Muscle Changes

Older adults lose both strength and the ability to produce force rapidly.¹¹ Sarcopenia is the loss of muscle mass and strength with aging.^67,114 There is a loss of the number of myocytes and a reduction of the protein content of the remaining muscle cells. Muscle strength decreases with aging at the level of single muscle fibers and force per unit area. Protein synthesis decreases, especially myosin heavy chains, with a disproportionate atrophy of type 2a (fast-twitch) fibers.⁹⁸ A decreased myosin concentration can play a key role, with a slower shortening velocity of single muscle fibers.³⁶ Aging muscle has a disproportionate loss of fast muscle fibers, with an increased proportion of muscle fibers with multiple myosin isoforms. Thus there is a blurring between type 1 and type 2 fibers, with the muscle overall having more slow-twitch characteristics than in young adults.¹¹ Muscle power decreases by 3.5% per year, whereas strength decreases by 1.4% to 2.5% per year beyond the age of 60 years.¹¹

Sarcopenia is probably driven by a combination of catabolic action and a reduction in anabolic influences.¹¹⁴ There is an increase in catabolic cytokines, such as tumor necrosis factor-α, interleukin (IL)-6, IL receptor antagonist, and IL-1β. Anabolic stimuli decrease, including estrogen, testosterone, growth hormone, protein intake, physical activity, and central nervous system input to promote movement.¹¹⁴ In both the healthy and the frail elderly, it is the type 2 fast-twitch fibers that are lost.¹²⁴ α-Motor neuron dropout occurs with a reduced number of them in the elderly. Sarcopenia does not typically cause a decrease in body weight, because the percentage of fat increases.²³

The role of cytokines in mediating muscle mass and strength is just beginning to be understood. For example, in a cross-sectional analysis of 617 women aged 70 to 79 years, a decline in insulin-like growth factor-1 was associated with poor knee extensor strength, slow walking speed, and self-reported disability.²⁶ In a cross-sectional study of 3075 adults aged 70 to 79, the inflammatory markers C-reactive protein and IL-6 were lower in those who had higher levels of exercise and in those who used antioxidant supplements regardless of exercise status.³⁰ Adipose tissue has its own metabolic activity, including the secretion of inflammatory factors.¹³⁸ Increases in body fat might facilitate inflammation, with a differing role played by abdominal fat versus fat in the extremities.¹³⁸

The decline in muscle strength is not the same in all muscle groups. In a study of 120 men and women aged 46 to 79 years who were observed over a 10-year period,⁶⁷ women had slower rates of decline in elbow flexors and extensors (2% per decade) compared with men (12% per decade). In both men and women, knee extensor strength decreased by 14% per decade, and knee flexor strength by 16% per decade.

Mitochondrial function declines with old age.⁸³ One theory is that a sedentary lifestyle leads to decreased spontaneous physical activity (as distinct from voluntary purposeful activity), which further decreases mitochondrial function. Data are not yet available to determine if endurance exercise can delay or prevent this decline.⁸³

Older adults can have limitations in maximally activating muscle because of neural changes, such as increased agonist-antagonist coactivation, decreased motor neuron excitability at the spinal cord level caused by decreased afferent input, and inefficient transmission at the neuromuscular junction.¹¹ With training, young adults show more adaptations in spinal cord relay components, whereas older adults might rely more on supraspinal influences.¹¹ Older adults typically use a higher percentage of minimal knee strength than young adults, which can lead to more fatigue because they are working near full capacity.¹¹ The elderly can also have reduced power, because of a lack of rapid force development.¹¹

Gait Changes

From 8% to 19% of noninstitutionalized older adults have difficulty walking, and this increases to 67% of nursing home residents.³ Gait speed typically declines at the rate of 0.2% per year up to the age of 63 years, and then 1.6% after age 63 in older adults who are relatively free of neurologic, cognitive, or cardiovascular problems.³ Conditions associated with faster gait speed include greater hip extension, and ankle dorsiflexion and plantar flexion range of motion.³

Gait in the elderly is characterized by increased double-limb support, as well as by slower speed, shorter stride length, and a broader base of support. Pelvic rotation decreases and postural responses are slower. Gait studies have been done to identify factors associated with falling in the elderly (Boxes 59-1 and 59-2). In the subset of older people who fall, stride-to-stride variability in gait is increased.^62,92 Maki⁹² found that reduced stride length, reduced speed, and increased double-support time are associated with a fear of falling. His study also showed that increased stride-to-stride variability in length, speed, and double support was associated with actual falling. Stride-to-stride variability was the best single predictor of falling. In another study of elderly women with a mean age of 75 years, the peak ankle dorsiflexion power had strong associations with stair climbing time and chair rise time. Plantar flexion isometric strength was strongly associated with habitual and maximal gait velocity.¹²⁹ The study by Grabiner et al.⁵⁸ also showed that when young and elderly “nonfallers” were studied, the older subjects had a significantly larger stride width variability.

Osteopenia and Osteoporosis

The elderly have an increased incidence of osteopenia and osteoporosis. Osteopenia is defined as bone mineral density more than one standard deviation below the young adult level (T <–1 but >–2.5). Osteoporosis is present if the T score is less than –2.5.¹⁰⁶ This occurs in both genders, but is more common in women. Risk factors for osteopenia and osteoporosis include age, family history, glucocorticoid therapy, and smoking.^106,126

Osteoarthritis

Degenerative joint disease becomes much more common in the aged. Arthritis affects more than 60% of women and 50% of men who are 70 years and older.¹³ The reported incidence and prevalence of osteoarthritis vary depending on whether one uses radiologic findings, clinical symptoms, or a combination to define cases.⁸⁵ Limitations in range of motion can go unreported in some instances, because the person is unaware of the loss of range of motion as a result of its gradual progression.¹¹⁷

Osteoarthritis is the most prevalent articular disease in adults 65 years and older.⁸⁵ Because there is a strong association with aging, attempts have been made to determine whether osteoarthritis is a distinct disease.⁸⁵ In osteoarthritis, there are differences in the water content ratio of certain cartilage constituents, and an increase in degradative enzyme activity compared with that in nonosteoarthritic joints. It is possible that the reduction in chondrocyte density with aging leaves cartilage vulnerable to degeneration and osteoarthritis.⁸⁵

Changes in Special Senses

Vision declines with age. The lens has less adaptation. Macular degeneration, cataracts, and glaucoma become more prevalent with age. Decreased auditory acuity frequently develops. The usual pattern is a loss of higher frequencies; people with this type of hearing loss can hear speech but have difficulty understanding it.⁴⁷ With hearing loss progression, the lower frequencies are affected also, making it difficult to understand vowels and what is being said, especially in a loud setting.⁴⁷

Cardiovascular Changes

With aging the cardiovascular system has decreased arterial compliance, increased systolic blood pressure, left ventricular hypertrophy, decreased baroreceptor sensitivity, and decreased sinoatrial node automaticity.¹⁰⁸ The exercise-induced adaptations that occur in younger people, such as increased peripheral arteriovenous oxygen difference and increased cardiac size, stroke work, cardiac output, and left ventricular function,² are not as available to the elderly. Older patients with coronary artery disease have age-related increases in left ventricular and arterial wall stiffness and thickening, which limit some adaptations with conditioning.² In the operative setting, maintaining intravascular volume is important, because the aged heart depends on preload more than in the younger person. Because after-load is increased by outflow tract stiffness, there is decreased sensitivity to catecholamines and impaired vasoconstrictive responses in the elderly.¹¹³

Pulmonary Changes

Lung compliance increases and thoracic wall mobility decreases in the elderly, with a 20% increase in the effort needed to overcome elastic resistance.⁴⁶ Vital capacity typically decreases 40% to 50% by the age of 70 years.⁴⁶ The net effect is that during exertion, the elderly must rely on increased respiratory frequency rather than increased tidal volume.⁴⁶

Genitourinary Changes

Renal blood flow decreases with age,^22,29 as does glomerular filtration rate.¹⁰⁸ A 50-kg woman with a serum creatinine level of 1.0 mg/dL has a calculated creatinine clearance of 62 mL/min if she is 35 years of age, but only 32 mL/min if she is aged 85 years old.²⁹ Because serum creatinine reflects muscle mass, a normal serum creatinine level can be seen even with a reduced glomerular filtration rate.²² Urinary incontinence can develop on the basis of stress, or because of overflow secondary to prostatic hypertrophy. Increased collagen content causes decreased bladder distensibility.¹¹³ Decreased estrogen predisposes to incontinence by causing urethral sphincter changes.¹¹³ Subjective thirst decreases in the elderly, which can negatively affect fluid balance.¹¹³

Gastrointestinal Changes

There are many reasons for decreased food intake in the elderly.⁹⁷ Odor and taste can be decreased. Cholecystokinin levels increase with aging, causing gastric emptying to slow and increasing the effect of antral stretch to signal satiation. There can be a decline in the central feeding drive. If disease causes cytokine release, these immunoregulatory peptides cause anorexia, muscle wasting, and decreased albumin synthesis.

Dysphagia can develop because of dental problems or achalasia. The time from pharyngeal entry of food to laryngeal elevation increases.⁴¹. Stomach acid decreases, with subsequent impaired absorption of vitamin B₁₂, calcium, iron, zinc, and folic acid.^112,125 Thirst sensation is impaired and gut motility decreases. Hepatic metabolism is altered, with corresponding changes in drug clearance. The potency and duration of action of some drugs are increased.²² Hepatic blood flow decreases 12% to 40% in the elderly, and liver size decreases, with a resulting reduction in first-pass metabolism of drugs.²⁹ Impairment of normal liver function can also alter how a drug is treated in the liver, as drug interactions can alter liver enzymes and subsequent drug processing.²²

Malnutrition affects the elderly differently than younger people. Elderly patients (mean age, 79 years) were compared with middle-aged (mean age, 48 years) in a group with chronic malnutrition. The middle-aged patients lost fat mass, fat-free mass, and body cell mass in equal proportions, but the elderly patients proportionately lost more fat-free mass and body cell mass. Therefore the elderly were losing proportionately more from muscle and other body organs.¹¹⁸

Endocrine Changes

Changes in the endocrine system can cause deterioration in glucose tolerance. Hormonal changes that typically occur include decreased estrogen, testosterone, and growth hormone. Temperature regulation is impaired.¹¹³ End-organ responsiveness to medications can be different in the elderly, but this is just beginning to be explored.⁵³ There is an age-related decline in immune function, which in some studies has been improved with vitamin supplements.¹¹² Vitamin D deficiencies can exist because of inadequate intake, decreased exposure to the sun, and impaired efficiency in the conversion of the inactive to active forms.⁶⁶

Skin Changes

Skin fragility increases with age because of a combination of decreased moisture content, elasticity, blood supply, and sensory sensitivity. These changes increase the risk for injury to the skin in the elderly, including pressure sores.

Parkinson Disease

Parkinson disease is present in 1% of people older than 65 years,⁷ and clinically manifests with tremor, rigidity, and bradykinesia. Twenty percent of patients with Parkinson disease also develop dementia.¹⁶ The tremor is present at rest and increases with stress.⁷ Voluntary movement is slow. Gait is characterized by small shuffling steps without arm swing. It is difficult for the patient to initiate walking or other position changes.⁷ The gait can be festinating, in which gait speed increases as the patient attempts to prevent falling forward because of an abnormal center of gravity. Turning is particularly difficult and unsteady.⁷

Dementia

Dementia is found in 1.5% of people aged 65 to 70 years, and increases to 25% of people 85 years and older.¹¹⁴ The most common causes of dementia in the elderly are Alzheimer disease, vascular (multiinfarct) dementia, diffuse white matter changes (also called Binswanger dementia), alcoholism, Parkinson disease, and drug or medication intoxication.¹⁶

Depression must always be differentiated from dementia in the elderly.¹²⁸ Dementia should also be differentiated from benign forgetfulness of the elderly. The workup for dementia typically includes obtaining a serum vitamin B₁₂ level, thyroid function tests, serum electrolyte levels, a complete blood cell count, serology for syphilis, and brain imaging. Depending on the clinical setting, urine toxicology screen, lumbar puncture, and a general medical workup can be needed. If there is a history of falls or the patient is receiving anticoagulants, subdural hematoma should be ruled out. Infections should be ruled out. Acquired immunodeficiency syndrome can produce dementia in the elderly. The adverse effects of medications can sometimes include dementia, and depression can masquerade as dementia.

Dementia must be differentiated from acute confusion. Delirium is an acute confusional state with a fluctuating time course, with impaired cognition, attention, and level of consciousness.⁶⁹ Neurologists prefer the term acute confusional state.¹¹¹ Inattention and disorientation are the primary early signs, with a defect in attention. There can be drowsiness as well. The patient has decreased mental clarity, coherence, comprehension, and reasoning.¹¹¹ It can be clinically challenging to determine what is chronic and what is new when an elderly patient has confusion in the postoperative setting, because baseline dementia is the major risk factor for delirium (Box 59-3).¹¹³ Risk factors include age, preoperative cognitive impairment, poor functional status, alcohol use, and polypharmacy.¹¹³ In the postoperative period, undertreated pain can lead to delirium.¹¹³ Intraoperative blood loss and a postoperative hematocrit less than 30% are associated with an increased risk for postoperative delirium.¹¹³

Mild cognitive impairment is shown clinically by memory loss greater than expected for age, but this is not Alzheimer disease.¹⁰⁵ There are mild deficits in memory or some other aspect of cognition, with a progression to Alzheimer disease at a higher rate than healthy controls.¹⁰⁵ Cognitive dysfunction can show up first in executive functioning. In a study of community dwelling women aged 70 to 79 years at baseline, observed for 9 years, a decline in executive function preceded memory loss by about 3 years.²⁷ Executive function is needed for planning, initiating, prioritizing, and carrying out a series of goal-directed actions.²⁷

Approximately 10% of people older than 70 years have significant memory loss, and in more than half of the cases this is attributed to Alzheimer disease.¹⁵ The prevalence is 1% among those aged 60 to 64 years, and 40% among those 85 and older.³⁴ Alzheimer dementia typically progresses slowly over several years. Confrontation naming of items to command is typically impaired early in the course.¹⁵ Patients have difficulty learning and recalling new information, and there is a progressive language disorder.³⁴ Visuospatial skills are disturbed.³⁴ Executive function skills are impaired, including planning, judgment, and insight.³⁴ Apraxia with sequential motor tasks can occur.¹⁵ Alzheimer dementia can also feature delusions and hallucinations.¹⁵ Social inhibitions are lost, and the sleep-wake cycle is disturbed.¹⁵ A shuffling gait with rigidity can develop.¹⁵ The disease typically has an 8- to 10-year duration. The pathologic features typically include plaques with amyloid and neurofibrillary tangles in the neuronal cytoplasm.

Normal Pressure Hydrocephalus

The hallmark signs of normal pressure hydrocephalus are dementia, gait disturbance, and urinary incontinence.¹⁶ Normal pressure hydrocephalus can be idiopathic or related to prior meningitis or subarachnoid hemorrhage.¹⁶ The reduced physical turgor of the brain tissue with aging is thought by some experts to allow even normal pressure to produce hydrocephalus and brain atrophy. In some cases the patient’s condition can be dramatically reversed by shunting to achieve a reduction in central nervous system fluid pressure.

Cancer

The incidence and prevalence of most malignancies increase with age up to at least 85 years of age.¹⁰ The increasing incidence could be because of the length of time for a carcinogenic factor to take effect, as well as molecular changes occurring with aging that can favor certain cancers.¹⁰ Tumors can behave differently in older patients than in those who are younger, and this has to be kept in mind when designing a treatment plan.¹⁰

Osteoarthritis

Osteoarthritis is the major disease that limits activity in the elderly.¹¹⁰ Risk factors are increased age, obesity, quadriceps weakness, impaired proprioception, heavy physical activity, lack of estrogen replacement in women, and knee injuries.¹¹⁰

Traumatic Brain Injury and Spinal Cord Injury

Older patients sustain more traumatic brain injury and spinal cord injury in domestic falls than do younger patients.¹¹⁰ Patients older than 50 years typically require longer lengths of hospitalization for these injuries, with the cost being twice as high as for younger patients.¹¹⁰ Older patients with paraplegia and tetraplegia have increased rates of nursing home placement and less neurologic and functional recovery than do younger patients.¹¹⁰

Disuse, Immobilization, and Decompensation

Immobilization has more serious consequences for the elderly than for younger patients. One study showed that even in young men, 29 days of bed rest resulted in a 10% decrease in quadriceps volume and a 16% decrease in gastrocnemius or soleus muscle volume.⁵ With decreased muscle mass (even when actual sarcopenia is not present), immobilization and disuse of muscles increase the risk in the elderly of weakness sufficient to cause functional problems. In one study involving 10 days of bed rest, 10 healthy older adults (mean age, 67 years) showed a significant decrease in muscle protein synthesis, whole-body lean mass, and lower extremity lean mass, with a greater lean mass loss than younger adults showed after 28 days of bed rest.⁷⁸ Knee extension strength and stair climbing power decreased after 10 days of bed rest even with a eucaloric diet that provided the “recommended daily” allowance for protein.⁷⁹ In this study, voluntary physical activity decreased after the 10-day period of bed rest.

Orthostasis can also become problematic, with some elderly patients requiring therapy and even medication for postural hypotension.

In one hospital’s medicine service, low mobility and bed rest in a prospective cohort of 535 patients hospitalized from 1989 to 1991 predicted adverse outcomes. The study team noted that almost 60% of bed rest episodes in the lowest mobility group did not have a documented medical indication.²⁴ Vigilance is needed to prevent the immobilization of elderly patients unless absolutely required by their medical condition. Immobilization also can combine with incontinence, skin fragility, and inadequate nutrition in the elderly to greatly increase the risk for pressure ulcers.

Deconditioning associated with acute hospitalization is not uncommon in the elderly. There are some data supporting inpatient rehabilitation as a tool for enhancing discharges to the community, but not enough data to define the optimal program or site of care.⁷⁷

Pain

The etiologies of pain in an aged population can be different than in a younger group. Some conditions that typically produce pain in the elderly include osteoarthritis, spinal stenosis, rotator cuff tears, idiopathic peripheral neuropathy, and diabetic neuropathy. The elderly also frequently have less tolerance for pain medication, especially of the opioid type. The elderly deserve adequate pain management no less than other age-groups. Inadequate pain control can cause problems in many other aspects of life, including quality of life in general and self-care ability in particular.

History Taking

The history and physical examination for the elderly patient is essentially the same as for younger individuals, with some changes in emphasis. The examiner should be direct in questions. Some patients will not bring up a particular symptom because they assume it is due to “old age.” This is especially the case with pain. Initiation of bowel and bladder topics might also need to done by the physician.

In the outpatient setting, one should ask, “Have you fallen? If so, what were the circumstances?” The person who reports falling on the ice during his or her regular 2-mile walk clearly functions at a different level than the person who falls repeatedly enroute to the bathroom at home. The frequency of falls needs to be determined. The optimal way in which to screen patients to assess fall risk is still under discussion,⁸² but those who report a fall within the past year are at higher risk for future falls.

Questions about specific activities of daily living (ADLs) are important. Examples include, “Can you get in and out of a bathtub without assistance?” and “How often do you leave home?” Some people identify a functional problem before they bring it to the attention of a health care provider. Patients might have borrowed a cane for perceived gait problems, purchased clothing that is easier to don, or changed their manner of cooking. These are examples of the coping strategies that some elderly patients use to maintain autonomy when they notice difficulties with ADLs or independent living skills.¹⁰⁹

Some investigators have attempted to develop additional measures for assessing dangers to the elderly such as fall risk. One study looked at residents in a sheltered accommodation⁸⁹ who had dementia, stroke, and depression as their most common diagnoses. One finding was that if the resident stopping walking when talking, there was a prediction of a fall within 6 months (positive predictive value, 83%). A prolonged time difference between a walking task with and without carrying a glass of water was shown to identify who is at higher risk for falling among ambulatory elders in a sheltered accommodation who were observed for 6 months.⁹⁰

In the acute inpatient setting, the diagnosis responsible for hospitalization receives the major portion of the attention. When the patient goes to an emergency department for acute care, a combination of the need to focus on the primary diagnosis and the patient’s inability to provide a complete history can leave important gaps in the history. For a fall with fracture, for example, one needs to know about prior falls. Other seemingly minor problems can now become more relevant. A past rotator cuff tear might limit the ability of a patient with a hip fracture to use a walker. Knee degenerative joint disease can interfere with weight-bearing on the nonparetic side in a patient with a stroke. Decreased vision or hearing can be an issue when the patient is out of the familiar home setting.

The review of systems should include questions about sleep. If sleep is impaired, what is the reason? Sleep management is different if the patient has pain, nocturia, or a mood disorder. Nocturia can result from the nighttime mobilization of peripheral edema.¹⁰⁸ Urinary frequency, urgency, and subjective retention need to be identified and treated. If pain is a problem, then as usual one needs to identify factors that precipitate and alleviate symptoms. Urinary incontinence should be excluded as a problem, and the examiner should bring up the topic because patients might be embarrassed about raising the problem.

Is nutrition adequate? If not, is it because of a financial problem, being physically unable to get to a grocery store, being unable to carry food items back from the store, or being afraid of lifting hot items during cooking? One study in 12 elderly women who were observed for 9 weeks showed that inadequate protein intake led to declines in lean tissue mass, muscle function, and immune response.²⁸

When pain is a symptom, the history should specifically identify the sites and quality of the pain, as well as the inciting and relieving factors. Many older people have multiple potential causes of pain. Careful questioning is needed to sort out the details sufficiently to correctly diagnose and treat the cause of the pain.

In the history, one needs to ask about alcohol use, because alcohol may play a role in nutritional deficiencies and falls. Recognize that elderly patients might be having unprotected sexual intercourse with exposure to human immunodeficiency virus or other sexually transmitted diseases, and that age alone does not preclude the use of illicit drugs. Does the patient have informal support systems such as neighbors that can be relied on for some degree of assistance?

The current list of medications should be thoroughly reviewed. Sleeping pills, some antihypertensives (such as β-blockers), metoclopramide, tricyclic antidepressants, and antiseizure drugs can all cause cognitive impairment. Even if the person has been taking the medication for some time, the “tipping point” can be reached when added to other acute health problems. Drug levels considered “therapeutic” can exacerbate a problem such as cognitive impairment in the elderly.¹⁰⁸ Nonprescription medications should not be neglected in the history-taking process.⁵³

The history should include a detailed discussion of advanced directives.¹⁰⁸ At the time of writing, there is not a single document that is automatically transferred as one moves from facility to facility within the health care system in the United States. Wishes expressed by patients in an office setting to their primary care physician can be unknown to the care providers when a patient is transferred from an acute care hospital to a rehabilitation setting. The legal status of a “living will” varies from state to state. If patients are relying on a health care proxy form to express their wishes, the health care providers should have on hand a copy of the document that stipulates this direction.

Physical Examination

In addition to the standard physical examination, there are useful physiatric additions. If gait problems are present, hip abduction and extension strength might need to be examined while the elderly person is side-lying and prone, respectively. Hip extension range of motion should be assessed. If deficits in position sense are present, it should be determined whether they are only at the great toe or also at the ankle. The Achilles muscle stretch reflex will be absent in some elderly individuals.¹⁰⁸ Vibratory loss is typically more sensitive than position sense in picking up neuropathy.¹³¹ Cerebellar testing should include both finger-to-nose and heel-to-shin procedures. However, in patients with limitations of hip range of motion, it might not be possible for them to actually bring the heel up to the shin at the knee.

Balance can be tested in a variety of ways, including tandem walking. The ability to perform a tandem “stand” can be assessed if there is concern about a potential fall during the checking of tandem gait. Gentle challenges can be provided by the examiner to assess whether balance can be maintained. Dynamic balance can alternatively be assessed by having the patient lean in different directions, which simulates more of one’s daily needs. Sitting balance can also be assessed.

Cognitive testing can be done both formally and informally. The examiner must make certain that the person is able to hear the instructions, and that vision is adequate for the task. Ambient noise should be controlled to make certain that the patient can accurately hear the examiner’s questions. The examiner can ask questions about subjects of interest to the patient, such as sports or political news.

Formal mental status screening can be done with tests such as the Mini-Mental Status Examination of Folstein.⁶ A baseline mild dementia can be masked when the person is in the familiar home setting, but becomes noticeable when admitted to the hospital.

The range-of-motion examination is very important in the elderly. Even relatively minor losses in range of motion can affect function. The range of motion of the neck and shoulders should be thoroughly checked. Loss of shoulder internal rotation makes it difficult for the patient to get the hands to the back, as in attaching a bra strap. Loss of shoulder external rotation makes it difficult to get the hands to the top of the head for hair care. Wrist extension and flexion, and finger flexion and extension limitations can have important functional ramifications in many activities that require manual dexterity.

It is common to find limitations of hip extension and rotation in the elderly. This can have a negative impact on gait efficiency. In the patient with hip or low back complaints, the Ober test can be used to check for tightness of the tensor fascia lata. Limitations of knee extension and flexion should be identified, because such losses of range of motion can have a major impact on the efficiency of gait. If decreased range of motion of the ankle is found, it should be determined whether it is caused by a joint capsule contracture, a bony block, or a tight gastrocnemius. Loss of ankle dorsiflexion range of motion that occurs only when the knee is extended is typically caused by tightness in the gastrocnemius. Ankle inversion and eversion range of motion is important for walking on uneven surfaces. Examination of the major joints for stability should be done. The knee in particular should be evaluated, because instability in any plane can affect gait function.

Deformities of the feet are common in the elderly, such as a bunion (hallux valgus). Pes planus can also be present. Hallux rigidus can cause pain and interfere with gait efficiency. Hammer toes can be an incidental finding, a cause of pain, and a potential source of infection if skin integrity is not maintained. Skin calluses indicate the foot surfaces that are weight-bearing. Skin integrity is important in the feet for both prevention of infection and for comfort. Patients who are bedbound for a period have an increased risk for heel pressure ulcers.

There is not yet consensus on the best test to use in the clinic setting for functional mobility. The “Get Up and Go” test looks for unsteadiness as the person gets up from a chair without using the upper limbs, walks a few meters and returns.¹³² The Berg Balance Scale looks at 14 items on a scale from 0 to 4, assessing the ability to maintain static balance and while in functional positions.^18,32,96

Laboratory Assessment

A discussion of the full range of potential testing is beyond the scope of this chapter. As the physiatrist, one should bear in the mind that certain nutritional deficiencies (such as vitamin B₁₂ or vitamin D) can be more common in the elderly. Also, some elderly patients might not be aware of episodes of loss of consciousness. Consider that syncope might be occurring if the patient reports falls without known precipitants.¹³¹ A bone density scan can influence decision making for the primary care physician as to osteoporosis treatment and prevention.

Medication Usage in the Elderly

Medication use in the elderly must be judicious because of the changes in drug metabolism that occur with age. The reactions of the elderly to medications are not always the same as those of the population that was used to initially test the medication. Polypharmacy is a concern because the number of potential interactions increases as more medications are used. Compliance with a medication program can be a problem because of the complexity of the regimen proposed, the cost of the medication, and the cognitive status of the patient. Adverse effects of medications can be more severe in the elderly population.³³ Elderly individuals as a group have traditionally been less represented in clinical drug trials.³³ Therefore it should be kept in mind that new signs and symptoms can be an adverse effect of treatment rather than a new condition.

The treatment plan for an elderly patient has to be realistic. It is better to work with the patient to design a medication schedule that can actually be carried out, rather than to devise a plan that will work only under optimal conditions. This is particularly important if something completely new is being introduced to the patient, such as expecting a person with new diabetes and limited vision to learn to adjust insulin, check blood glucose levels four times a day, and change food preparation habits within a very short time. In a study by Kaufman et al.,⁷³ in ambulatory adult women older than 65 years, 12% had taken at least 10 different types of medications during the preceding week (including nonprescription medications or supplements), and 81% had taken at least one prescription medicine during the preceding week. In the same study, 71% of men 65 years or older had taken at least one prescription drug, and 19% had taken five or more during the preceding week.⁷³

The increase in adipose tissue that typically occurs with age causes a larger volume of distribution for fat-soluble drugs and prolongs their biologic half-life.²⁹ Conversely, total body water decreases by as much as 15% between 20 and 80 years of age, which decreases the volume of distribution of water-soluble drugs and thus results in a higher serum concentration.²⁹ Because drug elimination is so affected by renal function, it is wise to check drug levels²⁹ when drugs with a low therapeutic index and significant renal clearance are prescribed. Confusion, sedation, nausea, change in bowel habits, and balance problems are symptoms that can be confused with a new illness rather than as adverse reaction to medications. A serious error in treatment can occur when additional medications are added to treat what was actually an adverse reaction to medication.²⁹ The reported incidence of adverse drug reactions in the elderly is 20% to 25%.²⁹

Physical Exercise in the Elderly

Physical exercise can be used to improve strength, range of motion, balance, and coordination. The exercise program typically starts with formal physical therapy, followed by a home program that the patient can continue doing. In the elderly, as in other patients, each physical therapy prescription must be individualized for the patient’s diagnosis and condition. This will be detailed later in this chapter.

Ambulatory Assistive Devices

Ambulation might require the use of assistive devices to be safe and practical. Patients often resist the use of ambulation aids because the devices do not fit with their self-image. But if the aid decreases pain or leads to an obvious improvement in function, the person will usually accept it. A cane can be used to take some weight off a painful hip and provide additional stability for balance problems. Crutches can be used if a patient needs to take the weight off a lower limb more completely. Forearm crutches can be used if there are limitations with grip strength or painful joints in the hand that impede grip. A walker provides stability and allows the person to convey items from place to place with a bag or basket on the walker. A platform walker can be used if hand or wrist function, or both, limit grip on a standard style. Wheelchairs allow for distance mobility in the community, even if not used within the home.

Orthoses and Footwear

Changes in footwear can sometimes improve stability with movement. Lower heels cause weight-bearing to be spread over more of the foot than high heels, and change the work of the quadriceps. High-topped shoes that extend above the ankles give additional sensory feedback as to foot position. Air stirrup devices can also serve this function and give additional ankle stability. Orthotic devices can help with pes planus. Over-the-counter shoe orthoses might provide adequate improvement, but many conditions require custom shoe insert orthoses to handle specific foot problems.

Occupational Therapy

Occupational therapy can address ADLs, including bathing, toileting, and dressing. Occupational therapy also can teach the patient independent living skills such as cooking, laundry, and money management. Joint protection techniques can be addressed for patients with arthritis so that larger joints bear more of the workload. Transfer training is often needed to ensure that getting on and off the toilet can be done safely. Occupational therapists work with the patient and family to sort out the specific pieces of ADL equipment that can best allow for safety and efficacy in the home.

Patients living alone need to be able to do at least some meal preparation independently. Nonstick pads can be used to stabilize bowls needed for mixing ingredients. Using a microwave in conjunction with a rolling cart can enable the person to heat the food and then move it safely to the table. Large-handled utensils help people with arthritis to grip with less pain. These ADL devices are widely commercially available in the United States.

Cognitive training might have a role in promoting ongoing independence in ADLs. A large group of 2802 people with a mean age of 74 years was followed up for 5 years after randomization to receive either training for verbal episodic memory, inductive reasoning, or speed of processing (visual search and identification). The groups that received cognitive training had less functional decline than the controls assessed after 5 years specific to the abilities for which they were trained, with less functional decline in self-reported ADLs in the reasoning training group.¹⁴³

Speech Pathology

Speech therapy can assist the patient with many impairments, including problems with hearing, speech, language comprehension, orientation, and dysphagia. If auditory comprehension is a problem because of a loss of hearing, the speech therapist can also work with the patient on augmentative devices. Choosing a hearing aid requires a thorough analysis of the patient to discover and treat conditions that could interfere with the ability to use a complicated hearing device, such as arthritis, weakness, or sensation problems.⁴⁸ Print size can make a major difference in the person’s ability to read, and this can be addressed in the context of speech therapy. It is important that the patient’s senses are working as well as they can; this might require ophthalmologic procedures, glasses, hearing aids, etc. There are ongoing advances in commercially available technology that can be useful.

Psychosocial Support

The elderly have to deal with losses of family, friends, jobs, and function. These losses can lead to depression, even in people who never had depression earlier in life. Social work and psychology services are often critical in managing these life changes. Some problems can be addressed by facilitating access to services that an individual might not otherwise know about. For example, giving up a driver’s license can lead to a difficult lifestyle change, but it can be made easier if the individual learns to use the available transportation services. One may need to individualize goals so that by outcomes better measure success.⁴⁵

Modifying the Environment

Modifying the environment is an approach to disability that goes beyond the typical measures that reduce barriers. For an individual patient, details in the home can be addressed. For example, chairs can be designed to ease the difficulty an elderly person has in changing position.⁴ However, modifying the environment can be carried out on a broader scale, such as when traffic lights are timed to allow adequate time for elderly persons to safely cross a street.

Osteoporosis Prevention and Treatment

Geriatric rehabilitation can also address prevention of some of the complications associated with aging. Areas of concern include osteoporosis, nutrition, cardiovascular problems, muscle weakness, hearing, visual impairments, and impaired balance.

Osteoporosis can be used as an example in this regard (see Chapter 41). It can be addressed with a combination of diet, drugs, and exercise. Adequate calcium intake is essential. If there is a history of calcium kidney stones, the physiatrist should work with the patient’s primary care provider, to avoid hypercalciuria.⁸ Adequate vitamin D is needed also. Seasonal variation is found in 25-hydroxyvitamin D levels, which are lower in winter and spring, and decline with age.¹²⁴ This can be exacerbated by decreased exposure to the sun, such as is experienced by some nursing home residents or those who are housebound. Vitamin D supplementation is often necessary and can be combined with calcium when desirable. If an elderly patient has vitamin D deficiency, higher doses of vitamin D should be used for the first 8 weeks of treatment.⁸¹ In one metaanalysis the use of vitamin D reduced the risk for falls among ambulatory elders living in the community and in institutions.¹⁷ The early effect of vitamin D on reducing the risk for falls might be attributable to the active metabolite binding to a muscle tissue receptor.¹⁷ Based on prior studies, 400 international units (IU) daily might not be enough, and 800 IU might be needed in elderly patients.¹⁷

Medications can reduce resorption of bone. Estrogen was used widely in the past, but because of negative side effects, the so-called designer estrogens such as raloxifene are now used. Etidronate was the first bisphosphonate approved as an antiresorptive agent.⁸¹ Alendronate with calcium has been shown to improve bone mineral density and decrease the incidence of vertebral fractures and the progression of vertebral deformities.⁸⁴ It is necessary to ensure that vitamin D intake is adequate with alendronate use.¹⁹ Calcitonin is also used but tends to reduce vertebral rather than peripheral fractures.¹⁰⁶

A fracture in an elderly person that is caused by a relatively minor force is predictive of future fractures. For example, having a distal radial (Colles) fracture doubles the risk for having a future hip fracture. The presence of a vertebral fracture on radiographs increases the risk for an additional vertebral fracture four to five times.¹²⁶ Radiologists do not always comment on vertebral fractures that appear on routine chest radiographs.¹²⁶ Because future fractures of any type can have major implications for the health and overall function of an elderly person, any fracture should set in motion measures to prevent future fractures. Exercise works to reduce the chance of vertebral fractures related to osteoporosis.

A negative correlation exists between the strength of back extensor muscles and thoracic kyphosis in women with osteoporosis.^121,123

Vertebral fractures in postmenopausal women were studied over a 2-year period, then over a 10-year follow-up. Women were trained in back extensor-strengthening exercise.¹²¹ The average age at study entry was 56 years. The 2-year exercise period consisted of prone exercise with a backpack containing weights. The strength difference between the exercise group and the control group was significant; the relative risk for compression fractures was 2.7 times greater in the control than in the extensor exercise group.¹²¹

Specific balance training can also be helpful, because patients with osteoporosis and kyphosis maintain their balance with an increased use of hip strategies compared with the general population.⁹¹ In a randomized pilot study, seven women with osteoporosis and kyphosis received either extensor-strengthening exercises only or the same exercises with use of a weighted 2-lb thoracic orthosis worn 2 hours per day during ambulatory activities. The subjects who had the most abnormal balance and used the proprioceptive training device had the most improvement in balance.¹²² It is likely that improved balance decreases the risk for fractures caused by falls.

Preventing Falls in the Elderly

Falls are common in the elderly and have numerous potential etiologies. The physiatrist needs to identify which are the most likely causes and try to address them in a holistic manner. Some are more easily treatable than others (see Box 59-2).

Falls cause 90% of the fractures of the forearm, hip, and pelvis in the elderly.⁸⁰ There are multiple risk factors for falls (see Box 59-2).³⁹ Dim lighting and high beds can be a contributor to falls in nursing home patients.³⁹ Institutions such as nursing homes can also have staffing issues that contribute to falls.³⁹ In attempts to decrease falls in nursing homes, customized seating has been used to decrease the chance of slipping out from a chair from the front or the side.³⁹ Having the mattress close to the floor, or having a foam pad on the floor, can also help reduce the risk for injury from falls.³⁹

Falls and the fear of falling are both common.⁵¹ One question is which comes first: falling or the fear of falling? In a prospective study of 2212 individuals, those who reported falls at baseline but did not report fear at baseline were at a higher risk for fear of falling over a 20-month period. Individuals who limit activities because of fear of falling are also at a high risk for falling, which could be because they have more risk factors at baseline. It has also been suggested, however, that restricting activities leads to decreased function and therefore a higher fall risk. In this study the predictors of development of fear of falling in those without fear at baseline were female sex, taking four or more medications, and worse general health based on questionnaire scores. The predictors of falls at 20 months in those who were not falling at baseline were white race, female sex, history of stroke, sedative use, and fear of falling at baseline. The authors noted that the only modifiable factors were fear of falling and sedative use. In another randomized controlled trial (RCT), 57 elderly women with a history of falls with injury were randomly assigned to receive either balance and strength training three times per week, or placebo intervention. Three months later the intervention group performed better on motor testing, but there was no statistically significant difference in falls at 6 months.⁶¹

Hip fracture prevention is important in the elderly because of the ramifications of this injury. It has been reported that 22% to 75% of elderly patients with hip fracture do not regain their prior functional status by 6 to 12 months after injury.¹⁴

Balance training can be done in multiple ways. A wobble board can allow focus just on ankle movements. A 5-week RCT of 20 elderly individuals showed that the wobble board improved discrimination of ankle inversion movements.¹⁴⁰ Some balance exercises can easily be done at home without supervision in the relatively healthy elder, such as standing on one lower limb with upper limb support. Using a physioball for seated dynamic balance activities typically requires hands-on assistance from a physical therapist. More elaborate balance training devices are available that can alter vestibular, proprioceptive, and visual input as part of the training process.

Balance training might need to be tailored so that it is more useful in daily life outside the formal physical therapy setting. Gait speed was studied in a small RCT of 23 elderly subjects with impaired balance who underwent balance training either alone (single task) or while simultaneously focusing on a cognitive task (dual task fixed priority), or with dual tasks but with half of each session on balance as the priority and half on the cognitive task as the priority.¹²⁰ Only those subjects who received dual-task training were able to improve their walking speed while performing a cognitive task at the same time. The variable priority task group maintained their improvements in gait speed at 12 weeks’ follow-up. The balance single-task group was the only group to report increased self-confidence in daily activities, which highlights the importance of data collection in addition to self-report in assessing outcomes. A separate study looked at a choice step reaction time in which 41 healthy subjects (mean age, 79 years) stepped onto randomly illuminated targets with either leg.¹²⁸ All subjects performed the stepping task under conditions of no secondary task, simultaneously performing an easy or a difficult visuospatial task and an easy or difficult nonspatial task (counting backwards). The visuospatial tasks interfered more than the nonspatial task with the choice step reaction time. Balance training in the formal therapy setting might need to incorporate items that mimic daily tasks.

Balance or weight training, or both, were studied in 110 community dwellers with a mean age of 80 years.¹⁴⁵ In this RCT, participants were randomly assigned to balance training alone, strength training alone, balance and strength training, or education control for a 3-month intense training period. This was followed by 6 months of t’ai chi for maintenance.¹⁴⁵ Balance training improved balance to a level comparable with that of an individual 3 to 10 years younger.¹⁴⁵ There was no crossover, in that the balance group did not improve in strength, nor the strength group in balance. The exception to this was for single stance time, which improved in the strength training group.¹⁴⁵ There was some decline over the 6-month maintenance period in balance, although it should be noted that this was a relatively low-intensity intervention, in that the class met only 1 hour per week.¹⁴⁵

Another RCT used 200 participants 70 years or older in a 15-week study that compared t’ai chi or computerized balance training with an education control group.¹⁴⁴ The three groups had similar responses at baseline regarding number of falls in the year before study enrollment and to the fear of falling questionnaire at baseline.¹⁴⁴ The t’ai chi group showed decreased fear of falling, decreased falls, and reduced ambulation speed compared with the control group, with no effect seen in fall prevention in the balance training group.¹⁴⁴

Nelson et al.¹⁰² studied 40 postmenopausal women in a controlled trial of twice-weekly strength training over a year. Balance was measured by backward tandem walking. Muscle strength, muscle mass, and dynamic balance increased in the exercise group. In an observational study, 20 elderly practitioners of t’ai chi, with a mean age of 70 years, were compared with 20 elderly individuals who did not practice t’ai chi, and with young university students. All were ambulatory and ADL independent. The t’ai chi group had been performing t’ai chi three times per week for at least 1 year (mean, 7 years of t’ai chi). Different combinations of visual and platform sway positioning were tested. The 20 who were doing t’ai chi had better standing balance under conditions of reduced sensory input compared with control subjects, and were comparable with the young group.¹³⁴ Because the t’ai chi practitioners were self-selected, the improvements cannot necessarily be ascribed to t’ai chi rather than to other factors. In an RCT involving women with low bone mass between 75 and 85 years of age, 6 months of resistance and agility training reduced the risk for falls by improving postural stability. There was also a reduction seen in the stretching group, but not as marked.⁸⁶

T’ai chi was studied in a 1-year RCT of elderly persons who were transitioning to frailty. The control group received wellness education. The t’ai chi group had perceived improvements in ambulation.⁵⁹ A Dutch RCT on 277 elders who were taught to do t’ai chi at home twice a week showed no significant difference in the number of falls or fear of falling over 1 year.⁸⁷

In an RCT of 15 people with Parkinson disease, one group did balance and resistance training, and one did balance training only.⁶⁴ Balance training improved balance, with an enhanced effect if strength training was included. Both groups had increased strength after the study. The combination of balance and resistance training improved the ability to maintain balance on the most difficult balance tests in the study.⁶⁴

The optimal exercise program to prevent falls has not been clearly determined. The recommendations for someone who is frail might be different than those for a healthy elderly person. Two different exercise programs, one based on functional walking and a second based on t’ai chi balance exercises, were studied in 287 elderly persons with a mean age of 85 years in the Netherlands. The exercise programs were of 20 weeks’ duration, with 1-year follow-up. Both forms of exercise reduced the risk for falls compared with control in the prefrail group, but there was a higher risk in the frail group.⁴⁰

Exercise for Strength in the Elderly

In the past, it had been widely held that exercise could not actually increase strength in the elderly. A number of studies, however, have documented that exercise causes improvements in strength and power, in muscle force generation at the single-fiber level, and improvement in overall function in the elderly.

A study by Fiatarone et al.⁴³ measured knee extensor strength, chair stand time (rising from a straight-backed chair without use of upper limbs), and habitual and tandem gait speed before and after progressive resistance exercise in eight ambulatory patients aged 86 to 96 years. Tandem gait speed strength increased in the exercise group. Some subjects no longer needed canes for ambulation. There was no change in habitual gait speed. Some changes probably resulted from improved neural recruitment, because they were noted in the first 2 weeks, which is too early to produce muscle hypertrophy.

In another study, 100 frail nursing home residents were in an RCT looking at progressive resistance exercise with and without a multinutrient supplement.⁴⁴ An ambulatory aid was used by 83%. Muscle strength increased by 113% and gait velocity increased by 12% in the exercise groups. The use of a nutritional supplement did not affect the outcome.

In a study of the healthy elderly that included 3 months of resistance training, walking endurance increased from 25 to 34 minutes.¹ The authors noted that the effect was primarily seen because of increases in the male subjects.

Vincent et al.^136,137 reported a study in which low-intensity exercise (13 repetitions at 50% of 1 repetition maximum [RM]) was compared with high-intensity exercise (8 repetitions at 80% of 1 RM) in subjects aged 60 to 83 years. Both strength and endurance improved as compared with control subjects, with a decrease in the time needed to climb one flight of stairs. There was similar improvement in both the low- and high-intensity groups.

Frontera et al.⁵² reported an RCT showing that after 12 weeks of training, women aged 68 to 79 years showed increased strength, force, and whole-muscle size measured by cross-sectional area. Sauvage et al.¹¹⁵ reported a small RCT of subjects who tested lower than age-specific norms. The exercise group had 12 weeks of stationary cycling and lower limb training. Subjects in the exercise group improved in average stride length and velocity of gait.

Power is a product of force and velocity, and it tends to decline earlier and more rapidly than strength with increasing age. Power has been shown to correlate with functional status in some studies.¹¹⁶ High-velocity training was shown to significantly increase power compared with low-velocity training in a group of 30 women with a mean age of 73 years. Strength increased in both groups.¹¹⁶ However, in this study, functional performance measured by stair climb time, chair rise time, or gait velocity showed only a small change compared with the large improvement in peak power.¹¹⁶ Self-reported disability improved with the training, but the improvement did not depend on whether the training was done at high velocity or low velocity.¹¹⁶

Comparison of a walking program with high-velocity resistance training in community dwellers older than 70 years showed an improvement in leg press strength for both groups, with greater improvement in the high-velocity training group. Power improved in the high-velocity training group but not in the walkers.³⁷ The examiners noted that a ceiling effect might have precluded improvement in chair rise time in this study.³⁷ In another study a group exercise program of aerobic, strengthening, and balance exercises was offered in retirement communities.⁸⁸ Compared with the control group, the group exercise population had better 6-minute walking distances and reaction times.⁸⁸ The intervention program was particularly effective in fall prevention in people with a prior history of falls.

An exercise program has also been shown to improve mood disturbances in elderly patients with depression.¹²⁵ Participants in a 10-week program of supervised progressive resistance exercise of large muscle groups had improved depression scores, even when assessed at 10 weeks after the supervised exercise had been completed.¹²⁵

A pilot study of 10 subjects older than 55 years with knee osteoarthritis showed decreased pain and improved strength after 4 months of a home-based exercise program, compared with a group getting nutritional advice. There was no improvement in the nutrition control group. The exercise consisted of lower body exercise with progressive ankle weights.⁹ In a randomized trial comparing aerobic exercise, resistance exercise, and a health education program in people 60 years and older with knee osteoarthritis, both exercise groups had improved scores of physical disability, pain, and distance on a 6-minute walk test, and did better on a lifting and carrying task than the education control group.³⁸

Exercise programs in the elderly have been demonstrated to work at the center-based level, when people living in the community come to a facility to work out. There have also been studies of home-based exercise programs. Improvements were seen in a 6-month RCT with an attention control group that received 6 months of education on incorporation of fruits, vegetables, and calcium-containing foods into their diet.^100,101 Scores on a physical performance battery improved in the exercise groups but decreased in the control subjects. Maximum gait speed improved but did not reach statistical significance in the exercise group compared with the control subjects. The exercise groups also showed dynamic balance improvement, but strength did not improve. One concern was that the home exercisers needed encouragement to progress with increased weights in the training program. Study participants were reluctant to progress in weights unless instructed to do so in person at a home visit.¹⁰⁰ It should also be noted that two of the muscle groups tested on 1 RM testing were not actually being specifically trained.¹⁰⁰

A home-based strengthening program using elastic bands, for nondisabled, community-dwelling elders 65 years and older was conducted.⁷¹ Adherence rates for the exercise sessions ranged from 0 to 102% (as a percentage of prescribed sessions). After 12 to 15 weeks of exercise, the younger adults in the elderly population had a 10% improvement in knee extensor strength, and the men had improved vigor. The older women in the exercise group reported increased confusion, and the older men in the control group had an increase in anger compared with the exercise group.⁷¹ Although the study design intended to have the subjects progress through four different possible levels of the elastic bands to increase resistance, 9% did not change their level of resistance, and 35% changed only one level.

Older adults can respond to resistance training differently than younger adults. Training typically leads to more force, possibly by early recruitment of large motor units, more rapid excitement of individual motor units, decreased co-contractions, and improved coordination of synergists.¹¹ It might be necessary in the elderly to change from conventional resistance training with loads of 80% of maximum with no emphasis on speed, to exercise with less loading but including an emphasis on speed.¹¹

Exercise in Elderly Stroke Survivors

High-intensity training at 70% of 1 RM improved lower limb power and strength in an RCT that studied people who had survived a mild or moderate single stroke.¹⁰⁴ The mean age was 66, and the minimum age to enter the study was 50 years. Strength and power improved in both the paretic and the nonparetic limbs. In another study of seven subjects at 1 year after stroke and with mean age of 70 years, 12 weeks of progressive resistance exercise at 70% of 1 RM showed improvements in lower limb strength in both affected and nonaffected lower extremities, as well as decreased chair standing time and improved balance.¹⁴²

The American Heart Association scientific statement notes that exercise intolerance after stroke is common.⁵⁷ The energy costs of walking in patients with hemiplegia can be twice that of the able-bodied.⁵⁷ It is important to avoid deterioration in exercise tolerance immediately after stroke by getting patients upright as soon as possible with intermittent standing and sitting.⁵⁷ Aerobic conditioning can promote decreased body weight, decreased body fat, better glucose regulation, improved high-density lipoprotein levels, and coronary artery endothelial function.⁵⁷ Exercise can include upper or lower extremity ergometry at 40% to 70% of peak consumption. A treadmill can also be used with unweighting devices such as a harness or handrails when needed, with increasing grade used to increase exercise intensity.⁵⁷

Preexercise Evaluation in the Elderly

It is reasonable for older adults to have a medical screening examination before starting an exercise program.¹³ Contraindications to participation are summarized in Box 59-4.¹³ It is important to assess elderly individuals who are starting an exercise program to find problems that need further evaluation, such as a heart murmur or bruit. They can also need more optimal management of conditions such as congestive heart failure or asthma.¹³ A resting electrocardiogram is recommended.¹³

Exercise stress testing results have different meanings in an elderly than in a younger population.²⁵ For example, a short duration of exercise of less than 3 minutes might be interpreted as a sign of advanced coronary artery disease in a younger individual, but could be because of multiple physiologic problems in an elderly patient.²⁵ Bryant and Limacher²⁵ note that failure of the heart rate to rise appropriately during exercise is associated with a poor prognosis. The exercise protocol might need to be altered in an elderly patient, perhaps with shorter intervals between stages and relying more on change in grade for those who cannot walk briskly on a treadmill.¹³⁵

The guidelines of the American College of Sports Medicine and the American Heart Association suggest that all older adults who want to engage in moderate or vigorous exercise should have a screening exercise stress test.^13,55 But Gill et al.⁵⁵ suggest that these guidelines do not fit asymptomatic adults older than 75 years, particularly if they are contemplating a program of progressive resistance training rather than aerobic training. The concern is that with the high prevalence of asymptomatic atherosclerotic cardiovascular disease in the elderly, routine exercise stress testing could lead to invasive cardiac procedures without strong evidence to support their need.⁵⁵ Cardiovascular reserve can be tested in the office by having the elderly climb one flight of steps, cycle in the air for 1 minute, or walk 15 m. One can start with low-intensity exercise such as self-paced walking, or lower limb resistance training with tubing or ankle weights.⁵⁵ One can then progress to a more intense program after checking blood pressure and pulse rate, since blood pressure and pulse changes can guide the intensity of exercise.⁵⁵

A combination of progressive resistance training and aerobic exercise is recommended for community-dwelling older adults with stroke, osteoarthritis, cardiovascular disease, diabetes, osteoporosis, and balance problems.¹³ Although there is still much to be learned about exercise in respiratory diseases such as chronic obstructive pulmonary disease, exercise has been shown to improve 6-minute walk times and subjective dyspnea. Separate training of the upper and lower limbs has been advocated.¹³ The American College of Sports Medicine notes that both improved strength and hypertrophy can occur in older adults who perform single- and multiple-joint exercises as follows: one to three sets of 8 to 12 repetitions of each exercise are performed at 60% to 80% of the 1 RM, with 1 to 2 minutes of rest between sets. Power can be improved by performing one to three sets of 6 to 10 repetitions of each exercise at 40% to 60% of the 1 RM, and by using a high repetition velocity (American College of Sports Medicine).

Upper body resistance training can begin 3 to 4 weeks after myocardial infarction after a satisfactory baseline exercise tolerance test.² Resistance training should be delayed for 3 months after coronary artery bypass grafting to allow for full sternal healing.² The target heart rate should be lowered in aquatic exercise, because swimming can cause electrocardiographic changes at a lower heart rate than land-based exercise.⁴⁶

Aging With Spinal Cord Injury

The elderly typically have less ability to use the upper limbs to compensate for lower limb deficits. Shoulders can develop signs and symptoms of overuse, with degenerative joint disease and rotator cuff problems. If the upper limbs are used for wheelchair propulsion, transfers, and ambulation with devices, the amount of work done by the shoulders over the years is far greater than in the average individual. Shear forces become more problematic as skin fragility increases. Urinary incontinence can develop for a number of reasons. The day-to-day routines that had worked for a patient for years might no longer be adequate. The elderly person might need to adapt to a different technique for transferring—for example, with the use of a sliding board. Changes in the social support system can cause new challenges. A spouse might not be able to continue assisting with toilet transfers, necessitating major changes in a living situation.

A study of individuals with spinal cord injury showed that those with higher lesions sensed that they were aging more quickly.⁹⁵ Despite this, those with higher lesions did not report more health problems or fatigue than others in the sample. The longer a person had lived with spinal cord injury, the more there was a perception of accelerated aging. The authors also noted that one theoretic model is that age is a sort of “leveler.” A young person with a disability experiences more differences compared with able-bodied peers than occurs with the elderly with a disability.

Aging With Polio

Postpolio syndrome refers to late manifestations many years after the initial polio infection. Its onset is usually heralded by generalized fatigue, as well as new weakness and muscle atrophy.⁷² These new symptoms can be very distressing because they represent the sequelae of a disease that the patient thought had already done its damage years earlier. Weakness can develop in muscle groups that did not seem to be involved by the polio. However, these seemingly unaffected muscle groups have been shown on electrodiagnostic studies to have previously unrecognized effects of polio.⁷² Motor neuron dropout occurs because of aging, and also probably is accelerated in the patient with polio. At the initial illness, distal axon sprouts enabled reinnervation,¹³⁰ but motor neuron dropout can cause clinical changes with aging.⁷² Others have theorized that there is an ongoing viral presence, or that the postpolio symptoms are caused by a combination of aging processes.⁷⁶ In a study by Klein et al.,⁷⁵ muscle strength was measured in people with a history of polio. Thirty muscle groups were measured three times, each 3 to 5 months apart. The rate of decline of strength in upper limb muscles was much greater than that associated with normal aging. Strength decreased in all muscles measured in the upper limbs, and in the lower limb flexor muscles.

Treatment of the postpolio syndrome includes energy conservation measures, use of assistive devices, decrease of mechanical stress on joints and muscles, and nonfatiguing exercise programs that avoid overuse.⁷² Swallowing and breathing problems can also develop.¹³⁰ Respiratory muscles might already be weak, with additional negative contributions from bulbar muscle weakness, sleep-disordered breathing, obesity, and scoliosis.⁷⁶ Because there are no specific tests for postpolio syndrome, other etiologies for weakness, fatigue, and joint pain have to be ruled out.⁷²

Aging With Cerebral Palsy

Aging patients with cerebral palsy can notice changes in their functional level, despite having what they thought was a static condition. Mobility can be affected by years of abnormal gait mechanics, with secondary ligamentous laxity and degenerative changes in joints. A decline in muscle strength can necessitate change in techniques for transfers or ADLs. A new neurologic problem such as a stroke can worsen spasticity.

Proposed treatments and interventions must be individualized to meet the patient’s wishes and goals. Patients are frequently resistant to changing highly practiced and lifelong techniques. Some changes in a patient’s program include increased vigilance in skin management, changes in straight catheterization frequency, and changes in transfer technique to decrease stress on the shoulders.

Caring for those who are aging with a disability requires that primary care and preventive care be maximized. Klingbeil et al.⁷⁶ have shown an underuse of preventive care measures in adults with cerebral palsy. The possible reasons for this include physical inaccessibility of health care, financial barriers, demands on the primary caregiver, or the absence of a perceived need by the patient, the caregiver, or both. Issues that need to be resolved to even permit a visit for primary care can include such details as having the patient arrive on a stretcher rather than in a wheelchair to facilitate the physical examination.