if he/she knows the context.
4. Use a slightly slower rate of speaking.
Management of Age-Related Hearing Loss • It gives more time for the listener’s brain to pro-
Auditory rehabilitation cess and keep up with the flow of information.
Informative counseling is an important part of auditory • Avoid shouting because it will not help.
rehabilitation. The patient should be informed the pro- 5. Use appropriate distance.
cess of ARHL and the absence of any more serious ear • The more important high-pitched sounds are
pathology. Because ARHL is progressive and irrevers- very weak and are not able to travel far from the
ible, it is crucial to explain to the patient the appro- speaker.
priate care of residual hearing and encourage him/her 6. Control noise (unwanted sounds).
to audiologically manage hearing loss to maintain a • Noise will always interfere with communication
high QOL. For example, avoiding excessive noise expo- and many of these unwanted sounds will also be
sure (e.g., usage of ear plugs or protective ear muffs) picked up by a hearing aid.
and maintaining a healthy lifestyle may increase the 7. Spell words out, use gestures, or write down.
chance of conserving residual hearing. Some patients 8. Repeat back or change phrasing if the listener does
with ARHL may be reluctant to try a hearing aid or not understand at first.
hearing assistance (assistive) technology (HAT) owing 9. Speak toward the better ear, if applicable.
to the negative stigma of the usage of a hearing aid or
acceptance of ARHL as a natural course of aging. Sur- From Lew HL et al. Auditory, vestibular, and visual impairments. In:
prisingly, fewer than 30% have ever used hearing aids Cifu DX, Kaelin DL, Kowalske KJ, et al., eds. Braddom’s Physical
Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier; 2016;
among adults aged 70 years and older with hearing with permission.
impairment who could benefit from hearing aids.25
To prevent the patient from experiencing serious con-
sequences of untreated ARHL, such as depression and it is beneficial for healthcare providers and staff mem-
social isolation, a clinician can play a significant role in bers to use these communication strategies to accom-
encouraging him/her to actively seek a way to manage modate an elderly patient’s communication need.
his/her hearing loss by amplification or other means. On top of the informational counseling, there are
Furthermore, compensatory communication strate- two major aspects in the auditory rehabilitation:
gies that refer to behavioral and listening modifications 1. technical, including hearing aids, HAT, and cochlear
need to be discussed with the patient. These strategies implants (CI);
work with or without hearing aid use. Box 11.4 shows 2. perceptual, such as speech and language therapy
common communication strategies that can be used by and auditory training.
both the patient and conversation partner to enhance This chapter will mainly describe the technical
the understanding of conversation. More importantly, aspects of auditory rehabilitation.
Hearing aid. Hearing aids are personally worn elec- hearing aid, has the BTE component, but the tubing of
trical devices that process and amplify the incoming the BTE hearing aid is replaced with a wire attached to
sound based on an individual’s hearing configuration. the receiver that is inserted in the ear canal. The RITE/
Before hearing aid consultation, ear diseases should RIC hearing aids are becoming more popular owing to
be treated medically and surgically if treatments are various advantages (e.g., more features available over the
available. Hearing aids are designed to improve speech custom hearing aids, less occluded feeling in the ear).
understanding of the patient with hearing impairment Some hearing aids are cosmetically appealing than
and the most commonly used noninvasive devices. others in terms of visibility because many people still
The majority of hearing aids dispensed in the United consider a hearing aid as a sign of aging. However,
States are digital hearing aids that use a computer chip the size and cosmetics may not be the first thing to
to process incoming sounds. Generally, the incoming consider during the hearing aid selection for elderly
sound is picked up by a microphone(s) and converted patients with dexterity and vision problems that may
to a digitized signal by an analog-to-digital converter affect device manipulation, such as inserting/remov-
for further processing in the computer chip. Sophisti- ing a hearing aid, changing a battery, and cleaning
cated sound processing algorisms are available, such as the hearing aid. In addition, smaller hearing aids use
feedback management, noise reduction/suppression, smaller batteries, leading to less power and amplifica-
and speech enhancement. Then, the processed sound tion. Therefore, bigger hearing aids with more power
is converted to an analog signal by a digital-to-analog may be suitable for individuals with severe to profound
converter and sent to a final-stage amplifier and re- hearing loss.
ceiver (speaker). Batteries provide power for amplifica- Because most of the patients with ARHL have sym-
tion, and a single battery typically lasts approximately metrical bilateral hearing loss, binaural fitting of
7–10 days, depending on duration of the hearing aid hearing aids is recommended to benefit from spatial
use. hearing unless contraindicated. To maximize the ben-
For patients who suffer from tinnitus, it is well efit of binaural hearing, some digital hearing aids have
known that the hearing aid can help managing tinnitus features to exchange data between the right and left
because amplified background noise delivered by the hearing aid worn by the patient. Besides improvement
hearing aid provides a masking effect for the tinnitus. of audibility, recent studies found that listening effort
However, for patients with severe tinnitus, a combina- can be reduced by the hearing aids.26,27 Other studies
tion device (a hearing aid equipped with a sound gen- reported that hearing aids worn by the older adults can
erator) is used for either sound therapy or traditional reduce the negative effects of hearing loss on both their
tinnitus masking. In the sound therapy, various sounds, spouses/significant others and themselves.28,29 Inter-
such as oceanlike noise, fractal tones, and soothing estingly, a 25-year longitudinal study was published
sounds, are used to promote the distraction of atten- recently to indicate that the hearing aid use attenuates
tion to tinnitus, habituation to tinnitus, and relaxation. accelerated cognitive decline seen in the older adults.30
On the other hand, in the traditional tinnitus mask- Despite the variety of advantages in hearing aid
ing, a band of noise, such as steady white/speech noise usage, not everyone benefits from hearing aids because
that surrounds the pitch of the tinnitus, is used to mask of various factors. Consultation with an audiologist
(cover up) tinnitus. The volume of the sounds for tinni- for careful selection of the hearing aid is a crucial step
tus management can be adjusted by the patient directly for success in hearing aid use. First and foremost, the
on the hearing aid or via remotes/applications (iOS, hearing aids need to be programmed appropriately by
android). an audiologist or a hearing specialist, according to a
Fig. 11.3 shows the different styles of hearing aids. prescriptive formula or a manufacturer’s algorithm to
The behind-the-ear (BTE) hearing aid has a microphone set proper amplification for the individual’s needs and
located behind the pinna, and a custom earmold with a preference. Without this process, benefits of the hear-
tube conducts sound to the ear. A thinner tube and small ing aids cannot be maximized to the point of successful
dome are used for an open-fit mini BTE hearing aid that hearing aid use.␣
works especially for high-frequency hearing loss with
relatively good low-frequency hearing. In-the-ear (ITE), Hearing assistance/assistive technology. HAT ref-
in-the-canal, completely-in-the-canal, and invisible-in- ers to personal devices that assist an individual to com-
the-canal hearing aids are customized to a patient’s ear municate more effectively regardless of hearing loss.
and house all parts inside. The receiver-in-the-ear (RITE) These devices can be used alone or to supplement hear-
hearing aid, also known as receiver-in-the-canal (RIC) ing aids. One of these useful devices that can be coupled
mini BTE
BTE RITE mini RITE
Open Fit
Wire Wire
Tube with earmold Thin tube with dome Receiver with earmold Receiver with dome
ITE ITE
ITC CIC IIC
Full Shell Half Shell
FIG. 11.3 Types of hearing aids. BTE, behind-the-ear style; CIC, completely-in-the-canal style; IIC,
invisible-in-the-canal style; ITC, in-the-canal style; ITE, in-the-ear style; RITE, receiver-in-the-ear style (also
known as RIC, receiver-in-the-canal). (With permission by Oticon, Inc., Somerset, NJ.)
with a hearing aid is a personal FM system that trans- The speaker talks to the microphone directly and the
mits a speaker’s voice directly to an individual’s ear. A speech is directly delivered to the listener’s ear through
listener wears an FM receiver that can be coupled direct- the headset. The portable personal amplifier can be a
ly to the listener’s ear via hearing aids and other means great help in a physician’s office to assist communica-
(e.g., earphones, ear buds, induction loop, or CI) and tion with a patient with ARHL.
the speaker wears a microphone and FM transmitter.31 Because the hearing aid technology is advancing in
Wireless FM signal carries speech information between full speed, it is noteworthy to discuss Bluetooth tech-
the speaker and listener to avoid significant interference nology here. To help a patient with hearing loss hear
from environmental sounds. more clearly on his/her iOS devices, such iPhone, iPad,
Besides the FM system, a portable personal ampli- or iPod touch, “Made for iPhone hearing aids” (see
fier may be a simple HAT to be used for non–hearing https://support.apple.com/en-us/HT201466 for com-
aid users. The device is composed of a wireless or hard- patible hearing aid devices) can be paired with the
wired amplifier device, a microphone, and a headset. patient’s iOS devices via Bluetooth technology. The
advantage of this pairing is that the patient can hear US market). The CI is a FDA-regulated surgically im-
the speaker’s voice or sound through his/her hearing planted device that is designed to electrically stimulate
aid that is already adjusted and customized to his/ the auditory nerve via electrodes inserted into the scala
her hearing loss. Moreover, the volume of the paired tympani of the cochlea. A patient with ARHL is thought
hearing aids can be controlled by the iPhone. Patients to be a good CI candidate because direct stimulation of
with non-iOS device, such as Android phones, can still the auditory nerve by the CI bypasses the cochlear hair
have access to Bluetooth technology by wearing a dis- cells that are found to be pathologic in those patients.
crete Bluetooth transmitter around their neck. Such Benefits of the CI range from full communication func-
devices can also be clipped to a patient’s shirt or even tion to only the detection of environmental sounds,
hidden under a thin article of clothing. The Bluetooth depending on individuals. The patient with ARHL can
transmitter is paired to a patient’s cell phone that sup- benefit from the CI, but extra caution needs to be taken
ports Bluetooth and also paired to the patient’s hearing for those with chronic health conditions owing to sur-
aids. As the patient receives the call, he/she can answer gical risks.
the call by pushing a button on the transmitter and The CI is consisted of external portions (ear-level/
the conversation is streamed to his/her hearing aid/s body-worn speech processor with a microphone and
directly, allowing for hands-free conversations. transmitting coil) and internal ones (receiver/simulator
The manufacturer-specific Bluetooth transmit- and electrode array). The external speech processor pro-
ter can also connect a patient’s hearing aid and other cesses acoustic sound that was picked up by the micro-
devices, such as a television and remote microphone, phone. The transmitter and receiver/simulator receive
to accommodate patients’ communication needs. The processed signals from the speech processor and con-
television device can be paired to the transmitter and vert them into electric pulses that are sent to electrode
stream sound from the patient’s television directly to array in the cochlea for electrical stimulation of differ-
his/her hearing aid. This will allow for the patient to ent regions of the auditory nerve. After the surgery, the
listen TV sounds at an increased volume level through CI speech processor is programmed by an audiologist
the hearing aids, while family members can listen to based on objective and subjective measurements. New
the television at a regular volume that is not disruptive. CI users are required to learn speech through auditory
A remote microphone accessory could also be useful in training because electric hearing by the CI is different
noisy environments, such as inside a car, classrooms, from the natural sound perceived by the ears.
meetings, places of worship, or any place where noise In addition to the traditional CIs mentioned earlier,
or distance can interfere with communication, because the FDA approved a new type of the CI, called Cochlear
it reduces the speaker-to-listener distance. The micro- Nucleus Hybrid Implant System (Cochlear Ltd.) and
phone is paired to the transmitter and clipped on EAS (electric acoustic stimulation) Hearing Implant
or placed in front of the speaker. The speaker’s voice System (MED-EL Corp.). This new type of the CI is suit-
would then stream directly to the patient’s hearing aid able for an individual with residual hearing in low fre-
to enhance communications. quencies, sloping to severe to profound SNHL in high
Lastly, in patients with a severe or profound ARHL, frequencies. Amazingly, this new technology combines
nonauditory alerting devices may be useful to promote the CI with the hearing aid to provide amplification in
their safety and independence. These devices convert low frequencies through the hearing aid component
auditory signals to nonauditory ones, such as light and electrically stimulate high-frequency regions of the
or vibration. For example, sounds from alarm clock, cochlea via the shorter CI electrode arrays in the same
microwave oven, doorbell, or even smoke detector can ear. For more information, visit manufacturer’s websites.␣
be converted to either vibration or flash/strobe light
that are noticeable by these patients.␣ Middle ear implantable hearing aids. The middle
ear implantable hearing aids are mainly used for indi-
Surgical and medical treatment viduals with SNHL who received limited benefits from
Cochlear implant. Basically, the CI is a choice for a conventional hearing aid use but do not have enough
patient with severe to profound SNHL who received hearing loss to warrant the CI. Basically, the implanted
limited benefits from hearing aid use, as well as with portion is attached to one of the ossicles in the middle
sufficient anatomical structures to support CI func- ear and drives the ossicles directly to deliver sound to
tion. To receive the CI, the patient needs to pass the CI the cochlea. Currently, Vibrant Soundbridge (MED-EL
candidacy criteria that are set by each CI manufacturer Corp.), Esteem middle ear implants (Envoy Medical),
(Cochlear Ltd., MED-EL, and Advanced Bionics in the Maxum hearing implant (Ototronix LLC), and Carina
middle-ear implant (Cochlear Ltd.) are in the US mar- from social events, especially with elevated background
ket. For further details, please refer to manufacturers’ noise, to avoid people he could not understand.
websites or a review article.32␣ Mr. S.P. reported bilateral hearing loss in the high
frequencies and indicated that both parents had grad-
Regeneration of the cochlear hair cell and audi- ual hearing loss. No history of tinnitus, dizziness, noise
tory nerve. The cochlear hair cells (mechanoreceptors exposure, or other significant medical history was
in the auditory system) play an important role in sound reported.␣
perception. The human temporal bone studies in a pa-
tient with ARHL revealed missing and damaged hair Evaluation
cells, especially in the basal turn of the cochlea, contrib- A head and neck examination was unremarkable. Oto-
uting to high-frequency hearing loss.12,13 It is known scopic examination was also unremarkable in both
that mammalian cells in many organs are constantly ears. Fig. 11.4 illustrates Mr. S.P.’s audiologic testing
replenished or regenerated following injury, but no results. Pure-tone audiometry revealed a mild to severe
mammalian hair cell replacement or cell proliferation SNHL in both ears (see Pure-tone audiometry section
was observed. Researchers found that hair cells in other for the definition of SNHL). His SRTs were in good
vertebrates, such as avian, regenerate,33 and ongoing agreement with his PTAs, bilaterally. His word recogni-
human hair cell regeneration research is taking place tion scores using NU-6 were 88% in the right ear and
in animal studies, facing progress and challenges.34 On 84% in the left ear. Tympanograms indicated normal
the contrary, the auditory nerve is known to degenerate tympanic membrane mobility and middle ear function
after hair cell death. Research studies in preservation in both ears. Acoustic reflex thresholds were elevated or
and regeneration of auditory nerve, as well as hair cell absent in the higher frequencies, consistent with audio-
regeneration, are advancing forward. Following trans- logic results.␣
lational and large-scale clinical trials, regeneration of
the cochlear hair cell and auditory nerve may become a Management
medical treatment option in the future.35␣ His physician diagnosed Mr. S.P. with ARHL owing to
no indication of serious otologic disorders based on
Prevention of Age-Related Hearing Loss the evaluation. Informative counseling was provided to
The prevention of ARHL is not possible at this point explain his hearing status and management of his hear-
because the exact etiology of ARHL is unknown. How- ing loss. Based on the audiologic evaluation, hearing
ever, minimizing the contributing factors of ARHL that aids were recommended for Mr. S.P. After hearing aid
were discussed previously in this chapter is thought consultation with his audiologist, Mr. S.P. decided on
to reduce a risk of developing ARHL. New prevention binaural amplification with smartphone compatibility
strategy is on the way, using pharmacologic agents to satisfy his communication needs. The RIC-style hear-
such as antioxidants. Although pharmacologic pro- ing aids were selected owing to hearing configuration
tection of ARHL seems promising, large-scale clini- (relatively good hearing in low frequencies with high-
cal trials are still needed for these agents to be used frequency hearing loss), comfort, and cosmetics.
clinically.20␣ Hearing aids were fit to target and confirmed with
real-ear measurement. Devices were paired to his
Android phone and iPod. Hearing aid use and care were
CASE STUDY reviewed with him. At initial fitting appointment, Mr.
The following two case studies illustrate successful S.P. was counseled on communication strategies, need
management of ARHL. for consistent use, and realistic expectations with hear-
ing aid use. During his follow-up appointment, Mr. S.P.
Case Study: Age-Related Hearing Loss reported that overall he is doing well with music and
Background one-on-one communication; however, he still noted
Mr. S.P. is a 70-year-old recently retired male who slight difficulty understanding speech in background
reported a history of gradual hearing loss over several noise. Directional microphone program was added,
years. He and his wife moved to a new state after retire- and he was reminded of the phone application use
ment, and he started to notice communication dif- where he could control the directionality beam. Dur-
ficulties in new social situations. In particular, he was ing the second follow-up, Mr. S.P. reported satisfaction
mishearing names and street names, which caused frus- with the last adjustments and noted improvement in
tration and embarrassment. He admitted to withdrawing social situations. Mr. S.P.’s wife also reported that she is
Frequency in Hertz
250 500 1000 2000 4000 8000
-10 Key Right Left

0
10 Air
conduction
20
unmasked
30
Hearing level in dB
Masked air
40 conduction
50 Bone
60 conduction
70 unmasked
Masked
80
bone
90 conduction
100
No
110 response
120
PTA WRS % Level Test

SRT
correct material
Right 36 35 88% 75 dB HL NU-6
Left 35 35 84% 75 dB HL NU-6
FIG. 11.4 Audiologic testing results for case study: age-related hearing loss. PTA, pure-tone average;
SRT, speech recognition (reception) threshold; WRS, word recognition (speech discrimination) score.
not repeating herself as frequently and is less frustrated Evaluation

with Mr. S.P. during communication. He is no longer A head and neck examination was unremarkable. Oto-
embarrassed but proud to show his technology to his scopic examination was also unremarkable in both ears.
new friends. It was recommended that Mr. S.P. return Fig. 11.5 illustrates Ms. R.M.’s audiologic testing results.
to the clinic for audiologic evaluation, if any changes in The pure-tone audiometry revealed a mild to moder-
his hearing are noted.␣ ately severe SNHL in the left ear and moderate to severe
SNHL in the right ear. Her SRTs were in good agreement
Case Study: Age-Related Hearing Loss With with her PTAs, bilaterally. Word recognition scores were
Severe Tinnitus 76% in the right ear, 84% in the left ear, and 88% bin-
Background aurally. Tympanograms indicated normal tympanic
Ms. R.M. is an 82-year-old female with long-standing membrane mobility and middle ear function, bilater-
history of hearing loss and tinnitus. She had tried ampli- ally. Acoustic reflex thresholds were elevated or absent,
fication several years ago with no success. She admit- bilaterally, consistent with her audiometric results.␣
ted that she was wearing the devices inconsistently.
Ms. R.M. visited the clinic to seek amplification and Management
management of her tinnitus (constant bilateral high- Her physician diagnosed Ms. R.M. with ARHL owing to
pitched ringing, louder in the right ear). She explained no indication of other serious otologic disorders based on
that her hearing loss and tinnitus are seriously affecting the evaluation. Informative counseling was provided to
her daily activities and causing frustration and stress. explain her hearing status and management of her hear-
Ms. R.M. reported a history of asymmetrical hearing ing loss and tinnitus. Based on the audiologic evaluation,
loss with negative MRI results. No history of dizziness, hearing aids were recommended for Ms. R.M. After hear-
noise exposure, or other significant medical history was ing aid consultation with her audiologist, she decided
reported.␣ on binaural amplification with Bluetooth transmitter to
Frequency in Hertz
250 500 1000 2000 4000 8000
-10 Key Right Left

0
Air
10
conduction
20 unmasked
Hearing level in dB
30 Masked air
40 conduction
50 Bone
60 conduction
unmasked
70
Masked
80 bone
90 conduction
100 No
110 response
120
WRS % Test
PTA SRT Level
correct material
Right 48 45 76% 85 dB HL NU-6
Left 36 35 84% 75 dB HL NU-6
Binaural 88% 80/70 dB HL NU-6
FIG. 11.5 Audiologic testing results for case study: age-related hearing loss with severe tinnitus. PTA,
pure-tone average; SRT, speech recognition (reception) threshold; WRS, word recognition (speech discrimi-
nation) score.
stream sounds from her television and cell phones. ITE use sound generator. At the second follow-up, Ms. R.M.
half shell style with larger battery size was chosen to com- reported great control of tinnitus as well as her hearing
pensate her hearing loss and dexterity concerns. loss and satisfaction with her combination devices.␣
Hearing aids were fit to target and confirmed with
real-ear measurement. Hearing aids were paired to TV
accessory and cell phone via Bluetooth transmitter. CONCLUDING STATEMENT
Hearing aid use and care were reviewed with her. At her This chapter described diagnosis and rehabilitation of
initial fitting appointment, Ms. R.M. was counseled on ARHL. With increasing longevity, the number of older
communication strategies, need for consistent use, and adults who suffer from hearing impairment is growing. To
realistic expectations with hearing aid use. During her maintain a high QOL, audiologic management of ARHL
follow-up appointment, Ms. R.M. reported improve- is crucial for the prevention of negative consequences
ment in communication and better management of on individuals with ARHL and their spouse/caregiv-
tinnitus in background noise. However, tinnitus was ers. Although specialists, such as otolaryngologists and
still bothersome when she was in quiet situations, such audiologists, are working on detecting and rehabilitating
as at home by herself. Because her hearing aids were patients with ARHL, it is very important for other health-
combination devices with amplification and sound care providers to detect hearing impairment earlier by
generator, sound therapy was added to control her tin- conducting hearing screening. Performing simple audio-
nitus. The audiologist helped Ms. R.M. to select the metric screening by using a portable audiometer and
most effective sound to manage her tinnitus. She was screening questionnaires, such as the Hearing Handicap
shown how to change the volume of the sound and Inventory for the Elderly—Screening version,36 at the phy-
asked to adjust the level as needed. Ms. R.M. was exten- sician’s office is beneficial for the older adults to promote
sively counseled on tinnitus management and when to earlier audiologic management of hearing loss.
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CHAPTER 12
Rehabilitation in Musculoskeletal and

Sports Injuries in Older Adults
WILLIAM MICHEO, MD • LUIS A. SÁNCHEZ, MD
INTRODUCTION of performance in sports practice and competition.

Individuals aged 65 years and older make up 13% of They also expect good quality sports medical care once
the US population according to the US Census in 2010. they are injured, which will allow them to return to
This trend is expected to continue, and this population the competition.10 Many sports, including tennis, golf,
will double to 72 million over the next 25 years, with swimming, long-distance running, and track and field,
20% of the total population by the year 2030 being have age-based individual and team competitions for
considered old.1,2 athletes starting by age 25 years in swimming, above
Advancing age leads to physiologic changes that age 50 years in golf, and extending to categories for
result in loss of functional capacity, change in body individuals in their 80s in tennis.11–13 Participation in
composition, decrease in physical activity volume, masters sports competition carries risk of injury, with
intensity, and risk of chronic disease.3 Sedentary behav- 50%–60% or more of athletes suffering an injury,
ior also increases with age, making older adults the which requires stopping training and competition for
most sedentary population, with 65%–80% of their at least 1 week.7,14
waking time spent sitting.4 Sedentary behavior has neg- The goal of management of sports injury in the
ative effects on cardiometabolic health, muscle-tendon older athlete is to safely return the individual to normal
health, functional fitness, physical independence, body form and function. The injured athlete should have no
composition, and all-cause mortality. Conversely, phys- symptoms at rest and with activity, achieve normal flex-
ical activity and exercise have been well established as ibility, strength, muscle balance, and neuromuscular
strategies to reduce the risk of chronic disease, increase coordination and exhibit psychologic readiness before
life expectancy, and improve functional capacity and returning to participation in sports.
cognitive function as well as a medical intervention to The process of rehabilitation should start as early as
counteract the detrimental effects of aging.2,5 possible after the injury to minimize functional losses
Organized sports participation plays an important associated with acute or chronic recurrent injury. Evalu-
role in promoting exercise activity in older adults. ation, management, and rehabilitation of sports injury
Common sports practiced by masters athletes such as require an accurate diagnosis and specific treatment
swimming and racquet sports have proven beneficial addressing not only the area of injury but also the com-
for improving all-cause mortality and cardiovascular plete kinetic chain.
risks, whereas swimming has shown reduction in all- The purpose of this chapter is to review basic con-
cause mortality.6 In addition, higher quality of life, cepts of sports injury in the older athlete and how they
reduced smoking, and getting regular medical evalua- relate to planning and implementation of a rehabili-
tions have been reported for masters athletes.7 Playing tation program, describe the phases of rehabilitation,
team sports contributes more to the person’s motiva- present return to play criteria, and the components of
tion compared with individual exercise activity in older an injury prevention program.␣
adults. These benefits may be associated to the social
interactions during team sports activity.8
The masters athlete is commonly defined as an indi- BASIC CONCEPTS OF SPORTS INJURY IN
vidual older than 35 years, who either trains or partici- THE OLDER ADULT
pates in sports competitions specifically designed for Epidemiology of Sports Injury
older athletes.9 The American College of Sports Medi- Understanding the incidence and prevalence of inju-
cine defines the masters athlete as those aged 50 years ries based on variables, such as type and nature of
or older who desire to exercise and expect high levels the injury, age group, type of sports, sex, and time
161
since the onset of symptoms, among others, has con-

TABLE 12.1
tributed to the development of programs aimed at
Risk Factors for Injury in Older Adults
prevention, treatment, and rehabilitation of sports
injuries.15 Athletic injuries occur from acute or Intrinsic Factors Extrinsic Factors
chronic overload on the muscles, nerves, tendons, • Agea • Sport-specific demands
bones, or joints. The shoulder, knee, back, and • Gendera • Volume of activity
ankle are common sites of injury in older athletes, • BMI • Playing surface
and frequent diagnoses include rotator cuff inju- • Previous injurya • Training and competi-
ries, Achilles tendinopathies, meniscal tears, and • Anatomic misalignmenta tion equipment
osteoarthritis.9 • Muscle fatigue and
weakness
The location and type of injuries seen in athletes
• Inadequate flexibility
is influenced by the particular sport involved. Adult
aNonmodifiable.
recreational tennis players have been reported to suf-
fer three injuries per 1000 h of play, overuse injuries,
which affect the upper extremities, and acute injuries, Intrinsic factors can be modifiable (poor flexibility,
which affect the lower extremities. Increasing skill level muscle weakness, body mass index) or nonmodifi-
may increase injury risk, specifically of acute injuries. able (sex, height, ligamentous laxity, previous injury,
Common anatomic sites of injury included the elbow, and anatomic malalignment). Extrinsic factors that
shoulder, knee, and back.16,17 are modifiable include training and competition load,
Amateur golfers most frequently report injuries to playing surface, and sports equipment (Table 12.1).
the lower back and elbow. Lateral epicondyle injuries In tennis players, intrinsic risk factors, such as scapu-
are more common than medial epicondyle injuries in lar dyskinesis, glenohumeral internal rotation deficits
amateur athletes, whereas professional players exhibit (GIRDs), and weakness of the external rotators of the
similar frequency of both injuries. The nondominant shoulder are associated to rotator cuff impingement in
shoulder is commonly injured in the golf swing, as the the subacromial space.17 Golfers with abnormal swing
shoulder is positioned in internal rotation, flexion, and mechanics and poor conditioning present with low
horizontal adduction.18 back and upper extremity injuries.18 Training errors have
Masters runners have a reported injury rate of 46%, been reported to account for 60% of running injuries.
are injured more frequently than younger runners, and Excessive running distance, high training intensity, and
suffer multiple injuries. The knee and foot are the most rapid increases in running distance or intensity signifi-
common location of injury in these athletes, with a cantly increase the rate of injury.23 Masters athletes that
high prevalence of soft tissue injuries to the calf, Achil- participate in sports with high torsional loads, such as
les tendon, and hamstring muscles.19 The incidence of tennis and basketball, those that have suffered a prior
osteoarthritis in runners is not clear, but it has been joint injury, and those that have high body mass index
reported to be associated with high volume of activity are at a higher risk of osteoarthritis of the knee and hip.24␣
and elite level of competition.20␣
Classification of Injury
Identification of Risk Factors A sports injury can be defined as a pathologic process
The incidence of athletic injury can be affected by phys- that interrupts training or competition and may lead
iologic, biomechanical, anatomic, or genetic intrinsic the athlete to seek medical treatment. Sports injuries
factors, which may include muscle weakness and imbal- are usually divided into two basic types: those resulting
ance, inflexibility, age, gender, prior injury, and kinetic from macrotrauma and those associated with overuse
chain abnormalities. Extrinsic risk factors for injury and repetitive microtrauma. In traumatic injuries, there
include the inherent demands of the sport, intensity of is a clear inciting event that results in damage to previ-
training and competition, environmental conditions, ous normal tissue. Microtraumatic overuse injury occurs
and equipment.21 Psychologic factors have also been when repetitive exposure to sports activity results in a
found to influence injury risk through attentional and failure of normal homeostasis and an inability of tissue
somatic changes, muscle fatigue, and reduced coor- to recover from sports-related trauma. Acute injury can
dination. These include psychologic stressors such as be defined as one that occurred within 2 weeks of evalu-
negative life events, sports-related stress, personality ation, subacute injury is associated with symptoms of
variables such as trait anxiety, and maladaptive coping 2–6 weeks duration, and chronic injury has symptoms
strategies.22 that persist after 6 weeks.25,26
CHAPTER 12 Rehabilitation in Musculoskeletal and Sports Injuries in Older Adults 163
Injury definitions for use in epidemiologic studies

TABLE 12.2
have been standardized in different sports. A definition
Musculoskeletal Injuries Complex
of a recordable injury in athletics is a physical com-
plaint or observable damage to body tissue produced Clinical symptoms Pain
by the transfer of energy experienced or sustained by Instability
Swelling
the athlete during participation in training or compe-
tition, regardless of whether it received medical atten- Anatomic alterations Tissue injury
tion or its consequences with respect to impairments Tissue overload
in connection with competition or training. Sever- Functional alterations Biomechanical deficits
ity of injury can be related to the time lost from full Subclinical adaptations
participation in sports. It can be classified into slight
(1 day), minimal (2–3 days), mild (4–7 days), mod- From Kibler WB. A framework for sports medicine. Phys Med
Rehabil Clin North Am. 1994;5(1):1–8; with permission.
erate (8–28 days), serious (>28 days–6 months), and
long-term (>6 months) injury severity.27
Using the International Classification of Functioning, Complete diagnosis of athletic injury can be
Disability and Health, Timpka defined athletic injury as established using a modification of the musculoskel-
a sports impairment associated with pain and functional etal injury complex model described by Kibler.26 This
limitations and participation restriction with inability to model identifies the anatomic site of injuries, the clini-
compete as a result of acute trauma or chronic overuse cal symptoms, and the functional deficits (Table 12.2).
injury. If not managed appropriately within the health The clinical symptoms complex addresses the main
system, the athlete may present with chronic recurrent complaints of the injured athlete. Symptoms such as
symptoms, residual sports impairment, participation pain, swelling, feeling unstable, numbness, weakness,
restriction, and finally sports-related disability.28␣ or change in performance should be identified to be
appropriately treated. The anatomic alterations com-
Patient Evaluation plex identifies the site of the primary injury causing the
The history and physical examination are very impor- patient’s symptoms and the associated areas of tissue
tant in evaluating an injured athlete. Pertinent infor- overload. The functional alterations complex addresses
mation that should be obtained in the history includes the biomechanical deficits that result from an athletic
the type of sport, the mechanism of injury, the sever- injury, the adaptations used by the athletes to try to
ity of the injury, and prior treatment. In addition, continue to participate in sports, and the changes in
information regarding previous history of similar or sports and exercise performance.␣
related injury, associated medical problems, and use of
medications should be obtained.10 Psychologic issues Phases of Sports Rehabilitation
that should be investigated include history of anxiety, Rehabilitation of sports injury can be divided into
depression, and feeling vulnerable to injury.21 acute, recovery, and functional phases. Each phase has
The physical examination should identify postural specific goals and criteria for progression and can be
asymmetry, anatomic malalignment, lack of flexibility, correlated with the inflammatory, repair, and remodel-
muscle weakness and imbalance, neurologic as well ing stages of tissue injury29 (Table 12.3). Rehabilitation
as proprioceptive deficits, and ligamentous laxity. It is combines physical modalities, therapeutic exercise,
also important to evaluate core trunk and pelvic muscle assistive devices, and functional sports-specific train-
strength, neuromuscular control, and sports-specific ing. Its principal goal is to restore optimal function and
techniques. should begin immediately after the injury or surgery to
The treating physician also has the responsibility of minimize the deleterious effects of inactivity and facili-
ordering and interpreting the appropriate diagnostic tate the return to training and competition.30
studies to complement the history and physical exami- During the acute phase of treatment, the primary
nation and aid in treatment planning. These include focus is to decrease pain and swelling, protect the
laboratory tests, X-rays, musculoskeletal ultrasound, injured structures, and allow the tissue to heal. In this
bone scan, computerized tomography, and magnetic phase, treatment strategies include the use of analge-
resonance imaging. In the older athlete, it is important sics, nonsteroidal antiinflammatory drugs (NSAIDs)
to understand that abnormalities in diagnostic studies for a short period of time, and physical modalities, such
may be present, associated to the aging process, and not as cryotherapy and electrical stimulation, which limit
necessarily the cause of the patient’s symptoms. secondary tissue damage, reduce muscle inhibition,
that result from injury to the ankle, knee, shoulder, and

TABLE 12.3
spine is also a component of rehabilitation.32,33 Pro-
Rehabilitation of Sports Injury
gression of functional training without recurrence of
Phases Goals symptoms is required prior to advancing to the next
Acute Treat symptom complex phase of rehabilitation.
Protect anatomic injury site Finally, the functional phase aims to increase power
Recovery Correct biomechanical deficits and endurance, improve neuromuscular control in
Improve muscle control and balance functional activities, and prepare the athlete to return
Retrain proprioception to sports-specific training and competition. This phase
Start sports-specific activity emphasizes work on the entire kinetic chain and
Functional Increase power and endurance addresses residual biomechanical deficits and abnor-
Improve neuromuscular control mal adaptations in sports technique. Most of the train-
Work on entire kinematic chain ing during this phase takes place in the gym or sports
Return to competition venues and may include sports-specific drills, such as
kicking, jumping, running, or throwing. The resolution
of functional deficits or breaks in the kinetic chain is
and allow the initiation of therapeutic exercise. Iso- required prior to allowing the athlete to return to unre-
metric strengthening exercises can be started during stricted participation in sports.34␣
this phase. This static muscular training helps preserve
muscle mass and strength, usually is well tolerated, and
should be performed at multiple joint angles. Addi- REHABILITATION OF INJURIES COMMON
tionally, pain-free range of motions exercises can be IN THE OLDER ATHLETE
implemented actively or with assistance, with no load Rotator Cuff Injury
or minimal external load. Aerobic exercise, flexibility, Rotator cuff injury is one of the most common pathol-
strengthening, and balance training of uninjured com- ogies seen in older athletes, particularly in those who
ponents of the kinetic chain can be started in this stage perform overhead activities such as tennis. This lesion
of rehabilitation. In addition, the use of orthotic equip- can range from tendinopathy to tears that could be par-
ment may be required to protect the injured part.30,31 tial or full-thickness. It is described that aging has been
Control of pain, swelling, and tolerance of therapeutic associated with an increase in rotator cuff tears, but not
exercise are required prior to progressing to the next all are symptomatic.35 Symptomatic rotator cuff disease
stage of treatment. can be secondary to biomechanical deficits that include
The recovery phase aims to achieve full range of tight posterior shoulder structures and pectoral mus-
pain-free motion, improve flexibility, and regain nor- cles, GIRD, weak rotator cuff and scapular stabilizers,
mal muscle strength and balance. If pain persists with and weak and tight pelvic girdle muscles.36,37 A tennis
activity, analgesic medications and physical modali- player who suffers a rotator cuff injury will also show a
ties, such as superficial heat (i.e., hydrocollator packs, performance decline, such as difficulty with serve, over-
paraffin), deep heat (i.e., ultrasound), and electrical head, and backswing.16
stimulation can be utilized. These interventions help to The rehabilitation program should focus on com-
reduce edema, increase circulation to the healing tis- bining stretching and strengthening exercises, with
sues, and improve collagen flexibility. Biomechanical the aim of restoring shoulder range of motion, reduce
and functional deficits are addressed during this phase. pain, maintain stability, improve function, and prevent
Static flexibility exercises with emphasis on muscles further injury. In the acute phase, treatment strategies
that cross two joints and dynamic flexibility training include physical modalities (i.e., cryotherapy, electrical
that works on sagittal, frontal, and transverse planes of stimulation) to decrease pain and inflammation, with
motion should be integrated into the treatment pro- subsequent addition of isometric and closed chain
gram. Dynamic strengthening using open chain exer- exercises to the rotator cuff and scapular stabilizers
cises that isolate weak muscles and train both eccentric muscles. These should be performed within a nonpain-
and concentric muscle activities and closed kinetic ful range of motion, with the goal of preventing muscle
chain exercises that involve multiple joints and muscle atrophy. Additionally, strengthening of the trunk and
co-contraction in functional range of motion are key lower extremities should be started. Biomechanical
components in this phase. Neuromuscular training abnormalities, such as scapular dysfunction, can be
that addresses proprioceptive and muscle firing deficits addressed during this phase.38–40
During the recovery phase, biomechanical and func- The recovery phase program consists of pain-free
tional deficits, such as GIRD and throwing motion range of motion exercises and stretching of hip flexors,
abnormalities can be addressed. Treatment strategies iliotibial band, quadriceps, and hamstrings. Strength-
during this phase consist of heat modalities, shoulder ening is emphasized on quadriceps, hamstrings, and
joint mobilization, posterior capsule stretching, and pelvic girdle muscles, using open and closed chain
strengthening exercises. Goals are directed to achieve exercises.41–44 It has been described that a reduction
a normal passive and active glenohumeral range of in cartilage damage is seen in those who have greater
motion, scapular muscle control, and recover normal quadriceps strength. In addition, patients who perform
muscle strength and balance. The range of motion and strengthening exercises show improvement in balance,
stretching program should include internal/external proprioception, reduced pain intensity, and improved
rotation with a stick, cross-arm, and sleeper stretches patient functionality.9,41–44 Athletes can combine
to address flexibility deficits of the pectoralis, rotator stretching and strengthening exercises with cross-train-
cuff, and scapular stabilizer muscles.38–40 An adequate ing strategies. Aerobic and neuromuscular training is
strengthening program includes closed kinetic chain recommended for the older athletes for relieving joint
exercises for the rotator cuff and scapular stabilizers, loading and improving function.41–44
such as pushups against a wall. Additionally, strength- There are other alternatives for the management of
ening of the rotator cuff muscles and scapular stabiliz- patients with Knee OA. Among them are cycling, aqua-
ers can be performed in an open kinetic manner using therapy, and Tai Chi. Aquatherapy provides benefits
light weights or surgical tubing progressing to func- in the functional status and patient’s quality of life,
tional ranges of motion. although the results regarding improvement of pain
In the functional phase, the entire kinetic chain symptoms are controversial.24
must be worked and sports-specific training should be Furthermore, weight loss and mechanical interven-
started, including squats, lunges, and rotational exer- tions, such as knee bracing and insoles (i.e., lateral
cises to improve core, pelvic girdle, and lower extremity wedge) may be considered with the goal of decreas-
muscles’ neuromuscular control and strength. Normal ing knee joint loading. There is some evidence that an
motion, flexibility, strength, and symptom-free partici- unloader brace provides stability to the knee, decreases
pation in sports practice should be achieved prior to medial compartment loading, and improves functional
returning to play.38–40␣ levels in the runner.24
Older athletes who present with severe degenerative
Knee Osteoarthritis joint disease could be candidates for knee joint arthro-
Osteoarthritis is a multifactorial disease, affected by plasty. Joint replacement is a cost-effective treatment
activity, exercise, sports, and previous injury. OA in the option, which has been shown to improve pain, mobil-
lower extremities is associated to activities that increase ity, function, psychologic well-being, and most impor-
joint loading, such as high-impact sports, particularly tantly, quality of life. Undergoing a joint replacement
in older athletes. Knee osteoarthritis is commonly does not necessary means having to stop masters ath-
reported and is the result of biomechanical changes, letic participation, but activity modification is required
muscle weakness, increased joint loading, alteration to prevent hardware loosening, fracture, and reduced
in the gait pattern, and an increase in knee adduction prosthetic survival. These athletes should avoid high-
moment.9 Development of OA is associated to previ- impact activity such as running, but swimming, golf,
ous injuries and recurring microtrauma, and not neces- and cycling are recommended.9,45 Return to activity
sarily to an increase in physical activity.9 should be performed after restoration of the muscle
A comprehensive approach needs to be imple- strength of the quadriceps, hamstring, and pelvic gir-
mented during rehabilitation, and exercise is an essen- dle. There should be a balance between too little activ-
tial component of knee OA management. ity (due to a predisposition to decreased bone mineral
In the acute phase, the treatment should focus on density) and too much activity (due to increase wear
decreasing pain and swelling with NSAIDs, cryother- and loosening). Usually, learning a new sport is associ-
apy, electrical stimulation, and relative rest. In some ated with high joint loads, thus it is not recommended
instances, athletes present with knee effusions and a that athletes start participation in new high-impact
knee joint aspiration could be considered to improve sports after the surgical procedure. In addition, it is
joint mobility and pain. Isometric exercises are started unclear if tennis players can return to singles play after
during this phase to promote quadriceps activation, knee joint replacement; however, return to doubles is
thus preventing arthrogenic inhibition. allowed.9,45␣
Lumbar Spine Injury be made. This includes returning patients to the prac-
Lumbar spine injuries are associated to damage to mul- tice of their sport, and finally the clearance to partici-
tiple structures and a complexity of clinical symptoms. pate in competition. This important decision should
This results in a broad differential diagnosis in the older be based on clinical evaluation, results of objective
athlete that includes facet joint syndrome, lumbo- tests, and psychologic factors, and not rely solely on
sacral radiculopathy, and spinal stenosis. Biomechani- the absence of symptoms, and the time elapsed from
cal deficits, such as tight hip flexors and hamstrings, injury or surgery.
weak pelvic girdle and core muscles, predispose older Factors to consider include the type of sport and
athletes to develop lumbar spine symptoms, resulting position played, the treatment or surgery offered to the
in performance decline.46 For example, a tennis player patient, absence of symptoms at rest and with sports
could demonstrate loss of serve velocity, ability to vol- activity, normal flexibility, strength and neuromus-
ley, and difficulty reaching low balls.16 cular control based on clinical evaluation, isokinetic
Initial management consists of limited bed rest, ice, dynamometry and functional tests that may include
analgesics, NSAIDs, muscle relaxants, physical modali- jumping, running, and changing direction. Patient
ties, and a decrease in activities that involve repetitive satisfaction with the treatment offered, sense of con-
movements, such as back extension, rotation, and fidence with sports activity, and psychologic readiness
flexion. Isometric and static exercises should be initi- to participate in sports need to be addressed prior to
ated to retrain proper muscle firing patterns in patients returning to play, and may require the use of validated
with muscle inhibition and abnormal firing patterns. questionnaires.51,52␣
Painless light aerobic exercise can also be included in
the treatment program. In addition, spine-positioning Prevention of Sports Injury
abnormalities are identified, and proper spine biome- For the athlete that returns to practice and competition,
chanics education is provided.47,48 prevention of recurrent injury is very important. Pre-
Typically, as part of the aging process, older athletes vention programs have been developed for athletes that
tend to lose the ability to compensate for the instability have not been injured (primary prevention) and for
generated by a perturbation process, particularly if there those that have been injured (secondary prevention).
is a chronic low back pain history. Therefore strength- Prehabilitation is defined as conditioning strategies for
ening of core muscles is highly recommended, as they athletes susceptible to injury because of sports-specific
provide lumbar stability.49 For example, adequate core demands, and in formerly injured athletes, to prepare
stability is vital for the golfer, particularly to improve them for the stresses and demands of their sport. Pre-
trunk flexion velocity during the downswing.50 Low back vention programs focus on modifiable risk factors,
stability is achieved by the combination of static and neuromuscular deficits, and sports-specific techniques
dynamic components, static stability provided by struc- focusing in areas at risk or already injured in a specific
tures such as bones and ligaments, and dynamic stabil- sport.53
ity associated with neuromuscular control. Particularly, Components of a prehabilitation program include
dynamic stabilizers work on maintaining joint position stretching, strengthening, proprioception, and plyo-
or proper alignment through an equalization of forces.32 metric exercises. Static stretching as a clinical inter-
The muscles that are targeted for strengthening vention has been found to improve flexibility, but it
include the multifidi, quadratus lumborum, abdomi- has not been conclusively shown to reduce the risk of
nals, and hip girdle muscles. Dynamic flexibility train- injury, and should be combined with dynamic stretch-
ing in sagittal, frontal, and transverse planes of motion ing, which works in sport-specific ranges of motion.32
are started gradually as the pain subsides. Then, tight- Strengthening exercises are known to reduce the
ness of the hip flexors, rotators, and hamstrings, and risk of injury. Eccentric exercise, in particular, has been
gastro-soleus complex are addressed. Exercise train- found to reduce the risk of hamstring strains in elite
ing with gym balls, rotational patterns, and eccentric athletes.54 Balance training, learning how to fall from
loading of the spine are implemented. Normal spine a jump, modifying cutting techniques, and plyometric
mechanics for sports activities should be restored, and exercises that activate the hamstrings have been found to
progression of sports-specific training fulfilled prior to reduce the risk of anterior cruciate ligament injuries, and
completion of rehabilitation.46,49,50␣ should be integrated into injury prevention programs.53
Finally, education about modifiable risk factors,
Return to Play Considerations such as frequency and intensity of activity, sports tech-
Once the athlete completes a rehabilitation program, nique, type of playing surface, and equipment should
the decision to return to safe sports participation must be integrated into the prevention program.␣
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12. https://www.usga.org.
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13. https://www.usta.com.
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Rev. 2012;20:16–21. ciate ligament injury: identification of risk factors and
41. Fransen M, McConnell S, Harmer AR, et al. Exercise for prevention strategies. Curr Rep Sport Med. 2014;13(3):
osteoarthritis of the knee. Br J Sports Med. 2015;49(24): 186–191.
1554–1557. 54. Chu SK, Rho ME. Hamstring injuries in the athlete: diag-
42. Vincent KR, Vincent HK. Resistance exercise for knee nosis, treatment, and return to play. Curr Sports Med Rep.
osteoarthritis. PMR. 2012;4:S45–S52. 2016;15:184–190.
CHAPTER 13
Geriatric Psychiatric and Cognitive

Disorders: Depression, Dementia, and
Delirium
YEONSIL MOON, MD, PHD • MOOYEON OH-PARK, MD • JONGMIN LEE, MD, PHD
DEPRESSION complained as or with pain (such as headaches and/

Definition of Depression or musculoskeletal pain on joints) or dyspepsia rather
Depression can refer to both a symptom and a disease. than depressive mood.2
As a symptom, depression is recognized as a mood that Another typical feature of elderly depression is com-
stands on a continuum from sadness to pathologically bined cognitive decline. Depression causes the patients
severe depression,1 whereas as a syndrome, requisite to lose the power to think appropriately; hence, elderly
condition is needed. According to the fifth edition of with depression usually present slowed mental process-
the Diagnostic and Statistical Manual of Mental Dis- ing speed and diffuse cognitive dysfunction. Indifferent
orders (DSM-5), depression is diagnosed when the attitude to cognitive decline, dominant retrieval type
depressive symptoms persist over at least a two-week of memory loss, and self-report of cognitive decline
period and other related symptoms, such as weight loss without objective report by caregivers could be clues
or gain without changes in diet, insomnia or hyper- to differentiate “pseudodementia: dementia due to
somnia, psychomotor agitation or retardation, fatigue, depression.” However, it is not easy to distinguish, as
feeling of worthlessness or excessive or inappropriate Alzheimer’s disease (AD) also accompanies depressive
guilt, diminished ability to think or concentrate, or mood in the early stages of the disease.
recurrent thoughts of death or suicidal ideation, should Suicide is another issue to be evaluated carefully in
be added. elderly patients with depression. In the elderly, even
Depression is far more common and easily ignored one suicide gesture to attract concern is enough to cause
than dementia, although dementia is regarded as a fatality although the rate of suicide is much different
characteristic disease of the elderly. The prevalence of based on the age, gender, and country. Moreover, the
depression is estimated to be 1% of older adults aged suicide rate in the elderly who are not treated with anti-
65 years and over living in the community. Depres- depressants is relatively higher than in young patients.3␣
sion also adds to the morbidity of the patient’s
comorbid disease, and vice versa. In addition, Causes of Depression
depression is associated with a decline in mobility Increasing age is the most robust risk factor for depres-
and cognition, and it needs to be taken into consid- sion in the elderly, and this may be explained by dis-
eration for the preservation of physical and cognitive ability, poor health conditions, medical comorbidities,
function.␣ poor social support, and loneliness by bereavement.4
A physically disabled state causes depression in the
Clinical Features of Depression elderly; furthermore, depression can worsen the out-
In elderly patients, clinical features of depression are come of a health condition. This includes not only
different from those in young patients. Elderly patients physical disability such as gait disturbances and hearing
tend to minimize depressive moods and additional and visual loss, but also medical comorbidities such as
symptoms related with somatic concerns such as hypo- ischemic heart disease, cerebrovascular disease (CVD),
chondriasis. Psychomotor retardation is also common. or obstructive pulmonary disease, which are very com-
Several physical illnesses accompany aging, and these mon in the elderly. Among these diseases, CVD par-
comorbid diseases overlap with depression or could be ticularly contributes to elderly depression. This, called
the cause of depression. Hence, depression is usually “vascular depression,” is supported by considerable
169
evidence of relationship between depression and a is not consistent with a depressive status; however, there
cerebrovascular imaging marker, and the interaction is should be some concerns raised in regard to the mental
also bidirectional.5 health of the patient and further assessment is required.
The vicious cycle between physical disability, medi- Score over 2 is indicative of the presence of a depressive
cal comorbidities, and depression is mediated by a status. The patient needs to be referred to further spe-
synergistic interaction between health handicap and cialist consultation. Besides, the Hospital Anxiety and
social activity. Decreased social support due to the Depression Scale, the World Health Organization Well-
disability and medical comorbidities causes depres- Being Index, and the Cornell Scale for Depression in
sive mood in elderly patients, which exacerbates the Dementia are also widely used to evaluate depression.
prognosis of the disease. Economic problems might Laboratory tests such as those for anemia, glucose
not be the immediate cause that affects elderly depres- level, vitamin B12, and thyroid-stimulating hormone
sion; however, the elderly who are not well supported levels are necessary to rule out systemic disease that can
by caregivers because of socioeconomic problems are contribute or worsen depressive symptoms. As men-
very vulnerable to depression.6 Loneliness and bereave- tioned earlier, cognitive decline is a typical feature of
ment, which many elderly undergo, are common trig- elderly depression; neuropsychological testing is useful
gers for depression. Likewise, loss of significant beings to define comorbid dementia. However, it is recom-
such as pets or friends could be a stressful life event, mended that comprehensive neuropsychological testing
resulting in depression. Healthy elderly also become be avoided during an acute or severe phase of depression.␣
depressive after bereavement or separation; however,
a normal depressive response does not persist beyond Treatment of Depression
2–6 months after an event. At all ages, depression is Pharmacotherapy is a very effective treatment for
more frequent in women than in men.␣ patients with depressive disorder. Age should not be
a barrier for pharmacotherapy; however, clinicians
Diagnosis of Depression should be familiar with precautions in prescribing
Recording substantial history is important to examine medications to older adults. The number and affin-
patients with depression. Clinicians should note the ity of most receptors decrease with age; changes in
onset, progression, attitude, accompanied mood, and pharmacodynamics should be observed. Moreover,
personal characteristics. Validated tools, such as the polypharmacy is a characteristic of geriatric medi-
Patient Health Questionnaire 9, which reflect the diag- cine. Hence, clinicians should be always aware of
nostic criteria of DSM-5, are used to evaluate depres- drug-drug interactions, reduced renal clearance rate,
sion comprehensively.7 The Geriatric Depression Scale and decreased metabolism. Selective serotonin-
(GDS) is one of the most commonly used tools, and reuptake inhibitors (SSRIs) are the first-line treat-
it has been developed specifically for elderly depres- ment of depressive disorder. Sertraline, fluoxetine,
sion. The 15 questions containing a “short version of and paroxetine are effective in treating depression.
GDS” as well as the original version of 30 questions are Escitalopram tends to be more effective in treating
widely used and have been translated into the various severe depression.9 Side effects of SSRIs include nau-
languages of the world. In the case of the original ver- sea, headache, or diarrhea, and these symptoms are
sion of GDS (30 questions), the cutoff score of normal common in the elderly. The second-line medicines
are 0–9; mild depressives, 10–19; severe depressives, are serotonin-norepinephrine reuptake inhibitors
20–30. In the case of the short version of GDS (15 ques- (SNRIs): duloxetine and venlafaxine. Although there
tions), scores over 5 points is suggestive of depression are no significant differences between the effects of
and should warrant a follow-up interview for clinical SSRIs and SNRIs, SNRIs show more frequent adverse
purpose. Scores over 10 are almost always depression. effects than SSRIs.10 Tricyclic antidepressants (TCAs),
There is even a version of 4-questions, which includes an older generation of antidepressants, also have ben-
the most sensitive items from the original GDS: “Are you eficial effects on depression. However, the side effects
basically satisfied with your life?” “Do you feel that your of TCAs including dry mouth and orthostatic intoler-
life is empty?” “Are you afraid that something bad is ance are much greater than SSRIs or SNRIs. Atypical
going to happen to you?” and “Do you feel happy most antipsychotics are also used to treat patients non-
of the time?”8 The interpretation of GDS-4 questions is responsive to antidepressants. Treatment typically
as follows: Score 0 is not indicative of a depressive status; lasts between 6 and 12 months, or over 12 months in
however the patient should be monitored further for any some cases. The clinical pharmacology of these drugs
more signs displayed and also for their evolution. Score 1 is described in Table 13.1.
CHAPTER 13 Geriatric Psychiatric and Cognitive Disorders: Depression, Dementia, and Delirium 171
TABLE 13.1
Clinical Pharmacology of Medications for Depressive Disorder
Drug Starting Dose (mg/day) Maximal Dose (mg/day) Adverse Effects
TCA Desipramine 10–25 300 Hypotension, urinary retention
Nortriptyline 10–25 200
RIMA Moclobemide 150 600
SSRI Escitalopram 5 20 Sexual dysfunction, insomnia
Sertraline 25 200
SNRI Venlafaxine 37.5 375 Nausea, constipation, anorexia,
dizziness
Duloxetine 20–30 60
NaSSA Mirtazapine 15 45
DNRI Bupropion 100 300 Seizure, anorexia, constipation
SARI Trazodone 150 400 Hypersomnia, sedation, weight gain
DNRI, dopamine and norepinephrine reuptake inhibitor; NaSSA, norepinephrine and specific serotonergic antagonist; RIMA, reversible inhibi-
tor of monoamine oxidase-A; SARI, serotonin blockade and serotonin-reuptake inhibitor; SNRI, serotonin and norepinephrine reuptake inhibi-
tor; SSRI, selective serotonin-reuptake inhibitor; TCA, tricyclic antidepressant.
Psychotherapy is as effective as medication. Cog- alert mental status unlike patients with delirium who
nitive behavioral therapy focusing on identifying and have clouded consciousness. Dementia usually occurs
reframing negative, dysfunctional thoughts and encour- because of disease of the brain, usually of a chronic
aging participation in pleasurable and social activities or progressive nature, in which there is disturbance in
is a successful strategy to reduce depressive symptoms multiple higher cortical functions, including memory,
in the elderly. Interpersonal therapy, problem solving thinking, orientation, comprehension, calculation,
treatment, dynamic psychotherapy, and family therapy learning capacity, language, and judgment. Memory
have shown efficacy for the treatment of depressive loss is the most common and representative symp-
disorder.␣ tom; however, the impairment in cognitive function
is accompanied, and occasionally preceded, by dete-
Prevention of Depression rioration in emotional control, social behavior, or
As mentioned earlier, the risk factors of depression are motivation.1
multiple, mixed, and interlaced. Among these factors, According to the International Statistical Clas-
some factors including socioeconomic support or lone- sification of Diseases and Related Health Problems
liness are somewhat controlled by public health for 10th Revision (ICD-10), dementia is classified as
the primary prevention of depression. In patients with organic, including symptomatic, mental disorders
depressive disorder, there is considerable evidence that and coded by each cause of dementia.11 However,
maintaining medication is effective in preventing the DSM-5, which was recently released by the American
recurrence of depressive symptoms.␣ Psychiatric Association, replaced the term “demen-
tia” with “major neurocognitive disorder and mild
neurocognitive disorder.” The new terms focus on a
DEMENTIA decline, rather than a deficit, in function. The new cri-
Definition of Dementia teria focus less on memory impairment, allowing for
Dementia is a syndrome defined as a decline in variables associated with conditions that sometimes
mental ability severe enough to interfere with a per- begin with a decline in speech or language usage
son’s ability to perform daily activities. Dementia is ability.12
not a specific disease; rather, it is a general term that Nevertheless, the use of term “dementia” is still
describes various symptoms of epistemic or neuro- retained; the Alzheimer’s Association, which is one of
psychiatric decline. Although patients with dementia the leading voluntary health organizations in Alzheim-
have decreased higher cortical functions, they have an er’s care, support, and research, and the National
Institute on Aging, an agency of the US National Insti- and toxic Aβ is produced. Because the cleavage by
tutes of Health, continue to use the term when they γ-secretase is somewhat imprecise, it results in a het-
issued the new research criteria and guidelines for the erogenous peptide population.19 Among many dif-
diagnosis of AD.13␣ ferent Aβ species, those ending at position 40 (Aβ40)
are much more abundant than 42 (Aβ42), which are
Mild Cognitive Impairment more hydrophobic and fibrillogenic and the principal
Mild cognitive impairment (MCI) is one of the syn- species deposited in the brain.21 Oligomer are more
dromes that describe the decline in cognitive function readily formed from Aβ42 than Aβ40. These soluble
based on the age and education of the individual but and diffusible oligomers are cytotoxic, especially when
are not significant enough to interfere with their daily these form fibrils through assemblage. Because these Aβ
activities. This concept was proposed by Peterson in oligomers and fibrils are unlikely to occur in a healthy
1999 and has been in use until now.14 brain, the microglia and astrocytes would recognize
MCI is four times more prevalent than dementia15 these peptides as a foreign material and start forming
and is a very heterogenous group. MCI is mostly on the neuritic plaques, which are the representative biomark-
neurodegenerative spectrum from subjective cognitive ers of AD. However, it is important to note that certain
decline to dementia and shares the causes of dementia. level of neuritic plaques are also common in asymp-
However, the contribution of nonneurodegenerative tomatic patients older than 75 years and in those with
or nonvascular causes, such as depression or anxiety, is other neurodegenerative disorders such as cerebral
much higher in MCI than dementia. amyloid angiopathy (predominantly diffuse plaques),
MCI is important, as it progresses to dementia pref- dementia with Lewy bodies (DLB), and Parkinson’s
erentially than normal cognition in the elderly. Because disease (PD).22
MCI is a transitional stage evolving into dementia and Another protein abnormality observed in AD is neu-
usually convert to dementia with a conversion rate of rofibrillary tangles. It occurs in various neurodegenera-
10%–16% per year, it has important implications for tive disorders including AD. The hyperphosphorylated
patients and their families.16,17 The medical interven- tau causes microtubules to destabilize and disrupt.
tion for MCI is still not available. No drug, including The aggregates of abnormal tau protein form helical
cholinesterase inhibitors, ginkgo biloba, or testos- filaments, which then become neurofibrillary tangles.23
terone, has proven effective in the treatment of MCI. Unlike the total Aβ burden not being correlated with
Only controlling vascular risk factors, including stroke cognitive impairment, these neurofibrillary tangles are
prevention strategy such as blood pressure control, a pathologic marker of the severity of AD.19
glucose control, smoking cessation, and antiplatelet Besides protein abnormalities, mitochondrial dys-
medication, may reduce risk of progression from MCI functions including oxidative stress, an insulin-signal-
to dementia.18␣ ing pathway, vascular factors, inflammation, calcium,
axonal-transport deficits, aberrant cell-cycle reentry,
Causes of Dementia and cholesterol metabolism are also detected as molec-
Neurodegenerative disease ular mechanisms of AD.19 Genetic factors are also one
Alzheimer’s disease. AD is the most common cause of the important factors of AD; however, the dementia
of dementia, accounting for 50%–56% of cases at au- symptoms due to genetic mutation–based AD tend to
topsy and in clinical series. Another 13%–17% of the occur before the age of 60–65 years.
cases are also accounted for when combined with in- Although memory decline is a predominant symp-
tracerebral vascular disease.19 The most powerful and tom of AD, executive and visuospatial dysfunction
crucial risk factor for AD is age. The incidence of the along with neuropsychiatric symptoms such as apathy,
disease doubles every 5 years after 65 years of age.20 depression, anxiety, and agitation is common in AD.
The most representative molecular mechanism of Although the general neurologic examination is nor-
AD is the β-amyloid (Aβ) theory. Aβ peptides origi- mal at the early stage of AD, motor symptoms includ-
nate from proteolysis of the amyloid precursor pro- ing dysarthria, dysphagia, and gait disturbance are
tein (APP) and are divided into two types of proteins noted in patients with advance AD.␣
by the sequential enzymatic actions. If APP is cleaved
by α-secretase and γ-secretase, the sequence initi- Dementia with Lewy bodies. Dementia with Lewy
ates nonamyloidogenic processing; however when bodies (DLB) accounts for 20% of dementia. As sug-
sliced by beta-site APP–cleaving enzyme 1 (BACE-1), gested by the name, the pathologic hallmark of DLB is
a β-secretase, and γ-secretase, the aggregation-prone Lewy bodies. PD has Lewy bodies primarily affecting
TABLE 13.2
Comparison Between Neurodegenerative Disease (Alzheimer’s Disease and Dementia With Lewy
Bodies) and Vascular Dementia
Causes of Dementia Alzheimer’s Dementia Dementia with Lewy Bodies Vascular Dementia
Essential features Dementia with cognitive decline that disrupts activities of daily living
Patterns of cognitive Prominent and early More deficits in attention, Various patterns depending
deficit involvement of memory executive function, and on the lesion of CVA
decline visuospatial ability
Accompanying features Depression or apathy at RBD, loss of atonia during REM Early involvement of gait
early stage sleep-neuroleptic sensitivity disturbance, urinary fre-
quency, neurologic deficit
Main pathophysiology Cholinergic deficit due to Low dopamine transporter Decreased cerebrovascular
neuronal loss within the uptake in the basal ganglia with perfusion and neuronal
cholinergic nucleus basalis neocortical cholinergic deficit degeneration
of Meynert
Characteristics of brain Medial temporal atrophy on Marked deficits in the occipital Evidence of ischemic dam-
MRI coronal T2 regions with relative sparing of age including small vessel
the medial temporal lobe when disease, cerebral infarction,
compared with AD lacunar infarction, intracere-
bral hemorrhage
CVA, cerebrovascular attack; MRI, magnetic resonance imaging; RBD, REM sleep behavior disorder; REM, rapid eye movement.
the substantia nigra, locus ceruleus, and raphe nuclei, in Asia than Europe or North America.26 Because AD
whereas DLB is characterized by limbic, paralimbic, shares the risk factors with stroke and patients with AD
and neocortical Lewy bodies. Symptoms in patients often show concurrent stroke, especially in the elderly,
with DLB are somewhat overlapping with AD and PD. numerous patients with dementia show mixed pathol-
According to the consensus diagnostic criteria for DLB, ogy (CVD with other neurodegenerative pathology,
the core features include fluctuating cognition or level such as AD). It is not easy to clarify this overlapped
of consciousness, visual hallucinations, and parkinso- pathologies and symptoms; however, the most deci-
nian motor signs.24 Patients with DLB show more severe sive point to diagnose VD is the association between
impairment in visuospatial and executive function than CVD and cognitive impairment. Hence, the clinical
those with AD (which show more prominent memory neurocognitive deficit of patients with VD is much
decline) and earlier involvement of progressive cognitive linked with the location of their stroke lesions. How-
decline appearing before or within one year of parkinso- ever, the most common form of VCI is the subcortical
nian symptoms compared with PD dementia. type, which is revealed as white matter changes, lacunar
As patients with DLB show severe reduction in ace- infarcts, and cerebral microbleeds on brain magnetic
tylcholine levels in the brain network, the response to resonance imaging (MRI).27
acetylcholinesterase inhibitors (AChEIs) is quite accept- Decreased speed of mentation, executive dysfunc-
able to cognition and neuropsychiatric symptoms.␣ tion, and retrieval memory impairment rather than
input dysfunction are the features of cognitive dysfunc-
Vascular dementia tions of VD; however, it is not easy to identify, as elderly
Vascular cognitive impairment (VCI) is defined as a patients usually have multiple brain pathologies includ-
syndrome with evidence of clinical stroke or subclinical ing CVD, subcortical cerebrovascular injury, and asymp-
vascular brain injury and cognitive impairment affect- tomatic neurodegenerative disease. Relatively early
ing at least one cognitive domain. VCI encompasses involvement of gait disturbance, urinary difficulties, and
all stages of cognitive decline, and vascular demen- poststroke psychiatric disturbances such as depression
tia (VD) refers to the “dementia” stage of cognitive could be clues to diagnosis of VD in the elderly.
impairment.25 VD is the second most common cause A brief comparison of the three types of diseases
of dementia after AD and tends to be more prevalent that cause dementia is presented in Table 13.2.␣
obtained from patient and family members or care-

TABLE 13.3
givers is necessary. As many patients with dementia
Medications That May Trigger Cognitive
deny their cognitive decline, and many clinicians
Impairment
tend to interpret and ignore the elderly’s cognitive
Categories of Medication Examples of Medication complaints because of aging, the key tip to obtain
Anticholinergics Benztropine, tolterodine accurate information is to interview credible care-
Benzodiazepines Lorazepam, diazepam, givers who could provide much more information
Anticonvulsants clonazepam about the patients. During their review, the clini-
Antidepressants Carbamazepine, cians should focus on three categories: activities
Antihistamines phenobarbital, phenytoin of daily living, behavioral changes, and cognitive
Chemotherapeutic Fluoxetine, sertraline, decline, which are called as the “ABC of dementia.”
agents citalopram
(Table 13.4) Based on the patient’s daily life, the cli-
Narcotics Diphenhydramine,
Nonbenzodiazepine chlorpheniramine
nician assesses the daily activities that patient can
sedatives Busulfan, cytarabine and cannot execute any more only because of cog-
Oxycodone, morphine, nitive decline. Changes in patient’s character, mood,
codeine or behavior different from before should be appre-
Pentobarbital, hended. Cognitive decline is usually categorized into
mephobarbital five domains: executive, memory, language, atten-
tion, and visuospatial function. It could be divided
and clustered in various ways; however, the impor-
Other causes of dementia tant consideration is to evaluate the diverse cognitive
The causes of dementia are numerous, from the irre- domains as much as possible.
versible causes to reversible causes such as medication, After a diagnosis of dementia, the next step is to
hypothyroidism, or vitamin deficiencies. Almost all enumerate the possible causes of dementia. A neu-
cases of dementia are due to irreversible causes such as rologic examination is important to evaluate the
neurodegenerative disease and CVD. Among neurode- causes of dementia, especially detecting focal neu-
generative diseases, AD and VD are the most common rologic signs for cerebrovascular contribution to
types; however, many other diseases could cause cog- dementia. If the patient has no lateralizing signs,
nitive decline in patients. Besides DLB, frontotempo- the clinician could suspect the causes of dementia
ral dementia that is characterized by the early atrophy as more diffuse pathology, such as AD or DLB. Labo-
of frontotemporal lobes and noticeable personality ratory tests include vitamin B12 and thyroid-stimu-
changes or language dysfunction, Huntington’s dis- lating hormone levels, and structural brain imaging.
ease that shows executive dysfunction, or Creutzfeldt- MRI is more preferred than computed tomography
Jakob disease that progresses very rapidly, could be (CT); however, both are recommended to diagnose
causes of dementia. However, these diseases manifest dementia and classify the cause by the American
dementia symptoms relatively early, before the age of Academy of Neurology.30 The widely used cognitive
65 years, in patients. tests are the Mini-Mental State Examination28 and
Some causes of dementia could be reversed or Montreal Cognitive Assessment.29 Comprehensive
improved with appropriate treatment. Metabolic neuropsychological testing, usually applied as a bat-
and endocrine-related diseases such as hyponatre- tery of tests, is not mandatory but valuable for cog-
mia, hypoglycemia, or hypothyroidism; infectious nitive assessment. Laboratory tests include vitamin
and inflammatory diseases such as meningitis, B12 and thyroid-stimulating hormone levels, and
encephalitis, or autoimmune disease; nutritional structural brain imaging are also needed to clarify the
disturbances including vitamin deficiencies, or causes of dementia. MRI is more preferred than com-
dehydration; or medication reaction (Table 13.3) puted tomography (CT); however, both are recom-
could be a cause or concomitant factors affecting mended to diagnose dementia and classify the cause
symptoms of dementia.␣ by the American Academy of Neurology.30␣
Diagnosis of Dementia Treatment of Dementia

The first goal of patient evaluation is to establish Current medications approved by the US Food
whether dementia is present or not. To diagnose a and Drug Administration (FDA) are of only two
patient with dementia, the comprehensive history types: the cholinesterase inhibitors—donepezil,
TABLE 13.4
ABC of Assessing the Impact of Dementia on Lives of Older Adults
Category Description Examples Tools
A, ADL • What changes have occurred in his/her abilities to perform • IADL
household chores? • Barthel Index
• Do you have any problems managing your home finances? • BADLS
• Did you have trouble driving because of poor judgment?
B, Behavior • Do you feel sad or depressive? • NPI
• Are you less interested in your usual activities or in the • BEHAVE-AD
activities and plans of others? • CMAI
• Is the patient resistive to help from others or hard to handle?
C, Cognition • Do you have a problem with your memory or thinking? Screening
• Can you recall recent events? MMSE
• Do you often lose your way? MoCA
• Is it difficult to buy things and get change exactly? Mini-Cog
• Is it difficult to get clothes that suit the situation? Overall dementia severity
• Is it difficult to concentrate for a short time? CDR
GDS
ADL, Activities of Daily Living; BADLS, Bristol Activities of Daily Living Scale; CDR, Clinical Dementia Rating; CMAI, Cohen-Mansfield Agita-
tion Inventory; GDS, Global Deterioration Scale; IADL, Instrumental Activities Of Daily Living; MMSE, Mini-Mental State Examination; MoCA,
Montreal Cognitive Assessment; NPI, Neuropsychiatric Inventory (Questionnaire).
rivastigmine, and galantamine—and moderate affin- Prevention of Dementia

ity, uncompetitive N-methyl-D-aspartate (NMDA) The most efficient modifiable strategies to prevent
receptor antagonist—memantine. Moreover, these dementia are controlling lifestyle risk factors (espe-
drugs are not for all causes of dementia, but only for cially education and physical activity) and cardiovascu-
AD dementia, based on the cholinergic hypothesis of lar factors. Smoking cessation and a balanced diet with
memory decline31 and neuroprotective mechanism adequate supplement of antioxidants and vitamins can
against glutamate and calcium-mediated neurotoxic- prevent cognitive decline in the elderly. These are not
ity via NMDA receptors.32 Donepezil, the most fre- only effective primary preventions that protect neuro-
quently prescribed medication, has been tested in degeneration but also valuable secondary preventions
other disorders such as DLB and VD; however, there that prevent dementia in the elderly showing cognitive
is no current approval yet. The clinical pharmacol- decline, as well as tertiary preventions that retard fur-
ogy of these drugs is described in Table 13.5. In case ther progressive deficits in patients with dementia.7␣
of cholinesterase inhibitors, cholinergically medi-
ated gastrointestinal adverse effects such as nausea,
vomiting, and anorexia are relatively common, and DELIRIUM
precautions in patients with bradycardia, obstructive Definition of Delirium
pulmonary disease, or high risk for gastrointestinal Delirium is a clinical syndrome, which is a transient,
bleeding are needed. usually reversible mental disturbance that results in a
Nonpharmacologic interventions, such as confused mental state and/or a wide range of neuropsy-
physical exercise, cognitive training, music therapy, chiatric abnormalities. It is a commonly encountered
or aromatherapy, seem to be efficient methods to serious problem; about 20% of hospitalized patients
improve cognitive function and control the abnor- develop delirium.33 Elderly in the intensive care unit
mal behavior and moods in patients with dementia. (ICU) have especially high risk with increasing incidence
More evidence regarding the long-term effects are to 80%. It is not only a marker of severe sickness but
needed using a refined, objective, and comprehen- also associated with poor outcomes: increased mortal-
sive manual. As dementia is a multifactorial disease, ity, prolonged hospitalization, frequent discharge to the
the combination of two or more nonpharmacologic nursing home, and a high risk of developing dementia.34
interventions is important along with pharmacologic The pathophysiology of delirium is quite com-
treatments.␣ plex and not well understood, yet. Changes to the
TABLE 13.5
Clinical Pharmacology of Medications for Alzheimer’s Disease (AD) Dementia
Drug DOSAGE AND ADMINISTRATION Adverse Effects Contraindications
Cholin- Donepezil Route Oral Diarrhea, loss of appetite, Neuroleptic ma-
esterase muscle cramps, nau- lignant syndrome,
Starting dose 5 mg/day
inhibitors (all sea, trouble in sleeping, epileptic seizure,
stages of AD Maximal dose 10 mg/day, 23 mg/ unusual tiredness or atrioventricular heart
dementia) day (only in moder- weakness, vomiting block, torsades de
ate to severe cases) pointes, sick sinus
Half-life (h) 70–80 syndrome, sinus
bradycardia, asthma
Rivastigmine Route Oral, transdermal Diarrhea, indigestion, Symptoms of
loss of appetite, loss of Parkinson’s disease,
Starting dose 1.5 mg bid,
strength, nausea and extrapyramidal
4.6 mg patch/24 h
vomiting, weight loss, reaction, sick sinus
Maximal dose 6 mg bid, 9.5 mg fainting syndrome, slow
patch/24 h, 13.3 mg heartbeat, abnor-
patch/24 h (only in mal heart rhythm,
moderate to severe asthma, stomach or
cases) intestinal ulcer
Half-life (h) 2–8, 3–4 (patch)
Galantamine Route Oral Chest pain or discomfort; Epileptic seizure,
light-headedness; dizzi- atrioventricular
Starting dose 4 mg bid
ness; fainting; shakiness in heart block, slow
Maximal dose 12 mg bid the legs, arms, hands, or heartbeat, asthma,
Half-life (h) 5–7 feet; shortness of breath; obstructive pulmo-
slow or irregular heartbeat; nary disease
unusual tiredness
N-methyl-D- Memantine Route Oral Tiredness, body aches, Epileptic seizure,
aspartate joint pain, dizziness, nau- liver problems,
Starting dose 5 mg/day
receptor sea, vomiting, severe renal
antagonist Maximal dose 10 mg bid diarrhea, constipation, impairment
(moderate to Half-life (h) 60–80 loss of appetite
severe AD
dementia)
neurotransmitter system—reduced cholinergic func- Clinical Features of Delirium

tion, excess release of dopamine or norepinephrine, The clinical hallmarks of delirium are changes in the
and both decreased and increased serotonergic and level of consciousness and a change in baseline cogni-
gamma-aminobutyric acid activity—caused by hypoxia tion, which usually rapidly starts within a few days. The
or metabolic disturbance are taking an axis. Thereon, fluctuating confusion ranges from a hypoactive type
increased cerebral secretion of cytokines due to a wide with lethargy, stupor, or coma to a hyperactive type
range of physically stressful events can influence the characterized by agitation, aggression, and belligerent
activity of various neurotransmitter systems; these with existence of mixed type. Delirium is reported to
mechanisms may interact. Neuroinflammation induced be undiagnosed in a clinical setting, because hypoactive
by cytokines secretes systemic inflammatory factors delirium is typically unrecognized or misattributed as
and activates the action of microglial cells in the brain, dementia. Acute impairment in cognition includes vari-
which results in blood-brain barrier breakdown and ous domains with primary involvement of inattention,
neuronal death. Furthermore, additional medications and executive, memory, language, and visuospatial func-
to treat a medical disease also cause neurotransmitter tion are also often impaired. Psychotic symptoms are
imbalance and disruption of synaptic communication.␣ relatively common; visual hallucinations and changes
in sleep patterns are the most frequently observed. All

TABLE 13.6
these confusion and restless symptoms tend to worsen at
Common Predisposing and Precipitating
night; therefore it is called as the sundown phenomenon.␣
Factors of Delirium
Causes of Delirium Predisposing
The most important risk factors for delirium are aging Factors Precipitating Factors
and preexisting cognitive dysfunction. Visual and hear- Old age Drugs and drug withdrawal
ing impairment, disability, depression, malnutrition, Narcotics, benzodiazepine, anticho-
and alcohol abuse are also risk factors of delirium.34 linergics, methyldopa, nonsteroidal
Individuals with baseline risk factors might have delir- antiinflammatory agents
ium after aggravated by various precipitating factors. Male Electrolyte imbalance
Medications are the most common cause of delirium, Dementia Infection/fever
accounting for 12%–39% of all cases of delirium. The
Depression Sleep deprivation
most common precipitating drugs include high-dose
narcotics, benzodiazepines, and anticholinergic medi- Immobility Severe/acute illness
cations, and these drugs triple the risk of delirium in History of falls Hypoxia
the elderly.34 Numerous other drugs including antihis-
Polypharmacy Intensive care unit admission
tamines, antiepileptic drugs, muscle relaxants, dopa-
mine agonists, and steroids could be a precipitating Alcoholism Emotional stress and pain
candidate.36 Among these drugs, anticholinergic drugs Malnutrition Shock/dehydration
are frequently mentioned and are associated with the
occurrence and severity of delirium.37 Both hyperactive
and mixed delirium are commonly seen in cholinergic
toxicity, alcohol intoxication or withdrawal, stimulant uremic encephalopathies are the most common
intoxication, serotonin syndrome, and benzodiazepine causes of delirium. Of course, condition decline due
withdrawal. In other cases, hypoactive delirium is often to any illness other than the central nervous system
due to benzodiazepines, narcotic overdose, or hyp- could increase the prevalence of delirium. Common
notic intoxication.36 The mechanism of drug-induced predisposing and precipitating factors of delirium are
delirium is not well defined. Aging, polypharmacy, described in Table 13.6.␣
and age-related pharmacokinetic or pharmacodynamic
changes are thought to contribute to the incidence of Diagnosis of Delirium
drug-induced delirium in the elderly. The Global Attentiveness Rating, Memorial Delirium
Surgery is another common cause of delirium, espe- Assessment Scale (MDAS), Confusion Assessment
cially in the elderly. The risk of postoperative delirium Method (CAM), Delirium Rating Scale Revised-98
is increased in patients with cognitive dysfunction. The (DRS-R-98), Clinical Assessment of Confusion (CAC),
most common surgery causing delirium is thoracic sur- and Delirium Observation Screening Scale are used
gery including cardiac and noncardiac surgery. Depth of to diagnose delirium. The most pertinent choice of
anesthesia during surgery and development of postop- a tool may depend on the amount of time available
erative delirium are thought to be related; however, there and the discipline of the examiner; however, the most
is no sufficient evidence.38 Regional anesthesia might be widely used and supported tool by sufficient evidence
beneficial in reducing the incidence of postoperative is CAM.35 It is an instrument based on an algorithm.
delirium compared with general anesthesia; however, To diagnose delirium, acute onset of changes and fluc-
there are relatively few studies supporting this.38 tuations in the course of mental status (feature 1) and
Other iatrogenic precipitating factors include envi- inattention (feature 2), and either disorganized think-
ronmental factors usually found at a hospital setting: ing (feature 3) or altered level of consciousness (fea-
restraints, urinary catheter, multiple procedures, sleep ture 4) is required. Anyone who is trained for optimal
deprivation, or untreated pain.34 measure can use CAM, and an instruction manual is
Pathologic conditions are an important precipi- available online (http://www.hospitalelderlifeprogra
tating factor of delirium in the elderly. Especially, m.org/uploads/disclaimers/Short_CAM_Training_Ma
lesions of the brain can lead to delirium. Metabolic nual_8-29-14.pdf). There are several adapted versions
insult or inflammations are more vulnerable to deli- for using in various clinical settings such as the ICU,
rium than vascular damage among them hepatic and emergency department, and nursing home.
Before the evaluation of the causes of delirium, the interruption of essential therapy. Because FDA black
clinician should secure the airway, breathing, and cir- box warning indicates increased mortality of patients
culation of patients suspected of delirium. After secure- who were exposed to antipsychotics, clinicians should
ment, a detailed history including previous cognition, (1) check ECG for elongated QTc (time between the
recent symptoms of medical illness, and newly added start of the Q wave and the end of the T wave > 470 ms)
or dose changes of medication should be evaluated. before and after starting antipsychotics and (2) moni-
However, delirious patients often are confused; hence, tor the sedated patients for respiratory rate, pulse
clinicians usually cannot get sufficient and accurate oximetry, blood pressure, pulse, and temperature,
information from the patient. A detailed interview when considering pharmacologic intervention. The
with caregivers, family, and nursing staff is particularly common pitfalls in pharmacologic management of
important. Physical examination and neurologic exam- delirium include using antipsychotic medications in
ination are essential steps to assess delirious patients to excessive doses, administering them very late, or over-
find out the causes of delirium. A laboratory test, chest use of benzodiazepines.40 If the patient is older than
X-ray, and electrocardiogram are necessary to identify 65 years, haloperidol 0.5–1 mg hourly, maximum 5 mg
any systemic disease, especially infection. If focal neu- in 24 h, or haloperidol 0.5–1 mg every 2 h, maximum
rologic deficit exists, brain imaging including CT, MRI, 5 mg daily is permitted. Patients with a history of dys-
and lumbar puncture should be obtained. Especially tonia can be given olanzapine 2.5–5 mg orally, maxi-
lumbar puncture to patients with head trauma, after mum 20 mg daily (10 mg in the elderly) other than
neurosurgical procedures, or who are immunocompro- haloperidol.41 These drugs can relieve the symptoms
mised is indispensable even in the absence of cerebral of delirium; however, they may increase the duration
infection signs. If the cause of delirium is not identified of delirium. Cholinesterase inhibitors should not be
after this screening workup, comprehensive and exten- newly prescribed to treat delirium.38 Benzodiazepines
sive tests should be started. Additional serologic tests are not recommended for the control of delirium
such as those for ammonia, thyroid function, morn- except in the case of nonalcohol withdrawal–related
ing cortisol, vitamin B12, or autoimmune serologies delirium.42␣
and more specific sequences of MRI including diffu-
sion-weighted and gadolinium-enhanced MRI may be Prevention of Delirium
needed. Electroencephalogram should be applied to Delirium has been shown to be preventable in up to one-
anyone who is suspected of nonconvulsive status epi- third of the cases in hospitalized elderly patients.43 The
lepticus as soon as possible, and this helps to differenti- American Geriatrics Society recommends clinical practice
ate metabolic encephalopathy.␣ guidelines for the prevention of postoperative delirium
in the elderly.38 According to the guidelines, multicom-
Treatment of Delirium ponent nonpharmacologic interventions delivered by an
The most effective way to treat delirium is to remove the interdisciplinary team and medical evaluation should be
precipitating factors. Although age and preexisting cogni- administered to at-risk older adults to prevent delirium.
tive dysfunction are nonmodifiable, many precipitating Early and pertinent pain management including injec-
factors are iatrogenic that are modifiable. Discontinua- tion of regional anesthesia should be regulated, and
tion or change in the provoking drugs, natural recovery medication with high risk should be avoided. Although
from surgery, removal of intervenient tools such as cath- there is a study reporting moderate-quality evidence that
eter and lines might help delirious patients to improve. Bispectral Index (BIS)-guided anesthesia reduces the
If the hospital system is available, it is better to orientate incidence of delirium compared with BIS-blinded anes-
the patient frequently: who and where they are and what thesia or clinical judgment,33 use of several technologies
your role is; provide easily visible clocks, calendars, good such as processed electroencephalographic monitors of
lighting, and signage; and facilitate visits from friends anesthetic depth during intravenous sedation or general
and family. Encouraging early mobility under supervi- anesthesia has insufficient evidence of efficacy.␣
sion and performing active exercises are another effective
nonpharmacologic treatment of delirium.
Current evidence does not support the use of CONCLUSION
antipsychotics for the prevention or treatment of Depression, dementia, and delirium (3Ds) are highly
delirium.39 Medications are primarily reserved when prevalent in the elderly, with the presence of one
the symptoms of delirium threaten the patient’s own condition potentially increasing the risk of develop-
safety or the safety of others or would result in the ing others. The impact of these conditions on the
function and quality of life may surpass the impact 15. DeCarli C. Mild cognitive impairment: prevalence,
of physical impairment. A high index of suspicion prognosis, aetiology, and treatment. Lancet Neurol.
and proactive preventive strategies are the keys 2003;2(1):15–21.
to reduce the risk for these conditions. Clinicians 16. Langa KM, Levine DA. The diagnosis and management
of mild cognitive impairment: a clinical review. JAMA.
should be knowledgeable about pharmacologic and
2014;312(23):2551–2561.
nonpharmacologic interventions for these cognitive 17. Eshkoor SA, Hamid TA, Mun CY, Ng CK. Mild cognitive
conditions. impairment and its management in older people. Clin In-
terv Aging. 2015;10:687–693.
18. Bosch J, Yusuf S, Pogue J, et al. Use of Ramipril in pre-
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CHAPTER 14
Exercise Recommendations for Older

Adults for Prevention of Disability
DAVID Z. PRINCE, MD • MATTHEW N. BARTELS, MD, MPH
EPIDEMIOLOGY into older years by those seniors interested in maintain-

As the global population continues to advance in age, ing function as they age.14 At the high end of the func-
the value of maintaining physical function grows in tional spectrum, increased enrollment of those older
importance from an individual goal to a societal man- than 50 years in endurance and even ultraendurance
date. The “Aging of America” and the “Silver Tsunami” events continues to rise.15,16 Although the media inter-
in Asia are compelling epidemiologic evidence that it est generated by centenarian yoga teachers, marathon
is essential to maintain the elderly in their homes and runners, and cyclists captures the imagination of the
communities to reduce healthcare costs.1 More impor- general population, this belies the reality that only 49%
tantly, this also improves the quality of life for older of the general population meets the Physical Activity
adults and their families. The number of elderly people Guidelines for aerobic physical activity.17 In the United
globally will steadily increase until approximately 22% States, more than one-third of older adults 65 years and
of the population will be considered elderly by 2050.2 older are obese.18 In addition, there is an increased rate
One of the most effective ways to maintain indepen- of obesity in individuals between 65 and 74 years of age
dent function in older adults is the initiation of regular compared with those older than 75 years, and the rate
conditioning programs specifically designed for older of falls may be correlated with a low fitness level and
individuals.3,4 There is already interest in physical activ- general inactivity.19 The epidemic of obesity and seden-
ity by highly motivated members of the older popula- tarism leading to deconditioning, falls, and increased
tion; however, these participants remain at high risk for cardiovascular and cerebrovascular disease demands
injury and complications while exercising.5–7 Expand- attention and intervention by medical professionals
ing physical activity programs for the older adults will to translate current medical knowledge into actionable
expand the benefits of conditioning to a broader seg- plans for patients and health consumers.
ment of the population and one at increased risk for Although older individuals benefit greatly from regu-
morbidity and disability. lar conditioning programs, there are also potential com-
An essential part of this is addressing cardiovascu- plications in cardiovascular and musculoskeletal systems
lar and cerebrovascular diseases, which continue to that need to be considered when initiating an exercise
increase in the American population as a whole. Sim- program in this population. The rate of osteoarthritis,
ply increasing physical activity in targeted patient pop- decreased connective tissue elasticity, and reduced recov-
ulations can reduce many risk factors for both of these ery reserve can lead to a higher rate of injury, especially
highly prevalent disease states,8 because physical activ- during initiation of a new exercise program or when
ity is the cornerstone of coordinated efforts to reduce returning to a previous activity after prolonged interrup-
hypertension, hypercholesterolemia, and hyperglyce- tion.20,21 Medical professionals, especially physiatrists,
mic states.9–11 are uniquely positioned to offer education, structure,
The aging of the baby boomer population is affecting and accountability and provide appropriate rehabilita-
every aspect of life in the United States, both as consum- tion services when needed to maintain physical function
ers of commercial products, consumers of information, and safe conditioning for this population.␣
and consumers of exercise-related products and activi-
ties.12,13 The increased participation in athletic events
for older participants, or “Masters Events,” continues to PHYSIOLOGY OF AGING
increase to new levels and supports the assertion that To advise, educate, and prescribe exercise appropriately
there is growing interest and commitment to maintain- in older adults, it is essential to bear in mind that the
ing physical fitness at the highest possible level even physiology of natural aging leads to changes in the
181
TABLE 14.1
Physiologic Changes of Aging Relevant to Exercise Prescription
Organ System Changes With Aging Impact on Exercise Performance Decrease Per Year
Cardiac25 ↓ Maximum heart rate ↓ Peak cardiac output ↓ 1%–2%/year after age 25 years
↓ Stroke volume ↑ Risk of ischemia
Pulmonary26 ↓ Lung capacity ↓ DLCO ↓ Ventilation: 1%/year after age
↓ Lung compliance 30 years
↓ DLCO: 1%/year
Muscle27 ↑ Fatty infiltration ↓ Peak muscle strength ↓ Muscle strength of 1%–2%/year
↑ Fibrous infiltration ↓ Type 2 fibers after age 25 years
↓ Lean body mass ↓ Peak performance
↓ Strength
Neurologic28,29 ↓ Coordination ↓ Balance ↑ Dementia with aging
↓ Reaction times ↓ Coordination ↑ Blood flow and cognition with
↓ Peak performance exercise
DLCO, diffusing capacity of the lung for carbon monoxide.
pulmonary, cardiac, musculoskeletal, and vascular that can be reserved through physical activity. Skeletal
systems, among others. Reduced sex hormone levels muscle is the effector of movement and function in the
lead to reduced muscle mass and power generation human body. Age-related muscle mass decline or sarco-
during exercise. If the patient is interested in achieving penia begins in the third decade of life and continues
the highest level of conditioning possible, an assess- throughout the life cycle.30 Although deconditioning
ment of the maximum exercise capacity can provide a causes cardiac, vascular, pulmonary, and neurologic
patient specific VO2max (a measure of the maximum impairments, here we focus on the reduction in muscle
amount of oxygen). Individuals in their 80s have half mass due to inactivity, either acute or chronic, that is
the peak capacity of individuals in their 20s because seen in deconditioning. Chronic lack of movement,
of the physiologic decrement of 10% in VO2max per immobility, and an inactive lifestyle (sedentarism)
decade. For example, a 25-year-old sedentary indi- can all contribute to deconditioning. Acute decon-
vidual who has a VO2max of 35 mL O2/kg/min at age ditioning (e.g., from hospitalization) superimposed
25 years would have a VO2max of 17.5 mL O2/kg/min on age-related sarcopenia can lead to a synergistic loss
at age 80 years.22 Scaled to measurements of metabolic of function and independence in older adults.31,32 As
equivalents (METs) of energy, this equals a decrement the population ages, this becomes a phenomenon of
in peak capacity from 10 METs to 5 METs. It is impor- greater significance to society. Between 10% and 35%
tant to keep these general values in mind, especially of the American population is considered to be at an
when an older patient is initiating an exercise program increased risk for a physical disability based on reduced
and seeks advice regarding expectations and realistic skeletal muscle mass, a number that will continue to
goal setting. Referring to an MET table can be helpful increase over time. In 2004 the estimated cost to the
in educating patients regarding objective measures of American healthcare system attributable to sarcopenia
energy expenditure.23 The Duke’s Activity Scale Index was estimated to be more than $18 billion.33 Sarcope-
is a 12-question administered questionnaire that esti- nia is associated with increased disability, frailty, and
mates functional capacity and can be used to establish healthcare costs. Regular exercise can reduce the inci-
some degree of baseline functional capacity when the dence of sarcopenia with its associated disability and
gold-standard, maximal exercise testing is not feasi- decline in function.34 The details of deconditioning in
ble.24 A more detailed comparison of the physiologic other organ systems are described in Chapter 8 of this
changes with aging is summarized in Table 14.1.␣ book.
Exercise as medicine is a new paradigm in healthcare.35
To this end exercise must be considered and categorized
DECONDITIONING AND EXERCISE similarly to classes of medications—different types, dif-
Deconditioning is physiologic and anatomic changes ferent mechanisms of action, and different effects on
in multiple systems induced by physical inactivity organs and overall function. Aerobic conditioning is the
CHAPTER 14 Exercise Recommendations for Older Adults for Prevention of Disability 183
type of exercise most commonly associated with a thera- conditioning status, including an approximation of
peutic benefit in older populations, partially because of predicted METs extrapolated from daily activities and
the increasing awareness of cardiac rehabilitation/aerobic numerous balance assessment tools.24 The evaluation
conditioning following cardiac events.36 Progressive resis- of muscle power generation and flexibility are best
tance training (PRT) or weightlifting is less often associ- determined by the physiatric physical examination.
ated with the geriatric population, but it has been proved The same evaluations and tools that are used to inform
to benefit the elderly, as skeletal muscle responds to a physiatric prescription for physical therapy should
training throughout the lifecycle.37,38 Flexibility training be used to prescribe exercise activities for older adults
is important and usually a benefit of slow velocity move- (Table 14.2).␣
ment-based systems. Balance training should be initiated
as far in advance of an anticipated loss of balance as pos-
sible. Lastly, postural training is typically overlooked as EXERCISE PRESCRIPTION
an exercise modality, but the benefits of lifelong postural All prescriptive exercise should follow the FITT prin-
alignment are significant and allow all other modalities ciple, where the acronym FITT stands for: frequency,
to have an optimal effect.␣ intensity, time, and type of exercise.42 Following a
detailed medical examination and thorough functional
history, conditioning and functional goals can be iden-
PRECONDITIONING ASSESSMENT tified. It is essential to tie the exercise prescription
Owing to the standing recommendation “check with to functional goals that hold high personal value
your doctor before starting any exercise program,” many for each individual patient. Physically writing an
patients consult their primary physician before starting exercise prescription on a prescription pad, now less
an exercise program, although this usually does not guar- common with the advent of electronic prescribing, has
antee a thorough preconditioning assessment that incor- been shown to be more effective at modifying patient
porates goal setting specifically focused on functional behavior than verbal instruction alone.43 The exercise
preservation. This admonition also implies that exercise is prescription should be rooted in patient interests, and
a hazardous activity in middle-aged and older individuals ideally the clinician will review in detail how each rec-
when the opposite is actually true—sedentarism is a more ommendation will directly benefit the patient.
significant risk than exercise. Perhaps the warning should Techniques of motivational interviewing may be
be altered to: “Check with your doctor before NOT start- effective tools in facilitating behavioral change and
ing an exercise program.” Because the greatest risk from a because of their ease of use can be incorporated into
sudden increase in physical activity is the unmasking of patient discussions.44,45 An initial assessment regarding
occult coronary artery disease in the setting of an acute patient “stage of change” at the time of office visit will
coronary syndrome, this is usually the sole focus of stan- prevent patient and clinician frustrations based on mis-
dard medical evaluation. Maximal exercise testing with understanding of the motivational state. This includes
or without a cardiology consult can provide scientifically an assessment of patient interest and motivation to
valid risk stratification, but it should be remembered that make a change using an analogue scale or “readiness
the solution for coronary artery disease is not inactivity, ruler” for scoring. The readiness ruler is simply a 0–10
a common misconception that should be challenged analog scale going from 0: “Not prepared to change”
whenever possible. Patients found to be at an increased to 10: “Already changing” (see Fig. 14.1). The patient
risk for cardiovascular events should be stabilized and marks where they feel on the scale from 1–10. Patients
referred to cardiac rehabilitation as the first step to pre- whose motivation is 3 or less should be approached
venting further lifelong disability. Progression of exercise again at the next medical visit to determine if they are
program can be carried out following an introduction to ready to initiate an exercise program at the next clinical
exercise in the monitored setting. visit.46 For clinicians or their staff who are interested in
In parallel to cardiovascular risk stratification the incorporating health-coaching techniques and motiva-
physiatrist is uniquely suited to complete an overall tional interviewing into their practice, there are numer-
functional assessment to determine the patient’s abil- ous resources available throughout the United States.
ity to perform activities of daily living independently, The efficacy of these techniques is promising and cur-
as well as higher-level tasks that are functional priori- rently an area of active investigation.47,48
ties for that individual patient. There are many stan- Another possible tool to use to assess readiness to
dardized measurement tools available to assist the accept exercise is the Exercise Stages of Change Ques-
busy clinician in the objective evaluation of a patient’s tionaire49 seen in Box 14.1.␣
TABLE 14.2
Evaluation Tools for Cardiac and Muscular Capacity
Area of Evaluation Measurement Tool Example of Intervention
Exercise capacity Duke’s Activity Scale Index24 Exercise prescription with recommended intensity
level
Maximal predicted Karvonen formula39 Target heart rate zones for warm-up/cool-down
heart rate Target HR = (Max HR − Resting HR) × Target and aerobic conditioning
training intensity + resting HR Target intensity:
Max HR can be measured on exercise • Low: 60%–70%
test or estimated by the formula Max • Moderate: 70%–85%
HR = 220 − age. • High: 85%–95%
Blood pressure Patient blood pressure log Recommend optimal blood pressure range for
management patient during exercise
Balance assessment Berg balance scale40 Prescription of balance training or activity to
improve balance, e.g., Tai Chi
Aerobic conditioning Resting heart rate Frequency and intensity of exercise intervention to
Maximum heart rate41 achieve aerobic conditioning
Muscle power Manual muscle testing or 1-repetition max Recommend exercise, starting weight and repeti-
generation testing42 tions for Progressive Resistance Training program
(PRT), e.g., Weight training.
Flexibility Range-of-motion testing42 Referral to physical therapy for musculotendinous
unit restriction. Recommendation of low-velocity
home-based stretching program/activity, e.g.,
Yoga, Tai-Chi
HR, heart rate.
FIG. 14.1 Readiness ruler.
AEROBIC EXERCISE RECOMMENDATIONS is far more important to teach patients that any activ-
Aerobic conditioning should be the cornerstone of ity involving movement that elevates the heart rate can
every exercise program designed to prevent disability be considered to fulfill the exercise recommendations,
in older individuals. Aerobic training effectively low- including walking, cycling, dance, and other activities.
ers blood pressure in adults with hypertension and can Intensity can be directed with the use of the Borg scale
significantly reduce the risk of future cerebrovascular of perceived exertion—a validated scale that has been
disease.50–52 The current recommendation for aerobic shown to correlate with heart rate and is applicable in
conditioning is that all adults should participate in at this setting.59,60
least 30 min of moderately vigorous aerobic exercise Guidelines for when to consider a cardiac stress test
most days of the week or 150 min total exercise per before initiating an exercise program are well defined
week.53–58 The most effective aerobic exercise is the by the American College of Sports Medicine and Ameri-
type that a patient will actually perform on a regular can Heart Association risk stratification screening classi-
basis. The most common conceptualization of pre- fication into low, moderate, and high-risk groups. This
scriptive exercise is walking on a treadmill, but this stratification is based on cardiac risk.61 Patients who
should be challenged, as there may be barriers to access are asymptomatic and have one or less risk factors are
or other limitations that prevent treadmill walking. It low risk; patients with no symptoms and 2 or less risk
Stroke survivors usually have a VO2max that is 50%

BOX 14.1
peak aerobic power of healthy age-matched controls.62
Exercise Stages of Change Questionnaire
Individuals with reduced aerobic capacity gradually
For each statement, please mark yes or no reduce their intended activities to match their level
of cardiopulmonary reserve, and it has been demon-
1. I am currently physically active □ Yes □ No
strated that, although most stroke survivors are able to
(at least 30 min per week).
ambulate, less than 10% achieve normal ambulation
2. I intend to become more □ Yes □ No parameters.63 Improving aerobic capacity in stroke sur-
physically active in the next
vivors will provide the energy store needed to partici-
6 months.
pate in functionally important activities of daily living
3. I currently engage in regular □ Yes □ No that require both higher short-term energy expenditure
physical activity.
and longer endurance. Currently, stroke survivor con-
4. I have been regularly physically □ Yes □ No ditioning protocols have a goal intensity of 40%–70%
active for the past 6 months of VO2max. Aerobic conditioning has been shown to
Exercise Stages of Change—Scoring Key
improve the energy reserve from 10% to 15% in var-
ied older populations, whether obese, frail, or older
No to 1, 2, 3, and 4 Precontemplation stage than 75 years.64,65 Clearly, the advantages of aerobic
No to 1, 3, and 4, Yes to 2 Contemplation stage conditioning are significant throughout the lifecycle,
Yes to 1 and 2, No to 3 Preparation stage but initiating a regular conditioning program before
and 4 age 75 years yields greater benefits both in terms of the
Yes to 1 and 3, Yes or No Action stage percentage of conditioning achieved and time to accu-
to 2, No to 4 mulate benefit from overall risk reduction of chronic
disease.66
Yes to 1, 3, and 4, Yes or Maintenance stage
No to 2 The most common contributor to disability in older
individuals is arthritis.67 Any intervention shown to
improve functional outcomes in patients with arthritis
From American College of Sports Medicine. Exercise Is Medicine:
can be considered to be of significant benefit to the gen-
Healthcare Providers’ Action Guide. Available at: http://www.exerci
seismedicine.org/assets/page_documents/HCP_Action_Guide.pdf; eral population in preventing disability given the lifetime
with permission. risk of being affected by arthritis. Exercise therapy has
been shown to benefit patients with osteoarthritis of the
factors are moderate risk; and patients with symptoms knee in both pain reduction and increasing physical func-
of known cardiac, pulmonary, or metabolic disease or 3 tion.68 An umbrella review of meta-analyses of random-
or more risk factors are high risk. For patients with low ized controlled trials demonstrated that 85 meta-analyses
risk, no screening or testing is required for moderate or with 22 different chronic diseases resulted in statistically
vigorous exercise. For moderate-risk patients, there is significant improvements for 126 of 146 (86%) func-
no screening for moderate exercise and only a medical tional capacity outcomes, compared with the control
examination for high level exercise. For patients who groups.69 One can extrapolate from this that exercise
are high risk, there should be a physical examination therapy is a cost-effective way to preserve physical func-
and exercise test before both moderate and high-level tion and prevent disability.␣
exercise.61␣
BENEFITS OF SPECIFIC EXERCISE

THE ROLE OF EXERCISE THERAPY AND MODALITIES
PREVENTION OF DISABILITY Progressive Resistance Training
Aerobic conditioning has been shown to reduce mul- Muscle mass and strength first begins to decline in the
tiple cardiovascular and cerebrovascular risk factors third decade of life; however, a more rapid rate of decline
simultaneously.61 Improved blood pressure control at 2% each year starts in the sixth decade and continues
in hypertensive patients leads to a reduced risk of car- into old age.70 Changes in muscle physiology and overall
diac events and stroke. Functional independence is muscle mass contribute to age-related strength decline
affected by energy reserve that directly affects the abil- that can be attenuated by resistance training. Muscle
ity to execute functional activities such as walking and tissue responds to training even into the ninth decade;
dressing. As an example, we examine exercise in stroke. however, the presence of comorbidities can reduce the
effectiveness of PRT.71,72 Therefore, it is of greater benefit postmenopausal women who were not regular exercis-
to begin training as early as possible. As with all exer- ers before enrollment in the study. Analysis suggested
cise therapy, regularity is the key to achieving maximum that a combination resistance training, which included
benefit, and studies have consistently shown benefit high-impact and weight-bearing exercise, was more
from PRT that takes place at least two to three times a effective than PRT alone. In general, females of all ages
week. Consistent PRT has been correlated with numer- should be encouraged to incorporate resistance train-
ous functional improvements, including improvement ing into their conditioning routines with individual
in the timed up-and-go test, timed chair rise, and gait modifications for those at risk for osteoporotic fracture.␣
speed.73,74 Extrapolation to activities of daily living
based on these objective tests is reasonable. For example, Tai Chi
stair-climbing is often difficult for older adults because Tai Chi is a gentle system of traditionally standing group
of pain from osteoarthritis of the knees. The combina- exercise that integrates breathing and rhythmic move-
tion of decreased strength and pain can lead to a fear ments to achieve a conditioning effect. As Tai Chi has
of falling and an increased time to climb stairs. PRT is become a popular intervention to study in medical set-
a solution that has been demonstrated in numerous tings, programs integrating Tai Chi have proliferated to
studies to reduce time to climb stairs.75–77 It is impor- include poststroke rehabilitation, chronic obstructive
tant to keep in mind that with resistance training greater pulmonary disease (COPD), heart failure, and multiple
intensity is not necessarily better. One can assume that other medical diseases.85–87 Tai Chi has been adapted for
higher-intensity resistance training is more likely to wheelchair participants to include people with restricted
cause injury and potential disability, even if temporary. mobility and spinal cord injury.88 Owing to the lack of
In one small study there was no significant difference reported adverse events and overall safety of Tai Chi, new
between variable-intensity resistance training and high- variations are being developed, including a weighted-
intensity training in a group of older adults participat- vest Tai Chi to improve lower extremity strength and
ing in a 25-week training program.78 This challenges the water-based Tai Chi.89,90 These programs illustrate that
assumption that resistance training should be performed proliferation is giving rise to creative applications of
at the highest intensity that is considered feasible and this form of therapy. For example, the specific benefits
safe, a contrast from aerobic conditioning, which has of Tai Chi are seen in the setting of stroke rehabilitation
been shown to be of greater benefit at higher intensities. with improved balance, reduced fall rates, and improved
Resistance training can potentially reduce the risk of quality of life.91–93 Tai Chi can be adapted to suit the
disability due to osteoporotic fracture, although there particular health needs of special populations because
is no clear consensus on what is the most effective type of lack of adverse effects and an excellent safety profile.
of resistance training to prevent fracture-related disabil- In addition, Tai Chi may benefit older individuals in
ity. Osteoporosis is of significant concern globally, with improving dynamic balance and postural control and
more than 200 million people estimated to be affected reducing fall-related disability. Home- and community-
by this disease.79 Consequently, there has been exten- based Tai Chi has been demonstrated to reduce falls
sive interest devoted to the study of nonpharmacologic compared with a standard physical therapy supervised
approaches to improve bone mineral density (BMD) program of lower extremity strengthening.87 Efficiency
through resistance training. Various resistance train- of postural control and specifically control of the cen-
ing programs from two to six times a week in duration, ter of pressure have also been demonstrated following
using upper and lower body exercises, has suggested 6 months of Tai Chi instruction.94 It is unlikely there
but not definitively proved positive effects on femoral are any adverse psychological effects from Tai Chi;
neck and lumbar spinal BMD scores. The lack of sta- however, owing to the heterogeneous nature of medi-
tistically significant proof still makes definitive clinical studies concerning Tai Chi, no definitive conclusion
cal recommendations elusive.80–84 Numerous training regarding the psychological effects in older adults can
protocols have been investigated in recent trials includ- be drawn at this time. Still, it is logical to assume that
ing resistance only and resistance with high-impact or older adults would benefit from a community-based
weight-bearing exercises added in a combined training group exercise activity that has demonstrated numer-
protocol. Owing to variable training protocols, sample ous other benefits. It is reasonable to recommend
sizes, and inconsistent results, meta-analysis may sug- that patients who are at risk for falling begin a regular
gest current recommendations and future directions Tai Chi practice, as there is evidence to support the
of research. Zhao et al. completed a meta-analysis assertion that participation in this activity improves
of 24 controlled trials pooling data for 1769 healthy balance and reduces the future possibility of falling.␣
Walking Programs step goals and step diaries have been shown to be more
Walking is arguably the most functional of all con- effective at increasing participants’ physical activity than
ditioning modalities. There are few barriers to begin- those that do not.100,101 It has also been demonstrated
ning a walking program, and there is no financial that use of a pedometer can improve glycemic control
expenditure required. Self-directed walking programs in type 2 diabetic participants.102 Better glycemic con-
have been determined to be safe even for partici- trol reduces future disability from multiple causes.␣
pants at high risk for adverse cardiovascular events.95
Goodrich et al. reported that, in a clinic-coordinated
home-based walking program with 274 participants at INJURY PREVENTION IN OLDER ADULTS
high risk for cardiovascular events, almost 90% of all Fall in the elderly remain an important cause of mor-
reported adverse events were not related to the exercise bidity and mortality. Increasing mobility in older adults
program. The walking program is safe, and numerous through exercise prevents falls even while it exposes the
technological aides exist to support participants who individual to a higher-risk environment. Each clinician
are undertaking a walking program. Pedometers, smart- must determine the risk/benefit ratio for an individual
phone accelerometers, and GPS-enabled devices are all patient whether the proposed activity benefits the patient
available to help track, measure, and motivate patients more than the risk of falling during that activity. Exercise
seeking to begin a walking program. Self-directed walk- in general can also be delivered in a seating position,
ing programs are a safe and effective way to increase reducing fall risk. It is important to help patients maintain
physical activity levels with low risk of adverse events. a safe exercise routine because exercise-based fall preven-
Walking programs should be strongly encouraged by tion programs can reduce falls and their resultant injuries
providers throughout the medical community. The US in older adults.103,104 The most effective programs in pre-
Preventive Services Task Force and the American Col- venting falls incorporate multiple approaches to improve
lege of Cardiology/American Heart Association have lower extremity strengthening, endurance, and flexibility.
both concluded that rigorous examination and exercise Falls are not the only cause of injury in the older
testing is not required for patients who want to begin population. At the higher end of the functional spec-
an exercise program of moderate intensity as long as trum, increasing numbers of older adults participating
the participants are in communication with their phy- in physically demanding and competitive sports have
sicians.96,97 As with all interventions that involve a increased the rate of sport-related injuries.105,106 There-
behavioral change, it is important not to use a “one size fore it is essential that physiatrists understand their
fits all” approach when it comes to exercise counseling. important and unique role in preventing injury and
Patients should be encouraged to tailor their walking repeat injury when evaluating both sedentary individu-
programs to suit their own preferences. Adherence is als who are beginning an exercise program and provid-
improved when patients can select the type of walking ing care for the older athlete who is already exercising.
program that they prefer.98 Older athletes have been shown to sustain higher rates
Wearable electronic devices can have significant of lower extremity injuries whether at recreational or
benefits when added to a self-directed walking pro- elite levels of performance.107,108 In Sweden the rate of
gram. Use of pedometers has been associated with acute Achilles tendon rupture has increased between
increased physical activity, significant decrease in body 2001 and 2012, especially in the older population. The
mass index, and improved blood pressure control.99 By most common lower extremity cause of disability in
downloading an appropriate app, patients can use their older populations is due to osteoarthritis of the knees.
cell phones as pedometers to track their steps, turning Prevention of significant disability in an older popu-
the phones into pedometers and allowing patients to lation can be accomplished by stabilizing the knees
use the accelerometer that they likely were not aware is as much as possible with exercise to improve balance
part of all smartphones. As goal setting and attainment and quad strength. Early referral to physical therapy
is critical to achieving lasting behavior modification, when indicated can treat existing pain, improve gait,
pedometers can play an important and economical and prevent injury. Patients should be taught how to
role. Use of a pedometer allows the assignment of a incorporate a physical therapy–derived home exercise
measurable goal—steps/day. Having a step goal is a program into an overall routine of physical activity.
predictor of participants’ ability to successfully achieve Physical therapy maintenance exercises are often ideal
an increased level of physical activity. It is important for warm-up exercises, as they use stabilizing muscles and
participants to keep a step diary in which they record provide range of motion before the mechanical stress
the total number of daily steps. Interventions that use of prolonged exercise.
TABLE 14.3
Exercise Training Modalities to Prevent Disability
Modality Benefits Risks Recommendation
Aerobic Improvement in VO2max Acute coronary 150 min per week of moderate- to
conditioning Reduction in cardio/ syndromes high-intensity exercise
cerebrovascular risk factors Target heart rate: 60%–80% of predicted
Improved energy reserve maximum heart rate
Physiatric evaluation before starting to
screen for MSK conditions
Progressive Improved LE strength MSK injury ≥2 training sessions per week
resistance Reduction in falls Progress slowly to prevent injury
training Improved bone health Demonstrated benefit from high intensity
(70%–85% of 1RM)
Combined training programs more beneficial
for osteoporosis
Tai Chi Balance, well-being, fall No adverse effects Twice a week—1 h minimum per session
reduction, improved shoulder reported
ROM, reduced systolic blood
pressure109
Walking No cost, excellent safety Rare cardiac events, Increase walking distance and progress
profile potential hypoglycemia intensity within level of comfort
Fall risk (RPE 10–15 in 6–20 Borg scale)
1RM, 1 repetition maximum; LE, lower extremity; MSK, musculoskeletal; ROM, range of motion; RPE, rate of perceived exertion.
Injuries in older athletes are not restricted to the undertake a regular conditioning program that incor-
lower extremities. There is a more than 20% prevalence porates both aerobic and PRT methods. Additional
of full-thickness tears of the rotator cuff in senior ath- benefits from Tai Chi and walking are worthwhile and
letes, and there was no significant correlation between complimentary. The prevention of upper and lower
the severity of pain and degree of tear.109 This is consis- extremity injuries when undertaking a new exercise
tent with previous studies that described full-thickness program or when returning to a well-established pro-
rotator cuff tears in approximately 25% of individuals gram can be facilitated by early involvement of the
older than 60 years. Therefore one must always main- rehabilitation professional and rehabilitation team
tain a high rate of clinical suspicion for either the pos- (Table 14.3).␣
sibility of a preexisting rotator cuff tear or the potential
to create a new tear with a sudden increase in physical
activity. A careful history and thorough physical exami- FUTURE DIRECTIONS
nation with detailed focus on the range of motion of Although the literature is mature regarding the benefits
the shoulder should identify patients with shoulder of exercise and the role of exercise in preventing and
dysfunction who are at risk for rotator cuff impinge- treating disability, there are new and exciting investiga-
ment or tear. These patients should be sent to physical tions that can be highlighted as areas of future oppor-
therapy before participating in any sport that involves tunity and interest. Well-designed investigations of
stress to the shoulder girdle or rotator cuff. About 4 to high-velocity PRT or “Power training” should be under-
6 weeks of scapular stabilization with incorporation of taken in the older population. With aging, the ability to
appropriate exercises into a preexercise warm-up can generate lower extremity muscle power is lost more rap-
prevent shoulder complications from arising. idly than muscle strength.70,110 Improvement in lower
The overall benefits of a regular conditioning pro- extremity power generation has been demonstrated in
gram are clear: improved balance, glycemic control, older adults.111 If the ability of lower extremity muscles
hypertensive control, improved overall endurance, and to rapidly generate power can be reliably improved
fall reduction make a compelling case that the most with specialized training, hypothetically fall risk could
efficient way to prevent disability in the older adult is to be reduced even more than has been demonstrated
with traditional conditioning programs. Because nor- will be ever increasing demand for physiatrist-led edu-
mal ambulation can be viewed as “controlled falling” cational initiatives as well as the expertise habilitating
through the cumulative effect of a series of small per- older individuals, from athletes at all fitness levels to
turbations in balance resulting in successful and safe those with disabilities. The impact of technology on
forward locomotion, power training could have impli- the already existing multibillion-dollar fitness indus-
cations for fall prevention programs by improving the try will continue to produce novel ways to enhance the
ability to generate a corrective force quickly. A caution motivation, safety, and rehabilitation of older adults as
with power training is the increased potential for soft they engage in lifelong fitness regimens. Opportunities
tissue injury, which should be investigated in the con- are waiting for researchers who ask “how can I prevent
trolled setting of trials under medical supervision. disability and rehabilitate injury using emerging tech-
Smartphones and wearable devices continue to be nology.” The answers to this question will ultimately
an exciting area of developing interest to enhance phys- yield the greatest rewards for patients, researchers, and
ical conditioning. As the older population continues to society as a whole in the quest to prevent disability and
adopt smartphone and social media, wearable devices preserve function for all older adults.␣
are the next logical iteration of e-fitness. The potential
for technology to improve physical function and con-
ditioning is only limited by the creativity of the investi- SUMMARY OF RECOMMENDATIONS
gators who choose to explore this area. At the low end Aerobic exercise is the foundational modality to pre-
of the functional spectrum, home-based conditioning vent disease progression and disability.
programs and wearables could be used to collect and Moderate-intensity aerobic exercise (40%–60% of
catalogue physiologic information during home-based predicted heart rate maximum) can be safely used in
therapy.112–114 This valuable information can also assist almost all situations. Higher-intensity training may be
providers to assess the effect, progress, and medical appropriate for some patients as well whenever deter-
necessity of the therapy being provided. In both hos- mined to be safe and feasible.
pital and outpatient settings, smartphones are being Frequency of training should be a minimum of
used to relay patient communications, satisfaction, and twice a week, preferably three or more times a week.
activity level to care providers.115–117 Technology that Resistance training of variable intensity may be of
was initially used to bring patient information back to equal benefit to high-intensity training while poten-
the provider is now facilitating the flow of information tially reducing the risk of injury.
from provider to patient as well. Finally, patient educa- Adverse events for PRT are not adequately reported,
tion is a fertile area for the development of apps and and patient education, “prehab,” and close follow-up
interactive programs that will allow providers to query, are recommended in the older adult who is beginning
respond to, and send clinically relevant information to an exercise program.120
patients in real time. Presentation of written physical prescriptions for
Another area of potential growth in helping older exercise should continue to be given to patients, even
adults be more active is through motion-sensing tech- in the presence of electronic medical records.
nology commonly seen in the consumer computer Musculoskeletal optimization before conditioning
gaming industry. These technologies could be devel- of any type is recommended.
oped as physical therapy coaching programs to moni- Longer follow-up studies with functional outcomes
tor and offer form correction either remotely or under are needed regarding the benefits of exercise modalities
indirect supervision. Wearable devices can monitor other than aerobic conditioning.
cardiovascular response to therapy to keep partici-
pants within a safe heart-rate range.118 Lastly, patients
can receive instruction, feedback on their sessions,
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dle-aged people: trends in Northern Sweden from 1990
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to 2007. Glob Health Action. 2011;4:6347.
the taiwan society of cardiology and the taiwan hyperten-
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Med Assoc. 2015;78(1):1–47.
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2299.
CHAPTER 15
Spine Disorders in Older Adults

ADELE MERON, MD • VENU AKUTHOTA, MD
INTRODUCTION to the trunk while allowing movement in multiple

Back pain is one of the most common presenting com- planes. In all, 33 vertebrae make up the spine, includ-
plaints to physicians and a leading cause of disability in ing 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4
patients of all ages. Disorders of the spine have a consider- coccygeal. At each level, excluding the unique atlas
able burden on both the quality of life of affected patients and axis, the cylindrical bony vertebral body forms the
and the healthcare economy. Although it was previously anterior weight-bearing component of the spine. Paired
suggested that back pain was an ailment of the working- pedicles and lamina form an arch and convalesce pos-
age patient, more recent studies have shown that severe teriorly to form the spinous process. From the arch
back pain increases with age. Spine disorders affect both emanate the superior and inferior articular processes
the hospitalized and ambulatory communities and appear that articulate to form the zygapophysial joints, which
to affect the geriatric population to a greater extent. The connect adjacent vertebrae and prevent anteroposterior
global point prevalence of symptomatic low-back pain translation and twisting of the vertebrae. The vertebral
has been estimated to reach 10%, with both prevalence body’s connection to the posterior bony elements by
and disease impact increasing with age.1 Low back pain the pedicles forms the ring-shaped vertebral foramen,
has been cited as the highest burden of disability glob- which houses the spinal cord and surrounding cere-
ally. In 2010 patients older than 65 years made up 17% of brospinal fluid. The vertebral body comprises a shell
the US population and 48% of hospital discharges for low of cortical bone encasing a form of transverse and verti-
back disorders for an estimated 350,000 hospitalizations cal trabeculae promoting dynamic load bearing while
for low back pain in patients over 65 years in 2010.2 The minimizing mass. The intervertebral disc is a strong but
aging population will contribute significantly to the bur- deformable ring of fibrocartilage surrounding a gelati-
den of spine disorders on the healthcare economy in both nous central nucleus pulposus, the purpose of which is
hospital admissions and ambulatory pain management. to transmit force between vertebrae while allowing the
Analysis of the Medicare database estimated that Medi- rocking movement that permits flexion, extension, and
care beneficiaries used 4.8 million interventional spine lateral bending of the spine. The segmental motion at
procedures in 2011, which represented a 228% increase each level is limited owing to the shape of the articular
since 2000.3 Rehabilitation physicians practice in a variety and spinous processes and by the splinting of the rib
of settings from inpatient acute and subacute rehabilita- cage at the thoracic level. Although the combination of
tion facilities, inpatient consult services, and skilled nurs- bony elements and intervertebral disks provides stabil-
ing facilities to outpatient rehabilitation clinics and spine ity and protection of neurologic structures, while allow-
centers, all of which have the responsibility of caring for ing segmental movement, the actions of the powerful
older adult patients with spine disorders. The multidisci- flexor and extensor muscle groups augment motion,
plinary nature of a rehabilitation team provides an ideal stability, and position control of the spine from axis to
model for treating spine disorders. Care should be longi- sacrum. As these structures age, they lose their ability to
tudinal, with a sharp focus on optimizing function and perform these essential functions (Fig. 15.1A–C).␣
realistic goal setting. Understanding spine disorders that
affect the aging population is essential for all members of
the rehabilitation team.␣ AGING
At birth the entire spine is kyphotic and remains so
until the erect postures of sitting and upright walk-
SPINE STRUCTURE AND FUNCTION ing are initiated. At this point, the cervical and lumbar
The spine is a complex modular structure composed of spines become lordotic. Over the first year of life, the
alternating bony and fibrocartilage elements that pro- sacral and coccygeal vertebrae fuse to form a single
vides protection of neurologic structures and support wedge-shaped base. Each component of the spine
195
B
B
C
A D
FIG. 15.1 (A–D) Spinal anatomy. ((A) © Elsevier. Drake, et al. Gray’s Anatomy for Students. www.studentconsult.com.
Reproduced with permission. (B) From Lawry GV, Hall H, Ammendolia C, et al. The spine. In: Lawry GV, Kreder HJ, Hawker
GA, et al., eds. Fam’s Musculoskeletal Examination and Joint Injection Techniques. 2nd ed. Philadelphia: Mosby, Inc.; 2010;
with permission. (C) From Moulton AW. Clinically relevant spinal anatomy. In: Errico TJ, Lonner BS, Moulton AW, eds. Surgi-
cal Management of Spinal Deformities. 1st ed. Philadelphia: Saunders; 2009; with permission. (D) From Arakal RG, Mani
M, Ramachandran R. Applied anatomy of the normal and aging spine. In: Yue JJ, Guyer RD, Johnson JP, et al., eds. The
Comprehensive Treatment of the Aging Spine. Philadelphia: Saunders; 2011; with permission.)
CHAPTER 15 Spine Disorders in Older Adults 197
undergoes degenerative changes over time, contribut- diffusion. The balance of anabolic and catabolic activi-
ing to a cycle that alters the biomechanical properties ties of the cells is critical to maintaining the health and
of the spine, leading to a new environment that con- structure of the disc.4
tributes to further degenerative changes. Degenerative Biochemical changes within the disc are central to
processes of the individual tissues vary, but all share the changes that occur with age. The balance between
the basic principles of initial biochemical changes synthesis and degradation of matrix breaks down, lead-
leading to microstructural and then macrostructural ing to alterations in relative proportions of water, pro-
failure.␣ teoglycans, and collagen. Biochemical processes within
the disc begin changing at birth as the blood supply
to the disc diminishes and the cells adapt to anaero-
IS DEGENERATIVE DISC DISEASE A bic metabolism over the first decade of life. Cell con-
DISEASE? tent also changes with age as the proportion of cells
Although the aging process is subject to various genetic that exhibit necrosis goes from 2% in infancy to 50%
and external factors, overall the process is fairly uni- in young adults and 80% in the elderly. The proteo-
form. Thus the definition of a normal spine structure glycan content and size decrease with age. Within the
varies by age. In the absence of painful processes or nucleus pulposus, the proteoglycan content decreases
functional limitations, it may be misleading to describe from 65% in early adult life to 30% at age 60 years. In
these changes as a disease process rather than simply contrast, the collagen content in the nucleus and annu-
the typical process of aging.␣ lus both increase with age, whereas elastin decreases.
The water content in the disc also decreases from 88%
at birth to 65%–72% at age 75 years.4 In summary, the
INTERVERTEBRAL DISC discs become drier, more fibrous, and less elastic, mak-
The basic structure of the intervertebral disc includes ing them more resistant to deformation and less able
the central nucleus pulposus surrounded by the periph- to regain their shape after deformation occurs. A drier
eral annulus fibrosus (Fig. 15.1D). Although the disc is nucleus pulposus with decreased hydrostatic pressure
distinctly different at the center and at the periphery, can no longer transmit and disperse weight, and thus
the area where the two components merge is not a dis- the annulus fibrosus bears a larger proportion of the
crete line but a gradual merging of the two structures, weight with age. With chronic weight bearing on the
which share common components but are differenti- annulus, over time microcracks develop and provide
ated by their relative concentrations. In young adults, the foundation for larger concentric fissures and radial
the nucleus pulposus is a semifluid mass of mucoid tears to develop with continued load bearing. These
substance composed of 70%–90% water (although mechanical changes can lead to diffuse bulging of
this varies with age). The dry weight of the nucleus is the disc even without a discrete herniation of nucleus
approximately 65% proteoglycans and 15%–20% col- material through the annular ring. In addition, owing
lagen with rare chondrocytes interspersed within the to the arrangement of the lamellae, the posterior and
matrix. The biomechanical properties are similar to posterolateral segments of the annulus are susceptible
that of a fluid-filled balloon that stretches and deforms to thinning and can serve as a weak point for overt her-
with compression. In contrast, the annulus fibrosus is niation of the nucleus pulposus. Although loss of disc
60%–70% water, with a dry content of 50%–60% colla- height is frequently cited as a sign of age-related pathol-
gen and 20% proteoglycans, primarily in the aggregated ogy in the spine, studies have shown this may not be
form. In the transition from outer annulus to inner the case. In the absence of alternate pathologic deterio-
nucleus the proteoglycan content increases as the col- ration, the intervertebral discs actually increase in size,
lagen content decreases. The annulus consists of highly both in the anteroposterior dimension and in height.4␣
ordered layers of lamellae arranged in concentric rings.
The hydrostatic pressure in the nucleus is contained by
the surrounding annulus, allowing the distribution of VERTEBRAL BODY AND ENDPLATE
force over the entire surface of the adjacent vertebral The vertebral body is designed for longitudinal load
body. Maintaining the proteoglycan and collagen con- bearing. The external cortical shell is augmented with
tent requires metabolically active chondrocytes and internal vertical trabeculae that are able to sustain
fibroblasts, which require oxygen, glucose, and other great longitudinal loads and horizontal trabeculae that
substrates. As the disc lacks a robust blood supply to prevent bowing of the vertical trabeculae. The hori-
provide these nutrients, they are generally delivered by zontal trabeculae also transmit tension horizontally,
increasing the resilience of the structure. With age, ver-

tebral bodies exhibit a decrease in bone density and
strength as a result of the change in structural com-
position of the enclosed trabeculae. The strength and
weight-bearing capacity of the vertebral body rely on
the horizontal trabecular bracing of the vertical trabec-
ulae. The cortical shell typically provides only 15% of
the load-bearing capacity of the vertebral body. Over
time, there is a relative loss of the horizontal trabeculae,
decreasing the load-bearing capacity of the central sur-
face of the vertebral body and forcing the cortical bone
to support a greater proportion of the applied load.
The vertebral endplate lies at the interface between
the vertebral body and intervertebral disc and is formed
by layers of subchondral bone and cartilage of approxi-
mately equal thickness. The function of the endplate
is to distribute force over the surface of the vertebral FIG. 15.2 Applied anatomy of the thoracic and lumbar
body as well as provide a connection between the spine. (From Waldman SD. Functional anatomy of the lum-
fibrous disc and the vertebral bone. The endplate is bar spine. In: Waldman SD, ed. Physical Diagnosis of Pain.
permeable enough to allow water and solutes to pass 3rd ed. St. Louis: Elsevier, Inc.; 2016; with permission.)
through to supply nutrients to the disc; however, it is
dense enough to prevent extrusion of the disc material. shown that facet degeneration follows disc degenera-
Endplate thickness is variable, with increased thickness tion.6 Loss of disc height and segmental instability lead
at the periphery, which has been shown to correlate to increased load on the facets and increased joint sub-
with endplate strength. Disc properties also appear luxation. The process of facet degeneration is similar to
to influence the endplate structure. A connection has that of other diarthrodial joints. The process consists
been shown between the proteoglycan content of the of erosion of the hyaline cartilage, hypertrophy of the
disc and the thickness of the underlying endplate, sug- synovial membrane, sclerosis of subchondral bone,
gesting that the previously described age-related loss and formation of osteophytes. This begins a cycle of
of proteoglycan content of the disc may contribute to remodeling that contributes to decreased mobility of
changes in the endplate. Given the importance of load the joint. Facets are innervated, and their degeneration
distribution on maintaining the structural integrity of may cause its own painful syndrome. In addition, facet
the spinal elements, as the endplate undergoes degra- hypertrophy can lead to a cascade of structural changes,
dation, further structural changes in the vertebral body including nerve root impingement, central stenosis, or
are initiated. Concurrently, the vertebral body loses spondylolisthesis.␣
bone density, causing a two-hit model of degradation
of the vertebral body from both internal and external
factors. Biomechanical studies have shown the end- MUSCLES AND LIGAMENTS
plate to be the weakest component of the vertebral In addition to providing a significant contribution to
body under repetitive loading conditions.5 Weakened the mobility and stability of the spinal column, mus-
endplates and vertebral bodies predispose the spine to cles and ligaments have a proprioceptive role. Recep-
a variety of structural failures, including endplate frac- tors in these structures stimulate muscle contraction
tures, vertebral body fractures, and Schmorl nodes, all throughout the spine and core to provide stability and
of which are discussed later in this chapter.␣ balance, support complex movements, and protect
from movements that would cause excessive stress on
the spine. Ligaments are composed of a high concentra-
FACET JOINTS tion of collagen and serve a relatively minor stabilizing
The facet joints are diarthrodial, synovial joints that function to the spine, whereas their elastic components
add to the stability of the spine in flexion and exten- allow for some movement and flexibility. For example,
sion, limit axial rotation, and partially contribute to the ligamentum flavum, which connects adjacent lam-
weight bearing (Fig. 15.2). They are composed of sub- ina, has a higher concentration of elastin than most
chondral bone covered by hyaline cartilage. It has been spinal ligaments (80% elastin and 20% collagen)7 to
allow for stretch during flexion and return to rest dur-

ing neutral and extension. Longitudinal ligaments have
a higher collagen concentration and provide resistance
to flexion (posterior longitudinal ligament) and exten-
sion (anterior longitudinal ligament). As ligaments age,
they exhibit both biochemical and structural changes.
The elastin concentration increases, decreasing their sta-
bilizing capacity. The ligamentum flavum can undergo
hypertrophy, which can contribute to central stenosis.
Core muscles stabilize and mobilize the spine.
Muscle fibers degenerate over time and are replaced by
adipose. Tendinous attachments degenerate in a similar FIG. 15.3 Osteoporotic vertebral body (right) shortened
by compression fractures compared with a normal vertebral
mechanism to ligaments and osteophytes form at their
body (left). Note that the osteoporotic vertebra has a char-
attachment sites, decreasing their contractile forces.␣ acteristic loss of horizontal trabeculae and thickened verti-
cal trabeculae. (From Kumar V, Abbas AK, Aster JC. Bones,
joints, and soft tissue tumors. In: Kumar V, Abbas AK, Aster
SPINE CONDITIONS AFFECTING OLDER JC, eds. Robbins Basic Pathology. 10th ed. Philadelphia:
ADULTS Elsevier; 2018; with permission.)
Osteoporosis and Vertebral Fractures
Normal bone metabolism more vascular than cortical bone, making cancellous
Osteoporosis, put simply, is an imbalance of bone bone more susceptible to the metabolic alterations that
homeostasis whereby bone resorption outweighs bone lead to osteoporosis.␣
deposition. The primary risk factor for the develop-
ment of osteoporosis is age. Bone homeostasis is under Risk factors
the control of both intrinsic and extrinsic factors that Clinically, osteoporosis is diagnosed by dual-energy
affect the relative concentrations and activities of osteo- X-ray absorbometry (DEXA) scan with lumbar spine
blasts (bone-forming cells) and osteoclasts (bone-reab- measurements that are 2.5 standard deviations below
sorbing cells). As described earlier, the vertebral body the average value for a 30-year-old gender-matched
is mostly trabecular bone, a porous scaffold of inter- individual (t-score < 2.5). Osteoporotic compression
locking vertical and horizontal supports. A thin exte- fractures occur when the bone density reaches a level
rior of cortical bone surrounds the cancellous central where the loads imposed by daily activity exceed the
core. Both cortical and cancellous bones are composed strength of the vertebral body. Vertebral compression
of extracellular matrix with varying degrees of miner- fractures are the hallmark of osteoporosis and occur
alization. Osteoid, the nonmineralized component of more commonly in the early stages of osteoporosis
bone, is made up of collagenous and noncollagenous than any other type of fracture.8
proteins and is secreted by osteoblasts. The mineral- Vertebral compression fractures (Fig. 15.3) are pre-
ized part of bone is made up of calcium hydroxyapa- dictors of morbidity and mortality, social isolation, and
tite, and the mineralization depends on the amounts overall quality of life,9 and thus, identification of risk
of calcium and phosphate ions. The strength of min- factors for fracture is of paramount importance. Low
eralized bone increases with increasing concentrations bone mass is a clear predictor of osteoporotic vertebral
of calcium. Formation and mineralization of osteoid fractures, so it is important to be able to identify all
are initiated by osteoblasts with input from parathy- associated risk factors. Peak bone mass is achieved in
roid hormone (PTH) and 1,25-dihydroxyvitamin D. the second or third decade of life, followed by a slow
Osteoclast differentiation activity is also mediated progressive decrease. Although loss of bone mass is a
by PTH and 1,25-dihydroxyvitamin D, although not common cause of osteoporosis, it is important to note
through direct binding but through interaction with that it is not the only cause. Failure to reach peak bone
osteoblasts. Receptor activator of nuclear factor kappa- mass can lead to the development of osteoporosis
B (RANK) ligand is an essential mediator of osteoclast without the acceleration of bone loss later in life. Thus
differentiation. chronic disease during childhood and adolescence is
The architecture of bone has metabolic consequence an identifiable risk factor for low bone mass later in
and thus influences the susceptibility to osteoporosis. life. Female gender is a risk factor for bone loss. Men
Cancellous (trabecular) bone is more porous and thus lose bone at a rate of 0.3% per year. Women lose bone
at a rate of 0.5% per year; however, following meno- with anterior compression or a biconcave shape with
pause this rate accelerates significantly, up to 5%–6% a central depression. There are proposed methods for
per year in the first five menopausal years.10 Other risk quantitative and semiquantitative methods for frac-
factors for low bone mass include estrogen deficiency, ture assessment. As there remains a lack of consensus,
low body mass index (BMI), smoking, family history of it was recommended by the US National Osteoporosis
osteoporosis, and history of prior fracture.8 Inadequate Foundation’s Working Group on Vertebral Fractures
calcium intake is a risk factor for developing low bone that radiographic assessments should be performed by
mass. Elderly patients may have a decreased overall a radiologist or trained clinician who has specific exper-
food intake or financial constraints that lead to poor tise in the radiology of osteoporosis.13␣
calcium intake. In addition, once osteoporosis has
manifested, anterior vertebral body compression frac- Prevention
tures, leading to thoracic kyphosis, can promote early Calcium intake is critical for maintaining bone mass,
satiety,11 creating a self-perpetuating cycle of poor bone and the recommended intake is not regularly achieved.
health. Decreases in physical activity that often accom- The recommended intake in adolescence is 1300 mg/
pany aging also lead to decreased bone mass. Again, a day, and it is estimated that 25% of boys and 10% of
self-perpetuating cycle beginning with decreased activ- girls meet this recommendation. For older adults the
ity levels, which result in a decrease in bone mass, leads recommended calcium intake is 1000–1500 mg/day,
to vertebral compression fractures that further limit and 50%–60% of adults are meeting this recommenda-
physical activity. tion. Vitamin D is essential for calcium absorption, and
Although low bone mass is a significant predictor of 400–600 IU/day is recommended for adults.
fractures, research indicates that a propensity for falls Physical activity throughout life is critical for build-
is another important risk factor for fracture. Fracture ing bone mass and avoiding vertebral compression
risk has been associated with a history of falls, poor fractures. Studies have shown physical activity in child-
vision, environmental hazards, cognitive deficits, slow hood and adolescence contributes to higher peak bone
gait speed, and decreased quadriceps strength. Fall pre- mass.8 There are less data available on the effects of
vention is paramount in the prevention of vertebral physical activity on bone mass later in life; however,
fractures. there are strong recommendations for a multicompo-
Secondary osteoporosis is the result of a pri- nent exercise program that includes balance and resis-
mary medical condition or medication that leads to tance training in older adults and particularly those
decreased bone mass and increased risk of fracture. In who have sustained osteoporotic vertebral fractures14
women, secondary osteoporosis is most commonly for fracture prevention and to maintain functionality.
caused by hypoestrogenemia, glucocorticoid use, thy- Kyphotic posture is associated with vertebral fractures
roid hormone excess, and anticonvulsant use. In men, and can contribute to balance deficits and an increased
the most common causes are hypogonadism, use of risk of falls. Accordingly, a supervised exercise program
glucocorticoids, and alcoholism.␣ with a physical therapist is recommended.
Screening recommendations have been outlined by
Diagnosis the National Osteoporosis Foundation as a means of
Both asymptomatic and symptomatic fractures are pre- fracture prevention. Recommendations include screen-
dictors of increased morbidity and mortality. Studies ing for all women over the age of 65 years and men
have shown that only 25% of vertebral fractures are over the age of 70 years. Screening can be performed by
clinically recognized. This is in part due to not only DEXA of the hip and lumbar spine or calcaneal quanti-
the lack of presenting symptoms but also the rarity of tative ultrasound imaging.15 Adults under the screening
fracture in relation to the prevalence of back pain. Less age may also require screening based on the aforemen-
than 1% of back pain is related to fracture, so fracture tioned risk factors. The FRAX tool (Fracture Risk Assess-
is often not evaluated for in the absence of trauma.12 ment tool, World Health Organization Collaborating
Once a vertebral fracture is suspected, or it is deter- Centre for Metabolic Bone Diseases, Sheffield, United
mined that screening is warranted based on risk factors, Kingdom; www.shef.ac.uk/FRAX) has been developed
lateral radiographs of the spine should be obtained to determine a 10-year fracture risk based on eas-
to evaluate for fracture. There is a lack of standardiza- ily obtainable clinical information, such as age, BMI,
tion for diagnosing and grading vertebral fractures, parental fracture history, tobacco use, and alcohol use.
as vertebral deformity does not always represent a In addition, there are recommendations for
fracture. Fractures commonly occur in a wedge shape screening specifically for vertebral fractures. Despite
a proportion of them being asymptomatic, vertebral within the facet joints start at age 30 years and progress
fractures are diagnostic of osteoporosis, increase the until they are nearly ubiquitous by the age of 60 years.
risk of subsequent fractures, and are an indication Although there is clear evidence that intervertebral
for initiating treatment for osteoporosis. Indications disc degeneration incites degenerative changes in the
for screening imaging to assess for vertebral fractures facet joints, the reverse is also true. Motion abnormali-
include women older than 70 years and men older ties in the facet joints can lead to enhanced degenera-
than 80 years with T score < −1.0, women 65–69 years tion of the intervertebral disc. Orientation of the joints
and men 70–79 years with T score < −1.5, and post- determines which actions of spinal motion they resist.
menopausal women and men older than 50 years with The L4-5 facet joints are most coronally oriented (about
a low trauma fracture in adulthood, historical height 70 degrees from the sagittal plane), which makes them
loss of more than 4 cm, prospective height loss of more protective against flexion and shearing. Con-
more than 2 cm, or recent or ongoing glucocorticoid versely, the L2-3 and L3-4 joints are more sagittally
treatment.16␣ oriented (less than 40 degrees from the sagittal plane),
which makes them more resistant to axial rotation. The
Management orientation of facet joints also changes with age. With
The National Osteoporosis Foundation recommends age, facet joints at all levels become more sagittally ori-
initiating pharmacologic treatment for patients with ented. Orientation changes can differentially affect the
hip or vertebral fractures, those with osteoporosis facet joints at the same level, a phenomenon known as
diagnosed by DEXA (T score < −2.5), postmenopausal tropism.
women and men over 50 years with a diagnosis of Degenerative changes that can develop include bony
osteopenia by DEXA (T score between −1.0 and −2.5), erosions, subchondral sclerosis, osteophyte formation,
and those with a 10-year hip fracture probability of bony hypertrophy, and synovial cysts. Although these
>3% or a 10-year major osteoporosis-related fracture changes are well documented and easily identifiable
probability >20% based on the absolute fracture risk by standard imaging, the correlation between visual
model (FRAX).16 Current US Food and Drug Admin- degenerative changes and pain is less clear. To be a pain
istration–approved pharmacologic options include generator a structure must have a nerve supply. Each
bisphosphonates, calcitonin, estrogen agonist/antago- facet joint is dually innervated by the posterior primary
nists, PTH-134, and RANK ligand inhibitor. The selec- rami of the levels at the facet joint and one level above.
tion of the appropriate pharmacologic treatment for For example, the C5-6 facet joint is innervated by the
osteoporosis depends on efficacy, tolerability, and C5 and C6 medial branches and the L4-5 facet joint is
safety profile and should be a joint decision between innervated by the L3 and L4 medial branches, relative
patient and clinician.␣ to the fact that there is a C8 nerve but no C8 vertebrae.
The medial branches also innervate the multifidi, inter-
Facet Arthropathy spinous muscles, and the ligament and periosteum of
Although there is clear evidence of degenerative the neural arch.18␣
changes in the facet joints, the role of the facet joint
in the etiology of low back pain remains controversial. Clinical presentation
There is a debate surrounding the prevalence, effective- Diagnosis of facet-mediated pain may be the most con-
ness of imaging and clinical testing in diagnosis, and troversial aspect of this condition. Multiple signs and
treatment of suspected facet-mediated pain. The preva- symptoms have been proposed as predictors or diag-
lence of facet-mediated back pain has been reported nostic criteria for facet-mediated pain; however, there
between 15% and 52%, with some studies showing a has been little success in their validation. Suggested
greater prevalence in the elderly17 (Fig. 15.4). clinical symptoms include age over 65 years, unilateral
or bilateral low back pain in the absence of radicular
Pathogenesis features, pain not associated with cough or sneeze, and
As described earlier, facet joints are synovial joints low back pain with groin or thigh pain. Symptoms pro-
that form the posterior articulation between adjacent posed to be associated with facet-mediated pain include
vertebrae. With age and the degeneration of the inter- pain with extension, rotation, and lateral flexion that is
vertebral disc, load is transferred to the facet joints. In relieved by flexion and tenderness to palpation over the
healthy structures, the facet bears between 3% and 25% transverse processes or facet joints.19 None of these fea-
of the load, whereas degenerative joints can bear up to tures, however, has been able to predict the response to
47%.18 Based on imaging studies, degenerative changes local anesthetic block of the medial branches. Likewise,
A B
C D
FIG. 15.4 (A, C) Midsagittal and axial views of the normal cervical spine. (B, D) Midsagittal and axial
views of cervical spinal stenosis result from a combination of a congenitally narrow cervical spinal canal
and superimposed cervical spondylosis. (A) The anteroposterior spinal canal diameter. (B) The vertebral
body diameter. (C) The narrowest spinal canal opening as measured by the distance between the most
posterior aspect of a vertebral body, including its osteophytic spur, and the nearest point on the spinolami-
nar line formed by the junction of the lamina and spinous process. (From Tracy JA, Bartleson JD. Cervical
spondylotic myelopathy. Neurologist. 2010;16(3):176–187; with permission.)
radiologic studies have failed to show consistent cor- to identify consistent referral patterns. There was more
relation with clinical symptoms. consistency with provoked pain via electrical stimulation
Localization of pain to a particular joint is similarly of the medial branches; however, these did not match pat-
challenging. Patient-reported pain maps have been unable terns provoked with intraarticular facet injection.20␣
Diagnosis or placebo-controlled blocks for patient selection. The

Because of the lack of specificity of clinical signs and most stringent inclusion criteria was used by Dreyfuss,
symptoms of facet-mediated pain, there are very nar- who enrolled only patients who had 80% pain relief
row diagnostic criteria recommended. Facet-mediated following a medial branch block using 0.5 mL of 2%
pain should be diagnosed by radiologically guided, lidocaine and 80% pain relief for greater than 2 h fol-
comparative, or placebo-controlled intraarticular lowing a medial branch block using 0.5 mL of 0.5%
facet injections or medial branch blocks. Compara- bupivacaine.22 Of these patients who met these criteria,
tive blocks are important for the diagnosis owing to 87% obtained at least 60% pain relief for 12 months
a high false-positive rate for a single diagnostic block and 60% achieved at least 90% pain relief. In addition
using lidocaine, reported at up to 40%.18 As diagnosis to these stringent criteria, Dreyfuss further optimized
requires multiple interventional procedures and the these procedures by using 16-gauge electrodes and
natural history of axial back pain is generally favor- assessing the denervation of the multifidus muscles
able, definitive diagnosis of acute and subacute axial using electromyography to evaluate the success of the
back pain that is suspected to be facet mediated may procedure. In combination, these results suggest that
not be necessary before initiating treatment. Only in radiofrequency denervation can be highly effective if
the case of pain refractory to conservative measures patient selection is optimized.␣
are interventional diagnostic and therapeutic proce-
dures necessary.␣ Cervical Myelopathy
Degenerative cervical myelopathy is a nontraumatic
Management spinal cord injury caused by age-related changes to
Treatment of facet-mediated pain should consist of a the axial cervical spine resulting in spinal cord com-
multimodal approach, including medications, physical pression. The clinical syndrome is characterized by
therapy, procedural interventions, and, in some cases, gait imbalance, hand dysfunction, and loss of sphinc-
psychotherapy. Medications can include nonsteroidal ter control. This condition has a significant impact on
antiinflammatory drugs (NSAIDs) and acetaminophen. the function and quality of life and is among the most
No specific physical therapy program has been shown common indications for surgery among older adults.
to specifically affect facet-mediated pain; however, yoga Degenerative cervical myelopathy is the leading cause
and tailored exercise program have both been shown to of spine dysfunction in adults globally, and the annual
be generally helpful in axial low back pain.21 The effect incidence is estimated at 41 million per year in North
of intraarticular steroid injection is under debate. Mul- America.23 The pathogenesis of degenerative cervical
tiple studies have evaluated the effect of intraarticular myelopathy involves age-related progressive changes
steroid, and the results are mixed. Overall, it appears to a variety of spinal structures, including facet joints,
that a subset of patients with facet-mediated pain, par- intervertebral discs, or vertebral bodies; hypertrophy or
ticularly those with inflammatory changes, could have ossifications of the ligamentum flavum or the posterior
intermediate-term pain relief from intraarticular injec- longitudinal ligament; progressive cervical kyphosis; or
tions.21 This is based on studies using imaging to detect any combination of these processes.
inflammatory changes, including single-photon emis-
sion computed tomography and radionuclide bone Pathogenesis
scintigraphy; imaging modalities are not routinely used The process is thought to occur by a cascade of events
in spine diagnostics. starting with disc degeneration. Owing to anatomic dif-
Radiofrequency denervation is a widely studied ferences, the degenerative process in the cervical spine
treatment for facet-mediated pain that also has con- is slightly different than that in the lumbar spine. Discs
flicting evidence. In this technique, a needle is guided degenerate similarly with alterations in the proteo-
fluoroscopically to the medial branches that supply the glycan and collagen contents, resulting in loss of disc
affected joint (or in the case of L5, the dorsal ramus height and increased stress on joints. In the cervical
is the target). Radiofrequency energy is conducted spine, uncovertebral joints (joints of Luschka) lie on
directly onto the nerve to ablate the nerve supply to the the lateral aspect of the vertebral body where a superior
joint via a controlled burn. Some studies have shown a projection, the uncinate process, articulates with the
success rate as high as 80% for sustained relief, whereas undersurface of the cephalad vertebral body (Fig. 15.5).
others have shown much lower rates of success.21 As disc height decreases, the load-bearing responsibili-
Inconsistencies stem from varying methods for patient ties get transferred to the uncovertebral joints, which
selection; for example, not all studies used comparative in turn gradually flatten. This transfers load to the
A B
C
FIG. 15.5 Magnetic resonance imaging of the cervical spine. (A) Sagittal T2-weighted image of a 74-year-
old woman with multilevel cervical spinal stenosis worse at C5-6, more than C4-5, more than C3-4. There
is very little spinal fluid in front of or in back of the spinal cord at these levels. There is increased T2 signal
intensity within the spinal cord just below the C5-6 interspace level (arrow). (B) Axial T2-weighted image
at the level of maximal stenosis and spinal cord deformity (C5-6 interspace). The spinal cord is deformed
and thinned (banana-shaped) by a bulging disk and osteophytic spurring anteriorly and the laminae and
ligamenta flava posteriorly (arrows). (C) Axial T2-weighted image at a level between the interspaces below
the area of maximal stenosis showing T2 signal hyperintensity (arrows). (From Toledano M, Bartleson JD.
Cervical spondylotic myelopathy. Neurol Clin. 2013;31(1):293; with permission.)
vertebral endplates. Osteophytes form to improve the encroaching on the central canal. Other degenerative
load-bearing capacity of the endplates and to stabilize changes that can contribute to central stenosis include
the abnormal motion created by the degeneration. spondylolisthesis, disc herniation, and ossification of
Osteophytes encroach on the central canal, creating the posterior longitudinal ligament23 (Fig. 15.6).
anterior central stenosis. Posteriorly, the loss of cervi- In addition to the static factors listed before,
cal lordosis in combination with the loss of disc height dynamic factors contribute to central stenosis that
causes the ligamentum flavum to stiffen and buckle, leads to spinal cord compression. Neck flexion causes
A B C
FIG. 15.6 Lumbar canal stenosis. Magnetic resonance imaging. (A) Sagittal and (B) axial images through
L4-5 and (C) axial images through L5-S1, showing spinal stenosis at L4-5. (From Perkin GD, Miller DC,
Lane RJM, et al. Spinal disorders. In: Perkin GD, Miller DC, Lane RJM, et al., eds. Atlas of Clinical Neurol-
ogy. 3rd ed. Philadelphia: Saunders; 2011; with permission.)
the anterior osteophytes to encroach further into the Clinical presentation

central canal. Neck extension allows increased laxity in Symptoms of degenerative cervical myelopathy are
the ligamentum flavum, and the cord can be pinched related to the degree of compression of the various
between the vertebral body and the buckled ligament spinal cord tracts. The clinical syndrome ranges from
or the lamina posteriorly. mild difficulties with hand function and mild bal-
Biochemical changes within the cord contribute ance deficits to incontinence and complete paralysis.
to disruption of normal neurologic signaling. Both There are several studies that have shown a surpris-
vascular and neuroinflammatory changes have been ing prevalence of cervical spine imaging findings in
demonstrated in in vivo and in vitro studies. Chronic asymptomatic populations. In a study of asymptom-
compression of the cord leads to chronic ischemia atic patients aged 60–65 years, 90% of men and 75%
induced by microvascular and macrovascular changes of women had degenerative changes on lateral cervical
that cause an overall decrease in spinal cord perfusion. spine radiograph.25 Another study of asymptomatic
The result is hypoxic conditions, a decreased number patients aged 20–79 years found significant disc bulg-
of blood vessels, and reduced blood flow throughout ing in 87% of patients, evidence of cord compression
the axonal pathways, including the corticospinal tract. in 5.3%, high-intensity signal lesions in 2.3%, and
Hypoxic conditions in the cellular milieu lead to ionic flattening of the cord in 3.1%.26 This highlights the
imbalance in the neuron and excitotoxic glutamate difficulty of correlating imaging findings with clinical
release, increasing the boundaries of the local injury.24 symptoms.
Levels C5 through C7 have been shown to be the most As progression of symptoms is often slow, patients
susceptible to vascular insult and thus are the most may not be able to identify them without specific prov-
common levels for myelopathic changes. ocation. Accordingly, a thorough history and physical
In addition, studies have shown increased perme- examination are essential for early diagnosis. History
ability of the blood-spinal cord barrier with chronic should include difficulty with fine motor tasks, includ-
compression, leading to edema within the cord, neu- ing buttoning, using a smartphone or keyboard, or
roinflammatory changes, and neuronal breakdown. changes in handwriting. Upper extremity paresthesias
The combination of neuroinflammation and hypoxic and Lhermitte sign are also reported. An early com-
conditions leads to cellular apoptosis in the corticospi- mon finding in degenerative cervical myelopathy is the
nal tracts.24 Overall the ischemia, neuroinflammation, necessity of handrail use when negotiating stairs, which
demyelination, and neuronal apoptosis lead to abnor- a patient is unlikely to volunteer unless asked by a clini-
mal signaling in the spinal cord and the clinical condi- cian. Bladder dysfunction, a commonly queried red flag
tion associated with degenerative cervical myelopathy.␣ symptom, is a late finding of cervical myelopathy and
would suggest advanced disease rather than being used hypermobility at any segment. MRI provides a more
as an early screening question. detailed view of the soft tissues and spinal cord and can
Physical examination should include an examina- assess for disc herniations, facet hypertrophy, thickness
tion of the cervical spine, including range of motion. and position of the ligamentum flavum, and diameter
Upper extremity function testing should include and shape of the spinal canal and spinal cord. It can
examination for intrinsic muscle wasting and strength, also identify hyperintense T2 signal within the cord
and sensory examination should include all testable representative of edema or myelomalacia. Absolute ste-
myotomes and dermatomes. Tone examination of the nosis has been defined as a sagittal canal diameter less
upper and lower extremities may reveal spasticity in a than 10 mm and relative stenosis as less than 13 mm.
myelopathic patient. Reflex examination should be per- However, these absolute numbers should be inter-
formed in the upper and lower extremities, as hyperre- preted with caution, as they are subject to genetic varia-
flexia is a common finding. Hoffman sign is commonly tion and body size.
associated with cervical myelopathy, although it has As described earlier, MRI is able to detect subtle cord
been shown to have a relatively low sensitivity (58%) in compression and signal intensity abnormalities that
clinical studies. There is some evidence that the applica- correspond with variable clinical presentation. There
tion of a dorsiflexion force to the distal interphalangeal is an overlap in MRI findings between myelopathic
increased sensitivity to 77%. This is at the cost of speci- and nonmyelopathic cord compression, resulting in a
ficity, which decreases from 97% to 77% when compar- “clinical-radiological mismatch.” Prevalence of non-
ing dorsiflexion force with volar flexion force.27 Clonus myelopathic cervical cord compression has been found
may be present, as well as upgoing plantar responses. to be as high as 59% with an increase in age, from 32%
Gait examination should include tandem gait and heel in the fifth decade of life to 67% in the eighth.29␣
and toe walking, assessing for losses of balance and a
wide-based, unstable gait pattern. Management
The natural history of cervical myelopathy is vari- Controversy exists over the efficacy and timing of sur-
able and difficult to predict, despite multiple attempts gical intervention for degenerative cervical myelopa-
to identify risk factors for disease progression. Being thy. There have been several attempts to compare
able to predict clinical deterioration would allow clini- surgical decompression with nonoperative treat-
cians to pursue surgical intervention earlier in patients ment; however, there remains a paucity of random-
who were likely to decline. A classic study by Clarke and ized controlled trials (RCTs) evaluating the subject.
Robinson in 1956 retrospectively evaluated patients These studies typically use the Japanese Orthopedic
with cervical myelopathy and described distinct pat- Association (JOA) score, a patient-oriented outcome
terns of disease progression.28 They found that 5% measure to grade the severity of cervical myelopathy.
had rapid onset of symptoms followed by long peri- The largest RCT compared operative and nonopera-
ods of remission, 20% had slow and gradual decline in tive treatment in patients with mild cervical myelopa-
function, and 75% had a stepwise decline in function. thy and found no significant differences in the mean
However, more recent studies have shown a more vari- JOA change score or 10-min walk score between the
able disease course. Factors that have been suggested or two groups at 10 years. There were significant differ-
shown in individual studies to predict clinical deterio- ences in outcomes favoring the nonoperative group at
ration include increased neck range of motion, female 3 years. There was no standardization of conservative
sex, longer duration of symptoms, worse functional sta- care in this study, but treatments included intermit-
tus at presentation, and circumferential cord compres- tent use of a collar, antiinflammatories, avoidance of
sion on magnetic resonance imaging (MRI); however, high-risk activities, and intermittent bed rest.30 Other
follow-up studies have failed to consistently reproduce studies comparing operative and nonoperative treat-
these risk factors.␣ ment, as well as many operative studies, have shown
improvement in neurologic symptoms following sur-
Imaging assessment gical intervention.
Imaging typically starts with radiographs to assess for A large body of the literature has evaluated outcomes
disc space narrowing, facet arthrosis, osteophyte for- of surgical intervention for cervical myelopathy. Multi-
mation, degree of cervical kyphosis, and presence of ple large-scale studies have demonstrated improvement
ossification of the posterior longitudinal ligament. in functional outcomes in patients who underwent sur-
Flexion-extension films should be included to assess gical decompression for cervical myelopathy.31,32 These
for dynamic instability of any spondylolisthesis or studies have demonstrated greater improvement in
patients with higher severity at presentation, suggesting B

that surgery is most beneficial for those with moderate
to severe disease. There is evidence that all patients with
symptomatic cervical myelopathy, from mild to severe, A
show clinically significant functional and quality of life
improvement among a variety of populations and sur-
gical approaches.24 The most common surgical compli-
cation across all approaches is postoperative neck pain/
discomfort.
Efficacy studies of nonoperative management have C
shown minimal clinical improvement. Those studies
that did show clinically significant improvement with
nonoperative care included patients with soft disc her-
niations and dynamic myelopathy,33 suggesting this
subpopulation may benefit from a trial of conservative
care. The rate of conversion to surgical intervention
after a trial of conservative treatment ranges from 23%
FIG. 15.7 Spinal stenosis pathology. (From Goodman
to 54%.24
CC, Kelly Snyder TE. Screening the head, neck, and back.
An area of controversy exists over how to manage
In: Goodman CC, Kelly Snyder TE, eds. Differential Diagno-
patients with nonmyelopathic cervical cord compres- sis for Physical Therapists: Screening for Referral. 5th ed.
sion or ossification of the posterior longitudinal liga- St. Louis: Saunders; 2013; with permission.)
ment. Studies have sought to determine both the rate
of progression to symptomatic myelopathy and risk
factors for progression. Patients with asymptomatic Pathogenesis
cord compression or canal narrowing advanced to As with cervical myelopathy, degenerative lumbar ste-
symptomatic myelopathy at rates of 8% at 12 months nosis begins with the degenerative cascade, starting
and 23% at 44 months. Based on the lack of evidence with the intervertebral disc (Fig. 15.7). As the disc ages
for prophylactic surgery in this group and variable and collagen and proteoglycan contents shift, the disc
rates of progression, it would not be prudent to rec- loses its ability to bear load. The disc itself can encroach
ommend immediate surgical intervention in all of on the central canal owing to shortening and widening.
these patients but to instead counsel patients on the Consequently, as weight shifts to the facet joints, and
risks and signs and symptoms of disease progression eventually overloads their load-bearing capacity, joint
and provide close follow-up with serial neurologic hypertrophy and osteophyte formation ensue. This
examinations.␣ leads to further encroachment on the central canal. The
ligamentum flavum further invades the central canal as
Lumbar Spinal Stenosis disc height decreases. In addition, mechanical stresses
Lumbar spinal stenosis is ubiquitous among older induce changes in the tissue structure of the ligamen-
adults and is the most common indication for surgery tum flavum, leading to fibrosis and hypertrophy.
in those older than 65 years. The prevalence of lum- Lateral, or neuroforaminal, stenosis is defined as
bar stenosis is estimated to increase 60% by the year the entrapment of a nerve root, dorsal root ganglion,
2025.2 Degenerative lumbar stenosis is defined by the or spinal nerve as it exits the spinal column. Degenera-
North American Spine Society as “diminished space tive lateral stenosis can occur from facet hypertrophy
available for the neural and vascular elements in the or disc herniation. The superior and inferior borders
lumbar spine secondary to degenerative changes in the of the foramen are made up of the superior and infe-
spinal canal.”34 If compression of the neural structures rior pedicles, and this space can be constricted by disc
does not occur, the canal is referred to as narrowed height loss. The foramen can be narrowed laterally by
but not stenotic. Stenosis can almost always be attrib- the development of spondylolisthesis. In the case of
uted to three structures: a bulging intervertebral disc, a lateral stenosis, symptoms are more often unilateral
thickened ligamentum flavum, and hypertrophied facet radicular pain, radiating in a dermatomal pattern, and
joints. These degenerative changes are extremely com- weakness in a specific myotomal distribution.
mon but not always symptomatic, leading again to a Canal narrowing caused by a combination of the
clinical-radiologic mismatch. aforementioned mechanisms leads to radiographic,
and sometimes clinical, lumbar stenosis. However, not

all individuals with radiologic evidence of canal ste-
nosis experience symptomatic stenosis. Studies have
found disc degeneration, facet joint arthritis, or osteo-
phytes in 90%–100% of patients older than 64 years at
autopsy,35 and stenosis has been identified in 80% of
patients over 70 years. As described earlier with cervical
stenosis, there is poor correlation between spine imaging
and symptom presentation. Studies have shown that up
to 21% of asymptomatic adults over the age of 60 years
have radiologic evidence of lumbar stenosis. Therefore
there must be other factors that contribute to symptom
development in the presence of canal stenosis in addi-
tion to neural element compression. Compression on
the thecal sac has been shown to alter capillary flow and
electrophysiologic balance. Neural pressure also leads
to intraneural venous congestion and decreased solute
transport.36 These microscopic and macroscopic changes
to the neural environment contribute to an inflamma-
tory response that likely contributes to neuron signal-
ing and the development of symptoms. Although this FIG. 15.8 Spinal stenosis decompression. (From von
mechanistic explanation does not differentiate between Strempel A. Cosmic: dynamic stabilization of the degen-
people who become symptomatic and those who do erated lumbar spine. In: Yue JJ, Bertagnoli R, McAfee
not, it does open up another avenue for genetic variation PC, et al., eds. Motion Preservation Surgery of the Spine
to play a role in response to mechanical compression.␣ Advanced Techniques and Controversies. Philadelphia:
Saunders; 2008; with permission.)
Clinical presentation
The clinical presentation of lumbar stenosis is a vari- dermatomal or myotomal distribution of symptoms.
able combination of gluteal pain or leg pain and fatigue Moreover, a vascular examination should be performed
with or without low back pain. The classic presenta- to distinguish neurogenic from vascular claudication.
tion includes neurogenic claudication characterized In the elderly population, the two entities may occur
by pain, burning, cramping, heaviness, weakness, and concurrently. It is important to attempt to attribute
numbness in the lower extremities that is exacerbated symptoms specifically to either vascular or neurogenic
with lumbar extension or standing upright and relieved causes, particularly when surgery is being considered.␣
with forward flexion or sitting. Symptoms are typically
gradually progressive, and rapid neurologic decline Imaging assessment
from mild to moderate lumbar stenosis alone is rare.37 Radiographic assessment begins with plain radiographs
As multiple diseases can occur concurrently in the to assess the bony elements of the spine and their rela-
elderly population, it is important to consider the dif- tionship to canal size. Flexion-extension views should
ferential diagnosis of leg pain and fatigue when evalu- be obtained if dynamic spondylolisthesis is suspected.
ating for lumbar stenosis. The greatest mimicker of MRI provides more detailed imaging of the soft tissue
neurogenic claudication is vascular claudication due to and neural structures. Axial images reveal the level of
intermittent ischemia to the lower extremities. Patients stenosis of the central canal and presence of lateral
with advanced neurogenic claudication are unable to recess stenosis. Compression of neural elements can be
descend stairs or may do so backward to avoid the nec- identified, as well as the offending compressive struc-
essary lumbar extension, whereas patients with vascu- tures. In cases in which MRI is unobtainable or unclear,
lar claudication have more difficulty with ascending CT myelography can be used to visualize the cause,
stairs owing to the increased cardiovascular demand. localization, and impact of the stenosis.␣
The physical examination when evaluating for lumbar
stenosis in the elderly begins with observation. Observe Management
seated and ambulatory posture for forward flexion and The goal of treatment for patients with lumbar ste-
avoidance of extension. Motor and sensory evalua- nosis should be to improve function and minimize
tion of the lower extremities is essential to evaluate for discomfort (Fig. 15.8). Nonsurgical management
should be considered in elderly patients with multiple identify patients who will most benefit from surgery
comorbidities who may not be candidates for, or not and those with a lower risk of harm. Factors predicting
desire, surgical intervention. However, absolute age poor surgical outcome include radiologic findings not
should never be a contraindication to surgery. Goals concordant with patient symptoms, diabetes, obesity,
of therapy should be discussed with the patient before female gender, litigation, prior lumbar surgery, and
proceeding with a treatment plan. Conservative man- concomitant presence of spondylolisthesis or scolio-
agement consists of medications, physical therapy, sis.42,43 Although none of these factors is strictly pro-
injections, and functional support. NSAIDs can be hibitive and surgery remains a safe option overall, these
effective in the short term, although they need to be risks should be carefully considered and discussed with
used with caution in the elderly population owing to patients when making treatment decisions.␣
bleeding, gastrointestinal, renal, and cardiovascular
risks.38 Physical therapy has not been shown to be Sarcopenia
effective as a stand-alone therapy but can augment Sarcopenia is characterized by a global, progressive
other therapies and improve pain and function. Physi- loss of muscle mass, quality, and strength that is asso-
cal therapy program should focus on abdominal flex- ciated with disability and poor quality of life. Loss
ion exercises and core strength to maintain strength of muscle mass occurs at 1% per year after the age of
and range of motion and improve global functioning. 30 years and then accelerates to a 10%–15% per decade
Physical therapists are also able to provide ambula- after the age of 70 years.44 Starting at age 50 years, there
tion and balance training and assess when assistive is a decline in leg strength of 10%–15% per decade
devices are necessary. until this accelerates to 25%–40% per decade after age
The role for epidural steroid injections in lumbar 70 years. A decrease in both muscle fiber number and
spinal stenosis remains unclear; however, an RCT dem- fiber size is seen. Sarcopenia is considered primary if it
onstrated that epidural steroid injections with both is age related and secondary if it is activity related, dis-
lidocaine alone and glucocorticoid with lidocaine pro- ease related, or nutrition related. Owing to the vary-
vided clinically significant improvements in pain and ing definitions of sarcopenia, prevalence rates vary
function after 6 weeks, although there was no differ- across studies from 3% to 36% in older adults in the
ence in the two groups.39 This suggests a role for epi- community. In ambulatory and inpatient rehabilita-
dural steroid injections for short-term benefit in elderly tion facilities the prevalence of sarcopenia increases
patients with lumbar stenosis who may prefer a conser- to 40% and 50%, respectively. In post–hip fracture
vative treatment approach. community-dwelling patients, prevalence has been
Surgical intervention is recommended for patients seen as high as 71%. Not surprisingly, loss of muscle
with moderate to severe lumbar stenosis and for those mass and strength is associated with disability, falls,
patients who have failed conservative treatments. Stud- fractures, functional decline, decreased quality of life,
ies have shown that after 3–6 months of unsuccessful and increased mortality.45 Despite the clear impact on
conservative treatment, surgical intervention was more functionality, there are no standardized methods for
effective than continued conservative treatment.40 screening for sarcopenia nor is it regularly assessed,
There is a conception among providers that earlier sur- even in rehabilitation clinics or inpatient units. Some
gical intervention is always better in the case of lumbar proposed methods for assessing sarcopenia include
stenosis. However, this condition rarely exhibits rapid grip strength, calf circumference, and relative appen-
progression, and studies have shown that a trial of con- dicular skeletal muscle mass. Both DEXA and bio-
servative treatment, particularly in mild to moderate impedance electric analyzers can be used to evaluate
cases, can be advised, and those who fail conservative muscle mass.
treatment to go on to surgery still have good outcomes.41
Overall, operative treatment for lumbar stenosis shows Pathogenesis
favorable outcomes in pain, disability, and quality of The mechanism of sarcopenia is also not fully under-
life. Even in the elderly population, mortality rates are stood. Type I muscle fibers are most active during
low. A study of over 30,000 patients over 65 years who activities of daily living (ADLs), and type II fibers are
underwent decompression for lumbar stenosis showed recruited for higher-intensity activity. There is greater
mortality rates of 0.3% for decompression alone and relative loss of type II fibers with aging, likely due in
0.6% for decompression and fusion.42 Importantly, part to the decrease in higher-intensity activities.44
complications in elderly patients have not been shown Muscle fiber activity is also decreased with decreases
to be substantially different compared with a younger in actin-myosin bridging and single fiber force. At a
population. Nevertheless, it remains important to cellular level, there is a disproportionate decrease in
TABLE 15.1
Physical Activity Recommendations for Older Adults With Sarcopenia
Type Frequency Intensity Time
Aerobic training
• Vigorous intensity 3 days/week 70%–80% of max 20 min/day
• Moderate intensity 5 days/week 50%–60% of max 30 min/day
Resistance training 2 days/week Slow to moderate lifting 8–10 exercises
velocity at 60%–80% max 1–3 sets
8–12 repetitions
Power training 2 days/week High lifting velocity at 8–10 exercises
30%–60% max 1–3 sets
6–10 repetitions
Adapted from Iolascon G, Di Pietro G, Gimigliano F, et al. Physical exercise and sarcopenia in older people: position paper of the Italian Soci-
ety of Orthopaedics and Medicine (OrtoMed). Clin Cases Miner Bone Metab. 2014;11(3):220; with permission.
skeletal muscle protein synthesis and increase in pro- training, in patients with sarcopenia, fast-velocity resis-
tein breakdown.␣ tance training should be initiated early and proceed
with increasing loads to maximize effect (Table 15.1).␣
Management
Treatment interventions for sarcopenia should focus on
a combination of nutritional and physical rehabilita- CONCLUSIONS
tion goals. Protein status is directly linked to muscle Rehabilitation physicians are in a unique position to
mass and function and should be optimized in reha- provide comprehensive interdisciplinary spine care to
bilitation patients. Aerobic exercise is recommended the elderly population. Given the multiple settings in
to improve metabolic control, reduce oxidative stress, which physiatrists practice, it is crucial for all rehabilita-
and enhance exercise capacity. Resistance training (per- tion physicians to understand the full breadth of spine
forming the concentric and eccentric contraction of the conditions that can affect the elderly and their unique
muscle group over 2–3 s) is well established as a safe, characteristics and treatment considerations compared
effective, and feasible technique to increase strength with the general population.
in older adults. Studies have shown that a structured
resistance training program (22 weeks, 3 days per week)
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CHAPTER 16
Assistive Technologies for Geriatric

Population
MOOYEON OH-PARK, MD • JEAN H. OH, PHD
INTRODUCTION • Medication management applications

All older adults wish to stay independent and enjoy a • Video games (e.g., exergames)
life of high quality and meaning. Since 1980s, many Among the categories of ATs, in recent years robotics
assistive technologies (ATs) have emerged to provide technology has received increased public and research
innovative and effective ways to help seniors be inde- attention. Research areas in robotics geared toward ATs
pendent and reduce the burden for caregivers. The include mechanical prosthetic designs2 and cognitive-
roles of these technologies are often complemen- level artificial intelligence (AI).3 Whereas mechani-
tary to traditional healthcare services for enhancing cal engineering approaches seek solutions to develop
mobility of older adults, reducing hospitalizations, physical devices or platforms, the works in cogni-
and improving their social participation. Healthcare tive-level AI are centered around software solutions
providers should be knowledgeable on the role of ATs to support cognitive capabilities such as perception
for the specific needs of older adults including the and language understanding. For example, Fig. 16.1
pros and cons of ATs, target population, barriers to illustrates examples of conversational robots that can
implement AT, and how to overcome those barriers. interact and communicate with humans using natu-
This chapter will review the need of ATs for the care of ral language. To develop robots that can work in close
older adults, different categories of currently available proximity to humans as in assistive robots, research is
ATs and their effectiveness, and future development being conducted focusing on soft robotics techniques
and research.␣ that can be safe around humans; this work on inflated
robots4 inspired a robot caregiver character called Bay-
max in a Disney movie. Following a similar principle,
CATEGORIES AND TARGET AREAS OF soft sensor technologies focus on developing new
ASSISTIVE TECHNOLOGIES IN THE CARE types of sensors5 that are lightweight, breathable, and
OF OLDER ADULTS flexible.5 The notion of shared autonomy has been
ATs are defined as “any item, piece of equipment, prod- developed to facilitate a new robot control paradigm
uct system, whether acquired commercially off the wherein human users still feel that they have the full
shelf, modified, or customized, that is used to increase, control, while the robot’s autonomy assists this con-
maintain, or improve functional capabilities of indi- trol in a subtle way.6 In the end-user interface, speech-
viduals with cognitive, physical or communication based interfaces are becoming viable solutions owing
disabilities.” This definition was first described in the to the availability of high-end microphones and
Technology-Related Assistance to Individuals with Dis- speech processing systems such as Amazon Echo and
abilities Act of 1988 and revised excluding surgically the recent successes of machine learning and natural
implanted devices in the Individuals with Disabilities language processing.
Education Act of 2004.1 There are several areas targeted by ATs to maximize
Categories of ATs are as follows: the independence and quality of life of older adults.
• Information and communication technology (ICT) The main target area of ATs that has been researched
(e.g., using computers and the Internet) is chronic disease management via telehealth and
• Robotics (examples of research area are shown in medication management, because of their immediate
Fig. 16.1) relevance to the health of older adults. The ATs used
• Telemedicine for these two areas have shown evidence of clear ben-
• Sensor technology efits and a high degree of acceptability for older adults.
213
“Robot which can follow instructions of “Robot which can follow the instruction of “Robot which can follow the instructions
picking up green block” navigate outdoors” of inspection of environment and reporting
to a person”
FIG. 16.1 Robotics applications being developed for the care of older adults.
However, the role of ATs has been increasingly studied the information helped only “a little” or “did not help”
in other areas including falls, social isolation, loneli- them to improve self-care skills or to find new resources
ness, well-being, and caregiver burden. Various forms for exercise, diet, or support programs. In terms of the
of ATs may be applied to address the specific need of reliability of information from the Web, only 7% rated
older adults. this information as extremely reliable. These findings
Targeted Areas in Aging Care by ATs7 are as follows: highlight the need for health professionals’ guidance
• Access to general health information in navigating the Internet and finding accurate and
• Chronic disease management helpful information about health issues among older
• Medication optimization adults.
• Fall prevention and management Among older adults, there are some barriers and
• Social isolation, loneliness, and well-being potential risks of using the Internet. For those who
• Mobility (physical dependence) are not familiar with the ICT, education specifically
• Caregiver burden tailored to older adults is needed. There are a number
• Other (e.g., dementia, depression) of organizations and websites available to older adults
that provide training to use the computer and the Inter-
Accessing and Retrieving Health Information net (e.g., skillful senior, SeniorNet, or Microsoft acces-
ICT (e.g., the Internet), which is used to retrieve health sibility). These sites generally educate not only on how
information, is the least expensive form of AT. In the to use the computer, but also on proper ergonomics for
United States, the number of Internet users older than avoiding the development of pain and fatigue. Internet
65 years has grown from 4.2 million in 2002 to 19 mil- use can be time-consuming and may, in fact, be habit-
lion in 2012, with a growth rate of 16% per year in forming to some individuals, potentially encouraging a
contrast to 3% among those aged 30–49 years.8 A simi- sedentary lifestyle. Healthcare providers need to advise
lar trend has also been noted in the United Kingdom, older adults about these aspects of Internet use.␣
with a 9% increase per year in the number of Internet
users aged 65–74 years compared with a 1% increase Management of Chronic Diseases by
for the 35–44 age-group. Web designers and engineers Telemedicine and “e-Health”
have put a great effort into enhancing the usability of As the older population dramatically increases world-
the Web by older adults (e.g., readability and clickabil- wide, the prevalence of chronic diseases and physical
ity). Health information is reported to be one of the and/or cognitive disability has increased accordingly.
main reasons older adults use the Internet (e.g., search- As reported by the Milken Institute, 78% of the health-
ing for information about medications prescribed, care cost in the United States can be attributed to
in addition to hobbies, news, finance, shopping, and chronic diseases.11 Older adults tend to prefer living in
socialization).8,9 their own homes; however, difficulties in the manage-
The vast majority of older adults use search engines ment of chronic medical conditions or limited mobil-
such as Google and Yahoo to access and retrieve health ity may threaten their independent living. Optimal
information, whereas only 17% of this user group vis- management of chronic diseases requires frequent
ited sites recommended by healthcare professionals.10 monitoring of the patient’s status, to prevent exac-
In this study, 70%–82% of participants thought that erbation of these conditions and associated hospital
CHAPTER 16 Assistive Technologies for Geriatric Population 215
TABLE 16.1
Examples of Chronic Disease Management by Telemedicine
Disease Intervention Outcomes
Chronic heart failure14 Home-based telemanagement with one-lead 19% decrease in hospital readmissions due
trace to a receiving station with 24/7 healthcare to heart failure
provider access Mean costs for hospital readmission were
lowered by 35% compared with control
group
Diabetes mellitus15 Web-enabled computer with modem connection Superior control of diabetes mellitus
to an existing telephone line. Home telemedicine (HbA1c), systolic blood pressure, and lipid
unit has camera, home glucose meter, blood profile
pressure cuff, access to patient’s own clinical No difference in mortality rate between the
data, and communication with nurses telemedicine group versus control group
Amyotrophic lateral Ventilator parameters were monitored via modem Significantly lower rate of readmission and
sclerosis16 device connected to the ventilator emergency department visits, lowering
costs by 50%
Chronic obstructive Web phone with a touch-screen monitor. Daily Increased patient and family satisfaction but
pulmonary disease17 input of data by patient; and the system auto- no cost reduction
matically interacts with the patient and provides
advice tailored to changes in their conditions
admissions or emergency department visits. The term • Self-management: Goal setting and action plan-
“e-health” describes a range of the ICT that are used to ning19 and monitoring health behavior
provide healthcare.12,13 This term encompasses (but is The programs that have incorporated these features
not limited to) Internet or computer-based technolo- show superior effectiveness in terms of changing the
gies, telemedicine (monitoring and management), behavior of users (examples of the programs are in
and electronic health records.12,13 Telemedicine mon- Table 16.1). A brief report of 21 older adults showed
itoring the status of the patient at home has shown that this agent was acceptable and resulted in signifi-
positive effects on the management of various diseases cant increase in physical activity in older adults as com-
(Table 16.1) and helps patients avoid unnecessary hos- pared with the control group.20␣
pitalizations and visits to the emergency department.
The existence of cost savings from using telemedicine Medication Optimization
as compared with standard care is debatable because Medication optimization refers to a wide variety of
of the high implementation cost of hardware and technologies designed to help manage medication rec-
software.18 onciliation, adherence, and monitoring.21 Medication
The key aspect of chronic disease management optimization technologies are particularly applicable
is self-management and behavioral change toward for older adults, because 87% of older adults take pre-
healthy habits. There are many Internet-based educa- scription medications.22 On average, an older adult
tional and self-management interventions that support is prescribed between four and five medications. In
patients to change the health-related behaviors.12 The addition to prescription medications, 37.9% of older
four core interactive design features of Internet-based adults take over-the-counter medications, and 63.7%
health behavior interventions are as follows12: use dietary supplements.22 The number of medications
• Social context and support: facilitate perceptions of increases dramatically to an average of 14 medications
humanlike interaction and social support among older adults discharged from acute hospital care
• Contact with intervention: provide direct or mediat- to skilled nursing facilities.23 Poor adherence to medi-
ed contact with intervention or individuals respon- cation is reported as a worldwide problem of striking
sible for the intervention magnitude.24 In the United States, for example, only
• Tailoring and targeting: provide optimally relevant 51% of those diagnosed to have hypertension adhere
information matched to individual users (tailoring) to their prescribed medication regimen.25 In a survey
and groups of users (targeting) done by the American Association of Retired Persons
(AARP), more than three-quarters of caregivers indi-

TABLE 16.2
cated that they were interested in technologies that can
The Role of Technology in Medication
help with medication refills, delivery, and adherence.26
Adherence
A recent systematic review showed that interventions
for improving adherence are not very effective, calling Steps of Medication
for innovations to assist patients to take medications as Adherence Function of Technology
prescribed.27 Education A drug information app giving
There are various ATs available for this problem, rang- information about the drug,
ing in form from very simple to highly sophisticated. A instructions on how to take it,
technology can potentially provide one or more func- potential drug interactions, etc.
tions of the five steps of the medication-use process: (1) Remind A device or app reminding
assess, (2) prescribe, (3) dispense, (4) administer, and patients to take medication on
(5) monitor.21 Assessing and prescribing are the steps time
delivered by healthcare providers, and medications can Dispense A device that can automatically
be reconciled during this time. Personal health records dispense by day with a locking
and medication list software are often used during this mechanism to avoid double
process. Dispensing and administration encompass the dosing
patients’ process of adherence and are potentially the Ingest A device that detects whether
most challenging to address. This process is understood the patient took his/her
as a series of steps described in Table 16.2.28 medication
ATs are available for the steps of fill/education, Metabolize A device that detects whether
remind, dispense, report, and adjust. Some technolo- the patient metabolized his/her
gies are under development for detecting ingestion medication
and metabolizing of medications, including Magne- Report A logging function can be
Trace and Xhale’s SMART. The MagneTrace necklace added to the dispensing de-
can record exactly when magnetized pills pass through vice, which logs the date and
a patient’s esophagus and send the information to a time of medication taken and
smartphone or a computer. Xhale’s SMART system automatically sends the data to
is designed to verify whether patients have taken the the healthcare provider
right dose of breath-based medications. A recent sur- Adjust Automatic medication adjust-
vey about medication dispensing devices showed that ment based on the adherence
more than 90% of older adults reported high ease of Assisting healthcare provider
use and reliability.29 Almost all older adults in the
study reported that the medication dispenser helped Adapted from Center for Technology and Aging. Technologies to
Help Older Adults Maintain Independence. Advancing Technology
them manage their medications, although initially Adoption. Available at: http://www.techandaging.org/briefingpaper.
many were not comfortable with the machine.␣ pdf; with permission.
Improving Social Isolation, Loneliness, and

Well-being associated with isolation and loneliness are equivalent
Social isolation among older adults is estimated to be to the detrimental effects of smoking and obesity.32
up to 24%, as compared with 7% of the general popu- There are two types of technological interventions
lation, and its prevalence increases with the increasing that have been introduced to overcome social isola-
age.30 This is a growing concern in this population due tion and loneliness for older adults: ICT and robot
to decreasing financial and social resources, functional technologies. ICT intends to provide easy and afford-
limitations, death of family members, changes in fam- able communication and activities for older adults
ily structures, and the technically advancing modern and comes in textual, audio, and/or visual forms.30 In
society.31 Social isolation and loneliness are known risk pilot studies, communication programs (e.g., smart-
factors for physical and mental deterioration among phones, iPads, emailing, videoconferencing via Skype,
older adults, including cardiovascular diseases (e.g., and online chat rooms) and entertainment technology
coronary artery disease), depression, substance abuse, applications (e.g., Wii, TV gaming system, a virtual pet
self-neglecting behavior, and increased mortality and companion) have shown positive effects on alleviating
suicide.30,31 It has been reported that the health risks loneliness.
The potential benefits of using ICT are as follows30: trust issues, as well as the mobility and perception chal-
• Intergenerational communication: ICT allows older lenges of physical robotic platforms.␣
adults to adjust to their younger family members,
including their grandchildren, enhancing both the Falls and Physical Functioning
quantity and quality of their intergenerational com- The fall rate in acute care hospital settings can be as
munication high as 9.1 falls per 1000 patient days, and the rate in a
• Gaining social inclusion and support long-term care facility can be twice that number. Bed-
• Engaging in activities of interest (connecting with side rails and restraints have been traditionally used to
the outside world, e.g., via videoblogging) reduce falls, although their use is less frequent in recent
• Boosting self-confidence (“feeling young,” “becoming years because of their ineffectiveness and even poten-
one of the modern generation,” “overcome challeng- tial harmfulness to patients. As an alternative, sensor
es,” “help others online”) technology–based alarm systems (e.g., bed-exit) have
The role of ICT in reducing loneliness, however, been used to alert the nursing staff and other caregiv-
still needs further investigation to better define social ers that a patient is attempting to leave the bed unas-
isolation/loneliness and the type, duration, and inten- sisted and to facilitate an immediate response to the
sity of the intervention ICT. A recent systematic review patient’s need. Because a pressure sensor is embedded
revealed a high attrition rate of older adults in ICT under the sheet, mattress, or chair seat, nuisance false
studies, although some older adults can benefit from alarms are not uncommon. A recent systematic review
ICT and will use it consistently after training. Many fac- showed that false (nuisance) alarms account for about
tors including living setting, cultural barriers, level of 16% of all alarms, which is too high, possibly caus-
interest in and motivation for ICT, level of cognition ing staff desensitization to alarms, as well as being
and education, vision health, and ability to use the intrusive to patients and their family.36 Dual sensor
computer (e.g., using a mouse) are to be considered in alarms using both pressure sensors and infrared beam
determining the suitability of ICT for the elderly. detectors seem to detect a patient’s true attempt to get
Robotics technologies have been used to reduce out of bed with a higher accuracy as compared with
loneliness and promote well-being among older adults. a single pressure sensor–based alarm.37 Even with
Such social robots are designed to provide assistance, dual sensor alarm systems, the significant rate of false
guidance, education, and entertainment to older alarms still remains an issue. Although one report
adults.33 For instance, robot therapy—using robots in found a reduction of up to 77% in fall-related injuries
place of the animals in animal-assisted therapy—has using sensor-based technologies, overall the evidence
been tried. A seal-type robot named Paro was developed is inconsistent as to whether these technologies can
in long-term care facilities in several countries. This type prevent falls.38
of robot has specific features to stimulate people’s expe- Alarm systems monitoring patient movement in
riences of animals and to bring out their feelings when bed and wheelchairs are widely used in long-term-
they are interacting with animals.33 It has been reported care facilities and endorsed by the Joint Commission
that the use of interactive robots in care facilities on Accreditation of Healthcare Organizations.39 Incor-
improved the mood, stress level, and loneliness of older porating user opinions in developing and introducing
adults and reduced the burnout of nursing staff.33,34 The alarm systems is an essential aspect of successful imple-
price of these robots and ethical debates concerning the mentation of these technologies. Nursing staff report
use of robots remain for further discussion.35 positive perceptions about the usefulness of alarm sys-
More recently, with steep progress being made in the tems. However, receiving a sufficient amount of train-
field of machine learning and AI in general, the idea ing on the use of alarm technologies is necessary for the
of robotic assistants/companions is becoming more staff to experience their full benefits. Bressler reported
plausible than ever. Affordable speech interface systems on a downside of using alarm systems in which sys-
such as Amazon Echo/Alexa or Google Home have tematically planned removal of alarm systems led to
brought the possibility of older adults having an inter- a reduced number of falls and a calmer environment
active, conversational, caregiving robot. Techniques for the patients and staff. This report emphasized that
for language comprehension and dialoging have been staff members began to become more attuned to the
developed for indoor and outdoor navigation prob- need of patients once they ceased to rely on alarms.36
lems, but for such technologies to be transferred to An alarm is not a substitute for staff, and thus adequate
the companion/caregiving domain, there are several staff availability is necessary when residents wish to
new challenges to be addressed, including safety and leave their beds.37
For community living settings, an unobtrusive, in- pathway, and the user only needs to focus on obstacle
home sensor system that continuously monitors older avoidance and speed control without thinking about
adults for assessment of fall risk and detects falls has path-planning or navigation.48␣
been developed.40 This sensor system consists of a
pulse-Doppler radar, a Microsoft Kinect, and two web Wearable devices
cameras as a part of a more complete sensor network. Wearable robotic exoskeletons have been studied for
The results of a pilot study showed a fall detection rate gait training in spinal cord injury or stroke popu-
of 98% and a strong correlation between in-home gait lations. For individuals with lower motor neuron
velocity and gold standard fall risk measures.40 Measur- disease (e.g., poliomyelitis), innovative knee-ankle-
ing in-home gait speed may provide a more accurate foot orthosis can assist people with leg weakness to
and precise picture of the physical function of older achieve normal joint kinematics during walking. An
adults; however, the installment of such equipment interesting point for wearable devices for mobility
and associated costs remain as limitations.41 is whether using ATs leads to a therapeutic effect.
Exercise-based video games, also known as exer- This combined assistive-therapeutic model for AT
game technologies, have been used to improve physi- has been demonstrated for foot drop stimulators,
cal function and prevent falls.42–45 Traditional exercise in which long-term use of a foot drop stimulator
interventions demonstrate a benefit in reducing fall improves the ability of a person to walk and may
risk. However, adherence to exercise programs has been strengthen corticospinal connection.49␣
a great challenge for many older adults. Exergames
were developed to improve adherence to exercise via Assisting Caregiving
engaging in recreation, performance feedback, and Millions of people are providing care for their loved
social connectivity via competition.42 Older fallers ones by providing emotional support, help in daily
tend to make a stepping error during a perturbed situ- activities, aid in household chores, and medical man-
ation. They often take a step in the wrong direction, agement. An estimated 43.5 million adults in the
take too short a step, or step too slowly.46 Schoene et al. United States have served as unpaid family caregiv-
investigated the effectiveness of a stepping exergame to ers.50 On average, caregivers spend 20.4 h per week
improve the stepping ability of older adults. This study providing care. More than 50% of caregivers are aged
showed that a stepping exergame improved stepping 50 years or older, with 10% being ≥75 years of age.
reaction time and physical functional scores, reducing Although caregiving has essential value for keeping
the risk of fall in older adults.42 However, as per a recent older adults in their homes and avoiding institution-
systematic review of the use of virtual reality (e.g., Wii alization, it can be stressful and burdensome. There
balance board, Mario & Sonic on Olympic Games, Nin- have been behavioral and psychologic interventions to
tendo video sports games), there is still no substantial reduce caregivers’ stress. Although these interventions
evidence that exergame use facilitates improvements may help caregivers’ stress, they do not reduce the
in physical functioning among older adults, either actual work of caregiving. Technology-based interven-
as a complement or an alternative to other types of tions, however, can reduce the burden on caregivers
interventions.45␣ by assisting in caregiving activities (e.g., monitoring of
care recipient, medication adherence), as can be seen
Mobility Assistance in Fig. 16.2.
The main interest of mobility research in ATs has been One of the advantages that ATs can realize is
an integration of the capabilities of the user and the AT persistent care (i.e., 24/7 monitoring) and atten-
via improving the AT mechanics, the user-technology tion, which is required for patients with advanced
physical interface, and sharing of control between the cognitive impairment. In the case of mild cognitive
user and the technology.47 impairment patients, a conversational companion
system can help patients to participate in socially
Power wheelchairs engaging activities that are central in preventing cog-
In addition to traditionally joystick-operated power nitive decline. Technologies for intelligent dialoging
wheelchairs, a collaborative wheelchair assistant was systems are still in their early stages, and thus further
developed for those who are not able to use the stan- investigation is needed to study the effects of such
dard power wheelchair but have sufficient sensory systems.
abilities to detect when stopping is necessary. A collab- Based on a report from the AARP, 57% of caregivers
orative wheelchair assistant guides the user on a known used technology at least once a week in at least one way
Physical need for care

(e.g. 24 hour supervision,
mobility, ADL)
Human based interventions Technology based interventions

Caregiver
• Skill building (problem • AI for 24/7 monitoring
solving) burden • Natural interface for
• Individualized Psychological supporting communication
interventions based on needs
changing needs Physical • Shared autonomy for
physical assistance
Psychological and social

support
FIG. 16.2 Future approach to reduce caregiver burden using technology. ADL, activities of daily living; AI,
artificial intelligence.
to assist with their caregiving duties.26 The common interested in using technology for management of
uses for ATs were electronic scheduling, organizing, and their health conditions and to maximize their inde-
medication refill and delivery. More than three-quarters pendence. Among caregivers, lack of awareness was
of caregivers expressed that they were interested in tech- the most frequently reported barrier to adopting
nology that helps them check on or monitor a loved ATs.26 Older patients and their family need to be
one, although monitoring technology is currently used educated by “tech-health” coaches who are not only
by only 10% of caregivers.26,51 The barriers to adopt- knowledgeable about the quality of various ATs and
ing ATs include lack of awareness, cost, perceptions that their applications for health conditions, but also
it may not be helpful, and lack of time to learn new understand the social situations of patients. Health-
technologies. The following are the greatest interest of care providers caring for older adults need to be
caregivers for the possible role of AT. familiar with ATs currently available for patients to
• Prescription refill and pickup make appropriate recommendations to meet the spe-
• Making and supervising medical appointments cific needs of individual patients. Costs of ATs remain
• Assessing health needs and conditions another main barrier to the dissemination of ATs.
• Ensuring home safety Two-thirds of patients and their family reported that
• Monitoring medication adherence they had to pay for ATs, and efforts with insurance
• Checking and monitoring care recipient payers should be made for coverage of the costs of
• Managing stress and emotional challenges of car- AT working.
egivers␣ There are technical challenges as well. The compo-
nents used in ATs need to be durable, light, and small.
The control interfaces must be intuitive and user-
FUTURE DIRECTIONS IN THE friendly. For robotic devices, software algorithms may
DEVELOPMENT AND ADOPTION OF not be mature enough to produce a natural motion.
ASSISTIVE TECHNOLOGY IN THE CARE OF Involvement of the end user throughout the develop-
OLDER ADULTS ment process is essential to come up with truly trans-
Technology use will rise with time across healthcare formative ATs that can enhance the lives of the older
settings and patients’ homes. Many older adults are adults.
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Index
A Berg Balance Scale (BBS), 38 Central nervous system (Continued)
Acetabular rim syndrome, 87–88, 89f Biologic injectables, 100–101 peripheral neuropathy (PN), 58
Acetaminophen, 98 Bisphosphonates, 30 sensory and motor changes, 58
Active/passive range of motion (ROM), Bone-resorbing activity, 31 traumatic brain injury (TBI), 63
29 Bone-specific alkaline phosphatase, 29 visual and auditory changes, 57–58
Activity of daily living training, 117 Cerebrospinal fluid (CSF), 60–61
Adverse drug events (ADE), 121–123, C Chondrocytes, 83
121b, 123f, 123t Calf muscle dysfunction, 77 Chronic conditions, 2
Aging, 19 Cam-type morphology, 86, 86f Chronic neuropsychiatric disorders,
chronic conditions, 2 Cardiovascular Health Study Frailty 2–4
chronic neuropsychiatric disorders, Phenotype (CHSFP), 6–7 Chronic venous insufficiency (CVI), 77
2–4 Central nervous system (CNS) CHSFP. See Cardiovascular Health
comorbidity, 2 aging, 57–59 Study Frailty Phenotype (CHSFP)
delirium, 5 behavioral changes, 58 Circulatory system, 114
demographics, 1–2 brainstem nuclei, 57 Claudication, 75
disability. See Disability cognitive changes, 58 Clinical Frailty Score (CFS), 6–7
frailty. See Frailty crystallized intelligence, 58 CNS. See Central nervous system
geriatric syndromes, 4–6, 5f dementia, 58 (CNS)
Hospital Elder Life Program (HELP), depression, 58 Cognition rehabilitation, 117
5–6 dizziness, 57–58 Cognitive changes, 58
multidisciplinary care. See fluid intelligence, 58 Cognitive impairment, 53
Multidisciplinary care gait apraxia, 64 Comorbidity, 2
multimorbidity, 2–4 geriatric medicine, 57 Computed tomography (CT), 32
normal aging, 2 geriatric population, 59 Computed tomography angiography
physical activity. See Physical activity cerebrovascular disease, 59 (CTA), 76–77
physiologic changes, 2, 3t–4t intracranial hemorrhage (ICH), 59 Connecticut Collaboration for Fall
populations, 1–2 stroke, 59 Prevention (CCFP) program, 5–6
rehabilitation medicine, 10 transient ischemic attack (TIA), 59 Contractile layer, 85
unintentional injury, 5 venous thromboembolism (VTE), Corticosteroid injections, 99–100
Alendronate, 30 59 Crystallized intelligence, 58
Alternative oral agents, 99 hearing loss, 57–58
American Academy of Orthopaedic medication metabolism changes, D
Surgeons (AAOS), 97, 98t 58–59 Deep brain stimulation (DBS), 62
Androgen deprivation therapy (ADT), 28 memory changes, 58 Deep vein thrombosis (DVT), 32,
Ankle-foot orthotics (AFO), 75 neurodegenerative disorders, 60–63 114–116
Arthroplasty cerebrospinal fluid (CSF), 60–61 Delirium, 5, 32
hip arthroplasty patient, 101–102 classic motor symptoms, 60–61 causes, 177–178, 178t
implant selection, 101–102 deep brain stimulation (DBS), 62 clinical features, 176
incidence, 101, 101t, 102f dementia, 60 definition, 175–176
prevalence, 101, 101t, 102f episodic gait patterns, 62 diagnosis, 177
total hip replacement complications, freezing of gait (FOG), 62 prevention, 178
102–103, 103t mild cognitive impairment (MCI), treatment, 178
total hip replacement survivorship, 60 Dementia, 58, 60
103–104 multiple sclerosis (MS), 62–63 Alzheimer’s disease, 172
Asian Working Group on Sarcopenia parkinson disease (PD), 60–62 causes, 172–173
(AWGS), 19 preclinical/prodromal symptoms, Creutzfeldt- Jakob disease, 174
Autonomic symptoms, 70–71 60–61 definition, 171–172
shuffling and festinating gait dementia with Lewy body (DLB),
B (FSG), 61–62 172–173
Bed rest complication prevention, 116 neurologic disorders, 59 diagnosis, 174, 175t
Bed rest-induced delirium, 115 normal pressure hydrocephalus frontotemporal dementia, 174
Behavioral changes, 58 (NPH), 63–64 Huntington’s disease, 174
Note: ‘Page numbers followed by “f” indicate figures, “t” indicate tables and “b” indicate boxes.’
223
224 INDEX
Dementia (Continued) Dysphagia (Continued) Falls (Continued)

infectious and inflammatory oral phase, 135 novel interventions, 53–54
diseases, 174 oral preparation phase, 135 older community-dwelling adults,
medication reaction, 174 oropharyngeal dysphagia, 138 48
medications, 174, 174t pharyngeal phase, 135 physical therapy, 48
metabolic and endocrine-related presbyphagia, 135 prevention cost-effectiveness, 53
diseases, 174 rehabilitative approaches, 142–143, prevention programs, 53
mild cognitive impairment (MCI), 172 143f public health intervention, 53,
neurodegenerative disease, 172–173 symptoms and signs, 137, 139t 53b
prevention, 175 treatment, 141–143 Stopping Elderly Accidents,
treatment, 174–175, 176t videofluoroscopic swallow study Deaths, and Injuries (STEADI),
vascular dementia, 173, 173t (VFSS), 140, 141t 48
Denosumab, 31 technological applications, 53–54
Depression, 58 E vitamin D, 51
causes, 169–170 Ecchymosis, 32 orthopedic injuries, 45
clinical features, 169 Edema, 77–78 outcomes, 44–45
definition, 169 Electrodiagnosis (Edx), 69, 73–74 postfall anxiety syndrome, 46
diagnosis, 170 Electromyography (EMG), 74 postfall syndrome, 46
prevention, 171 Endocrine system, 115 rates, 43–44
treatment, 170–171, 171t Episodic gait patterns, 62 risk factors, 46–48
Developmental dysplasia of the hip Ethnicity, 89–90 assessment, 48
(DDH), 85–89, 88f–89f European Working Group on cardiovascular instabilities, 46–48
Disability, 2–4 Sarcopenia in Older People community-dwelling older adults,
activities of daily living (ADLs), 7 (EWGSOP), 19, 20f 48, 51f
aging physiology, 181–182 Excitation-contraction coupling endocrinological and renal issues,
deconditioning, 182–183 system, 23–24 46–48
epidemiology, 181 Exercise, 24 extrinsic risk factors, 48
exercise, 182–183 Exercise program, 51 intrinsic risk factors, 46–48
aerobic recommendations, multifactorial fall risk assessment,
184–185 F 48, 49b
future directions, 188–189 Fall prevention programs, 53 neurologic illnesses, 46–48
injury prevention, 187–188, 188t Falls, 217–218 older adults, 46, 47b
prescription, 183, 184f definition, 43 psychotropic medications, 48
prevention, 185 epidemiology, 43–46 rehabilitation facilities, 46, 47b
progressive resistance training, fragility fractures, 31–34 screening, 48
185–186 delirium, 34 risks, 43–44
Tai Chi, 186 epidemiology, 31 slips and trips, 43
therapy, 185 infection, 34 spinal cord injury, 46
walking programs, 187 orthopedic management, 32–33 traumatic brain injury (TBI), 44–46
instrumental activities of daily living orthopedic treatment, 32 Fear of falling, 48
(IADLs), 7 outcomes, 31–32 FEES. See Fiberoptic endoscopic
older adults, 2–4, 7 perioperative care, 32–34 evaluation of swallow (FEES)
preconditioning assessment, 183 postoperative complications, 34 Femoroacetabular impingement (FAI),
Distal muscle weakness, 70 preoperative care, 32 85–86
Diurnal variation, 72 thromboembolic disease, 34 acetabular rim syndrome, 87–88, 89f
Dizziness, 57–58 International Statistical conservative, 87, 88t
Donut-shaped pads, 75 Classification of Diseases and developmental dysplasia of the hip
Dual-energy X-ray absorptiometry, Related Health Problems (ICD)-10 (DDH), 87–89, 88f–89f
20–21 codes, 43, 44t goal, 87
Dysphagia, 135 interventions management, 87–89
aging, 135, 136f cognitive impairment, 53 rehabilitation, 87, 88t
causes, 135–136 exercise program, 51 surgical approaches, 87, 88t
clinical/bedside swallow evaluation, fear of falling, 48 Fiberoptic endoscopic evaluation of
138–139 gait and balance evaluation tools, swallow (FEES), 140, 141t
compensatory approaches, 141–142 48, 50t Fluid intelligence, 58
counseling, 141 hip protector pads, 51 FOG. See Freezing of gait (FOG)
education, 141 hospitals and rehabilitation Food and Drug Administration (FDA),
esophageal phase, 135 facilities, 53 30–31
fiberoptic endoscopic evaluation of level of evidence, 51 Formidable cane, 96–97
swallow (FEES), 140, 141t long-term care facilities, 51 Fracture-integrated rehabilitation
identification, 136, 138f Matter of Balance program, 48 management of the hip joint (FIRM-
instrumental swallow examination, neurologic/musculoskeletal HIP) program, 35, 35t
140, 140t etiologies, 48 Fracture risk assessment tool (FRAX), 29
INDEX 225
Frailty Geriatric population (Continued) Hearing disorders (Continued)

adverse drug events (ADEs), 7 oral phase, 135 pathology, 146
Cardiovascular Health Study Frailty oral preparation phase, 135 prevention, 155
Phenotype (CHSFP), 6–7 oropharyngeal dysphagia, 138 pure-tone audiometry, 148–149,
Clinical Frailty Score (CFS), 6–7 pharyngeal phase, 135 149t, 150f
concept, 6–7 presbyphagia, 135 questionnaires, 151
deprescribing, 7 rehabilitative approaches, speech audiometry, 149–150
functional homeostasis, 6 142–143, 143f standard audiologic evaluation,
multimorbidity, 6 symptoms and signs, 137, 139t 148–150
polypharmacy, 7 treatment, 141–143 surgical and medical treatment,
symptoms, 6 videofluoroscopic swallow study 154–155
Freezing of gait (FOG), 62 (VFSS), 140, 141t symptoms and impact, 145, 146b
intracranial hemorrhage (ICH), 59 tinnitus, 156–157
G malnutrition, 131 Hip fractures, 32–33
Gait apraxia, 64 aging, 131 Hip joint pathomorphologies, 85–87
Garden’s classification system, 32–33 anorexia, 134 Hip osteoarthritis
Gender, 89 approaches, 132–135, 133f, activity, 94–95
Genetics, 89–90 133b–134b age, 91
Genomic instability, 23 caloric intake, 132 anatomy, 85
Geriatric medicine, 57 dental problems, 134 biomechanics, 85
Geriatric population, 59 food intake, 132–133 cam-type morphology, 86, 86f
assistive technologies identification, 132 classification and reporting, 92–93,
accessing/retrieving health stroke, 59 92t
information, 214 transient ischemic attack (TIA), 59 clinical diagnostic criteria, 91–92
assisting caregiving, 218–219, 219f venous thromboembolism (VTE), 59 contractile layer, 85
chronic disease management, Geriatric rehabilitation program, 24 developmental dysplasia of the hip
214–215, 215t Geriatric syndromes, 4–6, 5f (DDH), 85–86
development and adoption, 219 Connecticut Collaboration for Fall dietary factors, 90
falls, 217–218 Prevention (CCFP), 5 elderly patient caring, 94
information and communication Hospital Elder Life Program (HELP), epidemiology, 84
technology (ICT), 214 5–6 ethnicity, 89–90
loneliness, 216–217 multifactorial health conditions, 4–5 FAI. See Femoroacetabular
medication management pathophysiology, 4–5, 5f impingement (FAI)
applications, 213 risk factors and intervention formidable cane, 96–97
medication optimization, strategies, 5 four-layer approach, 85
215–216, 216t Grading osteoarthritis, 92–94 gender, 89
mobility assistance, 218 Gross deformity, 72 genetics, 89–90
older adults, 213–218 grading osteoarthritis, 92–94
physical functioning, 217–218 H hip joint pathomorphologies, 85–87
power wheelchairs, 218 e-Health, 214–215 inert layer, 85
robotics, 213, 214f Hearing disorders Kellgren and Lawrence classification,
sensor technology, 213 age-related hearing loss, 145–155 92–93, 93t
social isolation, 216–217 auditory nerve, 155 lifestyle modification, 94–95
telemedicine, 213–215 auditory rehabilitation, 151–154 neurokinetic layer, 85
video games, 213 auditory testing, 151 nonoperative/operative hip
wearable devices, 218 background, 155 preservation care, 86
well-being, 216–217 case history, 146 obesity, 90
cerebrovascular disease, 59 clinical evaluation, 146–151 occupation, 91
dysphagia, 135 cochlear hair cell, 155 osteochondral layer, 85
aging, 135, 136f cochlear implant, 154 patient education, 94
causes, 135–136 complexity, 146, 147f pharmacologic management, 97–99
clinical/bedside swallow contributing factors, 146 physical therapy program, 95–96
evaluation, 138–139 definition, 145 pincer-type morphology, 86–87, 87f
compensatory approaches, etiology, 146 qualitative assessment, 92–93, 93t
141–142 evaluation, 155 radiologic indices, 93b
counseling, 141 hearing aids, 152, 153f risk factors, 89–91
education, 141 hearing assistance/assistive Tönnis and Heinecke classification
esophageal phase, 135 technology, 152–154 system, 92–93, 92t
fiberoptic endoscopic evaluation immittance audiometry, 150–151 vitamin D, 90
of swallow (FEES), 140, 141t management, 151–156 Hip protector pads, 51
identification, 136, 138f middle ear implantable hearing Hospital-acquired deconditioning
instrumental swallow aids, 154–155 activity of daily living training, 117
examination, 140, 140t otoscopic examination, 146–148 assessment, 116
226 INDEX
Hospital-acquired deconditioning J Multidisciplinary care (Continued)

(Continued) Joint contracture, 112–113, 113f, 116 physiatrists, 10–11
bed rest complication prevention, 116 Joint space articular cartilage, 83 rehabilitation medicine, 10
bed rest-induced delirium, 115 rehabilitation services, 10–11
circulatory system, 114 K Multidisciplinary fragility fracture care
cognition rehabilitation, 117 Kellgren and Lawrence classification, program, 35
cognitive function, 116 92–93, 93t Multimorbidity, 2–4
constipation, 115 Knee osteoarthritis Multiple sclerosis (MS), 62–63
deep vein thrombosis, 114–116 activity, 94–95 cognitive deficits, 63
dual-energy X-ray absorptiometry classification and reporting, 91, 92t diagnosis, 63
(DXA), 111–112 clinical diagnostic criteria, 91–92 disease-modifying agents, 63
endocrine system, 115 elderly patient caring, 94 initial symptoms, 62–63
epidemiology, 111 formidable cane, 96–97 Muscle fatigue, 70
functional incontinence, 116 grading osteoarthritis, 92–94 Muscles
immobility, 111, 112t, 115 lifestyle modification, 94–95 atrophy, 23–24
intensive care unit rehabilitation, patient education, 94 function, 23
116–117 pharmacologic management, 97–99 performance, 23
joint contracture, 112–113, 113f, 116 physical therapy program, 95–96 size, 23
metabolic system, 115 strength, 23
motor function training, 117 L weakness, 23–24
musculoskeletal system, 111–113 Lifestyle modification, 94–95 Musculoskeletal system, 111–113
nutrition and metabolic disorders, Liver function tests, 29
117–118 Long-standing diabetes mellitus, 72 N
organ systems, 115–116 Long-term care facilities, 51 Negative sensory symptoms, 70–71
orthostatic hypotension, 114, 116 Neurokinetic layer, 85
osteoporosis, 113 M Neurologic disorders, 59
pneumonia, 116 Magnetic resonance angiography Nonsteroidal antiinflammatory drugs
pressure injury, 116 (MRA), 76–77 (NSAIDs), 99
psychologic support, 117 Magnetic resonance imaging (MRI), 74 Nonsurgical treatment, 32–33
range of motion (ROM), 112–113 Malnutrition, 131 Normal pressure hydrocephalus
respiratory system, 114 aging, 131 (NPH), 63–64
sarcopenia, 111–112 anorexia, 134 Novel interventions, 53–54
social isolation, 115 approaches, 132–135, 133f,
subacute stage reconditioning 133b–134b O
rehabilitation, 117 caloric intake, 132 Obesity, 90
ulcer, 116 dental problems, 134 Occupation, 91
urinary tract infection, 116 food intake, 132–133 Older community-dwelling adults, 48
Hospital Elder Life Program (HELP), identification, 132 Opioid analgesics, 75
5–6 Matrix metalloproteinases (MMPs), 82 Oral bisphosphonates, 30
Hyaluronans, 100 Matter of Balance program, 48 Orthopedic injuries
Hyaluronic acid (HA), 83 MCI. See Mild cognitive impairment acute management of fractures, 45
Hypercalcemia, 29 (MCI) low femoral bone mineral density,
Hypocalcemia, 29 Metabolic system, 115 45
Metatarsal pain, 75 wrist fractures, 45
I Mild cognitive impairment (MCI), 60, Orthostatic hypotension, 114, 116
Ibandronate, 30 172 Orthotics, 75
Immobility, 111, 112t, 115 Mobility Osteoarthritis
Inclusion body myositis (IBM), 70 age-related physiologic changes, 124 acetaminophen, 98
Individual joint components, 82–84 assistance, 218 alternative oral agents, 99
Inert layer, 85 CNS. See Central nervous system American Academy of Orthopaedic
Inflammation, 81–82 (CNS) Surgeons (AAOS), 97, 98t
Intensive care unit rehabilitation, PNS. See Peripheral nervous system arthroplasty, 101–104
116–117 (PNS) bilateral knees, 84, 84f
International Classification of Diseases Polypharmacy. See Polypharmacy biologic injectables, 100–101
(ICD-10-CM codes), 20 Motor function training, 117 chondrocytes, 83
International Osteoporosis Multidisciplinary care, 10–12 corticosteroid injections, 99–100
Foundation, 29 attributes, 10 epidemiology, 81
International Statistical Classification Comprehensive Geriatric Assessment hip osteoarthritis. See Hip
of Diseases and Related Health (CGA), 10 osteoarthritis
Problems (ICD)-10 codes, 43 comprehensive geriatric assessment hyaluronans, 100
Intraarticular injections, 99–101 (CGA), 11–12 hyaluronic acid (HA), 83
Intracranial hemorrhage (ICH), 59 dwelling modifications, 11 individual joint components, 82–84
Isometric contraction, 36 hospitalization, 11 inflammation, 81–82
INDEX 227
Osteoarthritis (Continued) Osteoporosis (Continued) Physical activity

intraarticular injections, 99–101 treatment, 30–31, 30t aerobic exercises, 9–10
joint space articular cartilage, 83 T-score, 27–28 American College of Sports
knee osteoarthritis. See Knee vitamin D, 37–39 Medicine, 8
osteoarthritis fall prevention, 38 arthritis, 9–10
matrix metalloproteinases (MMPs), fall risk measurements, 38 benefits, 8
82 interventions to prevent falls, geriatric exercise prescription, 8–9
meniscal tears, 83–84 38–39 group therapy programs, 9
nonsteroidal antiinflammatory drugs Mobile Outreach program, 38 intensity, 9
(NSAIDs), 99 Timed Up and Go (TUG) test, 38 limitations, 8
pathogenesis, 81–84 workup, 29–31 obesity, 9–10
primary osteoarthritis, 82–84 World Health Organization criteria, Physical therapy program, 95–96
proinflammatory mediators, 81–82, 27t Pincer-type morphology, 86–87, 87f
82b Osteoporotic vertebral compression Plain X-rays, 32
subchondral bone, 83, 83f fractures, 33 Pneumonia, 116
supplements, 97 Polypharmacy
synovium, 83 P adverse drug events (ADEs),
total joint replacement, 101–104 Parathyroid hormone therapy, 121–123, 121b, 123f, 123t
type II collagen, 82 30–31 age-related physiologic changes, 124
Osteocalcin, 29 Parkinson disease (PD), 60–62 comprehensive medication review,
Osteochondral layer, 85 Peripheral arterial disease (PAD), 126–127, 127b
Osteoporosis, 113 75–77 consequences, 124b
androgen deprivation therapy computed tomography angiography epidemiology, 121–124, 122f
(ADT), 28 (CTA), 76–77 intervention, 126–127
approaches, 29 diagnostic workup, 76–77 medication classes, 125
bisphosphonates, 30 history, 75–76 mobility impairment, 125–126
bone mineral density (BMD), 27 magnetic resonance angiography patients evaluation, 125–126
clinical diagnosis, 27t (MRA), 76–77 patients with, 127–128, 128b
community care, 36 mobility disability, 75 pharmacodynamic changes, 125
definition, 27–28 physical examination, 75–76, 76t pharmacokinetic changes, 125
denosumab, 31 rehabilitation management, 77 risk factors, 121, 121f
diagnosis, 27–28 Peripheral nervous system (PNS) safe drug, 127
epidemiology, 28–29 ankle-foot orthotics (AFO), 75 Positive sensory symptoms, 70–71
exercise ankle plantarflexion contracture, 72 Posterior leaf spring orthotics (PLSO),
community-based exercise, 37 definition, 70–75 75
home-based exercise, 36–37 diagnostic workup, 72–74 Postfall anxiety syndrome, 46
falls and fragility fractures, 31–34 electrodiagnosis, 73–74 Postfall syndrome, 46
delirium, 34 imaging study, 74 Power wheelchairs, 218
epidemiology, 31 laboratory test, 74 Pressure injury, 116
infection, 34 diurnal variation, 72 Primary osteoarthritis, 82–84
orthopedic management, 32–33 electrodiagnosis (Edx), 69 Primary osteoporosis, 28
orthopedic treatment, 32 gross deformity, 72 Proinflammatory mediators, 81–82, 82b
outcomes, 31–32 history, 70–72 Proximal muscle weakness, 70
perioperative care, 32–34 long-standing diabetes mellitus, 72 Proximal thrombosis, 34
postoperative complications, 34 motor neuron disease, 70–71
preoperative care, 32 myopathies, 70–71 R
recurrent/repeated fractures, neurologic examination, 72 Range of motion (ROM), 112–113
31–32 orthotics, 75 Rate of falls, 43
thromboembolic disease, 34 peripheral vascular disorders, 75–78 Receptor activator of nuclear factor κ-B
fracture risk assessment tool (FRAX), PAD. See Peripheral arterial ligand (RANKL), 31
29 disease (PAD) Recurrent/repeated fractures, 31–32
glucocorticoids, 28 venous system disorders. See Rehabilitation management, 74–75, 77
laboratory studies, 29 Venous system disorders Relative immobility, 36
long-term care, 36 physical examination, 70–72 Replacement arthroplasty, 32–33
management, 29–31 posterior leaf spring orthotics Respiratory system, 114
nutrition, 37 (PLSO), 75 Risedronate, 30
parathyroid hormone therapy, 30–31 rehabilitation management, 74–75 Robotics, 213, 214f
primary osteoporosis, 28 sensory nerve-mediated symptoms,
rehabilitation 70–71 S
acute and subacute phase, 35–36 symptomatic treatment, 75 Sarcopenia, 111–112
postoperative rehabilitation Peripheral neuropathy (PN), 58 aging, 19
program, 34–35 Peripheral vascular disorders, 75–78 Asian Working Group on Sarcopenia
risk factors, 28–29 Pharmacologic management, 97–99 (AWGS), 19
228 INDEX
Sarcopenia (Continued) Spine disorders (Continued) Subchondral bone, 83, 83f

bioelectrical impedance, 20–21 degenerative disc disease, 197 Supplements, 97
definition, 19 endplate, 197–198 Synovium, 83
diagnosis, 20–21, 21t facet arthropathy, 201–203, 202f
dual-energy X-ray absorptiometry, clinical presentation, 201–202 T
20–21 diagnosis, 203 Telemedicine, 213–215
European Working Group on management, 203 Telomere shortening, 23
Sarcopenia in Older People pathogenesis, 201 Thoracic kyphosis, 29
(EWGSOP), 19, 20f facet joints, 198, 198f Tönnis and Heinecke classification
excitation-contraction coupling function, 195 system, 92–93, 92t
system, 23–24 intervertebral disc, 197 Total joint replacement, 101–104
exercise, 24 lumbar spinal stenosis Traumatic brain injury (TBI), 44–46,
functional performance tests, 23 clinical presentation, 208 63
geriatric rehabilitation program, 24 imaging assessment, 208 antiplatelet and anticoagulant
intermuscular fat, 23 management, 208–209, 208f medications, 45–46
International Classification of pathogenesis, 207–208, 207f cardiovascular instabilities, 46–48
Diseases (ICD-10-CM codes), 20 muscles and ligaments, 198–199, National Study on the Costs and
muscles 198f Outcomes of Trauma, 45–46
atrophy, 23–24 osteoporosis and vertebral fractures subarachnoid hemorrhage, 45–46
function, 23 diagnosis, 200 traumatic subdural hemorrhage,
performance, 23 management, 201 45–46
size, 23 normal bone metabolism, 199 Type II collagen, 82
strength, 23 prevention, 200–201
weakness, 23–24 risk factors, 199–200, 199f U
nutritional supplementation, 24 sarcopenia, 209–210 Ulcer, 116
physiological changes, 22–23, 22f management, 210, 210t Ultrasonography, 74
prevalence, 21–22 pathogenesis, 209–210 Unintentional injury, 5
sarcoplasmic reticulum, 23–24 structure, 195, 196f Urinary tract infection, 116
skeletal muscle index, 20–21 vertebral body, 197–198 Urine hydroxyproline, 29
static (isometric) strength, 20–21 Sports injuries
t-tubules, 23–24 classification, 162–163 V
variability, 19 epidemiology, 161–162 Venous system disorders
World Health Organization, 19 goal, 161 chronic venous insufficiency (CVI),
Semiquantitative measurement, 72 masters athlete, 161 77
Sensor technology, 213 older athlete clinical presentation, 77–78
Sensory examination, 72 knee osteoarthritis, 165 management, 78
Sensory nerve-mediated symptoms, lumbar spine injury, 166 Venous thromboembolism (VTE), 34
70–71 prevention, 166 Vertebral fracture, 31
Short Physical Performance Battery, 23 return to play, 166 Videofluoroscopic swallow study
Shuffling and festinating gait (FSG), rotator cuff injury, 164–165 (VFSS), 140, 141t
61–62 organized sports participation, 161 Video games, 213
Social isolation, 115, 216–217 patient evaluation, 163 Vitamin D, 37–39, 51, 90
Spinal cord injury (SCI), 46 rehabilitation phases, 163–164,
Spine disorders 164t W
aging, 195–197 risk factors, 162, 162t Wearable devices, 218
back pain, 195 Statin-induced myopathy, 70 World Health Organization (WHO),
cervical myelopathy, 203–207 Stem cell exhaustion, 23 19, 27–28
clinical presentation, 205–206 Stopping Elderly Accidents, Deaths,
imaging assessment, 206 and Injuries (STEADI), 48, 53 Z
management, 206–207 Subacute stage reconditioning Zoledronate, 30
pathogenesis, 203–205, 204f–205f rehabilitation, 117

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Geriatric

GERIATRIC REHABILITATION ISBN: 978-0-323-54454-2

Copyright © 2018 by Elsevier, Inc. All rights reserved.

Content Strategist: Kayla Wolfe

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Editors Mooyeon Oh-Park, MD

Blessen C. Eapen, MD Matthew N. Bartels, MD, MPH

Shih-Ching Chen, MD, PhD Dennis D.J. Kim, MD

Michelle Didesch, MD Jongmin Lee, MD, PhD

Shari Goo-Yoshino, MS, CCC-SLP Sewon Lee, MD

Peter J. Moley, MD Christopher K. Rogers, MPH

Yeonsil Moon, MD, PhD Luis A. Sánchez, MD

Epidemiology of Aging, Disability,

INTRODUCTION next 50 years, the trends associated with aging are

people with multimorbidity is higher for the below GERIATRIC SYNDROMES

Linear Concentric Interactive Concentric

INTRODUCTION motor performance, and the loss of the capacity of

MAKING THE DIAGNOSIS normal values and the adjustment of measurements

DXA, dual-energy X-ray absorptiometry.

Muscle Strength Muscle Function and Performance

Osteoporosis and Fragility Fracture

INTRODUCTION setting. However, as up to 80% of bone strength is

recommends the use of a uniform Caucasian (non–

Recently, fracture risk prediction algorithms, such TABLE 3.4

Workup and Management of Osteoporosis reflect an underlying malignancy or hyperparathy-

Treatment of osteoporosis intravenous preparations affording high bioavaila-

Early Life Late life

muscles is also beneficial, for example, by placing

COMMUNITY CARE AND LONG-TERM

Fall Prevention and Intervention

TABLE 4.1 BOX 4.1

Screen for fall or fall risk with 3 questions

Older Adults in Long-Term Care • An exercise program should be implemented with

Older Adults in Hospitals and Rehabilitation

Central Nervous System Disorders

Neurodegenerative Disorders substantia nigra and locus coerulus. PD affects 1% of the

Peripheral Nervous System and

Impaired mobility from PNSDs

Weakness No weakness (isolated sensory

Presence of sensory Length-dependent

Demyelinating type; AIDP,

Arthritis and Joint Replacement

INTRODUCTION (posttraumatic), older age, metabolically associated

GENERAL OVERVIEW OF OSTEOARTHRITIS Inflammation and Primary Osteoarthritis

per milliliter.2 There may be cases where the synovial

Individual Joint Components and Primary 4. Metabolically associated (obesity), and

The joint space articular cartilage is frequently

osteoarthritic cascade. Similarly, labral tears, muscle

morphology become symptomatic, given that only a

present to diagnose FAI syndrome, with the primary

Management of femoroacetabular impingement Developmental dysplasia of the hip

known as Bernese periacetabular osteotomy.58,60 Patients

ASSOCIATED RISK FACTORS FOR HIP

Knee OA Clinical Pearl: Studies demonstrate that knee

Genetics and Ethnicity

were inconsistent among patients with hip osteoarthri-

TABLE 7.5 TABLE 7.6

osteoarthritis can be achieved through the combination Physical Therapy Program

adjunct in every case. The goal is to provide the patient