Category / Rehabilitation

Understanding the Types of Rehab for Stroke Therapy

February 15, 2019

A breakdown of the various offerings and where insurance fits in
By Lisa Fields

After a stroke, only about 10 percent of people recover almost completely without intervention. For everyone else, therapy is a crucial part of the recovery process. Whether you need physical, occupational and/or speech therapy following a stroke depends on your needs, but the goal is the same: to help you regain control of your body and be independent once again. The therapy you receive should be tailor-made to suit your lifestyle.

“Is the goal returning to driving or returning to work, or (is the person) a retiree who needs to take care of their own bodily functions and participate in playing with a grandchild?” says Glen Gillen, professor and director of programs in occupational therapy at Columbia University in New York and a fellow of the American Occupational Therapy Association.

Kinds of Rehabilitation Facilities

Most stroke patients stay in the hospital for five to six days. Their therapy needs are assessed within the first two days, and therapy may begin on the second. Some patients are sent home from the hospital right away. They may receive outpatient therapy sessions three times a week or get therapy at home from visiting nurses or therapists.

“If they’re higher-functioning, they can potentially go to outpatient therapy, if they have the means to get there,” Gillen says. “That is a challenge for many.”

Many stroke patients are discharged from the hospital to inpatient rehabilitation facilities, where they receive therapy at an intensity that’s best for their needs, based on the severity of the disability. Some go to acute inpatient rehab facilities, which offer the most intense therapy for the most responsive patients. Those with a greater degree of impairment may be sent to “subacute rehab” facilities, where the therapy isn’t as intense as acute rehab.

At acute rehab facilities, “people are guaranteed a minimum of three hours of therapy a day, and a physician visits six days a week,” says Dr. Alexander Dromerick, professor of rehabilitation medicine and neurology and chairman of rehabilitation medicine at Georgetown University Medical Center in Washington, D.C. “(At a subacute facility), they may get a few minutes a day, up to two hours a day, of therapy, and a physician visits every few weeks. They’re very different levels of intensity of care.”

Patients who are making great strides in a subacute facility might be moved to an acute facility for more intense therapy. Those who don’t have the endurance to tolerate an acute facility’s therapy, might be transferred to a subacute facility. “A subacute unit can be a way station back to the community,” Dromerick says, “or it can be a way station to go to a nursing home for the long term.”

Types of Therapy for Stroke Patients

Stroke patients often need physical therapy to strengthen their muscles, retrain their sense of balance and coordination and relearn certain movements. They may need occupational therapy to ensure they can do the tasks associated with daily living, like getting dressed, feeding themselves, showering or relearning skills necessary to return to work. Speech therapy also might be required to relearn how to speak or swallow food.

“Sometimes occupational therapists and physical therapists work together, but occupational therapists focus more on mobility activities that have to do with returning to work or returning to their role in their family or community,” says Carolee Winstein, professor of biokinesiology and physical therapy and director of the Motor Behavior and Neurorehabilitation Laboratory at the University of Southern California. “Physical therapists work on fundamental skills that are needed to be functional in their particular life, whatever it is. We work a lot on mobility. We teach people a lot about the importance of remaining physically active.”

Physical therapists help patients overcome physical challenges — this includes when a stroke has weakened or partially paralyzed one side of the body. Medical professionals refer to that side as “paretic.”

“If they’re having trouble reaching and grasping with their paretic side, I have them do it with their less paretic side to remind them what it should feel like,” Winstein says. “A lot of motor skills are implicit — we don’t think; we do it automatically.”

Occupational and speech therapists also address cognitive challenges.

“We consider most tasks physical, like dressing yourself, (but) all tasks that we do across the day have a cognitive component,” Gillen says. “With getting dressed, it’s the sequence of the clothing: which goes on what body part, which goes on first. If cognition is involved after a stroke, it’s a time-consuming process. We know it will take much longer, much more repetition of practice to get them there.”

Insurance Plans Could Limit Therapy

Health insurance may limit how much therapy a person can receive during a single calendar year or during his or her lifetime. If a person can afford to pay out of pocket, he or she may continue therapy without interruption. Otherwise, many therapists offer plans that patients can follow at home or at a fitness center either on their own or with the help of a family member, friend or personal trainer.

“You can keep working on the stroke problems indefinitely,” Dromerick says.

Therapists hope to get stroke patients functioning independently again, even after their sessions are complete.

“They may need a cane and a brace, but (we teach) them how to navigate with their disability so their disability does not become a barrier in their participation of being active,” Winstein says. “If there are certain things they can’t do, we show them what they can do and get them to work on those things.”

To learn more about stroke rehab and recovery, check out the American Stroke Association’s website.

By Lisa Fields
Lisa Fields is a writer who covers psychology and health matters as they relate to the workplace. She publishes frequently in WebMD and Reader’s Digest.

Simple Steps to Keep the Deadly C. Diff Infection at Bay

January 22, 2019

The contagious bacterial infection can be more serious for older adults
By Mark Ray

When you were a child, did you worry about monsters hiding under your bed or lurking behind your closet door? It turns out one monster — clostridium difficile, or C. diff — may actually be closer at hand, at least in hospitals and nursing homes.

Transmitted via fecal matter, the C. diff bacterial infection can cause severe diarrhea, nausea, fever, dehydration, abdominal pain, kidney failure and even death. Older adults are more vulnerable to it because of naturally weaker immune systems, more likelihood of underlying health issues and more time spent in health care settings.

  1. diff is resistant to some antibiotics, but there are some shown to work against it. In serious and recurrent C. diff cases, patients may undergo a fecal transplant or surgery to remove a portion of the colon.
  2. diff spores adhere to every imaginable surface, including toilet seats, faucet handles, doorknobs, linens, bedrails, nurse call buttons, chair arms, ceiling vents and even floors. A 2017 study in the United Kingdom detected it in floor corners in 86 percent of hospital rooms that had undergone routine cleaning.

Since its spores resist standard cleaning methods and alcohol-based hand wipes, C. diff is tough to eradicate. “We know those spores can last nine months or more in a room,” says Dr. Kate Mullane, an infectious disease specialist at The University of Chicago Medicine. “It takes a high concentration of bleach to kill the spores: a cup of bleach in a gallon of water.”

And killing the spores is critically important because C. diff itself is a killer. The most common microbial cause of health care-associated infections in the United States today, it causes nearly half a million infections and 15,000 deaths annually — almost as many deaths as drunk driving and HIV/AIDS combined,  according to the U.S. Centers for Disease Control and Prevention (CDC). Eighty percent of C. diff deaths occur among people 65 and older, and one in 11 patients in that age group dies within 30 days of diagnosis.

A two-pronged approach can keep this microscopic, but deadly killer, at bay. Prong one is antibiotic stewardship; prong two is infection control.

Antibiotic Stewardship

You’ve doubtless heard the world uses far too many antibiotics, wasting money and contributing to the growing problem of antimicrobial resistance. The Pew Charitable Trusts reported that 30 percent of outpatient antibiotic prescriptions in the U.S. are unnecessary (antibiotics prescribed for a viral infection, for example).

Doctors are getting more judicious in their use of antibiotics, but Mullane says patients should still talk with their doctors about the drugs they’re prescribing. If you can avoid antibiotics, or at least broad-spectrum antibiotics, you will be less vulnerable to C. diff. This is because, along with the bad bacteria the drugs are after, antibiotics also kill much of the good bacteria in our intestines. This leaves C. diff an opportunity to overwhelm the gut and cause illness.

  1. Diff Infection Control

Given C. diff’s persistence in health care environments, it’s also important to prevent transmission between patients, health care workers and visitors — including people who aren’t symptomatic.

“We know at any one time, about 5 percent of the population is colonized with C. diff,” Mullane says. “They may not be sick with it, but they’re at least carrying it.”

The easiest way to stop transmission is with proper handwashing, according to Anna Barker., a researcher in the medical scientist training program at the University of Wisconsin-Madison. “Even with hospital-grade hand sanitizer, which in many cases is pretty similar to what you would buy out in the community, you do still need to use soap and water,” she says.

“It’s not only the soap and water (that gets rid of the germs), it’s the friction and having your hands under the tap water, which you just don’t get when you use (hand sanitizer) gel,” Barker says. A good rule of thumb to make sure you get rid of the germs: Wash your hands for as long as it takes to sing Happy Birthday to You.

But hand hygiene is just the beginning. In the April 2018 issue of the journal Clinical Infectious Diseases, Barker and two colleagues reported their research on the effectiveness of nine discrete C. diff hospital interventions, including everything from patient hand hygiene to terminal cleaning (deep cleaning of a room after a patient is discharged).

Using computer models, Barker and her colleagues found that daily room cleaning with a sporicidal cleaner plus screening for C. diff at the time of admission reduces hospital-associated infections by roughly 82 percent and asymptomatic colonization by about 91 percent.

“When hospitals try to combat their C. diff rates, they’ll end up doing lots of things at once,” Barker says. “This paper showed you can get a considerable reduction in C. diff with only those two interventions.”

What Patients Can Do

While patients don’t have much control over infection-control practices in a hospital or clinic, they can take two concrete actions.

The first is to ask health care providers if they’ve remembered to wash their hands.

“That’s easier said than done given everything we know about power dynamics and the patient-doctor relationship, but I think that really has a potential to make a big impact,” Barker says.

The other action, perhaps surprisingly, is to reduce the clutter in hospital patient rooms.

“One of the things we hear from the cleaning staff is that it’s very difficult to clean a patient’s room effectively if there are newspapers everywhere or books or food or other items throughout the room,” Barker says. “They can’t, at least at our institution, move the patient’s things for them.”

While decluttering your hospital room may not be quite as simple as switching on the lights to banish an under-bed monster, it can go a long way toward keeping you safe from C. diff.

Mark Ray is a freelance writer who has written for Scouting, Eagles’ Call, Presbyterians Today, Kentucky Homes & Gardens and other publications. He has also written, edited and/or contributed to a dozen books for the Boy Scouts and the Presbyterian and United Methodist churches.

18 Questions to Ask Any Nursing Home

January 14, 2019

How to find a place that wants to be a real home
By Denise Logeland

Part of the Transforming Life as We Age Special Report

What makes a nursing home a good place for you or your parents? While “good” can mean a lot of things, it should include qualities like dignity and self-determination for the people who live there. The Pioneer Network offers tips on how to check for those qualities.

Formed 20 years ago, the nonprofit Pioneer Network is made up of professionals who work in long-term care, people who live in long-term care and families who advocate for them. The network, active nationally and through coalitions in 36 states, belongs to a broad-based movement in long-term care that is sometimes called simply “culture change.” That is a movement away from generic, system-based care and toward more individual, person-directed care. With culture change, residents have a large voice in the care they get and have as many of the freedoms they had in their earlier homes as possible.

You can find out if a nursing home is guided by the principles of culture change by asking specific questions when you visit to take a tour. A few examples:

  • Can residents wake up when they want to in the morning?
  • How do you get to know the people who live here?
  • How do you build a sense of community and give those who live here a voice in how things are done?
  • What is the turnover rate for the direct care workers on your staff?

There are 18 questions in all to ask at nursing homes, and a similar set of 16 to ask when looking at assisted living facilities. You can see the questions and the answers to listen for on the Pioneer Network website, where they are also available as downloads.

Denise Logeland is a writer and editor in Minneapolis who has covered business, health and health care. She is the author of Next Avenue's ebook, 10 Things Every Family Should Know: Aging With Dignity and Independence.

Doing your homework before joint replacement leads to a better recovery

December 6, 2018

Meeting with a physical therapist and educating yourself before you have joint replacement surgery can help you to have a quicker, less stressful recovery.

Patients who meet one-on-one with a physical therapist (PT) and educate themselves prior to knee or hip replacement surgery feel better prepared to leave the hospital and report less pain and joint stiffness during recovery compared to those who did not, according to a study by Hospital for Special Surgery (HSS). The study evaluated the effect of a face-to-face counseling session coupled with web-based education on patient satisfaction and functional outcomes.

The goal of the education session was to manage patient expectations of the surgery and recovery before undergoing the surgery—rather than after the surgery, when they might be dealing with fatigue, pain or anxiety—so they were able to better absorb and retain the information. Researchers followed 126 patients who underwent knee or hip replacement for osteoarthritis.

All patients attended a group education class before surgery—the standard of care for those scheduled for joint replacement at HSS. They were then randomized into two separate groups. In group one, 63 patients attended the one-on-one education session with a physical therapist in addition to the group class and were granted access to an informational web portal featuring videos. The control group of 63 patients attended the standard group class and received a booklet about what to expect after joint replacement—with no further education.

Using patient satisfaction and patient-reported scores to measure pain, joint stiffness and function both before and after surgery, researchers determined that the patients who attended the extra one-on-one PT counseling session indicated they were better prepared to leave the hospital after surgery and were overall more satisfied with the preoperative education they received. Almost 97 percent of these patients accessed the informational web portal, and all of them said they would recommend it for patients undergoing the same procedure.

Almost 70 percent of patients from the group that did not receive the supplemental educational session or web portal access believed they could have benefited from additional education before surgery. Patients who received one-on-one counseling also needed fewer physical therapy sessions in the hospital before discharge and met PT discharge measures sooner, including being able to get out of bed, walk with or without an assistive device and go up and down stairs independently.

The upshot of this research is that, if you are considering joint replacement surgery, ask to meet one-on-one with a physical therapist BEFORE your surgery if that is not your doctor’s standard approach. And take advantage of any and all learning materials your doctor may give you—specifically online videos and information.

The more you know, the better your recovery may be.

Person-Centered Care Focuses on Patients' Needs

November 19, 2018

What person-centered care means and how you can get it

By Patricia Corrigan

The way patients and health care providers think about health care delivery is changing, with an increasing desire to involve patients in decisions and planning. Today, many providers also work to meet patients’ needs that go beyond medical treatments. This philosophy is known as person-centered care.

The SCAN Foundation, an independent public charity (and funder of Next Avenue), defines that philosophy as putting older adults “at the center of the decision-making process” by making use of a care team “that considers the full range of needs of individuals and their families.”

Rebecca Kirch, executive vice president of health care quality and value at the nonprofit National Patient Advocate Foundation in Washington, D.C., is a proponent of the philosophy. “So often in our health care system, when we are asked what’s the matter, the provider’s response to our answer doesn’t always align with what matters in our lives to us or to our families,” Kirch says.

What does person-centered care look like, and how can you get it? Here are some examples and advice to help you start a conversation with your doctor about a broader range of care for yourself or a loved one:

‘We Listen to What Patients Need’

Sharp Rees-Stealy Medical Group in San Diego has committed itself to person-centered care, with the goals of improving communication channels and offering more support services.

“Medical groups across the country are paying more attention to what patients need and want because patient involvement produces the best outcomes,” says Janet Appel, Sharp Rees-Stealy’s director of population health. The organization serves some 220,000 patients who make more than a million doctor visits each year.

Appel added, “If people are not engaged in how they receive care, their health goals will most likely not be met.” The medical group practices person-centered care in several ways, including:

  • Phone or video appointments
  • Webinars on topics such as diabetes education
  • Expanded evening and weekend hours
  • Case management services
  • Support programs
  • Nurse navigators to help with difficult diagnoses
  • Texting to receive reminders and health tips

“The texting program is especially popular,” Appel says. “Patients choose how often to receive texts with tips for healthy living, reminders about appointments or information on where and when flu shots are available. They can also text us with questions, and texting answers back to them helps us stay connected at the patients’ convenience.”

Appel noted that Sharp Rees-Stealy actively seeks feedback so it can make changes that will help communications and practices evolve based on what patients want. “We listen to what patients need in order to improve patient engagement to improve healthy outcomes,” she says.

Delivering Care Where Patients Are Is ‘Critical’

At Inland Empire Health Plan (IEHP), a not-for-profit Medi-Cal (California’s Medicaid program) and Medicare health plan, the focus on person-centered care extends to individuals who may need it the most. Based in Rancho Cucamonga, IEHP is a network of more than 6,000 providers and 2,000 team members who serve more than 1.2 million people.

Through the Affordable Care Act, a large pilot program called the Behavioral Health Integration and Complex Care Initiative allows IEHP to provide person-centered care for its low-income plan members at locations convenient to them.

Working with a dozen agencies, IEHP has staff at 30 sites. “We’ve put nurses, behavioral health specialists and care coordinators at primary care offices, behavioral health clinics, substance abuse treatment clinics, adult day care centers, assisted living centers and pain management clinics,” says Dr. Bradley P. Gilbert, IEHP’s chief executive officer.

“Many people we serve face many complicated issues, including with their health, housing, transportation and other challenges, so making sure they are part of the planning and then delivering care to them where they are is critical,” Gilbert says.

The project has made significant improvements in people’s health, based on measurements regarding depression, anxiety, blood pressure and more, Gilbert says. “We’ve had great feedback from members, and providers also say they like the structure of the health care delivery.”

Currently, the pilot program is in transition. The number of sites is increasing, and nurse care managers, social workers and community health workers are being added at each. Plus, IEHP is working to house high-risk members who are homeless.

Ask Your Doctor About Person-Centered Care

What about your needs?

Is it a hardship to arrange transportation for X-rays, screenings or blood tests done across town from your primary physician’s office? Maybe you see specialists in two separate health care systems and you want them to better coordinate your care. Could you benefit from a talk with a social worker about local agencies that help pay some living costs?

Speak up, the experts advise.

“Let your voice be heard,” Appel says. “Ask what patient-centered care means at your doctor’s office, and if it’s not available, ask how you can help get that started.” You may be surprised, she adds, at the doctor’s willingness to listen.

“The medical world has gotten into what retail has done all along — listening to the consumers and then drawing them in by offering what the consumers want,” she says. “Today, there is a lot of competition, with many places to go for health care.”

Person-centered care can be especially important when individuals are coping with serious illness. Kirch, at the National Patient Advocate Foundation, gave this example: “Palliative care, now part of mainstream medicine, presents a bullet-proof case for person-centered care that aligns treatment with the goals and the specific needs of the person and the family affected, rather than focusing only on the disease. Providers must ask about those goals, document them and honor them.”

‘What We Need Now is More Public Demand’

Like Appel, Kirch encourages speaking up for what you want from your provider. “Public demand makes medical practices change faster than any policy or payment incentive,” she says.

How would Kirch assess the status of person-centered care in the U.S. today? “We have more than a toehold, but not yet a foothold,” she says. “We have demonstration programs in place in some pockets of the country, but it’s not yet scaled to where it needs to be. Still, I’m optimistic. What we need now is more public demand.”

© Next Avenue - 2018. All rights reserved.

Smart Technology Takes Hold in Retirement Communities

October 12, 2018

From FaceTime to iPods, residents at senior living spaces embrace technology

By Mike King
September 10, 2018

Connected technology in our homes is fast becoming part of our daily routine. For good reason: it offers entertainment, convenience, connection to others, improved security and increased comfort. It’s also becoming routine in senior living communities. According to a survey by Pew Research, four in 10 older adults now use the internet and own smart phones — up 50 percent from four years ago.

As the president and CEO of Jewish Senior Life, a continuing care retirement community in Rochester, N.Y., I can say that our team’s experience has given us a strong understanding of how technology can help enrich the lives of those we serve.

From email and webcams that connect with family and friends, and games and puzzles that stimulate minds, to technology-enhanced rehabilitation programs that improve hand-eye coordination, residents with a wide range of physical and cognitive abilities are now enjoying technologies adapted just for them. Even those who’ve never used a computer before.

Through technology, they’re able to continue learning, socializing and doing the things they enjoy doing, which helps them stay engaged, informed, in touch and in control.

These technologies also help foster relationships between staff and residents, who enjoy using them together.

Keeping Lines of Communication and Connection Open

Older adults are increasingly adept with laptops, tablets and smartphones. Many of our residents enjoy using platforms like Skype and FaceTime to keep in touch with family members and longtime friends. Video chatting is more personable than a phone call and allows our residents to be “present” at milestone occasions, such as birthday parties, school performances, graduation ceremonies and weddings.

Whether they’re taking a lifelong learning course, engaging in social media, listening to podcasts or paying bills, today’s older adults want ready access to all that the internet has to offer. Just like they did at home.

Hey Google, When is My Therapy Appointment?

One of the many technology devices we rely on at Jewish Senior Life is Google Home. It’s a voice-activated smart speaker. Our transitional care (short-term rehabilitation) patients enjoy using it during their stays to get instant access to information such as the weather forecast, history and current events, as well as where they need to be when. In short, it helps them stay connected to their hobbies and interests, and on top of their schedule.

Other devices that are increasingly common in assisted living centers, retirement communities and medical facilities include:

  • iPads preloaded with medication reminders or “face-to-face” check-ins
  • Automated pill dispensers, useful for anyone with a complex pill regimen or a memory disorder
  • Wireless pendants that activate a phone if a client has a fall
  • Health-monitoring devices that can be applied to a parent’s unit as a motion-detector
  • Devices that monitor vital signs, or even manage medications

At Jewish Senior Life, we also utilize the It’s Never 2 Late® (iN2L) system. It’s an adaptive computer system with a picture-based, touch-screen interface that allows users to “touch” their way to find all kinds of engaging content for a variety of interests and uses, and it can be personalized for each resident.

Music, the Universal Language

Many people living in a long-term care residence face cognitive and physical difficulties and have left behind their familiar surroundings, familiar faces and even their favorite music.

We have 65 iPods loaded with MUSIC & MEMORY®, a personalized music software program, which helps them find renewed meaning and connection in their lives in the present and helps them reconnect with their past.

We find it also helps residents relax during sundowning — a symptom of dementia in which an individual experiences late-day confusion or agitation. Hearing pieces of music they know gives them a sense of calm, a sense of peace, puts them at ease. It reminds them of what they were like before they had dementia. And since music is the universal language, the MUSIC & MEMORY program also helps eliminate communication hurdles.

Smart Technology Isn’t a Luxury, It’s a Must-Have

Given the rapid pace at which today’s older adults are embracing technology, and all that it enables them to do, from connecting with grandchildren to playing Scrabble and solitaire to reconnecting with their best selves, the role of connected technology in senior living communities will only increase in prominence.

It can be a wonderful companion and a way to keep the mind stimulated and engaged. Technology can also be a great distraction and source of comfort and help older residents cope and adapt to cognitive and physical challenges.

If you’re considering a move to senior living for yourself or a family member, be sure to ask what technologies are available to the residents and staff. The benefits they bring are immeasurable.

May is Older Americans Month!

May 1, 2018

Throughout the month of May, Presbyterian SeniorCare Network will be embracing the Engage at Every Age theme and will utilize the power of Facebook to publicize our inspiring resident and team member stories. We’ll keep the buzz going all month, so be sure to check Facebook often and be sure to share our posts with your friends and family!

Each May, the Administration for Community Living leads our nation’s celebration of Older Americans Month. The theme for 2018 is Engage at Every Age. This powerful theme emphasizes that you are never too old (or young) to take part in activities that can enrich your physical, mental, and emotional well-being. Participating in activities that promote mental and physical wellness, offering your wisdom and experience to the next generation, seeking the mentorship of someone with more life experience than you—those are just a few examples of what being engaged can mean.

No matter where you are in your life, there is no better time than now to start!

Dispensing Pills Systematically

February 28, 2018

Do you take daily medications? Have trouble remembering to take your pills? A pill dispenser may be just what you need. 

Ten percent of all admissions to hospitals and 23 percent of all admissions to nursing homes can be traced to faulty medication administration, such as failure to take the prescribed dose. This forgetfulness costs the United States an estimated $50 billion each year. 

To avoid medication errors in the homes of elderly individuals, it is a good idea to dispense pills and capsules from a tray with compartments for one or more doses for a particular day or specified time.

These trays are designed to simplify drug rounds for home-care providers and reduce the risk of medical errors, and studies have proven their effectiveness. Medication errors are twice as likely to occur with pills or capsules that are not in dispensers compared those from a dispenser. Pill dispensers are inexpensive tools that prove their worth many times over in an age when more elderly individuals rely on daily medications than ever.

The benefits of using a pill dispenser include significant monetary savings, peace of mind and avoiding medication errors. Patients and caregivers feel better when a pill dispenser ensures that the patient will take his or her medication in the prescribed doses and at the correct times.

As most dispensers only need to be filled once a week or less, they can easily be filled by a caregiver or relative for a forgetful senior. Also, filling the dispenser once a week is a great way to keep on track with refills and ensure that the elderly person has all the pills they need for the week (and next week, too).

Tap into our additional Senior Experience here.

Can Technology Predict Falls in Older Adults?

November 21, 2017

Fascinating new research sheds light on the precursors to potentially deadly spills


By Randy Rieland for Next Avenue


The prospect of aging can conjure up a multitude of horrors — a mind stolen by dementia, a body debilitated by illness, a soul crushed by social isolation. For most, fear of falling would be well down the list.

But falls are, in fact, one of the more common and consequential risks faced by older adults. The statistics, compiled by the Centers for Disease Control, are both eye-opening and alarming.

One out of four Americans 65 or older falls at least once every year. Every 11 seconds, an older adult in the U.S. is treated in an emergency room for a fall; every 19 minutes, one dies from a fall. By 2020, the financial cost related to falls by older adults in the U.S. is expected to top $67 billion per year.

Figuring Out the Early Signs of Falls

So, it’s not surprising that an increasing amount of research is focusing on ways to predict if, and even when, a person is likely to fall. The goal is being able to take actions to reduce the risk. Much of that effort is built around using emerging technologies — from infrared depth sensors to brain imaging to virtual reality.

“Technology allows you to monitor people in their homes in a way you couldn’t have in the past,” said Marjorie Skubic, a professor of electrical and computer engineering at the University of Missouri and director of the school’s Center for Eldercare and Rehabilitation Technology.

She’s been refining the use of sensors and motion-capture technology to study older adults in their homes for more than a decade, and she’s enthused about its potential for helping people age in place. “We’ve found that once sensors have been in a place for three or four weeks, people completely forget about them. And that’s what we want — to capture their normal activity in their homes.”

Here’s how Skubic and other scientists are using technology to sharpen their ability to predict falls:

Gait Watching

While Skubic’s research has focused broadly on how sensors can help detect early signs of physical and cognitive decline, a recent study zeroed in on finding a more precise correlation between a person’s walking gait and his or her likelihood of falling.

Using sensor measurements of walking speeds and stride length of residents at TigerPlace, a retirement community in Columbia, Mo., researchers found a clear connection between a slowing pace and the risk of falling. In fact, analysis of the multi-terabyte-sized set of data, gathered over 10 years, showed that people whose gait slowed by 5 centimeters per second within a week had an 86 percent probability of falling during the next three weeks. That was four times more likely than someone whose walking speed hadn’t changed.

The shortening of a person’s stride was also determined to be indicator of a fall in the near future, albeit not as clearly as decreasing speed. It was associated with a 50.6 percent probability of falling within three weeks, the study said.

When the sensor system detects notable changes in a person’s gait, it sends an alert to the caregiver so she or he can take steps to help prevent a fall.

Invasion of Privacy?

But what about privacy concerns? Aren’t people anxious about having their every step recorded?

The key, says Skubic, is that the system reflects each person as only a silhouette, instead of a clear image captured by a conventional camera. “It’s not streaming video,” she noted. “You can’t tell what someone’s wearing or if their hair is made up. You just get this shape, but you can get a lot of information from that shape.”

At first, Skubic thought she might need to blur the silhouettes to have people feel more comfortable. It turned out that wasn’t necessary.

“There’s this interesting relationship between perceived need and what might be considered an invasion of privacy,” she said. “People said they could see that a crisp silhouette could be easier to interpret, in terms of looking for something related to fall risk. They were OK with that.”

Advantages of Passive Home Observation

Skubic pointed out several benefits of a sensor-based warning system. For starters, it does not require people to wear or interact directly with a device. She cited research that found older people were less likely to engage with technology if they weren’t feeling well — a time when captured data can be most helpful.

Perhaps more importantly, the sensor system enables monitoring to occur over a long period of time in a home environment. “The big difference is that we’re looking at the average in-home gait speed,” Skubic said. “We and other researchers have found that your typical at-home gait pattern is different than if you’re in a lab and someone says, ‘Now walk across the room.’ People walk differently in their own homes.”

Skubic added that research suggests that sensor monitoring can make a difference in enabling older adults to age in place. Another study found TigerPlace residents whose homes had sensors were able to stay there 1.7 years longer than those in a control group without sensors.

A testament to Skubic’s belief in the sensor system was her decision to install one in the home of her aging parents, who live several states away in South Dakota.

“My mother is 93. My father just turned 96. And they want to stay in their own home,” she said. “So I put a system in there. Now I’m able to see from my firsthand experience what it feels like to be the adult child of somebody who has these sensors in their home. I can see how it can help me help them. I installed it on my mother’s birthday in January. It was my birthday present to her.”

Brain Work

Researchers at the Albert Einstein College of Medicine in New York have taken a different approach in using technology to predict falls: they’re looking into people’s brains.

Specifically, they tracked the brain activity of a group of 166 high-functioning adults with an average age of 75 as they performed various activities — walking, talking and then walking while talking. They found that those who needed the front part of their brains to work harder while multi-tasking — reciting every other letter of the alphabet while walking — were more likely to have a fall in the next few years.

A lead researcher for the study, Dr. Joseph Verghese, explained that cognitively impaired people tend to fall at a much higher rate than those with more normal cognition. The challenge was to see if there was a way to determine which people in the second group might have a higher risk of falling.

“When you look at them in the community, they’re walking around doing their activities without any impairment,” he said. “You really need to stress them to reveal the abnormality that would predict falls.”

The high-functioning people did slow down a bit when walking and talking, but that’s pretty typical, and Verghese said it wasn’t enough to help predict falls. But their brain activity told a different story.

“When we measured their brain activity, it appeared they were trying to compensate really hard, using their brain function to maintain their physical performance,” Verghese noted. “It wasn’t something you could see. But you could measure it.” The brain activity was signaling its stress.

More Brain Activity, More Falls

Through follow-ups with test subjects every few months over the next four years, the researchers found that 71 of the 166 had fallen, some more than once. And those who had registered more brain activity while walking and talking were more likely to be in that group. In fact, each incremental increase in brain activity resulted in a 32 percent increased risk of falls.

The goal, said Verghese, is to be able to use this approach to detect if a person has a higher risk of falls before any physical signs appear. “Most of the research has been on identifying impairments that lead to falls. Less attention has been paid to abnormal biology or brain abnormalities that might do that,” he said.

“But what if you could step back to an earlier point in time and treat this as a biological syndrome that leads to clinical impairments like poor balance or worse gait, which then lead to falls? The idea would be to catch this early,” he said.

Verghese said the next phase of the research will look at the activity levels of other parts of the brain during the walk/talk test to see what role they may play in how people perform.

Putting Virtual Reality to Work

Meanwhile, researchers at the University of North Carolina and North Carolina State University have been exploring the potential of virtual reality to provide insights into why some people are more prone to falls.

In a recent study, the scientists had people walk on a treadmill facing a large curved screen showing a moving hallway. That created the sensation they were losing their balance. Through motion-capture technology, the researchers closely tracked how the subjects’ muscles that control posture and foot placement adjusted to the perceived loss of balance.

“We’re not actually causing people to fall,” said lead researcher Jason Franz, “but the variability goes way up — that’s the size of correction people are making from one step to the next. We see that as a key marker to a person’s susceptibility to a balance impairment.”

Franz pointed out that visual cues are particularly important for older adults to maintain balance. Young and healthy adults can rely on “sensors” in their feet and legs to give them a good sense of body position. But that sensitivity tends to diminish as we age, which is why it’s often more difficult for older adults maintain their balance while walking in the dark.

“Since older adults have to rely on vision much more for balance control, we use VR to trick the brain into telling people they’re falling,” he said. “Then we use the motion-capture cameras to measure the motor responses of their bodies.”

What the Muscles Tell Us

By closely tracking how different muscles respond to the sense of falling, scientists can develop a roadmap for detecting a person’s balance impairments and their risk of falling in the future, Franz said. He also believes that a similar approach using VR could be used to train people to improve their balance while walking.

“We think that virtual reality could help detect balance impairments that might not be apparent otherwise, even in clinical testing,” he said. “The key to doing that is to challenge their balance and see how their body responds.”

This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and AARP.

© Twin Cities Public Television - 2017. All rights reserved.

Prepare for Surgery With Exercise and Diet

May 16, 2017

'Prehabilitation' is slowly being recognized as valuable for success after a procedure


By Judith Graham for Next Avenue


A dozen years ago, at the age of 50, Lillie Shockney decided to have breast reconstruction surgery after two bouts of cancer and two mastectomies. The procedure called for removing a flap of skin and fat from her abdomen, used to rebuild her breasts.

Shockney knew a lot about breast cancer and the trials of recovery: she was (and still is) director of the breast center at Johns Hopkins’ Sidney Kimmel Cancer Center. Characteristically, this dynamic nurse didn’t want to stay in the hospital for any longer than absolutely necessary.

Taking Action to Prepare for Surgery

So, Shockney contacted a physical therapist and asked for exercises that would strengthen her abdominal muscles before she went under the knife. “My hope was that that would result in my getting up and about sooner,” she said.

Over the next six weeks, Shockney lay on her back, lifted each leg 18 inches and held the position for 15 seconds — 30 times, twice a day. The effort paid off when she became the first Johns Hopkins patient to go home three days after the surgery, a day or two earlier than other patients.

Today, all women who undergo DIEP (Deep Inferior Epigastric Perforator) flap breast reconstruction at Johns Hopkins undergo a similar exercise regime — a form of rehabilitation-before-treatment, or prehabilitation.

Not a New Idea

The principle behind prehabilitation is universally embraced by athletes, Shockney noted: Prepare for surgery by getting in good (or great) shape before you subject your body to significant stress, so you’re better able to endure that stress and minimize the potential for complications.

Orthopedists have incorporated prehabilitation into their practices for decades, with positive outcomes for people getting knee and hip replacements, among other procedures.

“We’ve learned that the steps you take before surgery are just as important as what happens during and after surgery,” said Dr. Howard Luks, an orthopedic surgeon who practices about 60 miles north of New York City.

He recommends that people getting knee replacements have five to six sessions with a physical therapist before surgery, during which they work on enhancing their strength and flexibility and learn how to use walkers or canes that might be needed during their recovery.

“Your range of motion before surgery is associated with your range of motion after,” said Luks. “And if your muscles are strong and used to being stressed, they’re going to do better after surgery as well.”

Preparing for Cancer Treatment

More recently, prehabilitation has begun to find a place in cancer centers for patients about to undergo surgery, chemotherapy or radiation therapy.

“Prehabilitation in cancer is really in the early stages,” with researchers trying to learn which interventions are most effective for patients, when therapies should be initiated and how long they should last, said Dr. Julie Silver, an associate professor at Harvard Medical School and founder of Oncology Rehab Partners, which disseminates model cancer prehabilitation and rehabilitation programs.

At McGill University, Dr. Francesco Carli, a professor of anesthesia, has shown that patients with colorectal cancer who follow a structured exercise program; add whey protein to their diet and learn stress reduction techniques before surgery return to the previous level of functioning far more quickly than patients who didn’t prepare for surgery by following this regimen.

Research Supports Benefits

About 80 percent of patients who participated in prehabilitation had returned to their before-surgery “normal” baseline two months after surgery, compared with 30 percent of patients who received usual post-surgery services, Carli and colleagues reported in 2014 in the journal Anesthesiology.

Today, all colorectal cancer patients at McGill are evaluated by a kinesiologist, who tailors recommended exercises to their personal circumstances; a nutritionist, who evaluates their diet and suggests needed supplements and a psychologist, who addresses the fear and anxiety that often precede major medical treatment.

Typically, home-based therapies are initiated a month or two in advance of surgery.

The interventions are especially important for older patients, who have often become inactive and lost muscle strength and physiological resilience, Carli noted. “Our recent findings show that elderly with low fitness are potentially benefiting the most and their functional capacity increases greatly compared to those who are already fit,” he wrote from overseas in an email exchange.

At Lahey Hospital and Medical Center in Burlington, Mass., patients with early stage lung cancer are undergoing a five-stage prehabilitation protocol: getting a nutrition assessment (with coaching to increase protein intake prior to surgery), being counseled to stop smoking (with smoking cessation aids disseminated, if necessary), having a psychological assessment (with people in distress referred for mental health counseling), undergoing a lung assessment (with pulmonary rehabilitation exercises recommended, as needed) and being advised to enhance general conditioning (by walking several times a week for increasingly long periods).

Responding to Patients

“People ask all the time, ‘What can I do to prepare for surgery?’” said Dr. Andrea McKee, Lahey’s chair of radiation oncology. “Previously, we would have told them ‘nothing by mouth after midnight the night before surgery’ or ‘quit smoking.’ We didn’t do the kinds of comprehensive assessments and evaluations of patients that we’re doing now.”

Still, the evidence proving that prehabilitation interventions work is slim, and most hospitals don’t offer these services. Nor does insurance pay, in many cases.

Lahey is offering the services free to patients because it believes they’ll recover from surgery more readily, with fewer complications and potentially reduced costs, McKee said.

“What we’re doing makes a lot of sense intuitively, especially for older patients with multiple medical conditions who need to get through big surgeries safely,” said Silver, who’s working to expand prehabilitation services across the country. “But changing clinical care always takes time.”

Learning the Hard Way

Some patients have recognized the need for prehabilitation on their own. Barbara Charnes, 84, found herself in this position after an April 2015 surgery on her ankle left her bedridden, incontinent and deeply distressed.

Charnes, who lives in Denver, hadn’t known what to expect from the surgery, the first stage of an ankle replacement that called for another procedure. She hadn’t paid attention to her physical conditioning or emotional readiness beforehand, and doctors hadn’t discussed this with her.

It took almost a year for Charnes to recover before a second surgery to insert a new metal ankle in February 2016. This time, she found a therapist in advance so she could talk through concerns and have someone she could depend on for emotional support. Also, she got on a stationary bike months before the procedure, exercising for half an hour every day and gradually increasing the level of difficulty.

“I think for everyone my age, surgery is physically and emotionally daunting,” Ms. Charnes said, sitting in her sunlit study. “And I think it’s foolish not to prepare if, say, you’re not in very good shape. This time, I understood much better what was going to happen and I felt that I was really ready. And that made all the difference.”

 

© Twin Cities Public Television - 2017. All rights reserved.

 
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