Recent%20study%20sought%20to%20monitor%20pattern%20of%20HRT - PowerPoint PPT Presentation

Title: Recent%20study%20sought%20to%20monitor%20pattern%20of%20HRT


1
Recent study sought to monitor pattern of HRT use
from 1993 to July 2003. From 1993 to 1999,
annual prescriptions rates rose from 58 to 90
million and remained steady until June
2002. However, from July 2002 until July 2003-
after the publication of HERS, HERS II and
WHI- prescriptions fell by roughly 50 or 57
million prescriptions.
Hersh AL et al. National use of postmenopausal
hormone therapy Annual trends and response to
recent evidence. JAMA 2004291(1)47-54.
2
Care of the Chronic and Terminally Ill Patient.

• COLDs
• Affects 15 million Americans
• 5th leading cause of death
• Epidemiological evidence indicates that
• incidence of COLDs has risen more rapidly
• than any of the 10 other most common
• causes of death among persons over age 65.

3
Estimated that 80 of all COLDs directly related
to smoking. Onset may be in 70s or 80s, even
if stopped smoking decades earlier.
S S productive cough, dyspnea, wheeze. If
osteoporotic Increased freq of pink puffers
blue bloaters.
Treatment bronchodilators, anticholinergic
inhalers
4
Asthma

• 10 of elderly Americans
• Half of elderly asthmatic patients have
• onset of symptoms after age 65.
• Mortality 20-fold greater among adults
• over age 45 compared to children.

S S wheeze, SOB, chest tightness,
non- productive cough, and persistent URTI.
5
6 Key Strategies to Manage Asthma
1. Education 2. Objective measurements of lung
capacity 3. Environmental control 4.
Pharmacological therapy for chronic
asthma. 5. Pharmacological therapy for acute
asthma. 6. Regular follow-up care.
Symrnios NA. Asthma a six-part strategy for
managing older patients. Geriatrics
199752(2)36-44.
6
Other suggestions

• cover mattress and pillow with plastic
• damp wipe mattress every 2 weeks
• wash bedding weekly in hot water
• replace feather pillows
• avoid basement bedrooms
• cover air ducts with filters
• maintain smoke-free environment
• remove or vacuum any carpet weekly
• humidity at 30-50
• wash pet regularly
• increase ventilation with A/C

Jones AP. Asthma and the home environment. J
Asthma 200037103-24
7
SMT and Asthma
Although no change in FEV following SMT in a RCT,
there were improvements in QOL, decreased drug
usage and decreased symptoms.
Reviewers of the Cochran Library concluded that
there was insufficient evidence to support or
refute SMT for asthma.
Balon J et al. NEJM 19983391013-1020 Hondr
as MA et al. Cochrane Library, Issue 2, Oxford
200017
8
Did SMT in addition to optimal medical management
result in clinically important changes in
asthma-related symptoms among children. Outcomes
Pulmonary function test patient and parent
rated asthma-specific QOL and asthma
severity questionnaires morning and evening
peak expiratory flow rates daily diary-based
day and nighttime symptoms.
9
After 3 months, the use of SMT and
optimal medical management children rated
their QOL substantially higher and their asthma
severity substantially lower.
Bronfort G, Evan RC, Kubic P et al. Chiropractic
pediatric asthma and chiropractic spinal
manipulation A prospective clinical series and
randomized clinical pilot study. JMPT
200124(6)369-377.
10
Cancer

• In general, rates of cancer declined 0.7
• between 1990-1995.
• Death rates from 4 most common cancers
• (lung, breast, prostate and colorectal)
• all declined.
• Likelihood of developing a cancer within
• a persons life 40
• Primarily disease of the elderly, with age
• the major determinant of cancer risk.
• One third of all cancers occur in persons
• over age 70.

11
May be related to prolonged exposure to
environmental carcinogens. Decrease in
mitochondrial activity Impaired cellular repair
ability Impaired immune system
12
In the field of oncology

• Because older patients thought to have
• poor prognosis
• cognitive impairments
• decreased quality of life
• decreased social worth
• limited life expectancy

13

• They receive
• less screening for cancer
• less staging for diagnosed cancer
• less aggressive therapy,
• and often no treatment at all.

Older patients less likely to receive proper
pain management for cancer
Cleary JF, Carbone PP. Palliative medicine in
the elderly. Cancer 199780(7)1335-47.
14
As A Result
Older patients are often labeled as
being resistant to treatment, clinically
uninteresting, and are often provided with only
generic and narrow treatment options.
Palmore EB. Ageism Negative and Positive. New
York Springer Pub Co. Inc. 1999.
15
Lung Cancer

• WHO estimates 3 million people die world-
• wide due to Lung cancer, with highest rate
• among North Americans.
• 178,000 new cases a year
• Most common cause of cancer death
• (160,000 annually).
• Incidence dropped among men since 1980s
• Increased among women, more common
• than breast cancer

16

• Highest risk factor is smoking
• Apparent by demographic studies with
• a 20 year time lag.
• 80-90 of lung cancer attributable to
• smoking.
• Proportional to both total number of
• years person has smoked and number
• of cigarettes person smokes.
• Earlier quit greater impact
• 3,000 die/yr from second-hand smoke

17
S S Most cases untreatable at time of
Dx. Lung cancer tends to be clinically
silent until detected. Unexplained weight loss,
dyspnea, chest pain, bone pain, haemoptysis,
wheezing, signs associated with brain mets,
recurrent and unresolving pneumonia.
TNM Staging Medically managed Prognosis 5
year survival 10-15
18
Breast Cancer

• Most commonly diagnosed cancer among
• Canadian and American women, and second
• only to lung cancer in terms of cancer deaths.
• Affects 19 women.
• 150,000 new cases a year. 44,000 deaths
• 29 of all cancer among women
• 18 of all cancer deaths
• Among women age 15-54, leading cause
• of cancer death.
• 70 of cases dx in women over age 50.

19
Risk Factors
Gender Age Exposure to estrogen Diet Genetic
factors BRCA 1 and p53 (17) Family History S-E
factors (more common in high SE) Radiation
exposure Personal history of endocrine
cancer History of benign breast disease
20
In general, the longer a women exposed to
estrogen, the greater her chance of developing
breast cancer. ie early Menarche or late
Menopause (late menopause twice the risk).
Some protection conveyed by pregnancy (related
to increase in prolactin). BC Pill (?)
21
Also related to large body mass and abdominal
obesity. Diet increased risk with change in
diet with more fat and total calories.
22
Screening Protocols
Monthly self-examination Mammogram between age
35-40. Every 2 years between age 40 to 50 Yearly
thereafter.
S S non-painful, tender, firm palpable mass.
23
Treatment

• Depends on stage of disease
• Lumpectomy or mastectomy
• lymph node dissection and radiotherapy.
• Unconventional treatments

Iscador, 714-X, green tea, vitamin A,C, E. Essiac
and hydrazine sulfate.
Berestiansky J. Breast cancer a current
summary. Top Clin Chirop 19996(1)18-24.
24
Prognosis related to presence or absence
of axillary lymph nodes.
Primary Prevention exercise, balanced diet
(antioxidants), increase in linolenic acid,
decrease use of BC pill. Secondary Prevention
Breast self-exam. Clinical exam.
Mammography. Tertiary Prevention Post-op care,
follow-up visits, patient education.
25
Prostate Cancer

• 50 of men over age 70 have evidence of
• prostatic cancer.
• Second most common cause of death.
• 244,000 diagnoses a year. 40,000 deaths
• Afro-Americans have highest incidence
• in world (19).

Tends to be clinically silent. Often metastasis
to bone
26
Screening Digital rectal exam.
PSA testing. Bone scan for
mets.
Medical management. TURP
27
Gynecological Cancers
Endometrial cancer most common of gynecological
cancers. Harbinger Post-menopausal bleeding.
Cervical Second most common. Peak incidence
fifth and sixth decade. Related to viruses.
Ovarian Less common, more deadly. Leading cause
of gynecological cancers deaths in USA.
Incidence is highest in 65-85 year old.
28
Colorectal Pancreatic Cancer

• Highly prevalent among older patients.
• Second only to lung cancer as the most
• common malignancy among both men
• and women.
• 90 of all cases occur over age 50
• 150,000 new cases/year.
• Adenocarcinoma constitutes 95 of all
• cases

29
Associated with diets that are high fat, high
refined sugars and char-grilled meats and low
fibre. Other risk factors family history,
IBD, polyps other colon tumors. Typically
asymptomatic until found. Suspected if presence
of occult blood, Fe- deficiency or abdominal mass.
30
Pancreatic Cancer

• Fourth most common cancer in USA
• 25,000 cases annually
• Related to cigarette smoking, diabetes,
• high -OH use, saturated fat and coffee,
• chronic cholecystisis, exp to carcinogens.

SS unexplained wt loss, jaundice, GI
pain Prognosis 5 year survival 10
31
Myeloproliferative Disorders
CLL is most common leukemia among elderly. May be
related to Epstein-Barr virus. Often incidental
findings.

• Multiple myeloma. More common among
• Afro-Americans. Usually persons over age 50.
• Genetic, radiation, toxins and viruses.
• Bone pain most common presenting complaint
• Multiple biconcave compression on X-ray

32
Chronic Illness
Recall studies by Hawk (JAGS 2000),
Bressler (Spine 1999) and Rupert (JMPT 2000).

• Estimated that 80-85 of all people will
• experience a significant health problem
• that predisposes them to pain after age 65.
• 20-50 significant pain
• 45-80 if in nursing home

Gallagher et al. Sources of late-life pain and
risk factors for disability. Geriatrics
200055(9)40-47.
33
BUT...

• Prevalence of pain declines with age.
• Age-related changes to nociceptors
• More reluctant to report pain
• Artifact of high mortality rates/institutionizat
  ion.

That said 36-83 of elderly report
pain interferes with ADLs and QOL.
Mobily PR et al. An epidemiological analysis of
pain in the elderly the Iowa 65 study. J Aging
Health 19946139-154.
34
Chronic pain in and of itself does not lower
QOL. Related to changes in sleep, physical and
social functioning, depression, and increased
need for health services
Symptoms of pain and depression intensify each
other. Health related QOL scores of people with
chronic non-malignant pain are among lowest
observed for any medical condition.
Gallagher et al. Ibid
35

• Development of chronic pain influenced by
• Patients interpretation of pain.
• patients reaction to pain.
• Other biopsychosocial factors.
• Score of MMPI
• involvement of workers comp or litigation
• 90 more likely to develop chronic pain.

Hoffman B. Confronting psychosocial issues in
patients with low back pain. Top Clin Chirop
19996(2)1-7.
36
Breaking Bad News
situation where there is either a feeling of no
hope, a threat to a persons mental or physical
well-being, a risk of upsetting an established
lifestyle, or where a message is given which
conveys to an individual fewer choices in his or
her life.
Bor R et al. The meaning of bad news in HIV
disease counseling about dreaded issues
revisited. Counsel Psych Q 1993669-80.
37
However, different people interpret bad news
differently. Depends on personality,
interpersonal skills, news-specific variables,
situation-specific. May only be confirming
patients suspicion.
38
Must be certain of news before its conveyed!

• Cannot be delegated to a surrogate
• Jurisprudence dictates informing pt
• Fortify rapport between patient and
• doctor if done well. Conversely, if done
• poorly, may impede patients long-term
• adjustment to news.

39
Three ways to convey Bad News 1. Bluntly and
insensitively 2. Kindly and sadly 3.
Understanding, positive and flexible
Key Convey info in such as manner as to
facilitate acceptance and understanding,
minimizing risk of denial, ambivalence,
unrealistic expectation, overwhelming
distress patient.
40
Strategies to Convey Bad News
41
Bowers L. Ive got some bad news Top Clin
Chirop 19996(1)1-8.
42
Studies indicate that delivering bad news is
stressful for the clinician as well. May be
afraid will be blamed, fear of unknown, fear of
unleashing emotional response from pt, discomfort
of not having all the answers, personal fear of
unknown or death. Therefore, clinician should
not give news if he or she is anxious or
uncomfortable. Beware of burn-out
Ptacek JT et al. Breaking bad news. A review of
the literature. JAMA 1996276496-502.
43
End of Life Issues

• Palliative care
• Provide dignity and comfort
• Best QOL.
• Address physical, mental, emotional and
• spiritual needs.

Encourage opportunities to reminisce. Be a good
listener. Empower individual by involving them
in own health care decisions.
44

• Remind patient to have a living will.
• What heroic means (DNR)
• Organ donation
• When to withhold care.
• Can achieve good death

Fisher R et al. A guide to end-of-life care for
seniors. University of Toronto and University
of Ottawa. Health Canada 2000.
45
Recent study reported that half of
caregivers (n217) of patients with dementia
reported spending at least 46 hours/week
assisting with ADLs or IADLs. More than half
reported that they were on-duty 24 hours a
day, that the patient has frequent pain and that
the caregiver had to end or reduce employment
owing to these demands.
46
Caregivers exhibited high levels of depression
but showed remarkable resilience after the death
of the person under care (symptoms of depression
started to lift by 3 months). 72 of caregivers
reported that they found the persons death to be
a relief to them, and 90 thought it was a relief
to the patient.
Schulz R et al. End-of-life care and effects of
bereavement on family caregivers of persons with
dementia. NEJM 2003349(20)1936-42.
47
A recent study investigating the experience of
1578 patients who had died. Last place of care
67 institution (1059) 33 at home
(507) Of these 507, 198 (38) did not receive
nursing services, 65 had nursing services and
256 (49) had home hospice service.
48
One quarter of all patients with pain or dyspnea
did not receive adequate treatment, and one
quarter reported concerns with physician
communication. More than one third of patients
under home health agency/nursing home/hospital
care reported insufficient emotional
support, compared to only 1 out of 5
patients receiving hospice care.
49
Family members of patients receiving hospice
services were more satisfied with overall
quality of care. Many patients in institutions
had unmet symptom amelioration, physician
communication, emotional support, and being
treated with respect.
Teno JM et al. Family perspectives on end-of-life
care at the last place of care. JAMA
2004291(1)88-93.h
50
Hospice Model
i. Each person is unique.
ii. Everyone dies.
iii. Comfort and happiness are very important.
iv. Adverse consequences of medical evaluations
and treatments.
v. Compromise in carrying out plans.
vi. Ability to treat without diagnosing.
Goodwin JS. Geriatrics and the limits of modern
medicine. N Eng J of Med 1999340(16)1283-1285.
51
Evidence-based medicine is not kind to the
elderly. This movement trusts only the products
of randomized clinical trial or,
preferentially, meta-analyses of those trials.
But subjects over the age of 75 years are
rarely found in such trials, thus rendering
this population invisible to scientific
medicine
52
If we teach only what we know, and if we know
only what we can measure in clinical trials, then
we can say little of importance about the care of
the elderly. The most important resources
required in caring for the old- sufficient time
and empathy- are not included in the critical
pathways of managed care.
Goodwin JS. Geriatrics and the limits of modern
medicine. N Eng J of Med 1999340(16)1283-1285.
53
Sleep Disorders
Affected patients often have concomitant pathologi
cal disorders that disturbs their sleep patterns
Only those problems that persist for longer than
one month are considered clinically significant
54
Age-related
disturbances of sleep include
More time in bed less time asleep
More easily aroused from sleep
Experiencing daytime fatigue napping
Less tolerant of phase shifts of the
sleep-wake cycle
55
Botanical Medicines for Sleep Disorders
German Chamomile Passion Flower Hops Lemon Balm
56
Psychological stress
the self-fulfilling prophesy of not being able
to sleep
57
Treatment of sleep disorders
Advisable to use sleeping pills as a last resort,
many different non-pharmacological approaches
Establish a regular sleep schedule
Ensure a comfortable temperature noise-free
surroundings
58
Activities
3.
It is suggested not to associate the bed with
frustration of not falling asleep.
The patient should not use the bed for such
non-sleep activities such as reading or
watching TV.
If the patient cannot fall asleep for more than
30 minutes, the person should leave the bedroom,
do something else, return
59
Fluid, drugs exercise
4.
Avoid nocturia by discontinuing fluids after a
certain time.
The patient should avoid foods or drinks with
stimulants
Exercise is extremely beneficial in the
treatment of sleep disorders
60
The pharmacological approach involves the
prescription of certain established drugs.
However,
many of these medications have serious
side-effects
61
DRUG
SIDE EFFECT
Antidepressants Benzodiazepines (ie. Diazepam)
Postural hypotension confusion Problems of
tolerance, dependency withdrawal Decrease
Stage IV sleep
62
DRUG
SIDE EFFECT
Chloral hydrate Anti-histamines (ie.
Benadryl)
Development of tolerance to dosage.(increase in
serum anticoagulants) Anticholinergic
effects can result in mental confusion urinary
changes
63
Iatrogenic Drug Reactions
64
Definitions
Iatrogenic caused by medical tx. Polypharmacy u
se of medications for treatment of
multiple co-morbid conditions.
65
Adverse Drug Reaction World Health Organization
Any noxious, unintended or undesired effect of a
drug, which occurs a doses use in humans for
prophylaxis, diagnosis or treatment. Does not
include therapeutic failures, intentional or
accidental overdoses, errors in administration or
non-compliance.
66
Medical Statistics of Drug Use
and The Prescription Cascade
67
30 of all drugs and 40 of over-the-counter
drugs are purchased by those over age 65. 2/3 of
older Americans use at least one drug a day. 45
more than one a day. 25 of older patients
receive inappropriate medication.
68
The most frequent medical intervention performed
by a medical doctor is the writing of a
prescription.
67 of physician visits result in a drug
prescription
40 involve the prescription of 2 or more
medications.
69
In the United States, estimated annual cost of
treating drug-related mortality morbidity is
76.6 billion
70
It has been estimated that 45 of the elderly are
taking
SEVERAL prescription medications CONCURRENTLY
71
The number of drugs that the average geriatric
patient is taking, including prescription
medications, supplements and over-the-counter
drugs is
72
The most commonly misused prescription medication
are
Antibiotics
It has been estimated that 60 of antibiotic use
is either unnecessary or inappropriate
73
Age-Related Changes to Pharmokinetics
Pharmodynamics
Kidney 30 decline in glomerular function
rate, renal mass and blood flow. Liver Decline
in hepatic function, mass and blood flow. Less
drug clearance and Increase in Bioavailability of
Drug.
74
Tissue more susceptible to pharmacological
effects of the drugs prescribed.
75
Geriatric Paradox
Older patients more commonly prescribed
medications, despite that fact that they are the
least able to handle their side-effects.
76
Besides the problems of tolerance and
dependency, there is the risk of developing a
Prescription Cascade
occurs when an adverse reaction to a drug is
misinterpreted as a new symptom
A new drug is then prescribed, increasing the
risk of still more symptoms and pathological
developments
77
Subsequent Treatment
Initial Drug
Adverse Drug
78
To prevent the Prescription Cascade
Doctors should ALWAYS consider ANY sign or
symptom as a possible consequence of current drug
treatment.
Before a new drug is prescribed, the need for
the new medication should be re-evaluated and a
non-drug treatment should be considered

79
This problem is only compounded by the common of
practice of older people 1. Self-medicating
themselves 2. Sharing medications with their
friends who say they have the same problems.
McCarthy KA. Peripheral neuropathy in the aging
patient common causes, assessment, and risks.
TICC 19996(4)56-61
80
Other Problems
Tolerance Dependence Withdrawal
81
NSIADs
8,000 to 16,000 deaths annually 100,000
hospitalizations
Cohen J. Avoiding adverse reactions. Effective
lower-dose drug therapies for older patients.
Geriatrics 200055(2)54-64.
82
10 to 17 of all hospitalizations for older
patients are the direct result of inappropriate
drug use.
Cohen J. Avoiding adverse reaction. Effective
lower-dose drug therapies for older patients.
Geriatrics 200055(2)54-64.
83
The Boston Collaborative Drug Surveillance Project
estimated that about 30 of all hospitalized
patients experience an ADR, and that 3-28 of all
hospitalizations are related to ADRs. Other
studies have estimated that the rate of ADRs to
be 6.5/100 hospitalized patients, of which 28
were judged to be preventable.
Bates DW et al. The cost of adverse drug
events in hospitalized patients. JAMA
1997277307-311.
84
One study estimated that cost of ADEs was 2,595
for all ADEs, and 4,685 for those ADEs thought
to be preventable.
57 of ADEs judged to be significant 30 serious
12 life-threatening 1 fatal.
18 target GI or CNS, 16 CVS or allergic
85
Estimated that the cost to a 700- bed hospital to
be 5.6 million for all ADEs 2.8 million for
preventable ADEs
Bates DW. The cost of adverse drug reaction
in hospitalized patients. JAMA 1997277307-311.
86
One study For every dollar spent on drugs in
nursing homes, 1.33 in health
care resources were consumed in the
treatment of drug- related problems.
Andrews et al. An Alternate Strategy for
studying adverse drug reaction. Lancet.
1997349(9048) 309-313
87
Recently published study of over 1000 patient
hospital files found 18 had at least one serious
ADR while under hospital care, and the
likelihood of experiencing an ADR increased 6
for each day spent in the hospital.
Andrews LB et al. An alternative strategy for
studying adverse events in medical care. Lancet
1997349309-313.
88
Cohort study of all Medicare enrollees (30 397
person-years) cared for in a multispecialty
clinic over a 12-month period. Investigators
found 1,523 identified ADEs, of which 28 were
considered preventable. Of these, 38 were
serious, life-threatening or fatal.
89
Most errors occurred at the prescription stage
(58), monitoring (61) and errors in patient
adherence (21). Cardiovascular Rx most commonly
involved, followed diuretics, nonopiod
analgesics. hypoglycemics and anticoagulants. Sys
tem most commonly involved electrolyte/renal,
GI, hemorrhagic, metabolic/ endocrine and
neuropsychiatric.
90
Conclusions More serious adverse drug events
are most likely to be preventable.
Gurwitz JH, Field TS, Harrold LR. Incidence and
preventability of adverse drug events among older
persons in the ambulatory setting. JAMA
2003289(9)1107-1116.
91
2,216,000 patients have serious ADRs
annually. 106,000 fatal ADRs a year.
Four to sixth leading cause of death.
Lazarou et al. Incidence of Adverse Drug
Reacations in Hospitalized Patients. JAMA.
1998279(15) 233-7
92
Examples of Adverse Reactions to commonly used
drugs
93
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94
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95
Botanical Med Cross-Reacting Potential
or Herb Drugs Consequence ___________________
________________________ Echinacea Anabolic
steroids Hepatoxicity
Amidarone,
Methotrexate Feverfew NSAIDs
Negates effect on headache Feverfew,
garlic Warfarin Alter bleeding Gingko,
Ginseng
time
96
Botanical Med Cross-Reacting Potential
or Herb Drugs Consequence ___________________
________________________ St Johns wort
MAO inhibitors, Headache,
SSRIs
sweating Valerian Barbiturates
Sedation Evening Primose
Anticonvulsants Lower Sz.

threshold
97
Botanical Med Cross-Reacting Potential
or Herb Drugs Consequence ___________________
________________________ Ginseng HRT,
corticosteroids Addictive Hawthorn
Digoxin Cardiac Siberian
ginseng
dysfunction Chamomile Anticoagulants (?)
Change
coagulation.
Miller LG. Herbal medicines. Selected clinical
manifestations focusing on known or potential
drug-herb interactions. Arch Intern Med
19981582200-11
98
General Effects of Exercise
99
Physiological Effects
in blood flow in endurance in ROM
flexibility - in blood pressure - in resting
heart rate
100
Physiological Effects
- in bone loss - in loss of strength in
oxygen uptake in neurological function - in
peripheral body fat
101
Exercise is also a non-pharmacological therapy
for
Stress Sleep Disorders Anxiety
Diabetes Coronary Heart Disease Hyperlipidemia
Obesity Hypertension
102
Frailty
This occurs when an older person loses their
physical reserve when they are no longer capable
of carrying out their IADLs. It is usually a
combination of severe muscle wasting and
cognitive decline.
Morley JE, Thomas DR. Recent advances in
geriatrics. Top Clin Chhiro 20029(6)1-6
103
Other definitions of frailty include three or
more of the following unintentional weight loss,
self reported exhaustion, weakness (grip
strength), slow walking speed, and low
physical activity. Prevalence of 6.9
104
Loss of muscle mass (sacropenia) is
major component of frailty, which is related
to physical disability and inactivity. Over-weigh
t people with low muscle mass (fat frail) most
disabled.
Morley JE, Thomas DR. Recent advances in
geriatrics. Top Clin Chhiro 20029(6)1-6
105
The Necessity of Strength Training
For the Older Patient
106
Muscle Strength
is considered to be the most physiologically-limit
ing factor in the older adult.
107
Changes in Muscle with Age
Loss of Muscle Mass (sarcopenia)
Decrease in Number of Muscle Fibres
Decrease in Muscle Fibre Size
Remodeling of Neuro-Muscular Junction
Decline in Number of Motor Units
108
Collateral Innervation
partially compensates for decrease in motor unit
numbers.
But this results in decline in
Motor Control
109
Non-uniformity of Muscle Strength Decline
UWO Atrophy of Quadriceps muscle
Less than Atrophy of Tibialis Anterior
Biceps However Impairment in ADL and
Increase in Risk of Falling
110
Risk of Falling
111
Uncompensated decline in muscle strength results
in a spiraling decline in
Functional Independence
Mitigated or Reversed by
Strength Training
112
UWO Research
Measurable gains in strength in as little as 6
weeks even among frail elderly.
Gains can last up to 1 year even with
de-training.
113
Relationship Between Strength Gains Functional
Improvement
Gait, Balance, Decrease in Risk of Falling Gains
in Chair-rising abilities, modality tasks
( stooping, transferring, stair climbing )
114
The Threshold Value
Minor improvement in strength can result in
remarkable gain in functional abilities.
115
Threshold Value
work
socialize
mobile in home
chair bound
116
Psycho-emotional gains have also been attributed
to strength gains. Increase in confidence
self-esteem, and progressive resistive
training was found to be an effective
anti- depressant among depressed people.
Singh N, Clement K, Fiatarone M. A randomized
control trial of progressive resistive training
in depressed elders. J Gerontol A Biol Sci Med
Sci 199752(1)M27-35.
117
Strength Training can be a benefit to all five of
the
Five I s
that challenge the older patient.
118
Intellectual Impairment
Immobility
Instability
Incontinence
Iatrogenic Drug Reaction
119
Risk of Strength Gains ? Increase
in Physiological Burden ?
McMaster subjects engaged in moderate strength
training (weight training) exposed to no more
circulatory risk than created by a few minutes of
incline walking.
No other evidence of increase in frequency of
injury occurrence in those patients undergoing
either supervised or unsupervised strength
training with clear instructions.
120
Main motivational factors for older person to
adhere to exercise program
Health Maintenance
Social Cohesiveness
121
Prescription of Strength Training can be
considered to be
Primary
Secondary
Tertiary Prevention
122
Mechanical Joint Pain
Most common presenting Chief Complaint to a
chiropractors office. Generator of the pain
poorly understood. Joint dysfunction/subluxation.
Assessed by history and NMS exam.
123
One author has suggested that the
disease management paradigm that serves
medicine so well often fails in the field of
LBP. Thus, back pain in primary care has some-
times been characterized as an illness in
search of a disease, analogous to
fibromyalgia, IBS or chronic fatigue syndrome.
Deyo RA. Diagnostic evaluation of LBP. Arch
Intern Med 20021621444-7
124
This diagnostic challenge is further frustrated
by the common findings of anatomic abnormalities
such as herniated discs, bulging discs
and annular tears among healthy, asymptomatic
patients.
Deyo RA. Diagnostic evaluation of LBP. Arch
Intern Med 20021621444-7
125
Recent article directed at medical physicians
emphasized importance of history taking in order
to reach a diagnosis. Pain characteristics,
intensity, timing (onset, duration and pattern),
location, radiations and associated factors.
Cohen RI, Chopra P, Upshur C. Low Back Pain,
Part I. Primary care work-up of acute and chronic
symptoms. Geriatrics 200156(1)26-37.
126
Assessing pain behaviors, medication history and
Alternative interventions.
Physical Exam posture, gait, palpation,
SLR, Patricks, Flexion, Extension, Kemps
Neurological exam. Use of Imaging.
Cohen et al. Ibid.
127
Stated that mechanical low back or leg pain
account for 97 of patients with LBP in primary
care. 70 Idiopathic (includes FM/MPS) 10
DJD 4 Herniated disc 3 Spinal
stenosis 4 OP
128
By contrast 1 Non-mechanical (cancer,
infection, arthritide) 2 visceral (prostate,
PID, renal disease aortic aneursym, GI)
129
Conservative Treatment
Review and modifications of ADLs Ice, heat,
modified sleep positions. To date,
evidence-based literature reviews show no
advantage to acupuncture for back pain when
compared to trigger point injections or TENS.
Cohen RI, Chopra P, Upshur C. Low Back Pain,
Part II. Guide to conservative, medical and
procedural therapies. Geriatrics 200156(1)38-47.
130
Spinal manipulation has shown a minimal
advantage. Massage therapy, as compared to
TENS and manipulation, is not advantageous.
131
Three-step analgesia Step 1 NSAID, Cox-2
inhibitors Step 2 Opioid therapy
(codeine) Step 3 Morphine, methadone
May need to add adjuvant medications to any of
the above steps .
132
Patient education exercise, ADLs, nutrition,
sexual concerns. Surgery decompressive
laminectomy fusion, disketomy.
Some studies suggest the results of treatment of
pain, instability, spinal stenosis and nonacute
spondylolisthesis with decompression or fusion
may not be more efficacious as compared to
conservative treatment.
133
Although conservative management is the
recommended first-line management, appropriate
medical management includes the generous and
thoughtful prescription of single of multiple
drug regimens, based on patients pain levels and
extent to which pain interferes with activities
of daily living.
Cohen et al. LBP. Ibid
134
Spinal Manipulative Therapy
SMT Passive movement by external force
into the paraphysiological space, but
not exceeding anatomical limit. High
Velocity, Low Amplitude thrust.
Adjustment Any procedure that utilizes
force, leverage, direction, magnitude,
amplitude and velocity directed at
specific joint.
135
Seventy-three RCTs on SMT have been published in
peer-reviewed journals. Often compare SMT to
placebo, other therapeutic options, and to
common medical management approaches.
Most studies demonstrate either
clinical effectiveness, some showed no
difference. None found SMT less effective.
Meeker WC, Haldeman S. Chiropractic A profession
at the Crossroads of mainstream and alternative
medicine. Ann Int Med 2002136216-227
136
43 RCTs of SMT for treatment of acute, subacute
and chronic LBP have been published. 30
favored SMT 13 found no significant
difference No trial to date has found
manipulation to be statistically or clinically
less effective than the comparison treatment.
137
Of the 11 RCTs investigating SMT and neck pain, 4
positive 7 equivocal. Seven of 9 RCTs on SMT
and headache were positive.
Systematic reviews and meta-analyses made
cautiously positive or equivocal statements
about the effectiveness of SMT for LBP, neck
pain and headaches.
138
There are many studies, comprehensive reviews
of the literature, and authoritative opinions
that support chiropractic care as safe,
appropriate, clinically useful, and often
cost effective compared with surgery, drug
therapy, bed rest, physical therapy and patient
instruction.
Cooperstein R et al. Chiropractic Technique
Procedures for Specific Low Back Conditions
Characterizing the Literature. JMPT
200124(6)401-24
139
SMT The Older Patient
Gleberzon BJ. Chiropractic care of the older
person Developing an evidence-based approach.
JCCA 200145(3)156-171
140
Case Studies N25
Successful management of Cervical spondylotic
radiculopathy Spinal stenosis Diabetic
neuropathy of tarsals TOS Dislocation
of S-C joint DISH Rotator
cuff tear
Re-habilitation Vertigo and tinnitus
Myastenia gravis Post-surgical
repair to quads. Back pain and

short leg
141
Other studies emphasize importance of being
vigilant to other pathologies that may present as
uncomplicated back pain.
Prostatic metastasis Synovial
facet joint cyst Bronchial carcinoma
Thalamic pain syndrome Abdomnianl aortic
aneursym MVA Cerebellar infarct or Jeffersons
fracture Fracture of femoral neck following
radiation therapy Chrondrosarcoma and myositis
ossificans
142
Clinical Guidelines N18
Challenges of assessing older person Elder abuse
Falls, injuries, trauma Exercise Strength
training Nutrition Special consideration for
X-ray use Special consideration for SMT
143
Clinical Trials N4
All four studies investigated benefits of
osteopathic manipulation on older patients
for 1. changes in bowel habits 2.
prevalence of falling 3-4. patient with pneumonia
Only patients with pneumonia showed any clinical
improvements reduced antibiotic use and
hospital stay.
144
SMT and the Older Person
Most clinical trials exclude by design older
patients.
Therefore, must extrapolate from studies
involving younger persons which have
demonstrated efficacy of SMT for acute and
chronic neck and low back pain, and certain
types of headaches.
145
Cooperstein and Killinger
Review of available research on chiropractic
technique
Older persons do not appear to suffer more
adverse reactions to SMT than younger persons,
and they may suffer fewer.
Patient variables ie greater joint
stiffness Doctor variables ie rely on low force
techniques
greater prudence
Cooperstein R, Killinger LZ. In Gleberzon BJ.
Chiropractic Care of the Older Patient. 1st
Print. Butterworth-Heinemann, 2001.
146
Cooeperstein and Killinger cont
Issue related to SMT may be less one of force and
more one of pressure.
Alternative to HVLA SMT Instrument-assisted
techniques (Activator) Blocking techniques
(SOT) Drop-assisted techniques (Thompson) Mechanic
ally-assisted techniques (Cox) Upper cervical
techniques (NUCCA)
147
Risks of Spinal Adjustments/Manipulations
No serious complications noted in more than 73
RCTs or any prospectively evaluated case series.
49 among persons age 47-65 reported a
side-effect. Most local discomfort (53),
headache (12) or tiredness (11). Mild to
moderate in 85 of cases. Disappeared within 24
hours in 74 of cases.
Senstead O et al. Spine 199722(4)435-441
148
Rehabilitation of the older person
Impact of age-induced changes on rehab is
over-estimated. McGill reported that endurance
of back muscles is of primary concern in any
exercise program, rather that absolute strength.
McGill S. Low back exercises evidence for
improving exercise regiments. Phys Ther
199878754-765.
149

• Exercise Programs (in general)
• Modified to patients particular
• abilities.
• Enjoyable for patient
• Social interaction where possible
• Affordable (cost/ space).
• Re-check if give stretches.

150
Most back injuries are not due to frank trauma
but more likely the results of trivial events
associated with motor control errors causing
inappropriate muscle activation and aberrant
joint motion.
Jull GA, Richardson CA. Motor control problems in
patients with spinal pain a new direction for
therapeutic exercise. JMPT 200023115.
151
In general, supervised training has been shown to
be far superior to non-supervised efforts
patients achieve better results when they are
under the direct guidance of a trainer.
Reilly K et al. Differences between a supervised
and independent strength and conditioning
program with chronic low back symptoms. J Occup
Med 199931540-550.
152
Klaber Moffett program
Patients up to age 60 with chronic LBP 8 1-hour
evening classes over 4 weeks consisting of
stretching, low-impact aerobics, and
strengthening exercises. Improvements in
disability, coping-with- life skills and lost
work time.
Klaber Moffet J et al. Randomized controlled
trials of exercise for LBP Clinical outcomes,
costs and preferences. BMJ 1999319270-83.
153
Other rehab programs documented in well-conducted
clinical research trials have successfully
managed older patients, addressing areas of
flexibility, strength, endurance, coordination,
and balance.
Byfield D. Spinal Rehabilitation and
stabilization for the geriatric pain with back
pain. In Chiropractic Care of the Older Patient
(BJ Gleberzon ed). BH. First Printing, 2001
154
Cornerstone of Low Back rehab is extensor muscle
endurance and motor control. Principles of
program design 1. Address functional loss 2.
Establish training objectives 3. Reach
sufficient intensity, dosage and duration.
155
Lateral flexors, particularly QL, are considered
to be one of the most important stabilizers of
the lumbar spine.
Byfield D. Spinal Rehabilitation and
stabilization for the geriatric pain with back
pain. In Chiropractic Care of the Older Patient
(BJ Gleberzon ed). BH. First Printing,
2001 McGill Ibid.
156
5 Main Areas 1. Extensor muscle endurance and
co-contraction 2. Trunk muscle balance 3.
Spinal stabilization 4. Balance and
coordination 5. Lower limb strength. Flexor/exte
nsor ration 1/1.51
157
Cervical Spine Rehab
Cornerstone strength training. Although C/S
muscles represent only 8 of total body weight,
compared with 65 for lumbar muscles, cervical
muscles are twice as strong overall. Postural
demands, and balance weight of head during ADLs
158

• Exercise Programs (in general)
• Modified to patients particular
• abilities.
• Enjoyable for patient
• Social interaction where possible
• Affordable (cost/ space).
• Re-check if give stretches.

159
Issues of Jurisprudence
160
Consent PARQ i. Voluntary ii. Personal and
limited to specific act iii. Mental capacity iv.
Proof it was obtained v. Risk/benefit if
material risk Confidentiality Record Keeping
161
Mandatory Reporting
i. Child abuse ii. Sexual abuse iii. Ability
to operate a car
162
House Calls Advantages vs.
Disadvantages