Aging with a Spinal Cord Injury

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Aging with a Spinal Cord Injury

• Suzanne L. Groah, MD, MSPH
• Brenda Gilmore, RRTC SCI Life Consultant

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What Does Aging Mean?
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Aging Processes

• Physiologic changes
• Changing social roles
• Self-realization

4
Aging Issues

• Medical changes
• Functional changes
• Socioeconomic changes
• Support changes
• Varies with genetics, body habitus, lifestyle,
  general state of health

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What Doesnt Aging Mean?

• Disease and aging are synonymous
• Older are less physically active
• Older are less mentally active
• Diminished quality of life

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What is Normal Aging?
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Normal Aging Cardiovascular

• Decreased stroke volume
• Decreased ability to maintain vessel tone
• Gradual increase in sBP and dBP
• Related to loss of arterial elasticity
• Increased orthostasis
• Increased syncope related to micturition

8
Normal Aging Pulmonary

• Decline in
• Vital capacity
• Maximum voluntary ventilation
• Expiratory flow rate
• Forced expiratory ventilation

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Normal Aging Pulmonary

• Decreased lung compliance
• Inability to expand on inspiration
• Loss of flexibility of chest wall
• Decreased muscle strength in chest
• Restriction of pulmonary function

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Normal Aging Integument

• Loss of subcutaneous tissue
• Thinning of skin
• Loss of elasticity of skin
• Skin tears and bruising more common

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Normal Aging Gastrointestinal

• Transit time increases
• Incomplete absorption of medications
• Overabsorption of medications
• Excessive water reabsorption (due to prolonged
  transit time)
• Dilated colon
• Rectal fissures
• Hemorrhoids
• Decreased force/coordination of smooth muscle
  contraction of colon

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Normal Aging Nervous System

• CNS
• Neurons slowly lost from 24 years
• Decrease in short term memory
• Loss of speed and motor activities
• Slowed rate of central information processing

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Normal Aging Nervous System

• PNS
• Decline in conduction velocity
• 60 reduction in vibratory sense in LE
• 20 reduction in reaction time
• Decreased balance
• Decreased strength
• Decreased coordination
• Decreased agility

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Normal Aging - Musculoskeletal

• Osteoporosis due to loss of calcium
• Muscles lose strength and coordination
• Joint capsules tighten and lose flexibility
• Contractures may develop
• Lean muscle replaced with adipose
• Athletic build changes to overweight with
  protruding abdomen and stooped posture
• Degenerative joint changes universal in WB joints
  by 60 years

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Normal Aging - Musculoskeletal

• Muscle changes
• Decrease in muscle mass
• Decrease in muscle fiber size
• Decrease number of myofibrils
• Reduced concentration of mitochondrial enzymes
• Occur regardless of activity level

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Normal Aging - Musculoskeletal

• Muscle changes
• Muscle strength declines 20-30 by 60 years
• Maximum power output declines 45 after 50 years

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Normal Aging Endocrine

• Reduction of hormones responsible for repair of
  cellular tissues
• hGH
• Testosterone
• Reduction in or effectiveness of insulin and
  insulin like growth factor
• Cellular and humeral decline in immune response

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Normal Aging Renal

• Loss of glomeruli
• Renal insufficiency

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After the Doom and Gloom

• Large functional reserve for each organ

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How Does Spinal Cord Injury Factor In?
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Aging Changes

• Variations in the rate of decline for different
  organ systems in the body
• 60 decline pulmonary function
• 15 decline nerve conduction velocity

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Functional Phases During the Aging Process with
SCI

• Acute restoration phase
• Maintenance phase
• Decline phase

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Functional Phases During the Aging Process with
SCI

• Acute restoration phase
• Immediately after SCI
• Regains maximal functional return
• Maintenance phase
• Variable in length
• Stable level of function
• Decline phase
• Result of degenerative effects of overuse and
  physiologic changes

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Functional Decline After SCI

• Variable and depends on
• Genetics
• Life style
• Level of injury
• Age
• Weight
• Health history
• Level of support
• Comorbidities

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Functional Decline After SCI

• May begin as early as 10-15 years post-SCI
• 93 of those 15 years post-SCI had experienced
  functional decline

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Functional Decline After SCI

• Impact of age at injury
• Age at SCI during or prior to adolescence
• Maintenance phase of 20 years
• 55 years old at time of SCI
• Maintenance phase of 5-7 years

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Summary of Craig Collaborative Aging Study
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Craig Collaborative Aging Study

• Purpose
• Evaluate the health and functional status of
  people living with long-term SCI
• Inclusion criteria
• Injured between 1943 - 1970
• Between 15 - 55 yo at time of injury
• Located in 13 county catchment area
• Admitted within one year of SCI
• Survival at least 1 year

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Participants

• 834 met criteria
• 2/3 with paraplegia, 1/3 with tetraplegia
• Most injured in late teens and early 20s
• 412 survivors
• 282 participated in 1990
• 227 re-recruited in 1993
• Classification by neurologic level of injury

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Neurologic Groups
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Changes by System as an Individual Ages with
Spinal Cord Injury
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Aging with SCI Pulmonary

• Normal Aging
• Decreased compliance
• Decreased muscle strength in chest
• Restriction of pulmonary function

• Affects of SCI
• Restrictive lung disease due to muscle paralysis
• May have obstructive component due to airway
  hyperreactivity

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CCAS with SCI - Pulmonary

• Natural reduction in lung function with age
• Chest infections
• More common in TetraABC than ParaABC and All Ds
• More common in youngest age group and those with
  shorter duration of injury
• Sleep apnea

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Aging with SCI - Gastrointestinal

• Normal Aging
• Transit time increases
• Excessive water reabsorption
• Decreased force/coordination of smooth muscle
  contraction of colon

• Affects of SCI
• Reduction in natural bowel contractions
• Decreased colonic motility
• Prolonged colonic transit
• Decreased colonic compliance
• Diminished tolerance for certain foods

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CCAS with SCI - Gastrointestinal

• 74 with hemorrhoids
• more common in ParaABCs and TetraABCs
• incidence increases with age and duration of
  injury
• 43 with abdominal distention
• 43 autonomic dysreflexia related to bowel
• 20 with difficult bowel evacuation
• Gallbladder disease greater in SCI
• Problems increase with time since injury

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Aging with SCI Endocrine

• Normal Aging
• Reduction of
• hGH
• Testosterone
• Reduction of insulin
• Cellular and humeral decline in immune response

• Affects of SCI
• Reduced GH
• Reduced testosterone
• Impaired glucose tolerance
• Reduced capacity to maintain lean tissue
• Increased insulin resistance
• Impaired calcium metabolism
• Reduced cellular repair

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Aging with SCI - Endocrine

• Diabetes
• 4x more common in men with SCI
• Obesity more common
• Obesity without overweight
• Dyslipidemia
• 40 had low HDL cholesterol
• gt70 paraplegics need treatment according to NCEP
  guidelines

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Aging with SCI - Musculoskeletal

• Normal Aging
• Osteoporosis
• Muscles lose strength
• Joint capsules tighten
• Contractures
• Lean muscle replaced with adipose
• Degenerative joint changes in WB joints
• Decreased flexibility

• Affects of SCI
• Osteoporosis universal
• Joint capsules tighten
• Change in body composition
• UE pain/overuse
• Increases with time
• Peripheral nerve entrapment

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Aging with SCI - Musculoskeletal

• 2/3 have compressive neuropathy in UE
• gt50 with median neuropathy
• 25 bilateral
• Overuse syndromes
• DJD
• Rotator cuff tendinitis
• Subacromial bursitis
• Capsulitis

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Aging with SCI - Musculoskeletal

• Osteoporosis universal
• 22 in first 3 months
• Continual linear loss for at least 2 years
• Greatest in areas of paralysis
• Spine BMD may be unchanged or even gt
• Fractures 6 after SCI
• Most occur in femur
• Around the knee

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Aging with SCI - Musculoskeletal

• Scoliosis universal in peds (97)
• Approx 50 in adults

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CCAS with SCI - Musculoskeletal

• Joint pain stiffness
• Highest in ParaABC than both TetraABC and All Ds
• Increased with increasing duration of injury

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Aging with SCI - Integument

• Normal Aging
• Epidermis thins
• Skin becomes less flexible
• Delayed wound healing

• Affects of SCI
• Thinning of SQ over WB surfaces
• Thinning of skin
• Loss of elasticity
• Skin at risk of breakdown and harder to heal
• Body composition changes

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Aging with SCI - Integument

• Pressure sores
• Most common cause of morbidity
• Incidence increased with increasing age
• Decubitus ulcer rate increases with time since
  injury

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Aging with SCI - Genitourinary

• Normal Aging
• Renal function declines with age
• Loss of glomeruli
• Renal insufficiency

• Affects of SCI
• UTIs
• Most common cause of morbidity
• More common in TetraABCs than ParaABCs or All
  Ds

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Aging with SCI - Nervous System

• Normal Aging
• ? conduction velocity
• ? vibratory sense
• ? reaction time
• ? balance
• ? strength
• ? coordination
• ? agility
• ? fine coordination
• ?entrapment neuropathies

• Affects of Aging
• Motor sensory changes
• 3 times more common in All Ds
• More common in oldest and those with longest
  duration of injury

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Aging with SCI - Cardiovascular

• Normal Aging
• Decreased stroke volume
• Decreased ability to maintain vessel tone
• Gradual increase in sBP and dBP
• Increased orthostasis
• Increased syncope related to micturition

• Affects of SCI
• Risk of CVD higher due to SCI

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Aging with SCI - Cardiovascular

• Normal Aging
• ? incidence of heart disease
• ? blood pressure
• ? cholesterol levels
• ? glucose tolerance

• Affects of SCI
• Risk of CVD higher due to SCI
• Predisposition to lipid and carbohydrate
  metabolism abnormalities

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More on CVD After SCI
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Epidemiology of CVD

• CVD is 1 cause of death in US
• 1993 CVD mortality rate 163 per 100,000
• 1993 CHD mortality rate 95 per 100,000
• 28.6 decline in mortality due to MI
• 84.6 of mortality due to MI in 65yo

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Reversible Risk Factors for CVD

• Hypertension
• Low HDL cholesterol
• Hypercholesterolemia
• Hypertriglyceridemia
• High lipoprotein A

• Tobacco use
• Sedentary lifestyle
• Abdominal obesity
• Diabetes mellitus
• Hyperinsulinemia

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Irreversible Risk Factors for CVD

• Male gender
• FHx premature CVD
• H/O CVD
• H/O occlusive peripheral vascular disease
• H/O cerebrovascular disease

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Cholesterol Level by Neurologic Group
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Serum Lipids

• Cholesterol significantly higher in ParaABCs and
  All Ds than TetraABCs
• HDL significantly lower in TetraABCs than All
  Ds
• HDL decreased significantly in ParaABCs and
  TetraABCs over time

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Cumulative probability of CHD
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Relative Risk of CHD
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CVD and CHD Mortality

• 33 total deaths
• CVD mortality rate 42
• CHD mortality rate 33
• CVD case fatality rate 22
• CHD case fatality rate 17

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Epidemiology of CHD and CVD

• General population
• CVD 1 COD
• CHD prevalence 12.7-22
• CHD accounts for 51.2 of CVD mortality
• 17 CVD mortality in lt65 yo

• Long-term SCI
• CVD 1 COD
• CHD prevalence 15
• CHD accounts for 79 of CVD mortality
• 64 CVD mortality in lt65 yo

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CHD in SCI

• CHD incidence increases with
• age
• duration of injury
• Risk of CHD is higher in ParaABCs and All Ds
  than TetraABCs
• Why?

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What is Accelerated Aging?
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Is Aging Accelerated in SCI?
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Impact of SCI on Aging

• Individual is young at the time of injury
• Immediate reduction in some of the functional
  reserve and capacity
• Some body systems experience more rapid decline

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Life Expectancy
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Is Aging Accelerated in SCI?
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Disability Knowledge and Skills

• Brenda Gilmore, BFA

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Barriers for People with Disabilities
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Goals

• To raise awareness of some of the common barriers
  experienced by people with disabilities
• To provide strategies to overcome these barriers

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Types of Barriers

• Environmental
• Structural
• Attitudinal

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Environmental Barriers

• Transportation
• Availability
• Timeliness
• Cost

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Strategy

• Be flexible
• Time allotted for appointments
• Tardiness beyond patients control

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Office accessibility

• Parking
• Elevators and doorways
• Examination rooms
• Diagnostic Equipment
• Staff communication

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Strategy

• Make the experience easy for the patient
• Inform patient of office layout
• Prepare for patients appointment by adjusting
  barriers
• Ask patient how best you can help

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Structural Barriers

• Structure of health care policies and procedures
• Limitation of visits
• Limitation of durable medical equipment coverage
• Referrals to specialists
• Length of time spent with health care provider

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Strategy

• Allow adequate time for the patients visit
• Provide easy method for referrals

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Attitudinal Barriers

• Lack of provider knowledge about SCI
• Lack of attention to issues other than SCI
• Preventive screenings, sexuality, exercise,
  wellness

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Strategy

• Speak to SCI patient as an intelligent adult
• Counsel and address SCI patients total well being

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Communication with people with disabilities
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Goals

• To identify communication issues and needs when
  interacting with people with disabilities
• To determine critical communication skills
• To identify strategies to improve communication
  with individuals who have disabilities

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Attitudes and behaviors

• Person with a disability is a person first, a
  patient second, and an individual with special
  needs third
• Dont make assumptions or jump to quick
  conclusions about the reasons they come to see
  you
• Approach the individual with a disability just
  like everyone else

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Attitudes and Behaviors (continued)

• Dont make assumptions about the social life of
  people with disabilities
• Do not automatically provide assistance
• Make sure you look at and talk directly to the
  person with a disability

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Use of appropriate terminology

• Awareness of language and terminology is critical
  for the development of a trusting relationship
  between the individual with a disability and the
  healthcare provider
• In the medical community it is not uncommon to
  identify people by their condition as if that
  constitutes their whole identity.

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Terminology (continued)

• Identify communication issues when interacting
  with people with disabilities
• Overview of communication issues (e.g. speech
  impairments, general attitude and behavior)
• Define and describe critical communication skills
• Group suggestions to improve communication with
  people with disabilities compare with
  suggestions made by consumers with disabilities

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Communication ground rules

• Offering assistance
• Introduce yourself and offer assistance.
• Don't be offended if your assistance is not
  needed.
• Ask how you can help and follow instructions.
• Be courteous, but NOT condescending.
• Assist when necessary or requested, but do not
  discourage their active participation

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Introductions and General Communication Rules

• Use a normal tone of voice when extending a
  verbal welcome. Do not raise your voice unless
  requested.
• When introduced to a person with a disability, it
  is appropriate to offer to shake hands.

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• Shaking hands with the left hand is acceptable.
• For those who cannot shake hands, touch the
  person on the shoulder or arm to welcome and
  acknowledge their presence.

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Rules (continued)

• Treat adults in a manner befitting adults
• When addressing a person who uses a wheelchair,
  never lean on the person's wheelchair since the
  chair is part of his or her personal space

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• Offer assistance in a respectful and sensitive
  manner If your offer for assistance is declined
  do not proceed to assist. If the offer is
  accepted, listen and accept instructions.
• When talking with a person with a disability,
  look at and speak directly to that person and not
  through a personal assistant or family

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• When offering help with bags or carrying items
  inquire whether you may help
• Do not hand a cane or crutches unless the
  individual requests this.