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Trauma In Elders: Applying Evidence To Acute Care Practice

02/23/2018

Property of Maguire, McDonell and Stillwell. Not to be copied without permission. 1

TRAUMA IN ELDERS:APPLYING EVIDENCE TO ACUTE CARE PRACTICE

Stacey Maguire, PT, DPT, NCS

Brian McDonnell, PT, DPT, GCS

Shannon Stillwell, PT, DPT, GCS

Combined Sections Meeting 2018New Orleans, LA

February 21-24, 2018

DISCLOSURES

• The presenters have no potential conflicts of interest to report.

INPATIENT REHABILITATION SERVICESBETH ISRAEL DEACONESS MEDICAL CENTER

BOSTON, MA


02/23/2018


LEARNING OBJECTIVES

Recall how the aging process leads to physiological changes that compromise the ability of elders to respond to the stress of injury.

Explain the PT’s role in reviewing medications and their potential impact upon health, impairments, functional limitations, and disabilities.

Apply a hypothesis driven examination strategy to initial evaluation of an elder after trauma in the hospital setting.

Appreciate the risk factors for development, tests for screening and interventions to treat hospital-acquired delirium

Create therapeutic interventions of proper intensity to address a variety of common impairments in elders who have been hospitalized after trauma.

Recognize the value of utilizing standardized tests and outcome measures to help drive clinical decision making.

WHY GERIATRIC TRAUMA?

EPIDEMIOLOGY

• Those aged 65 or over.

• The most rapidly growing segment of the population.

• By 2050, this number of geriatric individuals is expected to grow to 2 billion.

• Living longer and leading more active lifestyles.

(Tieland, 2017)


02/23/2018


GERIATRIC TRAUMA

• Elders are more susceptible to injury.

• Pre-existent comorbidities

• Pre-existent impairments in body structure and function

• Leading Causes:

• #1 Falls

• #2 Motor vehicle accidents

• Traditional trauma outcomes are not applicable to elders.

• Under-triage: Elders are less likely to receive care in trauma centers.

• 9th leading cause of death amongst the elderly, BUT:

• 35% of trauma healthcare expenditures

(Gaebel, 2017; Brooks, 2017)

WHAT HAPPENS AS WE AGE THAT MAKES US VULNERABLE?

PHYSIOLOGICAL CHANGES

o Connective Tissue Changes

• Decreased water content

• Increased stiffness

• Decreased strength

• Decreased cross sectional area and volume

o Joint Structure and Function Changes

• Limited healing

• High load activities/occupations = OA

• Decreased water content in discs

• Increased stiffness and decreased ROM

(Guccione, 2011)


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o Boney Changes

• Increased osteoclast activity, decreased osteoblast activity

Decreased ability to absorb load

o Increased risk of fracture with age

o Muscular Changes

• Atrophy of muscle mass and strength

o Muscle mass replaced with fat mass

• Slowing of contractile properties

Type II fast twitch atrophy faster than Type I slow twitch

• Decreased force production

(Guccione, 2011)

o Cardiovascular Changes

• Loss of heart rate variability

• Cardiac function declines by 50% by the time we are 80

• Stiffer myocardium = Decreased pump effectiveness

o Decreased cardiac output

o Pulmonary Changes

• Anatomic, muscular and connective tissue changes

o Ineffective pulmonary system

• Decreased ability to fight off post-operative complication

o Neurological Changes

• Cortical atrophy

• Plaque build up

(Sharma, 2006; Vigorito, 2014)

o Other Changes

• Endocrine Changes

o Decreased VitaminD

o Decreased Estrogen and Testosterone

o Increased Insulin resistance

• Malnutrition

• Altered Drug Metabolism

(Guccione, 2011)


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SO WHAT DOES THIS MEAN FOR ELDERS?

PHYSIOLOGICAL FRAILTY PHENOTYPE

• Weight Loss

• Exhaustion

• Physical Activity

• Walk Time

• Grip Strength(Bellal, 2014; Fried, 2001)

APPLICATION TO PT


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ICF MODEL

o Impairments in body structure and function:

• ROM

• Strength/Force Production

• Joint Mobility/Integrity

• Posture

• Endurance

o Activity Restrictions

• Impaired balance

• Impaired gait

• Impaired ADLs

o Participation Restrictions

• Family roles

• Occupational roles

• Leisure roles

• Loss of independence

MRS M.

87 year old female admitted s/p fall down stairs

• Found down by her sister

• + Loss of consciousness

• Sustained several injuries• Non-displaced fractures of maxillary wall

• L orbital floor fracture, small L subdural hematoma

• L 8th and 9th rib fractures.

• Hypotensive on admission

• Found to have urinary tract infection

PAST MEDICAL/SURGICAL HISTORY

• Ventricular arrhythmia s/p pacemaker placement

• Mitral regurgitation

• Coronary artery disease s/p stents 2014

• Congested heart failure (ischemic cardiomyopathy with reduced ejection fraction: 25%)

• Hypertension

• Hyperlipidemia

• Gallstone pancreatitis s/p laparoscopic cholecystectomy

• Hard of hearing in right ear

• s/p hysterectomy

• s/p back surgeries (unknown)


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IMAGING

• Head CT: small acute L subdural hematoma without evidence of midline shift. Non-displaced fractures of maxillary wall, L orbital floor fracture.

• Chest XR: L posterolateral 8th and 9th rib fractures

LABS

• WBC: 8.7

• HgB: 8.0*

• Hct: 25.4*

• Plt: 242

• Cr: 1.3*

• BUN: 30*

• Positive Urine Culture (Klebsiella Oxytoca)

WHAT DO WE WANT TO LEARN ABOUT MRS M?


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PATIENT INTERVIEW

SOCIAL/FUNCTIONAL HISTORY

• Retired. Previously employed in various jobs. Enjoys crafting.

• Widowed. Lives with son and daughter-in-law. Enjoys time with her twin, who lives in Maine.

• Two story home with 10 steps to enter with bilateral railings.

• Baseline independent ambulation without assistive device. Independent in ADLs. Family assist with IADLs. Independent medication management. Drives short distances. Sedentary.

• +hard of hearing R ear (doesn’t use hearing aide), no visual aides

• History of falls, usually about 2/year, but reports 2 in past 2 weeks.

PATIENT INTERVIEW

• Social and Work History

• Living Situation

• Baseline functional and activity level

• Detailed information regarding falls: frequency, symptomatology, situational information

• Medications and management

• Screening for psychosocial considerations (depression, neglect, abuse)


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“Physical Therapist patient/client management integrates an understanding of a patient’s/client’s prescription and nonprescription medication regimen with consideration of it’s impact upon health, impairments, functional limitations, and disabilities.”

https://www.apta.org/uploadedFiles/APTAorg/Payment/Medicare/Coding_and_Billing/Home_Health/Comments/Statement_MedicationManagement_102610.pdf

APTA POSITION STATEMENT

WHY IS MEDICATION MANAGEMENT AN IMPORTANT CONSIDERATION WITH ELDERS?

POLYPHARMACY

• The use of multiple medications by a patient

• Varying definitions of number of medications (range 5-10)

• In a 2003 survey 46% of Medicare beneficiaries were taking 5 or more medications

(Fried et al, 2014)

AGE-RELATED CHANGES

• Increased distribution

• Natural decline of renal and hepatic function

• Larger drug storage and decreased clearance = increased plasma concentrations

• Increased sensitivity

CONSEQUENCES OF POLYPHARMACY

• Increased health care costs

• Adverse drug reactions

• Drug interactions

• Non-adherence

• Cognitive Impairments

• Falls

• Urinary incontinence

• Poor nutrition

• Functional decline


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POLYPHARMACY AND FALLS

Kojima et al, 2012:

• Followed 172 patients for two years and documented fall occurrence (by self report).

• Falls were associated with older age, osteoporosis, number of comorbid conditions and number of medications.

• Number of medications (5 or more) was independent predictor of falls.

AMERICAN GERIATRICS SOCIETY BEERS CRITERIA POTENTIALLY INAPPROPRIATE

MEDICATIONS

• Anticonvulsants

• Antipsychotics

• Benzodiazepines

• Eszopiclone, Zaleplon, Zolpidem (Nonbenzodiazepine Hypnotic Agents)

• Tricyclic Antidepressant Agents (TCAs)

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Opioids (excludes pain management due to recent fracture or joint replacement)

(American Geriatrics Society 2015 Beers Criteria Update Expert Panel)

MRS M: HOME MEDICATIONS

• Plavix 75 daily• Atorvastatin 20mg daily• Metoprolol 100mg twice daily• Losartan 50mg daily• Ranexa 500mg SR q12hours• Spironolactone 25mg daily• Lasix 40mg daily• Lantanoprost 0.005% eye drops, both eyes q HS


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PATIENT INTERVIEW

• Social and Work History

• Living Situation

• Baseline functional and activity level

• Detailed information regarding falls: frequency, symptomatology, situational information

• Medications and management

• Screening for psychosocial considerations (depression, neglect, abuse)

DEPRESSION

• > 1 in 10 elders in the US has depression.

• This frequency increases in elders with chronic illness.

(Steffens, 2009)

• Association with poor physical performance

• 970 non-depressed elders in Italy, followed for 4 years

• Associated identified between poor performance at baseline and the development of depression

(Veronese et al, 2017)

ATTITUDES AND BELIEFS ABOUT DEPRESSION IN ELDERS

• 58% believe it is a normal part of ageing.

• 38% believe it is a health problem.

• 42% would seek help from a health professional.

(http://www.mentalhealthamerica.net/conditions/depression-older-adults-more-facts)


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HYPOTHESIS-DRIVEN EXAM

• Targeted impairment-level testing

• Standardized outcome measures

• Goals:

1. Make a clear connection from Pathology to Activity to Participation.

2. Determine etiology of falls.

WHAT ARE THE PRIORITIES OF HER PHYSICAL EXAM?

EXAM


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IMPAIRMENT LEVEL TESTING: COGNITION

• Alert and oriented to self, birthdate, place, date and situation.

• Follows all simple and 2 step commands with single verbal cue.

• Hard of hearing.

Is this good enough?

IMPAIRMENT LEVEL TESTING: COGNITION

• Increased age• Sensory deprivation

(visual/hearing impairment)• Sleep deprivation• Social isolation• Physical restraint• Use of bladder catheter• Polypharmacy (>3 new

meds added)• Use of psychoactive drugs• Malnutrition and low serum

albumin

• Pain• Co-morbidities• Severe illness (especially

infection, fracture or stroke)

• Prior cognitive impairment• Temperature abnormality

(fever or hypothermia)• Dehydration• Pre-fracture ADL functional

impairment

(Inouye, 1999; National Institute for Health and Clinical Excellence, 2010; Leslie, 2008)

DELIRIUM: DEFINITION

DSM-IV criteria for a formal diagnosis of delirium:

• Disturbance of consciousness with reduced ability to focus, shift or sustain attention

• Change in cognition or perception that is not explained by a pre-existing, established or evolving dementia

• Acute onset and fluctuating course

• Evidence of an underlying general medical cause

3 Types

• Hyperactive

• Hypoactive

• Mixed


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DELIRIUM: CONSEQUENCES

• Mortality

• Duration (Bellelli, 2014)

• Discharge to location other than home including admission to long-term care (Inouye, 1998)

• Emotional distress for caregivers and patients (Breitbart, 2002)

• Prolonged cognitive impairment (>1 year) (Moller, 1998)

• ICU delirium has been closely associated with and loss in independence in ADLs for up to one year following hospitalization (Brummel, 2014)

• Poor functional outcomes in post acute care settings (Kiely, 2006)

.

DELIRIUM: DIAGNOSIS

• Delirium diagnoses are missed in up to 46-50% of cases.

(Ryan, 2013; Kishi, 2007)

• Detection rates are even lower in hypoactive cases.

(Fang, 2008; Voyer, 2007)

DELIRIUM: ROLE OF PT INEARLY IDENTIFICATION

• Months Backwards Test

• Pass

• Under 60 years old: state all months without omission/error within 30 seconds

• Over 65 years old: state all months without omission/error within 60 seconds

(Meagher, 2015)


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HTTP : / /WWW.HOSPITALELDERL IFEPR OGRAM.ORG

IMPAIRMENT LEVEL TESTING: HEMODYNAMIC RESPONSE

CONSIDERATIONS

• Goal directed: What are you looking for?

• Positional Tolerance

• Activity Tolerance

• Pulmonary Tolerance

• Assessing a baseline is crucial.

• Consider the position of the patient.

MRS. M’S VITAL SIGNS

Heart Rate Blood PressureRespiratory Rate

SpO2

Rest, Supine 80 112/46 16 98% 2L NC

Rest, Sitting 88 100/54 28 92% RA

Rest, Standing 92 92/48 28 92% RA

Ambulation, Standing

96 100/52 24 86% RA, 94% 2L NC

Recovery 80 110/52 16 96% 2L NC


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INTEGUMENTARY

• Bilateral LE 2+ pitting edema distal to knee to foot

• Bilateral LE hypertrophic toe nails

• Bruising noted throughout L thorax and under chin

FUNCTIONAL PERFORMANCE

• Bed mobility: MinA with use of bed rail

• Sit to stand: minA, required multiple attempts

• Ambulation: 50’x2 with RW and CGA, seated break

• Decreased step length and cadence with wide base of support

• Flexed posture with inability to achieve full hip extension

• Stand to Sit: minA 2/2 poor eccentric control

MUSCULOSKELETAL FINDINGS

POSTURE

•Flexed trunk with increased thoracic kyphosis, scapular protraction

STRENGTH

•Bilateral UEs grossly 3+/5, limited by pain from rib fractures

•Bilateral LEs 4/5, suspect B hip extensors weakness which were observed to be weak with both ambulation and stand to sit

ROM

•WFL bilateral UEs/LEs except bilateral ankle DF to neutral only

SENSATION

•Denies paresthesias, bilateral great toe proprioception intact


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PAIN

INTENSITY

• 7/10 rest

• 9/10 mobility/deep breaths

• 8/10 recovery

LOCATION

• L thorax

QUALITY

• Constant, worst with deep breaths and mobility

• Sharp, aching

PULMONARY EXAM

• Gas Exchange: impaired with ambulation, requires supplemental O2 via nasal cannula

• Ventilation: impaired with incentive spirometer noted to 500mL

• Thoracic Excursion: impaired, decreased excursion L > R

• Cough Strength/Effectiveness: weak, congested cough, non-productive of sputum

• Auscultation: crackles noted throughout posterior lungs, diminished L > R

WHAT DOES ALL OF THIS INFORMATION MEAN?


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Medications

UTI

Dehydration

Impairments in Body Structure and

Function

↓DF ROM

↓ Muscle Strength

↓ Endurance

ActivityRestrictions

↓ Balance

↓ Ambula on

↓ Sit ↔ Stand

Orthostasis

Participation Restrictions

↓ family role as sister

↓ I in home

↓ community role

CHF

FALLS Injurious FallsPlavix

Rib Fractures

Pain

↓ Inspiratory Volume

↓ Airway Clearance

↑ Risk for PNA

Decreased Activity Tolerance

↓ Func onal Mobility

INITIAL INTERVENTIONS


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MINIMIZE RISK OF DELIRIUM

Delirium is preventable in 30–40% of cases

(Inouye,1999)

EVIDENCE BASED INTERVENTION: BEST PRACT ICE ST AT EMENT FROM T HE AMERICAN GERIAT RICS

SOCIET Y

• Sensory enhancement (utilizing glasses, hearing aids, or listening amplifiers.)

• Mobility enhancement (ambulating at least twice per day if possible.)• Orientation protocols

• Provision of clocks, calendars, windows with outside views, verbally reorienting patients may mitigate confusion that results from disorientation in unfamiliar environments.

• Cognitive stimulation (tailored to the individual's interests and mental status.)• Regular visits from family and friends. Crossword and other puzzles. TV News.• Sensory overstimulation should be avoided, particularly at night.

• Nutritional and fluid repletion enhancement.• Sleep (daytime sleep hygiene, non-pharmacologic sleep protocol, and nighttime

routine.)• Medication review.• Minimization of restraints and tethers.

(Inouye, 2015)

INITIATE EARLY DISCHARGE PLANNING


02/23/2018


EVIDENCE BASED INTERVENTIONS: DISCHARGE

PLANNING

• 30% of patients reported having received < 1 day advance notice of discharge.

(Horwitz, 2013)

• Poorly coordinated transitions of care can lead to:

• Adverse medication events

• Patient and caregiver dissatisfaction

• Functional decline

(Jeffs, 2017)

DISCHARGE PLANNING:PATIENT CENTERED PRACTICE

• “Physical therapists should account for patient’s sense of identity, goals, history, and social context in order to engage in a process of communication and deliberation with the patient, with the goal of maximizing patient autonomy and developing a patient-centered care plan that call can accept.”

• For action to qualify as autonomous, a substantial degree of understanding is required.

(Hunt, 2011)

ADVOCATE FOR OPTIMAL MEDICAL MANAGEMENT


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EVIDENCED BASED INTERVENTION: ADVOCATE FOR

OPTIMAL PAIN MANAGEMENT

• Increased pain means decreased likelihood of discharge home.

(Brotemarkle, 2015)

• Scheduled acetaminophen if appropriate.

(Americn Geriatrics Society, 2015)

• What about opioids and delirium?

• Evidence for prescribing non-opioids only < Evidence that adequate pain control reduces delirium.

(American Geriatrics Society, 2015)

INTERVENTIONS TO ADDRESS MEDICATION MANAGEMENT

• Patient/Caregiver Education:

• Timing

• Understanding of effects

• Management

• Empower to advocate for changes if indicated

• Medication Reconciliation:

• Consider Beers Criteria and discuss high risk medications

• Advocate for Pharmacist or Geriatrician involvement

(Pellegrin, 2017)

• Communicate suspected medication effects and impact on patient presentation

EVIDENCE BASED INTERVENTIONS: ADVOCATE FOR

GERIATRICS CONSULTATION

• Involvement of geriatricians has been associated with:

• Lower rates of delirium and discharge to long term care.

(Lenartowicz, 2012)

• A reduction in hospital-acquired complications such as functional decline, falls, delirium, and death.

(Fallon, 2006)

• Better recovery of function over the year following injury.

(Tillou, 2014)


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ADDRESS PSYCHOSOCIAL ISSUES

• Advocate for social work consult:

• Emotional support and coping

• Possible facilitation of outpatient follow up with mental health services

PHYSICAL THERAPY INTERVENTION

CONT.

EXERCISE CONSIDERATIONS

• MODE

• FREQUENCY

• INTENSITY

• DURATION


02/23/2018


EXERCISE INTENSITY

• Overload stimulus is key

• 60-80% of 1 rep maximum

• At least one set

• 2-3x/week

• Intersperse strengthening with aerobic exercises and motor learning activities

• Continual re-assessment

• Consider Rate of Perceived Exertion (RPE) use, especially in the hospital setting

(Guccione, 2011; Avers, 2009)

WHAT DOES THIS MEAN IN THE HOSPITAL SETTING?

• Prescribe therapeutic exercise of adequate intensity

• Use RPE

• Target weak muscles that will improve function

• Utilize your rehab aides and other ancillary staff

• Empower your patients to perform their exercise programs independently

HOW DO WE INTERVENE FOR PULMONARY DEFICITS?


02/23/2018


THORACIC TRAUMA INTERVENTIONS

• Main goal is to prevent pneumonia (PNA) and other complications

• Pain control

• Pulmonary hygiene

• Splinted Coughing

• Deep breathing

• Chest wall excursion

• Incentive Spirometer use

• Advocate for frequent walking with nursing

(Shulzhenko, 2017; Winters, 2009)

PATIENT PROGRESS FOLLOWING TARGETED INTERVENTIONS

FUNCTIONAL PERFORMANCE

Initial Evaluation

• Bed mobility: Min A with bed rail

• Sit to stand: MinA

• Ambulation: 50’x2 with RW and CGA

• Decreased step length and cadence with wide base of support

• Stooped posture with inability to achieve full hip extension

• Stand to Sit: MinA

Hospital Day 5

• Bed mobility: Min A (without rail)

• Sit to stand: I

• Ambulation: 150’ with RW S

• Improved but still present deviations

• Stand to Sit: I

• Stairs: Flight of stairs with step-to pattern and S


02/23/2018


IS ASSESSMENT OF BASIC FUNCTIONAL MOBILITY ENOUGH?

ONGOING EVIDENCE BASED EXAMINATION:

VALUE OF STANDARDIZED TESTS AND OUTCOME MEASURES

• Inform discharge recommendations (Bland, 2014)

• Evidence-based approach (Jette, 2003)

• Quantify observations (Potter, 2011; Sullivan, 2011)

• Improve continuity of care between settings (Thier, 2006)

• Identification of impairments (Guide to Physical Therapist Practice)

• Establish a baseline (Guide to Physical Therapist Practice)

HOW DO YOU SELECT AN APPROPRIATE STANDARDIZED TEST OR OUTCOME MEASURE?

Considerations Dynamic Gait Index Comfortable Walking Speed

Valid and Reliable for Elders (Jønsson, 2011) (Fritz, 2009)

Impairment Central to Patient Presentation

x

Fall Risk (Wrisley, 2010) (Fritz, 2009; Ostir, 2012)

Functional Prognosis/Discharge Disposition

(Ostir, 2012)

Responsiveness to Change (Pardasaney, 2012) (Perera, 2006)


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MRS M’S RESULTS

DYNAMIC GAIT INDEX

• 1.Gait level surface: 2

• 2. Change in gait speed: 2

• 3. Gait with horizontal head turns: 2

• 4. Gait with vertical head turns: 2

• 5. Gait and pivot turn: 2

• 6. Step over obstacle: 2

• 7. Step around obstacles: 2

• 8. Steps: 2

• Total Score: 16/24

COMFORTABLE WALKING SPEED

• Pt demonstrated a comfortable walking speed of: 0.46 m/s

• With use of a RW over a 10 meter distance.

DISCHARGE PLANNING

DISCHARGE PLANNING: HOME VS. REHAB

• “When safety is prioritized over client-centered practice, the values of individual elders may not be adequately considered in discharge decisions.”

(Moats, 2017)• “Not safe for discharge home.”

• 21% of newly admitted nursing home residents had at least one fall within 30 days.

(Leland, 2012)• Between 16-27% of falls in nursing homes

occur due to environmental hazards.(Vu, 2004)

• 3-15% of patients at rehab facilities acquire an infection.

(Smith, 2008; Flanagan, 2016)


02/23/2018



• Therapy at skilled nursing facilities: 30-45 minutes of PT contact and 15-30 minutes of OT contact daily.

(Jette, 2005)

• Scheduled therapy time may not actually be a direct indication of intensity.

(Talkowski, 2009; Lang, 2009)


• Systematic reviews and meta-analysis have failed to show a significant differences between care settings regarding functional outcomes.

(Boland, 2017; Ward, 2008)

• “Elders with musculoskeletal disorders who received rehabilitation in the home had equal or higher gains than the inpatient group in function, cognition, and quality of life; they also reported higher satisfaction.”

(Stolee, 2011)

DISCHARGE PLANNING: VALUE OF HOME PT

• Interdisciplinary home care has been associated with;

• reduced nursing home and hospital admissions

• decreased falls

• Improved physical function

(Beswick, 2010)

• American and British Geriatrics Societies highly recommend home assessment and intervention to identify home hazards and promote safe performance of daily activities.

(Kenny, 2011)

• 30 day hospital readmission reduction

(Leppin, 2014)


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ASSESSMENT STATEMENT AT DISCHARGE

• Pt is a 87F who presents to physical therapy during hospitalization for UTI and rib fracture. In the setting of improved pain control, treatment of infection and optimization of medical management of HTN resulting in a more appropriate hemodynamic response to position change, patient has made progress in functional mobility and balance since initial evaluation. Education was provided to patient and family regarding fall risk. Patient declines rehab at this time. As consistent with her comfortable walking speed of 0.46m/s, patient will require assist with all ADLs which patient’s family reports is possible. Patient's Dynamic Gait Index score of <19 is consistent with increased risk for falls therefore recommend use of RW at all times and home PT to address balance impairment and make environmental changes as indicated. Pt has good potential to return to independence in ADLs given progress thus far and presuming continued improvement in pain with tissue healing.

Medications

UTI

Dehydration

Impairments in Body Structure and

Function

↓DF ROM

↓ Muscle Strength

↓ Endurance

ActivityRestrictions

↓ Balance

↓ Ambula on

↓ Sit ↔ Stand

Orthostasis

Participation Restrictions

↓ family role as sister

↓ I in home

↓ community role

CHF

FALLS Injurious FallsPlavix

Rib Fractures

Pain

↓ Inspiratory Volume

↓ Airway Clearance

↑ Risk for PNA

Decreased Activity Tolerance

↓ Func onal Mobility


02/23/2018


IN CONCLUSION…

QUESTIONS?

REFERENCES


02/23/2018


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