100 and Counting: PT Helps Centenarians
Monday August 16, 2010
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Bernadette “Dette” Martin, of Delray Beach, Fla., was 100 years old when she asked her physician to prescribe a walker. A recent fall and her plans to go on cruises in the following months fueled the centenarian’s concerns about being able to get around.
But the physician refused.
“When I was leaving [the appointment], I said, ‘Doctor, are you going to give me a prescription to get that walker?’” Martin says. “He said, ‘I have no intention of it. You go to therapy, and you won’t need a walker.’”
Martin took part in PT for 2 1/2 months and says she is stronger and ready for the first of her cruises to the Caribbean in January.
Independent Spirit
The latest census estimates there were 104,754 centenarians in the U.S on Nov. 1, 2009, and that is projected to increase to 601,000 by 2050.
The decision to send a 100-year-old to PT was a good call, says Michael L. Puthoff, PT, PhD, GCS, assistant professor and assistant director, PT, St. Ambrose University, Davenport, Iowa.
Even physicians sometimes make the assumption that PT no longer is useful as a way to prevent dependence among the very old. “They believe these things are a normal part of aging. People are supposed to get slower, weaker and lose their balance,” Puthoff says. “Yes, our bodies do lose some abilities as we age ... but we can always make improvements in those areas.”
In fact, Puthoff says, studies have shown that even centenarians can improve muscle strength and balance.
Studies also have shown that physical activity in older persons, in general, decreases the risk of depression and cognitive impairment and increases overall self-reported health, according to Cheryl Phillips, MD, AGSF, immediate past president of the American Geriatrics Society.
“I think there is a lack of awareness of the value of physical therapy assessment and intervention for gait and mobility function,” she says. “Doctors always think about PT after an injury. But it is less common that physicians who don’t have geriatric experience or training will think about the value of a physical therapy assessment for falls prevention or in strengthening programs for muscles of the lower legs that have to do with getting out of chairs and walking,” says Phillips, who is chief medical officer for On Lok, a program that offers an alternative to nursing home placement for the frail elderly living in the community.
New Thinking
The thinking that one can’t physically challenge the elderly patient is passe, according to Puthoff.
“We thought we had to use a lot lower weights or lower repetitions,” he says. “But there is a wide range of research out there showing that you can use higher-intensity exercise with the older adults. Now you’re not going to do high intensity the first session, which you might do for a college athlete ... but you can start at a lower weight and build up.”
Rudi Ide, PT, the sole practitioner in Boca Raton, Fla., who cared for Martin, agrees that even centenarians often are up for the challenge. Ide, who specializes in general geriatric PT, says Martin still drives and lives independently, and her goal is to keep it that way.
“When she comes in, and she spends about 1 1/2 hours to two hours each time, we show the other folks what this 100-year-old can do,” Ide says.
Martin had taken a fall in her bathtub before coming to see Ide. She had a hard time moving when she started PT because the fall caused a flare-up of traumatic arthritis, he says.
Ide treated Martin with hands-on work, along with an exercise routine of high repetitions and low resistance. “I know that a lot of PTs don’t do massage, myofascial release and joint mobilization techniques on some of these older folks, but I think that’s where you can see the most change,” Ide says. “You know they have arthritic problems ... but they have so many myofascial restrictions that need to be addressed — especially after an acute injury. Once you get that under control, you can see normal motion return, even where they didn’t have it before.”
The Whole Elder
Geriatricians are taught to look at the whole patient, according to Phillips, and PTs should take the same approach. People change physiologically with time. Even if a woman is the same weight at 100 as she was at 50, she will have less muscle mass and strength in her later life, Phillips says.
“So, whereas a 40-year-old can break his ankle, go to physical therapy and get an exercise program and probably be pretty much back to normal in four to six weeks, that same fracture in a 90-year-old may take six months — if they ever get back to normal,” she says.
Phillips also makes note that, with the elderly, PTs need to look less at the disease and more on function. “It’s less about their hip pain and more about how that hip pain might be keeping them from going to the bathroom or being able to prepare food at home,” she says.
Puthoff says that age should not cause a PT or any other practitioner to pre-judge a patient’s ability or outcome. Having said that, Puthoff says that PTs also have to know when something is outside their realm of expertise. This includes recognizing when an elderly patient needs to go back and see the doctor because of vision problems, hearing problems, nutritional issues and more. “If they’re not getting enough protein and calories, they’re not going to get stronger and not going to make improvements,” Puthoff says.
Getting the Word Out
Puthoff contends that it’s going to take work to get the word out to referring providers, PTs and consumers that PT prevention helps at any age.
“As PTs and healthcare providers, we could find those numerous success stories that we all have and highlight and share those with consumers, physicians and with each other,” Puthoff says.
Reimbursement is tricky when it comes to preventive services, experts say. Some diagnoses that clinicians have successfully used to refer elderly patients include generalized weakness and frailty. Describing the need for falls or injury prevention for an elderly patient doesn’t cut it with Medicare reimbursement, according to Phillips.
“But let’s say a person has a weakness that is demonstrated in an exam and I can describe that and give it a name, then I can send them to a therapist for evaluation and treatment. If someone has a new lower extremity weakness or a new loss of balance, and I can describe it in a diagnosis, then I can refer them to physical therapy for evaluation and treatment,” Phillips says.
“I think that one of the unused partnerships is physicians better understanding how and when they can refer to physical therapy,” Phillips says. •
Lisette Hilton is a freelance writer.
But the physician refused.
“When I was leaving [the appointment], I said, ‘Doctor, are you going to give me a prescription to get that walker?’” Martin says. “He said, ‘I have no intention of it. You go to therapy, and you won’t need a walker.’”
Martin took part in PT for 2 1/2 months and says she is stronger and ready for the first of her cruises to the Caribbean in January.
Independent Spirit
The latest census estimates there were 104,754 centenarians in the U.S on Nov. 1, 2009, and that is projected to increase to 601,000 by 2050.
The decision to send a 100-year-old to PT was a good call, says Michael L. Puthoff, PT, PhD, GCS, assistant professor and assistant director, PT, St. Ambrose University, Davenport, Iowa.
Even physicians sometimes make the assumption that PT no longer is useful as a way to prevent dependence among the very old. “They believe these things are a normal part of aging. People are supposed to get slower, weaker and lose their balance,” Puthoff says. “Yes, our bodies do lose some abilities as we age ... but we can always make improvements in those areas.”
In fact, Puthoff says, studies have shown that even centenarians can improve muscle strength and balance.
Studies also have shown that physical activity in older persons, in general, decreases the risk of depression and cognitive impairment and increases overall self-reported health, according to Cheryl Phillips, MD, AGSF, immediate past president of the American Geriatrics Society.
“I think there is a lack of awareness of the value of physical therapy assessment and intervention for gait and mobility function,” she says. “Doctors always think about PT after an injury. But it is less common that physicians who don’t have geriatric experience or training will think about the value of a physical therapy assessment for falls prevention or in strengthening programs for muscles of the lower legs that have to do with getting out of chairs and walking,” says Phillips, who is chief medical officer for On Lok, a program that offers an alternative to nursing home placement for the frail elderly living in the community.
New Thinking
The thinking that one can’t physically challenge the elderly patient is passe, according to Puthoff.
“We thought we had to use a lot lower weights or lower repetitions,” he says. “But there is a wide range of research out there showing that you can use higher-intensity exercise with the older adults. Now you’re not going to do high intensity the first session, which you might do for a college athlete ... but you can start at a lower weight and build up.”
Rudi Ide, PT, the sole practitioner in Boca Raton, Fla., who cared for Martin, agrees that even centenarians often are up for the challenge. Ide, who specializes in general geriatric PT, says Martin still drives and lives independently, and her goal is to keep it that way.
“When she comes in, and she spends about 1 1/2 hours to two hours each time, we show the other folks what this 100-year-old can do,” Ide says.
Martin had taken a fall in her bathtub before coming to see Ide. She had a hard time moving when she started PT because the fall caused a flare-up of traumatic arthritis, he says.
Ide treated Martin with hands-on work, along with an exercise routine of high repetitions and low resistance. “I know that a lot of PTs don’t do massage, myofascial release and joint mobilization techniques on some of these older folks, but I think that’s where you can see the most change,” Ide says. “You know they have arthritic problems ... but they have so many myofascial restrictions that need to be addressed — especially after an acute injury. Once you get that under control, you can see normal motion return, even where they didn’t have it before.”
The Whole Elder
Geriatricians are taught to look at the whole patient, according to Phillips, and PTs should take the same approach. People change physiologically with time. Even if a woman is the same weight at 100 as she was at 50, she will have less muscle mass and strength in her later life, Phillips says.
“So, whereas a 40-year-old can break his ankle, go to physical therapy and get an exercise program and probably be pretty much back to normal in four to six weeks, that same fracture in a 90-year-old may take six months — if they ever get back to normal,” she says.
Phillips also makes note that, with the elderly, PTs need to look less at the disease and more on function. “It’s less about their hip pain and more about how that hip pain might be keeping them from going to the bathroom or being able to prepare food at home,” she says.
Puthoff says that age should not cause a PT or any other practitioner to pre-judge a patient’s ability or outcome. Having said that, Puthoff says that PTs also have to know when something is outside their realm of expertise. This includes recognizing when an elderly patient needs to go back and see the doctor because of vision problems, hearing problems, nutritional issues and more. “If they’re not getting enough protein and calories, they’re not going to get stronger and not going to make improvements,” Puthoff says.
Getting the Word Out
Puthoff contends that it’s going to take work to get the word out to referring providers, PTs and consumers that PT prevention helps at any age.
“As PTs and healthcare providers, we could find those numerous success stories that we all have and highlight and share those with consumers, physicians and with each other,” Puthoff says.
Reimbursement is tricky when it comes to preventive services, experts say. Some diagnoses that clinicians have successfully used to refer elderly patients include generalized weakness and frailty. Describing the need for falls or injury prevention for an elderly patient doesn’t cut it with Medicare reimbursement, according to Phillips.
“But let’s say a person has a weakness that is demonstrated in an exam and I can describe that and give it a name, then I can send them to a therapist for evaluation and treatment. If someone has a new lower extremity weakness or a new loss of balance, and I can describe it in a diagnosis, then I can refer them to physical therapy for evaluation and treatment,” Phillips says.
“I think that one of the unused partnerships is physicians better understanding how and when they can refer to physical therapy,” Phillips says. •
Lisette Hilton is a freelance writer.
To comment, e-mail pteditor@gannetthg.com.
Monday August 16, 2010