Experts: Type of Illness, Treatments, Nutrition, Faith, Pain Relief, Drugs, Support Factor Into Hospice Care Services (2 of 2)

Pain Management Options

Based on the category of illness and their stage level of sickness and their levels of pain, pain is usually caused by underlying inflammation and terminally ill patients will rely on a specific class of opiates and other pain relievers as part of their plan of care and management.

In particular, morphine, an aggressive form of medication used to treat severe pain, is a member of the opiate class. Typically, it is prescribed and used when drugs such as acetaminophen, also known as Tylenol, or ibuprofen, also known as Advil or Motrin cannot provide pain relief.

Motrin can also be used to treat the shortness of breath, also known as dyspnea. Hydrocodone and oxycodone, also members of the opiate class, too, treat severe pain.

This class of drugs functions by binding to opioid receptors in the brain, the spinal cord and other parts of the body. They decrease the delivery of pain messages to the brain and scale back actual pain. When a patient follows instructions for using these drugs, he or she safely and effectively relieve pain.

To achieve pain relief, physicians and specialists may need to prescribe around-the-clock dosing of opiates for their patients. Once pain is relieved and a consistent level of dosing has been used for days, doctors may need to decrease the dose slowly without the pain ever returning.

Doctors refer to such a change in dosing as titration, which they recommend must be conducted carefully. They also suggest that patients who have been consuming opiates for over two weeks must scale back on their dose slowly, rather than ending it abruptly, to give their bodies time to adjust to the change.

When pain is not well-managed with around-the-clock dosages, doctors will not wait until the pain is intolerable to change regimens as poorly managed pain is difficult to handle and can cause a patient unbearable suffering. They will increase the dosing if pain does not respond or resumes after a pause.

Physicians and specialists may also use “breakthrough or rescue dosing” if pain is episodic, returning before the stoppage of a dose or because of an incident such as a patient being moved from one bed to another. Breakthrough or rescue dosing is an extra administration of an opiate in addition to a patient’s regular dosage.

Additionally, some patients may become tolerant of opiates, meaning that a stronger dose may be needed to manage pain. Tolerance is not addiction. The solution to tolerance may be to change to a different opiate drug, which may lead to greater pain relief.

Opiates, as a class of drugs, can produce side effects such as nausea, drowsiness, confusion and constipation. However, as a terminally ill patient becomes accustomed to the medication, side effects will subside or leave entirely. The ones that do remain can be controlled such as taking laxatives for constipation.

Most patients who have serious pain are frequently unable to sleep. At first dosing, opiates like morphine may sedate a patient for 24 hours as he or she makes up for lost sleep. With consistent dosing, normal mental activity will be restored.

Many individuals are concerned that using morphine and other opiates to treat serious pain in a terminally ill person will cause addiction or death. Researchers disagree, saying that the risk of addiction for patients at end of life who take morphine and other opiates for pain is non-existent.

They explain that research shows a brain in pain does not behave with morphine in the same manner that a brain that is not. Individuals grow addicted to or depend on opiates when they take them recreationally or when they do not have pain.

When well-managed by a palliative care, hospice or pain specialist, researchers say morphine or opiate administration will not likely lead to death. In fact, they argue that patients who use these pain relievers appropriately will live longer than those who do not.

Options for Non-Pain Symptoms

A terminally ill patient’s advance directive must include a section for symptom management for every stage of his or her physician’s plan of care, especially at the end of life. His or her specialists, families, friends and assigned health care agents are required to carry out these instructions, researchers say.

For instance, if the patient’s mental or physical health is declining, the projection for his or her treatment is growing bleak and there is no chance of him or her recuperating, he or she can request antibiotics for infections; dialysis for kidney failure; artificial ventilation for breathing problems, and; electroshock, stimulants or diuretics for heart failure.

He or she can also ask for heart regulating medications, including electrolyte replacement, if the heart rate becomes irregular; cortisone or other steroids if tissue swelling targets the brain, and; blood, plasma or replacement fluids in case he or she is bleeding or losing fluids.

These requests constitute “life support” as a means of temporarily allowing the body to heal so it can function fully once more. However, this is not meant for permanent use for a terminally ill patient.

In the case of a patient’s stopped heart, researchers do not recommend the use of a pacemaker and an implantable cardioverter defibrillator or ICD, which does not keep a patient alive, nor cardiopulmonary resuscitation (CPR) or with a defibrillator, a machine that generates electric shocks. CPR works primarily in patients who were once healthy and whose hearts have stopped.

It is not successful, however, in frail elderly patients. The level of pressure needed for CPR to be effective would create new problems such as broken ribs or collapsed lungs or lead to a more tragic death, especially in seniors.

Often times, a physician or specialist may recommend a ventilator, feeding tube or other technology to help a patient breathe or eat. The ventilator calls for intubation, which involves having a tube placed in the throat through its windpipe or trachea.

If the machine is needed for days, the doctor may request a tracheotomy instead, which leads to the tube placed into the trachea through a small incision he or she creates in the throat. This type of surgery can be risky, resulting in a collapsed lung, bleeding and a backed-up tube.

Additionally, tubes hold their own risks for infection, pneumonia and nausea. For a terminally ill patient, a tube may create more discomfort than not being fed. As a result, patients who have this form of feeding administered to them may often be given painkillers or are restrained.

Medicare, Medicaid, Long-Term Care Insurance To Pay

Federal spending for the Medicare hospice benefit rose about $1 billion annually. In fiscal year 1998, spending for the hospice benefit was $2.2 billion, while in fiscal year 2009, this figure increase to $12.1 billion.

Hospice care focuses on providing the terminally ill with “comfort, not cure.” Medicare and Medicaid benefits policymakers and managers say patients must cease treatments to take advantage of Medicare coverage for hospice care. Medicare will pay for any covered health issues that do not pertain to the patient’s chronic illness.

Hospice care is expensive because it is multi-faceted and comprehensive. Patients and their families pay for end-of-life care, relying on their financial status and the range of services they need.

End-of-life care can include palliative care or post-surgical care, home health care, hospice care and brick-and-mortar-based care such as that of a nursing home or assisted living facility.

A terminally ill patient’s resources to pay for hospice care could include his or her Social Security benefits, his or her pension or other retirement funds, his or her personal bank savings, his or her very limited coverage of private healthcare insurance and his or her own private home as a real estate asset through a reverse mortgage.

Patients can also use government health insurance such as Medicare and Medicaid and long-term care insurance.

Medicare covers needed care and hones in on acute care, including physician visits, medications and hospital stays. Benefits also cover short-term services for conditions that may improve such as physical therapy to restore physical ability after a fall or cardiac event.

The program does not directly recognize palliative care but Medicare Part B covers particular palliative treatments and drugs, as well as visits from specialists and social workers.

The post-surgical care or palliative care facility providing a terminally ill patient services will charge Medicare for services, given with copays or fees through a fee schedule.

For hospice care, beneficiaries are covered by Medicare part A, which is hospital insurance. A patient’s physicians and a hospice care medical director will determine whether a patient has a life-threatening disease and death can occur in six months or less.

The patient signs an advance directive to receive Medicare-covered benefits for his or her conditions and actually receives care from a Medicare-approved hospice care service.

Medicare-approved and covered hospice care services include physician services; nursing care; medical equipment such as wheelchairs and walkers; medical devices such as bandages and catheters; medications for pain relief and symptom management; short-term hospital care, including respite and inpatient care; home health aide and homemaker services; physical and occupational therapy; speech therapy; social work; nutritional counseling, and grief support.

Under Medicare policy, the patient or his or her family members must shoulder the cost of medications and inpatient respite care.

While “Medigap” policies, which are meant to supplement Medicare, do not cover end-of-life care directly, certain categories of co-payments can pay for nursing home services.

Medicaid covers particular end-of-life services such as personal care, home health care and nursing home care. Like Medicare, Medicaid does not acknowledge the term “palliative” and will cover particular treatments, drugs and visits from specialists.

Like Medicare, the palliative care facility serving a terminally ill patient may charge Medicaid for services but the patient must comprehend the copays and fees he or she must pay.
Medicaid’s hospice benefit is like the Medicare hospice benefit in the states where it is provided. However, some states might restrict the length of time covered or who qualifies so patients and their families may have to check with their state’s Department of Health or Agency on Aging.

Long-term care insurance can supplement coverage for services that Medicare and Medicaid do not cover. Some policies can cover a wide variety of options and benefits, including palliative and hospice care, that permit you to obtain services exactly when you need them.

Costs depend on a patient’s policy in terms of the type and number of services he or she selects, his or her age when he or she purchases his or her policy and other choices such as inflation-indexed benefits.

However, if a patient is already sick or has already begun to receive hospice or palliative care, he or she may not be eligible for long-term care insurance. This leaves patients with the option of purchasing limited coverage or coverage at a higher rate.
This could include nursing home-only coverage or a policy that combines home health care with assisted living, palliative, hospice or nursing home care.

SOURCES:

AGIS Network, Assist Guide Information Services, http://www.agisnetwork.com

Bickel-Swenson, D, Stephens, N., and Washington KT; Health Social Worker, “Barriers to Hospice Use Among African Americans: A Systematic Review.” (2008), Vol. 33, No. 4, pp. 267-274.

Bristowe, Katherine; Harding, Richard, and; Marshall, Steve; Palliative Medicine, “The Bereavement Experiences of Lesbian, Gay, Bisexual and/or Trans People Who Have Lost a Partner: A Systematic Review, Thematic Synthesis and Modeling of the Literature.” (September 2016), Vol. 30, No. 8, pp. 730-744.

California Association of Physician Groups, “Case Studies in Excellence 2012,” 35 pp., Los Angeles, Calif., http://www.capg.org/

Casarett, David, M.D., chief of palliative care and professor of medicine, Duke University, Durham, N.C.; Gupta, Deepak, M.D., clinical assistant professor of anesthesiology, Wayne State University, Detroit; Harris, John, M.D., assistant professor, University of Pittsburgh School of Medicine; Eric Widera, M.D., associate professor of clinical medicine, University of California, San Francisco, and director, hospice and palliative care, San Francisco VA Medical Center; Annals of Internal Medicine and HealthDay, online, “Terminally Ill Obese People Less Likely to Get Hospice Care,” (Feb. 6, 2017).

Compassion and Choices, http://www.compassionandchoices.org

Eldercare Locator, http://www.eldercare.gov.

GeroPreneur, http://www.GeroPreneur.com.

Hamilton, Jill B., PhD, RN; Mayer, Deborah K., PhD, RN, AOCN, FAAN; Spruill, Angela D., MSN, ANP-BC, OCN; Journal of Hospice and Palliative Nursing, “Barriers in Hospice Use Among African Americans With Cancer.” (2013), Vol. 15, No. 3, pp. 136-144.

Institute of Medicine (IOM) report, “The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved” (1999), 338 pp.

Jenq, Grace, Tinetti, Mary E., MD., Journal of American Medical Association, “Changes in End-of-Life Care Over the Past Decade More Not Better,” (February 2013) Vol. 309, No. 5, pp. 489-490.

Johnson, Kimberly S., MD, MHS, Journal of Palliative Medicine, “Racial and Ethnic Disparities in Palliative Care,” (November 2013), Vol. 16, No. 11, pp. 1329-1334.

The U.S. Department of Health and Human Services’ Administration on Aging (HHS-AoA), The National Clearinghouse for Long-Term Care Information, http://www.longtermcare.gov
National Institutes of Health (NIH) Senior Health, http://NIHSeniorHealth.gov.

National Institute of Nursing Research Report (NINR), “Building Momentum: The Science of End of Life and Palliative Care — A Review of Research Trends and Funding, (1997-2010), 156 pp, https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/NINR-Building-Momentum-508.pdf

National Institute of Nursing Research Report (NINR), “Spotlight on End-of-Life Research,” https://www.ninr.nih.gov/researchandfunding/spotlight-on-end-of-life-research.

Payne, Richard, M.D., Improving Palliative for Cancer, “Palliative Care for African Americans and Other Vulnerable Populations: Access and Quality Issues,” Memorial Sloan-Kettering Cancer Center, The National Academy of Sciences, (2001).

Westbrook, G. Jay, M.S., R.N., CHPN, Clinical Director, Compassionate Journey: An End-of-Life Clinical & Education Service, “Arresting Pain Without Getting Arrested” (workshop before the Advance for Nurses Career Fair in Pasadena, Calif., Sept. 9, 2010).

Westbrook, G. Jay, M.S., R.N., CHPN, Clinical Director, Compassionate Journey: An End-of-Life Clinical & Education Service, “Bereavement” (workshop before the Advance for Nurses Career Fair in Pasadena, Calif., Sept. 9, 2010).

Westbrook, G. Jay, M.S., R.N., CHPN, Clinical Director, Compassionate Journey: An End-of-Life Clinical & Education Service, “CHAPCA 1 – When Your Patient is a Substance Abuser” [California Hospice and Palliative Care Association (CHAPCA) pre-conference workshop in Lake Balboa, Calif., Oct. 5, 2011)].

Experts: Type of Illness, Treatments, Nutrition, Faith, Pain Relief, Drugs, Support Factor Into Hospice Care Services (1 of 2)

by Vladimire Herard

Diagnosis type, treatment cessation, nutrition, religion and spirituality, sedation or pain relief administration, the choice to prolong or end life, symptom management and drugs, physician, family or friend support and the development of advance directives factor into successful hospice planning and service, experts say.

Hospice care patients, especially seniors, tend to suffer from such chronic conditions as cancer, Parkinson’s disease, Alzheimer’s disease, non-Alzheimer’s dementia, non-infectious respiratory disease, heart disease or stroke, pneumonia, liver disease or kidney disease.

Hospice care patients count on family, friends, physicians, nurses and medical staff to navigate the health care and social work systems to enter the severe or terminal stage of their illnesses, the federal agencies National Institute of Nursing Research (NINR) and the Centers for Medicare and Medicaid (CMS), Institute of Medicine (IOM), hospices, nonprofits and relevant professional trade associations report.

Of the deadly illnesses treated in hospice care, cancer is the second leading cause of death nationally, being responsible for 25 percent of all such deaths, a 2013 study in the Journal of Hospice and Palliative Nursing found.

In fact, cancer is found to be the most common diagnosis, making up about 40 percent of the hospice patient population. The remaining 60 percent of hospice patients had diagnoses for heart disease, dementia and kidney, liver and lung diseases, the study revealed.

The aforementioned illnesses represent some of the top 20 hospice terminal diagnoses by the number of patients in hospice care researched and reported by the Centers for Medicare and Medicaid.

For example, the Centers for Medicare and Medicaid hospice data trends for 1998 to 2008 from the federal agency’s Health Care Information System (HCIS) show the top 20 diagnoses annually, based on the number of Medicare hospice patients with those illnesses; the percentage of Medicare patients for the year which the disease represents, and; the average length for that condition.

This particular data set demonstrates that twice as many Medicare beneficiaries enrolled and used hospice care services in 2008 than in 1998.

It also reveals that the frequency of some hospice diagnoses changed over time with fewer cancer patients and more non-cancer patients utilizing hospice care. The number of Medicare cancer patients in hospice care dropped from 52.8 percent in 1998 to 31.1 percent in 2008.

Lung cancer has been acknowledged as the most commonly diagnosed illness among Medicare hospice each year since 1998. Still, in 2006, non-Alzheimer’s dementia patients became the most common cohort served by hospice care.

Meanwhile, the percentage of Medicare hospice patients with lung cancer was nearly halved from 16 percent in 1998 to 9 percent in 2008. Additionally, hospice care facilities reported a rise in the number of neurologically-based diagnoses and unspecified conditions.

Aside from a change in the category of illnesses prominent in hospice care during that period, the Centers for Medicare and Medicaid reported a sharp increase in the average length of stay for hospice patients.

In 1998, the average length of stay for hospice care patients was 48 days but it grew to 73 days — a 52 percent increase — by 2006. Starting in 2006, the length of stay started to drop minimally, decreasing to 71 days in 2008 and amounting to a 48 percent increase from 1998.

By comparison, among the top 20 diagnoses in 2008, the length of stay spanned from 28 days for kidney disease to 105 days for Alzheimer’s disease and other degenerative illnesses.

While the length of stay from 1998 to 2008 for hospice patients with conditions such as kidney disease or cancers held relatively steady, they rose substantially for other illnesses, though it has begun to decease slightly nearly 20 years into the new millennium.

A team of physicians, surgeons, nurses, social workers, chaplains, pharmacists,
hospice or palliative medical directors and volunteers, pain specialists, government agency managers, nonprofits managers, support groups leaders and other advocates would engage and guide a severely or terminally ill patient and his or her family through advance care planning and ultimately through the hospice or palliative care processes.

With such guidance and instruction, the Institute of Medicine (IOM)‘s report titled “Approaching Death: Improving Care at the End of Life” describes a “good death” as “one that is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards.”

The IOM defines a “bad death” as one involving needless suffering and lack of recognition of the patient’s or family’s wishes.

NINR Research on Hospice Care

Aside from studying and documenting the basics of the hospice procedures nationally, NINR investigators discover and continue research on the health disparities in some facets of end-of-life care, especially as they pertain to culture, race, ethnicity and geographic location.

Some of the agency’s federal studies have found families with limited English proficiency are less informed about their hospice or palliative care choices and receive less support in intensive care units and other health care settings at meetings between physicians, specialists and families.

A 2009 study of the Journal of Palliative Medicine titled “Racial and Ethnic Disparities in Palliative Care” found that 40 percent or nearly two million individuals nationwide died using hospice care services.

Of that number, about eight million or 20 percent of seniors were members of racial or ethnic minority groups. This included 8.4 percent being African Americans, 6.9 percent Hispanics, 3.5 percent Asians or Pacific Islanders and less than one percent Native Americans.

The study finds these trends persist despite the number of white non-Hispanic seniors nationwide projected to increase by only 60 percent, contrasted by 160 percent for elder minorities.

Of this, the senior population of Hispanics are expected to grow by 202 percent, with older African Americans by 114 percent, 145 percent for Native Americans and 145 percent for Asians and Pacific Islanders.

Medical research and treatment experts with the New York-and-New Jersey-based Memorial Sloan-Kettering Cancer Center say research should be aimed at ridding palliative and hospice care of racial and ethnic disparities.

Despite higher death rates from cancer and presentation at later stages of disease, and similar figures for chronic obstructive pulmonary disease (COPD), kidney diseases and AIDS, minority groups substantially underuse palliative and hospice services.

In 1990, about 93 percent of patients using the Medicare hospice benefit were white. In its own research, the National Hospice and Palliative Care Organization (NHPCO) found that less than 10 percent of all hospice care patients were African-American.

Additionally, less than 10 percent of patients using hospice care in private medical service chains are members of racial or ethnic minority groups. Data from the Centers for Medicare and Medicaid chronicling an eight-year period (1992-1996) of the use of the hospice benefit found racial and ethnic minorities comprising only 14 percent.

As a result, financial and socioeconomic costs for African Americans not using the benefit at the end of life are significantly higher.

In 2000, the Medicare Payment Advisory Commission (MedPAC) revealed that expenses for terminally ill African Americans was about $32,000, against $25,000 for whites.

Reported mortality rates by the American Cancer Society in 1994 found deaths among African Americans to be higher than among whites.

Researchers are also finding geographic gaps in access to hospice care with rural areas being the most restricted. Additionally, NINR researchers are learning that the number of dying seniors in nursing homes has increased though more examination is needed to determine if there are quality control gaps in rural and urban areas.

This occurs because nursing home patients are more likely to have in-hospital deaths than in hospice care settings.

Another NINR study found that testing patients and their family members for depression was one of the services added to the menu provided in hospice care. Researchers learned that, when testing results were reported to multidisciplinary medical teams caring for the patients, incidences of patient depression were lower and quality of life were enhanced.

Yet more NINR research demonstrated that the family of a terminally ill patient is more likely to be satisfied with hospice care services if they enjoy the decision-making process.

Specifically, families were pleased if the intensive care unit medical staff recommended curtailing life support, if the staff took a patient’s wishes and their spiritual needs into account and if the family felt respected and supported throughout the process.

In the future, NINR researchers will study other aspects of hospice care:

–developing and testing other methods of lessening the physical and psychological hardships on and improving the health of caregivers, especially as the patient nears death;

–measuring the influence of physicians and specialists trained in palliative and hospice care on health care results, and;

–forging means of communication between physicians, specialists, patients, families and communities to encourage decision-making and problem-solving involving health care delivery for severe illness.

Hospice-Oriented Nonprofit

Additionally, Compassion and Choices, an end-of-life consultation entity based in Denver, Colo., hosted a panel discussion at an Aging in America Conference in March 2013 in Chicago presented by the professional trade and advocacy association American Society on Aging titled “What Is Patient- and Family-Centered Care and What Happens When We Fail to Prevent It?”

Focusing on the rise of unwanted patient care for terminally ill patients, Compassion and Choices featured its Chief Program Officer Mickey MacIntyre who testified about needless medical treatments and its consequences of costly suffering of patients before the Institute of Medicine (IOM)‘s Committee on Transforming End-of-Life Care before the conference.

Joining MacIntyre in the panel was Lynn Feinberg, senior strategic policy advisor for AARP Public Policy Institute and social worker; Brian Lindberg, executive director of the Consumer Coalition for Quality Health Care, and; Andrew MacPherson, director of the coalition.

The three panelists reported that millions of severely or terminally ill patients nationally suffer from onsufficiently treated pain and other symptoms, experience unnecessary and expensive tests and treatments and therapies in their final days and have their advance directives neglected or abandoned by their physicians and specialists.

They concluded the panel, agreeing that care for terminally ill patients ought not involve unwanted treatments and therapies and needless suffering and public policy actions must be taken to end these practices and improve end-of-life care.

The panel took place a month after a study published in the Journal of the American Medical Association reviewing Medicare claims data between 2000 and 2009 that showed that treatment in acute care hospitals declined while use of intensive care units expanded.

The study, titled “Changes in End-of-Life Care Over the Past Decade More Not Better,” stated in its conclusion: “The focus appears to be on providing curative care in the acute hospital regardless of likelihood of benefit or preferences of patients. If programs aimed at reducing unnecessary care are to be successful, patients’ goals of care must be elicited and treatment options such as palliative and hospice care offered earlier in the process than is the current norm.”

Differences between Hospice Care, Palliative Care

Hospice care and palliative care are two forms of end-of-life care that concentrate on providing and coordinating family, friend, medical team and social work support and solace for patients of severe or terminal illnesses while addressing pain and symptoms of these conditions and both can be used at the end of life, researchers say.

However, the two forms differ.

Hospice care creates and sustains a continuum of medical, pain relief, social work coordination, religious, spiritual and moral care for a terminally ill patient, his or her family and friends, they say.

In most instances, treatments and therapies for the patient’s illness end. Typically, his or her physician or specialist has deemed the patient as having less than six months to live as the Centers for Medicare and Medicaid defines it. The focus is on affording the dying patient peace and dignity, relieving the symptoms of his or her illness and improving his or her quality of life.

Symptoms that a hospice care patient’s physicians and specialists may treat will include pain; breathing difficulties; digestive issues such as nausea, vomiting, constipation and changes in appetite; skin problems such as lips, eyes and dry skin; bed sores; feeling too hot or too cold; caxechia, a wasting condition that accompanies a serious illness like cancer that leads to weight loss, muscle weakness, fatigue and loss of appetite; fatigue; distress; forms of dementia such as Alzheimer’s disease, and; delirium.

End-of-life care does not include 24-hour nursing care so family, friends, designated advocates or health agents, home care agencies, nurse associations, volunteers and faith-based groups contribute to his or her comfort.

Assisted living personnel may help with “toileting, bathing and dressing, also known as activities of daily living (ADL), administering medicines, housecleaning, grocery shopping and cooking, preparing and feeding meals and providing company and emotional support.”

Community-based senior citizens’ services, which supplement independent living and are supported by county and state funds, churches, synagogues, temples, mosques, ethnic-oriented or civic groups offer companionship visits, household assistance, meal programs, respite for family and friend caregivers, adult day care services and transportation.

Family members and friends may assist the patient, especially one receiving hospice care at home, by answering phones and the door; checking voicemail messages; picking up mail or newspapers; conducting laundry; feeding or taking out the family pet; tending to plants; babysitting; picking up prescriptions; shopping for groceries and organizing them, and; preparing and bringing meals.

Hospice can take place at a home, an assisted living facility, a nursing home, intensive care unit or a hospital.

The 2013 Journal of Hospice and Palliative Nursing study revealed that about 40 percent of deaths nationwide took place with hospice care services. Of these, 40 percent occurred in a terminally ill patient’s private home, 10 percent in an acute care facility, 19 percent in a nursing home, 10 percent in a long-term care facility or 21.1 percent in a standalone hospice care facility.

Some individuals believe a doctor may suggest hospice care at a time when his or her patient is dying but this is not always true, researchers say. In some cases, patients and their families begin hospice care in enough time to maximize its benefits.

By contrast, researchers say, palliative care is a form of comprehensive treatment of the pain, inconvenience, symptoms and stress of severe illness, regardless of the diagnosis. Unlike hospice care, a patient need not be dying to receive this mode of care.

Like hospice care, however, palliative care focuses on enhancing the quality of life and the patient’s most important treatments and therapies and can be provided with other modes of medical care as defined by the Centers for Medicare and Medicaid. It also entails the collaboration of a multidisciplinary, white-collar medical, social worker, nonprofit and religious team.

This category of care attempts to address a patient’s physical, medical, emotional, social and spiritual needs and that of his or her family. Palliative care patients tend to be stricken with such long-term diseases such as heart failure, chronic obstructive pulmonary disease (COPD), cystic fibrosis, HIV/AIDS and Parkinson’s disease.

Care can be administered in any medical setting such as hospitals, nursing homes, outpatient palliative clinics or in a patient’s private home. For example, Veterans Health Administration hospitals also have a palliative care program.

Federal research finds that terminally patients and their families who took part in a hospice care program were more pleased with their health and socio-emotional outcomes than those who did not participate in such services.

Some of the reasons for satisfaction include that hospice patients are more likely to benefit from high quality pain management and not be subjected to unneeded tests or medicines they don’t want or need than those who don’t take advantage of hospice care.

Common Services, Issues of Hospice Care

Some hospices and nonprofits such as Compassion and Choices “provide end-of-life consultation” services to terminally ill patients, their families and friends to address physical and emotional suffering and extreme physical pain and to avoid a tendency to “turn to violent means” to terminate their diseases and, thus, discomfort.

These nonprofits aim to enable patients and their families to make a decision to begin the hospice or palliative or post-surgical care procedures and to learn about and weigh their choices.

Hospice or palliative care consultation services include religious, spiritual or ethical support, emotional assistance and education, instruction, guidance, legal advocacy and leadership in a patient’s or family’s medical end-of-life care problem-solving, decision-making activity.

The nonprofits advise terminally ill patients, their families and friends to commit to the following issues when mapping their hospice care or palliative care journeys:

–They must discuss their end-of-life desires and values with their families and friends and ask them for support and respect;

–They are asked to be honest with their primary care physicians, family practice physicians, internal medicine physicians and specialists about their own wishes and concerns about dying;

–If they do not feel their wishes or choices are heard or honored, they are encouraged to seek out other more supportive doctors;

–They must spell out their desires for the manner in which they want their end of life handled in the form of an Advance Directive, a standard hospice care/palliative care document that patients, their families and friends must fill out that specify different aspects of their process and reflect their wishes and values, and;

–They are recommended to assign a health care agent who will lobby for their desires and values.

Specifically, with respect to their hospice care or palliative care desires and wishes, patients are entitled to the following choices, researchers say:

–They can remain in their private homes or move to a post-surgical/palliative care, skilled nursing facility, nursing rehabilitation care center or hospice care facility;

–They can decide to continue or stop any chronic illness medical treatments and therapies, whether these keep them alive or not and whether they are terminally ill or not;

–For instance, patients can determine if they wish to cease or continue: ”feeding tubes, medications (including antibiotics and blood transfusions), breathing machines, surgery, chemotherapy, and radiation or kidney dialysis,” experts say;

–They may choose to receive comfort care to handle any symptoms of the chronic illnesses they endure;

–They must comprehend and accept the “double effect” of their religious, moral and spiritual decisions concerning dying. For example, the “double effect” moral standard addresses such acts as the use of opiates and painkillers at the end of life;

–They can decide if they want to continue eating and drinking. With the proper form of medical supervision and family and friend support, this procedure allows dying to take place with grace and peace;

–They can converse with their physicians and the rest of a medical team to determine whether to use “total sedation” or anesthesia to the point of a lack of consciousness if traditional therapies does not provide end-of-life medical relief, and;

–As a measure of last resort, if there is no other effective form of relief from terminal illness, patients are allowed to consider self-administration for the end of life.

To reflect the wishes and intentions of a patient, most advance directives include documents that provide his or her instructions for each aspect of his or her life such as a living will, a health care proxy or a Do Not Resuscitate (DNR) order and a Physician Orders for Life-Sustaining Treatment (POLST).

Before preparing a living will, a patient, his or her family and friends may visit with his or her physicians and specialists in order to discuss the variety of treatment choices for different medical situations to determine which ones ought to be included in the document should she or he be too ill to speak for himself or herself.

To oversee the execution of his or her living will, a patient is encouraged to designate a family member, friend, attorney or member of his or her faith community to serve as his or her health care proxy.

The patient must inform his or her assigned proxy of all of his or her wishes and desires so that this person can adequately represent him to physicians, specialists and a medical team.
Also known as a representative, surrogate, agent or attorney-in-fact, this individual is named in an advance directive document or durable power of attorney document for health care. The durable power of attorney for health care applies to a person who is not a family member or relative of the patient.

A DNR order is a document that requires physicians and specialists not to perform CPR or other life-saving procedures if the terminally ill patient’s heart stops beating or he or she can no longer breathe. The order is signed by doctors and placed in the patient’s medical chart and forms to fill out for one are available in those hospitals and long-term care facilities.

A POLST is a document similar to a DNR order in that it instructs physicians and specialists on the actions to take for patients with severe illnesses. The patient discusses his or her treatment choices with his or her doctor who creates the POLST and signs it.

Federal research demonstrates that patients and their families who originate the DNR orders and POLSTs are more likely to have their medical and socio-emotional wishes and concerns addressed than those who do not.

Particularly, for their pain care management decisions, hospice care or palliative care consultation nonprofits advise patients to entertain the following factors:

–They can speak with their physicians and specialists about their wishes for symptom management and relay any worries they have about present or future suffering. They can also detail any problems they have had with pain relief;

–They must approach families or friends to serve as their advocates if they are unable to lobby for their own hospice care or palliative desires and values;

–They should keep their designated families or friends apprised of their pain issues and all of the medicines they are taking;

–They must inform their physicians, specialists and the rest of their medical team in their advance directives about their concerns or wishes for strong pain management at the end of life;

–They ought to maintain a “pain record” or journal if their symptoms are hard to handle. They must document the location and severity of their pain, whether treatments and therapies provided relief and when it took place. They should share their notes with their doctors or hospice care nurses;

–With each visit to their hospice care facility, they should notify their nurses of their pain levels. They and their assigned health care agent should know which persons to contact, especially in time of a “pain emergency,” and;

–They must know all of their medicines, how frequently they should be taken, the proper dosing, whether they come with side effects and how they should be handled.

Physical Therapy, Nutrition, NSAIDs, Creams, Surgeries, Medical Devices Target Forms of Arthritis, Experts Say (3 of 3)

SOURCES:

Advocates for Fibromyalgia Funding, Treatment, Education and Research, http://www.affter.org

American Academy of Orthopedic Surgeons, http://www.aaos.org

American College of Rheumatology (ACR), http://www.rheumatology.org

Arthritis Foundation, http://www.arthritis.org

“Aspirin for Reducing Your Risk of Heart Attack and Stroke: Know the Facts,” U.S. Department of Health and Human Services, Food and Drug Administration,
FDA-03-1502A

Centers for Disease Control and Prevention’s National Center for Health Statistics, http://www.cdc.gov/nchs

ClinicalTrials.gov, http://www.clinicaltrials.gov

FDA, http://www.fda.gov

Fibromyalgia Network, http://www.fmnetnews.com

Handout of Health, Recognizing the National Bone and Joint Decade: 2002 – 2011 – (Back Pain), National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH Publication No. 09-5282, July 2009

Handout of Health, Recognizing the National Bone and Joint Decade: 2002 – 2011 – (Osteoarthritis), National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH Publication No. 06-4617, July 2002 Revised May 2006

MAKOplasty, MAKO Surgical Corp., http://www.makoplasty.com, http://makosurgical.com

MedlinePlus, http://www.medlineplus.gov

National Center for Complementary and Alternative Medicine,
http://www.nccam.nih.gov

National Fibromyalgia Association, http://www.fmaware.org

National Fibromyalgia Partnership, Inc., http://www.fmpartnership.org

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), http://www.niams.nih.gov

National Institutes of Health’s Office of Medical Applications of Research (OMAR), http://odp.od.nih.gov/omar

NIH Clinical Research Trials and You, http://www.nih.gov/health/clinicaltrials

NIH RePORTER, http://www.projectreporter.nih.gov

Pub Med, U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pubmed

Questions and Answers About … Arthritis and Rheumatic Diseases, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH Publication No. 12-4999, April 2012, http://www.niams.nih.gov

Questions and Answers About … Fibromyalgia, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH Publication No. 12-5326 August 2012, http://www.niams.nih.gov

Questions and Answers About … Gout, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH Publication No. 12-5027, April 2012, http://www.niams.nih.gov

Physical Therapy, Nutrition, NSAIDs, Creams, Surgeries, Medical Devices Target Forms of Arthritis, Experts Say (2 of 3)

Diagnoses, Testing, Treatment of Arthritis

The diagnoses, testing and treatment of the different forms of arthritis vary. This includes degenerative joint disease, osteoarthritis, rheumatic arthritis, fibromyalgia, gout and back pain.

Degenerative Joint Disease, Arthritis in General

To diagnose degenerative joint disease and forms of arthritis in general, a rheumatologist or an orthopedist will examine a patient’s medical records, perform a physical exam and secure laboratory test results, X-rays and medical imaging.

The rheumatologist or orthopedist would see a patient more than once to complete an accurate diagnosis. For example, in the case of osteoarthritis, one test alone cannot fully diagnose this condition. The specialists would combine several methods to isolate the illness and rule out others.

To treat joint conditions or support joint health against degenerative disease and various forms of arthritis, pharmaceutical companies offer, as an alternative to drugs, such nutritional products or medical foods that use pure, concentrated ingredients in such items as green tea, dark chocolate, fruits and vegetables.

A medical food is regulated by the Food and Drug Administration (FDA) under the federal Orphan Drug Act that legally defines them as “a food which is formulated to be consumed or administered enterally (through digestion) under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.”

Seen as a safer choice to drugs and supervised by primary care physicians and specialists, medical foods do not undergo premarket review or approval by the FDA and are required to be labeled for nutrient health claims under the Nutrition Labeling and Education Act of 1990.

In particular, Fast-Acting Joint Formula is a one-a-day set of compounds to provide joint relief and capacity in a matter of days rather than weeks or months.

The formula offers the patient, in one daily capsule dose, 300 mg of solubilized keratin, a form of keratin protein that provides cysteine and other high-sulfur elements need to build joint tissue.

Keratin helps to oversee pre-inflammatory elements such as prostaglandin E2 that are linked to joint deterioration while promoting antioxidants such as superoxide dismutase and gluthathion to keep joints from aging.

The formula can be used with other nutritional products such as ArthroMax with Theaflavins. ArthroMax, also known as ArthroMax Advanced with UC-Il and ApresFlex, is a form of undernatured chicken cartilage (UC-Il). This product helps protect the immune system as it pertains to remedying joint pain or stiffness or reduced capacity in senior patients.

ArthroMax contains “UC-II chicken cartilage, 40 mg of glucosamine sulfate 2KCI extracted, which contains corn; 1500 mg ApresFlex (Boswellia serrata) extract, and; 100 mg of boron or calcium fructoborate, known commercially as FruiteX OsteoBoron, which contains 1.5 mg of corn.”

ApresFlex is a product of Laila Nutraceuticals. FruiteX B and OsteoBoron are products of BDF FutureCeuticals, Inc.

As another means of addressing immune issues of the joints, ArthroMax is also accompanied by Black Tea Theaflavins without chicken cartilage. Namely, inflammatory chemical activity are supervised by a series of cytokines in the human body. Aging produces an unhealthy balance of cytokines that create promote inflammatory disease.

Research finds that compounds in black tea prevent the inflammatory activity of cytokines. These compounds are called theaflavins and supervise the activity of genes and cytokines connected to inflammatory disease.

ArthroMax with Theaflavins and ApresFlex formulas provide these compounds as well as methylsulfonylmethane, or MSM, which consist of sulfur elements key to maintaining joint function. These formulas also contain commercially known Fruite X B OsteoBoron, a form of boron much like those found in food that promotes healthy bones and joints.

ApresFlex contains boswellia, which assists with resolving inflammatory diseases by inhibiting the enzyme 5-lipoxygenase or 5-LOX. Activity of 5-LOX allows an inflammatory compound known as leukotriene B4 to negatively impact aging joints.

Excess activity of 5-LOX results in the accumulation of leukotriene B4, a pro- inflammatory compound that affects aging joints. Boswellia binds directly to the 5-LOX enzyme to keep it from producing leukotriene.

Another nutritional product, Decursinol-50, a fluid compound extracted from the the herb Korean Angelica, acts quickly to protect joint health through the central nervous system to block the activity of “nuclear factor-kappa B, a DNA transcription factor” linked to inflammatory diseases. Decursinol-50 is taken in 200 mg doses per day.

Hyal-Joint, a form of hyaluronic acid that boosts the thickness of the synovial fluid to protect joint cartilage, is taken in 40 mg doses daily. The product is meant to guard against wear and tear and rebuild joints with a supply of hyaluronic acid, collagen and other glycosaminoglycans.

Additionally, Krill Healthy Joint Formula uses deep-sea krill oil in Antarctica, combined with hyaluronic acid and astaxanthin. Krill oil contains fatty acids successful in promoting joint health by particularly targeting joint tissue.

Hyaluronic acid, which is present in the joints through cartilage and soft tissue, moistens and protects them against potentially harmful physical activity. The acid is a large molecule that is not readily digested in the human body. However, when blended with krill oil, it can be more widespread and, thus, more effective in the blood than by itself as a substance.

Krill oil contains the antioxidant carotenoid astaxanthin, which suppresses free radical activity and improves mitochondrial function, guarding joints against aging. The formula holds 353 mg of these substances and can be taken as a dosage of one softgel per day.

Typically, for degenerative joint disease of the hip, rheumatologists and other specialists use non-surgical treatment methods first. This includes nutritional products or medical foods, rest for the hip, low-to-moderate impact exercise such as swimming or over-the-counter (OTC) drugs to handle joint pain.

However, if nutritional products or medical foods, exercise or OTC medications cannot treat degenerative joint disease, senior patients may have to speak to their rheumatologists or orthopedists. These specialists may turn to medical devices.

For instance, MAKO Surgical Corporation provides MAKOplasty, a surgical procedure that uses robotic arm technology to instruct an orthopedic surgeon to conduct total hip replacement therapy for severe patient cases of degenerative joint disease.

This form of therapy is aimed at boosting movement and capacity in the hip and other impacted parts of the body to enable patients to carry out daily physical tasks.

Also known as total hip arthroplasty, this therapy involves surgery in which the arthritic hip joint is removed and, instead, prostheses or implants are installed. The implants contain “a metal cup with a plastic liner, which replaces the socket (acetabulum) in the pelvis, and a metal femoral stem and head.”

The robotic arm is meant to provide an orthopedic surgeon with guidance to prepare a socket for the pelvis of a patient and to put prostheses or implants in the correct sites in the body.

The accompanying technology is meant to provide real-time data and imagery to allow an orthopedist to clearly identify and manage implant placement, which can be hard to accomplish using traditional surgery without a robotic arm.

Such medical devices can make for greater accuracy in placing hip implants in the body, decrease the odds of hip misplacement, ensure consistent leg lengths, reduce the necessity of a shoe lift, minimize the risk of implants and bones rubbing together to create discomfort for the patient or to lessen the effectiveness of the overall technology.

Prolonging the life of prostheses or implants is important as well and some artificial joints can last 10 to 15 years long. Implants can achieve and must be preserved for a long life span, depending on the patient’s weight, level of physical activity, quality of bone tissue and adherence with a rheumatologist’s or a orthopedic surgeon’s orders.

The orthopedic surgeon must conduct an exam to determine if a senior patient is a fit for the MAKOplasty procedure using the robotic arm. If the patient qualifies, then the orthopedist makes a computed tomography (CT) scan of his or her hip one to two weeks before the date of surgery.

The CT scan creates a 3-D model of the patient’s hip pelvis and femur. The specialist uses software with data about the model and the patient’s anatomy.

The orthopedist must decide if the patient must make a hospital stay for total hip replacement and also if he or she must be referred to a massage therapist, a physical therapist, an occupational therapist, a physiatrist, also known as a rehabilitation specialist, a licensed acupuncture therapist or a chiropractic for rehabilitative therapy.

In turn, senior patients and their families are asked to approach their assigned rheumatologist and orthopedic surgeon if they have questions or concerns about total hip replacement or other procedures:

–What causes my hip pain?
–Will scaling back on physical activity, taking pain or prescription drugs, getting injections or adding physical therapy ease my pain?
–Would total hip replacement relieve me from hip pain?
–Am I a fit for total hip replacement?
–What are the benefits and risks of undergoing total hip replacement?
–How long is the recovery time from total hip replacement?
–What is the life span of the implants that may be implemented in total hip replacement?
–How does my age influence the correct procedure for my illness?

Patients are also asked to manage degenerative joint disease in the following ways:

–Maintain proper weight to decrease joint pain and swelling.
–Recognize physical restrictions and how to cut back on physical activity in time of pain.
–Follow doctors’ orders in taking medications and a proper diet as instructed by dietitians and nutritionists.
–Make use assistive devices such as walkers and canes to reduce pressure on the joints.
–Keep a good posture to, again, reduce pressure on the joints.
–Put on sensible footwear that can bear weight.
–Maintain a sunny disposition to manage stress and control treatment.
–Take initiative in managing disease and adhere to a sound lifestyle.

Osteoarthritis

To diagnose osteoarthritis, including that of the hip, knees, hands, fingers and thumbs, spine or lower back or higher back, a rheumatologist or an orthopedist will examine a patient’s medical record and symptoms. He or she will watch the movement of the knees, grade knee and ankle joint alignment and test reflexes, muscle strength, motion capacity and the stability of ligaments.

These specialists may have X-rays conducted to measure the amount of joint or bone damage done, the mass of cartilage lost and whether bone spurs exist. More imaging tests such as CT scans or magnetic resonance imaging (MRI) can be used to pinpoint the damage and its spread.

The rheumatologist or orthopedic surgeon can order more blood tests to ensure that there are no other causes of the symptoms observed or request a joint aspiration procedure to draw fluid from the joint through a needle and examine its contents under a microscope.

Osteoarthritis is treated based on its mildness or severity in a senior patient. In either case, a primary care physician, a family practice physician, an internal medicine physician, an osteopathic physician, a rheumatologist or an orthopedist will recommend changes in a patient’s style of life to alleviate pressure on his or her joints.

Chronic illness and pain management strategies could include physical exercise, weight loss, reduced pressure on joints, physical therapy, steroid injections, over-the-counter pain medicine such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) or topical pain-relief creams, rubs or sprays.

Goals for treatment of osteoarthritis include controlling pain, improving joint capacity, maintaining a healthy weight and maintaining a sustainable lifestyle.

Otherwise, if none of these or other treatments aren’t effective, a physician or specialist may determine that surgery and possibly complementary and alternative therapies are needed to treat a patient’s incidence of osteoarthritis.

Exercise is used to treat senior patients for osteoarthritis because of its ability to improve mood, lessen physical pain, extend physical range of motion, strengthen hearts and blood circulation, control weight and boost physical activity.

The amount and type of exercise will rely on the strength and stability of a patient’s joints and whether joint replacement therapy has been conducted. Exercise regimens could include strengthening exercises, aerobic activity, walking, swimming and water aerobics, range-of-motion activities and agility motion.

Both medicinal and non-medicinal relief to treat the pain of osteoarthritis may include heat and cold therapy with warm towels, hot packs or a warm bath or shower; transcutaneous electrical nerve stimulation (TENS) to use an electronic device to send electric pulses to nerves under the skin of the area of pain; creams, rubs and sprays such as Zostrix, Icy Hot, Therapeutic Mineral Ice, Aspercreme and BenGay; painkillers such as Tramadol, codeine, hydrocodone, corticosteroids, and hyaluronic acid substitutes.

NSAIDs are used when acetaminophen ceases to work with the best examples being ibuprofen and naproxen. Oftentimes, opioids, a form of narcotic drugs, are prescribed as well.

Complementary and alternative therapies come into use when patients don’t receive pain relief from traditional medications and treatments for osteoarthritis. They include acupuncture, folk remedies and nutritional supplements. Sounder sleeping habits are also recommended.

Acupuncture, the practice of placing fine needles at particular points of the skin, is considered effective in treating osteoarthritis because of its ability to incite the release of painkilling chemicals from the nervous system.

Folk remedies for osteoarthritis include copper bracelets, herbal teas, mud baths and WD-40 on joints to “oil” them. However, no research demonstrates that they are able to treat this illness.

Nutritional supplements that are found to address the symptoms of senior patients with osteoarthritis include glucosamine and chondroitin and a prescription medical food known as Limbrel, which can be found at http://limbrel.com. More research is being conducted to study the validity of the claims of glucosamine and chondroitin.

Additionally, improving sleep can reduce pain and enable patients to handle the effects of osteoarthritis. Senior patients with sleep problems due to arthritic pain are asked to consult their primary care physicians or physical therapists about obtaining the right mattress, the most accommodating sleeping positions or the correct timing of medications to incur pain relief at night.

Patients are asked to improve their night’s rest by getting sufficient physical exercise during the daytime; steering clear of caffeine and alcohol at night; making sure the bedroom is “dark, quiet and cool”; and taking warm baths to relax and relieve aching muscles.

When medicinal and non-medicinal methods of treating ostearthritis don’t work, rheumatologists and orthopedic surgeons may turn to surgery such as MAKOplasty partial knee resurfacing.

Partial knee resurfacing is a form of knee replacement surgery that uses robotic arm technology to guide the orthopedist to use computer imagery and “intelligent” instruments to place a prosthesis or implant in the right spot of the knee.

The procedure can be conducted through a four-to-six incision over the knee with slits in both the femur or thighbone and the tibia or shin. Restoring healthy bone, tissue and ligaments with more precise implant placement leads to a more natural-feeling knee for the patient and wearer.

Rheumatic Arthritis

Primary care physicians, family practice physicians, internal medicine physicians, and osteopathic physicians find it hard to diagnose rheumatic diseases because of the overlap between their symptoms and signs and that of other illnesses. These doctors may examine a patient and refer him to a rheumatologist or orthopedic surgeon.

A doctor needs to conduct a thorough medical exam of a patient to make an accurate diagnosis, researchers say. He or she may pose the following questions to a patient:

–Is the pain in one or more joints?
–When does the pain occur?
–How long does the pain last?
–When did the patient first notice the pain?
–What was a patient doing when he or she noticed the pain?
–Does physical activity make the pain better or worse?
–Has the patient had any illnesses or accidents that may account for the pain?
–Is the patient experiencing any other symptoms aside from pain?
–Is there a family history of arthritis or other rheumatic disease?
–What drugs is the patient taking?
–Has the patient had any recent infections?

Sometimes, patients may be asked to maintain a daily journal that provides details of the pain. Primary care physicians, family practice physicians, internal medicine physicians, osteopathic physicians, rheumatologists and orthopedists may encourage patients to write down how the affected joint appears, how it feels, how long the pain lasts and what they were doing when the pain began.

Doctors may examine a patient’s joints for redness, warmth, damage, range of motion and tenderness. Some forms of arthritis such as lupus, may target organs and, thus, a complete exam of the heart, lungs, abdomen, nervous system, eyes, ears, mouth and throat may be needed.

These physicians may also require some laboratory tests to support a diagnosis. Samples of blood, urine or synovial fluid in the joint may be necessary. Tests may include the following: antinuclear antibody, or ANA; CCP; C-reactive protein tests; complement; complete blood count; creatinine; erythrocyte sedimentation rate, or SED RATE or ESR; hemocrit (PCV or packed cell volume); rheumatoid factor; synovial fluid examination; urinalysis, and; X-rays, CT, MRI and arthrography.

Treatments for rheumatic disease include sleep, physical exercise, sound nutrition, pain relief, medical devices and instruction from physical therapists, occupational therapists, physiatrists, licensed acupuncture therapists and chiropractics about massage and alternative therapy.

Primary care physicians, family practice physicians, internal medicine physicians, osteopathic physicians, rheumatologists and orthopedic surgeons plan treatment with the senior patient to enhance his or her lifestyle. The plans may blend different types of treatment and change, depending on the rheumatic illness and the patient.

Physical exercise for rheumatoid patients falls into three categories and the benefits feed into each other: range-of-motion exercises such as stretching or dance to move joints, boost flexibility and alleviate stiffness; strengthening exercises such as weight lifting, to support muscle strength, which translates into joint support and protection, and; aerobic or endurance exercises such as waking, bicycle riding and swimming, to promote heart fitness, control weight and effect overall health and well-being.

The most common medications to treat rheumatic diseases include oral analgesics or pain relievers taken by mouth; topical analgesics or pain-relieving creams, ointments and sprays; counterirritants; NSAIDs; DMARDs; biologic response modifiers; corticosteroids, and; hyaluronic acid substitutes.

Medical devices used to treat rheumatic diseases include TENS and a blood-filtering device titled the Prosorba Column to weed out dangerous antibodies for especially severely ill patients. Massage and alternative therapies include heat and cold therapies, hydrotherapy, mobilization therapy, relaxation therapy, splints and braces and assistive devices.

The categories of surgeries to treat rheumatic disease are anthroscopic surgery, needed to view the joint through a small scope inserted through a small slit over the joint; bone fusion used to remove joint surfaces from the ends of two bones; osteotomy, a procedure involving removing a section of bone to improve the positioning of a joint, and; arthroplasty or total joint replacement.

Fibromyalgia

NIAMS and NCCM research finds that fibromyalgia patients will visit with many specialists before they are provided with a diagnosis of the actual disease. This is because the attendant pain and fatigue, the key symptoms of fibromyalgia, overlap with other chronic illnesses.

As a result, doctors must isolate other causes of these symptoms before delivering a diagnosis. Additionally, there are no other diagnostic laboratory tests for the illness as lab tests do not show a physiological cause for pain.

Sometimes, because there is no official, standard test for fibromyalgia, a physician is forced to judge that a patient’s pain is not real or often inform the patient that he or she cannot help him or her.

The greatest approximation to a standard test are the nine paired tender points created by the American College of Rheumatology, or ACR, for fibromyalgia. As a result of this institutional and trade professional standardization, a physician is empowered to make a diagnosis based on the criteria by the ACR.

Criteria for a diagnosis may include a patient’s record of widespread pain spanning more than three months and other symptoms such as fatigue, being aroused from sleep and feeling unrefreshed and cognitive issues such as with memories or thoughts.

Under this standard, pain is defined as widespread if it influences all four quadrants of the body, meaning that the patient encounters it on the left and right sides of the human body and above and below the waist. ACR has set aside 18 sites in the human body for tender points.

Fibromyalgia is hard to treat. Not all physicians understand the disease and its treatment so patients must find a doctor who does and then a team of specialists must be formed to work with both.

Three drugs have been approved the FDA to treat fibromyalgia, duloxetine, which was once developed for and is used to treat depression; milnacipran, and; pregabalin, which is meant to treat neuropathic pain caused by damage to the nervous system. Other treatments for fibromyalgia include painkillers, NSAIDs, complementary and alternative therapies.

Still, overtime, with treatment, conditions for patients with fibromyalgia improve, researchers say. Fibromyalgia is not a progressive illness. It is not deadly and will not damage the joints, muscles or organs.

To improve their quality of life under fibromyalgia, patients are asked to get enough sleep, make changes at their place of work, practice sound nutritional habits and obtain physical exercise.

Gout

To diagnose gout, physicians would search for uric acid crystals or hyperuricemia around joints though some patients with hyperuricemia may not develop the illness. Bouts of gout may imitate joint infections and physicians who detect a joint infection rather than gout may also examine joint fluid for bacteria.

Physicians may confirm a diagnosis of gout by placing a needle in an inflamed joint and draw a sample of synovial fluid, which softens a joint. While uric acid crystals may not appear in an examination, this does not mean that a patient does not have gout.

Gout is treated with a number of therapies and the goals for these are to relieve the patient of pain associated with acute attacks, prevent future attacks, and avoid the formation of tophi and kidney stones. Common treatments include NSAIDs, oral colchicine, corticosteroids, weight loss, alcohol consumption and avoidance of high-purine foods.

The condition can be managed. Patients with gout can reduce the severity of attacks and lower their risk by taking drugs as prescribed. Gout is best treated with medications at the first sign of pain or swelling.

Patients are also encouraged to take other measures to treat gout include the following:

Inform the physicians about the drugs and vitamins taken and they will instruct whether any of them will boost their chances of hyperuricemia;
Conduct followup visits with physicians to monitor their progress;
Drink an abundance of fluids, including water and alcohol;
Practice physical exercise and keep a sound body weight, and;
Steer clear from foods high in purines.

Back Pain

To diagnose back pain, physicians and specialists will examine a patient’s medical history and conduct a physical exam. If needed, physicians may also request tests, which includes X-rays.

At the time of a patient’s medical examination, doctors will ask the following questions:

–Has the patient fallen or injured his or her back recently?
–Does his or her back feel better or worse when he or she lies down?
–Are there any activities or positions that ease or aggravate pain?
–Is the pain worse or better at a certain time of day?
–Does the patient or any family members have arthritis or other diseases that might affect the spine?
–Has the patient had back surgery or back pain before?
–Does the patient have pain, numbness, or tingling down one or both legs?

During an exam, physicians will watch patients stand and walk, check their reflexes to judge if they are slowed or heightened, test for fibromyalgia by checking their backs for tender points, watch for muscle strength and check for nerve root irritation.

These doctors may order the following tests: X-rays, MRIs, CT scans, blood tests, CBC, SED rates, CRP and HLA-B27.

Patients are asked to avoid back pain by exercising regularly, especially Tai Chi, yoga and weight-bearing exercise; keeping back muscles strong; maintaining a healthy diet, including one rich in calcium and vitamin D; practicing solid posture through supporting the back, and; avoiding heavy lifting whenever possible if this is not done by placing stress on the legs and hips.

They are also advised to visit the doctor only if back pain is accompanied by numbness, tingling, difficulty in urination, weakness, fever or unintended weight loss and a lack of pain relief from the use of medication or rest — as all of these symptoms are signs of more serious problems.

Back pain is typically treated based on whether it is acute or chronic. Treatments include pain relievers such as NSAIDs, acetaminophen, aspirin, ibuprofen, naproxen sodium, Tylenol, narcotics such as oxycodone or hydrocodone, and; creams, ointments and sprays such Zostrix, Icy Hot and Bengay.

Other solutions include physical exercises such as flexion, extension, stretching, aerobics and traction and; different categories of surgeries and medical devices such as hot and cold packs, corsets and braces, injections, nerve root blocks, facet joint injections, trigger point injections and prolotherapy, complementary and alternative therapies, spinal manipulation, TENS, acupuncture, acupressure, rolfing, and; surgical treatments such as laminectomy/diskectomy, microdiskectomy, laser surgery, spinal fusion and vertebroplasty, kyphoplasty, intradiskal electrothermal therapy or IDET, and; disk replacement.

Physical Therapy, Nutrition, NSAIDs, Creams, Surgeries, Medical Devices Target Forms of Arthritis, Experts Say (1 of 3)

by Vladimire Herard

Physical, message and alternative therapies, exercise, medical foods, nutrition, NSAIDs, DMARDs, corticosteroids, over-the-counter pain relievers, steroid injections, anti-pain creams, surgeries and medical devices are succeeding in treating senior patients with various forms of arthritis, researchers and experts say.

Through ongoing research and public policy, primary care physicians and specialists affiliated with the American Academy of Orthopedic Surgeons, the American College of Rheumatology, the Arthritis Foundation, the National Fibromyalgia Association, the National Center for Complementary and Alternative Medicine (NCCAM) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) are finding and recognizing a number of effective treatments and therapies for senior patients with arthritis.

These solutions remedy such forms of arthritis as osteoarthritis, rheumatic arthritis, fibromyalgia, systemic lupus erythematosus, scleroderma, infectious arthritis, gout, polymyalgia rheumatica, polymyositis, psoriatic arthritis, bursitis and tendonitis and back pain.

Influencing research and public policy on these forms of arthritis and on hand to treat them and to apply solutions are teams of primary care physicians, family practice physicians, internal medicine physicians, osteopathic physicians, rheumatologists, orthopedists or orthopedic surgeons, physical therapists, occupational therapists, dietitians, nurse educators, physiatrists, also known as rehabilitation specialists, licensed acupuncture therapists, psychologists and social workers.

Various Forms of Arthritis

With most of these forms, about 46 million sufferers of arthritis of a percentage of 100 rheumatic diseases nationwide experience pain, stiffness, redness and heat in their bodies and the joints, where the bones intersect, NIAMS researchers say.

The patients’ hands, knees and shoulders are stricken with soreness, become difficult to move and grow swollen or inflamed. However, other parts of their anatomies are affected, too, such as their eyes, their chests, their skin, tendons, ligaments, bones and muscles.

Degenerative Joint Disease, Osteoarthritis

Osteoarthritis, also known as OA, the most widely known form of arthritis and a major cause of disability globally, affects 27 million adults nationwide, especially senior citizens and women, the American Academy of Orthopedic Surgeons reports.

Patients suffer from osteoarthritis of the hands, at the ends of fingers and thumbs, spine (neck and lower back), knees and hips, which negatively impacts their quality of life. This usually means joint pain and stiffness.

With the nation’s population aging, the number of individuals stricken with osteoarthritis will increase. NIAMS researchers predict that, as of 2030, 20 percent of the population — or at least 72 million people — will reach age 65 and may be
affected by arthritis. Specifically, half of those at that age will have osteoarthritis in at least one joint.

Degenerative joint disease, also known as DJD, entails the deterioration and ultimate loss of joint cartilage, experts say. Cartilage is a type of protein substance that cushions the bones of a joint. With osteoarthritis, cartilage deteriorates, allowing bones underneath to rub together.

This chronic disease is the chief cause of hip pain. The hip ranks as one of the human body’s biggest “weight-bearing” joints. It is called a “ball-and-socket” joint because the femur, also known as the “round ball-shaped head of the thighbone moves inside the cup-shaped hollow socket (acetabulumi) of the pelvis.”

DJD is a chronic illness targeting millions nationwide with reduced physical activity overtime as a consequence, researchers say. Aside from osteoarthritis, there are four other forms of degenerative joint disease.

Post-traumatic Arthritis

The first, post-traumatic arthritis, involves “a severe fracture or dislocation of the hip.” A second form known as rheumatoid arthritis, or RA, is an inflammatory arthritis of the joints.

Avascular Necrosis, Hip Dysplasia

A third form, avascular necrosis, is an ailment in which a healthy blood supply has been cut off from the “ball” or femoral head, leading to bone death and disfigurement. Hip dysplasia is an illness in which the bones around the hip are not properly formed and misalign the hip joint.

Rheumatoid Arthritis

Rheumatoid arthritis is connected to a malfunction of the immune system. RA attacks the synovium or the lining of the joints and bones, especially the hands and feet and can harm internal organs.

The 1.3 million individuals with rheumatoid arthritis are afflicted with pain, stiffness, swelling, fatigue, a general feeling of un-wellness, a fever, weight loss, breathing difficulties, rash, itch, joint damage and loss of joint. Additionally, these symptoms may be signs of illnesses other than arthritis, researchers say.

Polymyalgia Rheumatica

One form of rheumatoid arthritis, titled polymyalgia rheumatica, concerns the “tendons, muscles, ligaments and joint tissues.” As NIAMS researchers report, “symptoms include pain, aching and morning stiffness in the shoulders, hips, neck and lower back”. These symptoms are the first signs of giant cell arteritis, an illness of the arteries manifesting “headaches, inflammation, weakness, weight loss and fever.”

Polymyositis

Polymyositis, a form of rheumatic disease, leads to inflammation and weakness in the muscles. It can influence the function of the human body, causing disability.

Another class of arthritis linked to “infectious agents” such as bacteria or viruses includes parvovirus arthritis and gonoccocal arthritis. Some of the symptoms associated with this type of arthritis can be found in Lyme disease, an illness caused by bacteria in the bites of ticks. In these instances, early diagnosis and antibiotic treatment are key to ridding the joints of infection and effecting damage control.

Gout

Gout, another form of arthritis, develops from chalky deposits of needle-like crystals of uric acid, accumulating in the joints and in the rim of the ear. Sometimes, the crystals can form in the kidneys and can lead to kidney stones, researchers say. This causes inflammation, swelling and pain.

The big toe is the most impacted but other joints in a patient’s physique such as the insteps, ankles, heels, knees, wrists, fingers and elbows may also be affected and this set of circumstances are called podagra. Experts say about six million adults aged 20 and older are said to have experienced gout at some point in their lives.

Fibromyalgia

While not a true form of arthritis because it does not cause inflammation or damage to the joints, muscles or other tissues, fibromyalgia syndrome is a disorder that causes tissue pain in the bones and joints, stiffness, fatigue, sleep deprivation and “tender points” in the muscles and tendons, including the neck, spine, shoulders and hips. About five million individuals aged 18 and older are struck by this illness, causing limitations in regular physical activity, researchers report.

Lupus

Often times, arthritis coincides with other conditions, including lupus, an autoimmune disease in which an afflicted person’s immune system goes on the attack of its own healthy cells, tissues, joints, the heart, the skin, the kidneys and similar organs, experts say. This means “inflammation of and damage to the joints, skin, kidneys, heart, lungs, blood vessels, and brain.”

Scleroderma

Scleroderma, also titled systemic sclerosis, impacts the skin, blood vessels and joints and internal organs such as the lungs and kidneys. With this condition, an excess amount of collagen, a fibrous protein, takes place in the skin and organs.

Psoriatic Arthritis

Psoriatic arthritis is a form of arthritis that accompanies psoriasis, a condition of scaly skin. It targets the “joints at the ends of the fingers and toes” and includes changes in the fingernails and toenails. Often, back pain may take place if the spine is affected.

Bursitis

Bursitis, another such condition, involves swelling of the bursae, “small, fluid-filled sacs,” that cut back on friction between bones and other structures in the joints. The inflammation may stem from arthritis in the joint or damage or infection of the bursae. The results are “pain and tenderness” that restricts movement of the joints.

Tendonitis

Tendonitis leads to the swelling of tendons, tough cords of tissue that link muscle to bone. This stems from overuse, injury or rheumatic illness. Like bursitis, tendonitis causes pain and tenderness and limits of joints.

Back Pain

Back pain is a common condition that, at best, is described as a persistent, blunt ache to immediate acute pain that debilitates its sufferer. It can be caused quickly by an accident, a fall or carrying heavy objects or can grow overtime from the aging of the spine. About 25 percent of adults nationwide will endure a day of back pain in a three-month period, researchers say.

Causes of Arthritis

Degenerative Joint Disease, Osteoarthritis

Degenerative joint disease, or DJD, and osteoarthritis of the knee, as a form of it, is caused by a variety of factors such as age, gender and genetics that influence the shape and functionality of the joints, researchers report. These factors include a prior hip injury, stress on the hip, joint dis-alignment and obesity.

The pain of degenerative joint disease of the hip and osteoarthritis of the knee is caused by the loss of cartilage or tissue lining. The cartilage acts as a cushion and makes for dexterity of the hip. When the cartilage deteriorates, the bones touch and rub together, causing swelling and stiffness.

Rheumatic Arthritis

Rheumatic diseases are caused by genetics and the environment, researchers report. This means that an individual may be born with a vulnerability to these conditions but elements in his or her environment will trigger their onset.

For rheumatoid arthritis and lupus, patients may have “a variation in a gene that codes for an enzyme called protein phosphatase nonreceptor 22.” Some viruses can awaken the disease in those genetically predisposed to it such as the link between the Epstein-Barr virus and lupus.

Gender also plays a role in the development of rheumatic diseases of patients. For example, lupus, rheumatoid arthritis, scleroderma and fibromyalgia are 80 to 90 more likely to take place in women and lupus is more likely to develop in African Americans and Hispanics than in whites. This means that hormones or gender differences factor into the progression of the condition.

Rheumatic diseases strike individuals of all races and ages with some conditions being more common among certain demographics than others. This form of arthritis takes place two to three times more in women than in men. Gout strikes men more than women but, after menopause, the likelihood of gout afflicting women starts to increase.

Gout

Gout, with its characteristic development of uric acid in the blood and crystals in the joints and kidney, also known as hyperuricemia, has multiple factors, experts report.

They include genetics with estimates ranging from 20 to 80 percent; gender with more men than women being stricken; obesity because of the presence of excess tissue making room for uric acid production; alcoholism; diet with foods rich in purines; exposure to lead poisoning; kidney failure; certain classes of medications such as diuretics and aspirin; niacin; cyclosporine or other such drugs that suppress the immune system, and levodopa in the treatment of Parkinson’s disease.

Other illnesses are connected to the high level of uric acid in the blood and they include high blood pressure, hypothyroidism, psoriasis, anemia, cancer, Kelley-Seegmiller syndrome or Lesch-Nyhan syndrome.

Uric acid is an element that originates from the dissolution of purines. Purines are a part of all human tissue and can be found in different foods. Uric acid should be digested in the blood and removed through the kidneys in urine. However, if it is not eliminated, it builds up in the blood via the process of hyperuricemia and gout develops.

Foods high in purines include alcohol, anchovies, asparagus, beef kidneys and other organ meats, brains, dried beans and peas, game meats, gravy, herring, liver, mackerel, mushrooms, sardines, scallops and sweetbreads and some ought to be avoided, researchers say.

Fibromyalgia

Patients with certain rheumatic diseases, lupus, or ankylosing spondylitis, also known as spinal arthritis, are just as likely to cultivate fibromyalgia. NIAMS researchers have also found that women with family members with fibromyalgia will contract the illness themselves and it is unclear that this may be linked to genetics or environment or both.

Back Pain

A number of factors determine the onset of back pain, NIAMS researchers say.

The first factor involves advancing age, starting at age 30 to 40. The second one is fitness level, especially for individuals who do not regularly perform physical exercise and have weak back and abdominal muscles that do not support the spine.

A third factor is a diet high in calories and fat and leading to obesity, which places stress on the back. Genetics, as a fourth factor, also plays a role in terms of the likelihood of developing ankylosing spondylitis.

Race also factors in fifthly with African American women three to four times more likely than white women to develop spondylolisthesis, a disease in which a vertebra of the lower spine, also known as the lumbar spine, slips.

A sixth factor is the onset of other illnesses that cause or lead to back pain such as such as endometriosis; diskitis; fibromyalgia; kidney stones; osteoarthritis; osteomyelitis; osteoporosis, rheumatoid arthritis; ankylosing spondylitis; spinal stenosis, “a narrowing of the spinal column that” places stress on the spinal cord and nerves; and cancers and tumors throughout the body that may affect the spine.

Occupational risk factors as a seventh rank that involves heavy lifting, pushing or pulling. The twisting or vibrating of the spine that such activity entails can cause injury and back pain. Otherwise, a sedentary job or desk job may cause back pain with poor posture or uncomfortable seating.

An eighth and final factor is cigarette smoking because of its connection to develop low back pain with sciatica, a category that involves radiating pain to the hip or leg because of stress on a nerve.

For instance, smoking may block your body’s capacity to bring nourishment to the disks of the lower back or lead to back pain through excessive coughing, obesity, osteoporosis, accidents, falls, back injuries, back surgery or fractured bones.

Symptoms of Arthritis

According to NIAMS researchers, symptoms of the various forms of arthritis vary. This includes degenerative joint disease, arthritis in general, osteoarthritis, gout and fibromyalgia.

Degenerative Joint Disease

The major symptoms of degenerative joint diseases, especially of the hip, is pain in the groin, outside of the hip, the lower area of the back and a thigh to its knee.

Oftentimes, sufferers may confuse the pain in the hip area with back pain and this category of pain may be treated accordingly until a primary care physician, diagnoses it as degenerative joint disease.

Arthritis in General

The symptoms of arthritis in general are described by researchers as “swelling in one or more joints;” early morning joint stiffness that takes an hour; consistent pain or tenderness in a joint; limited capacity in using a joint, and; joint warmth and redness.

Osteoarthritis

The main symptoms of osteoarthritis, one of the major forms of degenerative joint disease, includes pain or stiffness while standing or walking for a short time, taking the stairs up or down and sitting in or getting up from chairs; pain during physical activity; pain or stiffness while being physical active in a chair; stiffness while climbing out of bed; swelling in one or more parts of the knee, and; a grinding feeling in the knee when in use.

Osteoarthritis is characterized as developing slowly. In the early stages of the disease, joints may be painful after physical labor or exercise. Hours or days later, joint pain may persist. Additionally, a patient may endure joint stiffness, especially when he or she wakes up in the morning or lies or sits in a particular position for too long.

While osteoarthritis can take place in any joint, it mostly impacts the hands, knees, hips and spine near the neck or lower back.

With the hands, osteoarthritis may present as “small, bony knobs at the end joints” near the nails of fingers. They are referred to as Heberden’s nodes. Related knobs, known as Bouchard’s nodes, can manifest themselves on the middle joints of fingers. Fingers grow swollen and gnarled with pain, stiffness and numbness. Additionally, the base of the thumb joint is stricken by osteoarthritis.

For the hips, just as with knee osteoarthritis, the symptoms of hip osteoarthritis are pain and stiffness in the joint, groin, inner thigh and buttocks as well as knees. Hip osteoarthritis may restrict movement, making day-to-day activity such as wearing clothes or shoes difficult.

Spinal osteoarthritis, which affects the spine, may appear as stiffness and pain in the neck and lower back. Frequently, arthritic spines can lay stress on the nerves where they are outside of the spinal column, producing weakness or numbness in the arms and legs.

Gout

Signs and symptoms for gout include hyperuricemia, the formation of uric acid in the blood and crystals in the joints; the presence of such crystals in joint liquid; more than one incident of arthritis; arthritis that is cultivated in the course of a day, resulting in a red, warm and swollen joint, and; a bout of arthritis in one joint, namely the toe, ankle or knee.

Fibromyalgia

Symptoms for fibromyalgia include “pain; fatigue; cognitive and memory lapses, also known as ‘fibro fog’; sleep disturbances; morning stiffness; headaches; irritable bowel syndrome; painful menstrual periods; numbness or tingling of the hands and feet; restless legs syndrome; temperature sensitivity, and; sensitivity to loud noises or bright lights.”

Often, individuals stricken with fibromyalgia also have other chronic pain disorders such as fatigue syndrome, endometriosis, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction and vulvodynia.

Proper Diet, Exercise, Smoking, Drinking Avoidance, Tests Promote Bone Health In Seniors, Federal Agencies Say (2 of 2)

A separate 2002 study published in the Journal of the American College of Nutrition instructs osteoporosis patients to take calcium with phosphorus to ward off deficiency in the latter mineral.

Researchers explain that patients suffering from osteoporosis ought to take calcium phosphate because, if they increase their intake of calcium without phosphorus, they heighten their risk for falls and deficiency in phosphorus, which lead to rendering calcium less successful in protecting bones from loss.

Phosphorus is needed to combine calcium with bone and this important task is completed in the intestinal tract, researchers explain.

The NIH, CDC and the U.S. Surgeon General also asks senior patients to make regular their intake of vitamin D, which is critical to the absorption of calcium and bone health. Vitamin D is created in the skin through exposure to the sun.

While most individuals receive sufficient vitamin D naturally through such foods as milk and mushrooms, research finds that the supply of vitamin D is lowered in seniors, especially those who stay home away from sunlight, and at wintertime. Doctors are urged by the agencies to recommend that the senior patients supplement their intake of vitamin without overdosing.

About 40 percent to 100 percent of male and female seniors nationwide and staying at home lack an adequate supply of vitamin D. A 2002 study of long-term care senior patients, aged 85 and older, found that 91 percent took vitamin D supplementation, nearly 50 percent were vitamin D-insufficient and 16 percent were outright vitamin D-deficient.

For the ambulatory senior population, aged 78 and older where most patients took vitamin D supplements, 81 percent were deemed to be vitamin D-insufficient or deficient.

A lower supply of vitamin D in seniors leads to muscle weakness as well as compromised bone health. Muscle weakness translates into lessened physical capacity, which means a greater risk of falling and bone fractures.

Studies of vitamin D found that the nutrient affects muscle cell growth and function by binding to a receptor. Seniors who improved their intake of vitamin D and supplementation enjoyed muscle strength, walking ability and overall physical capacity, reducing the incidence of falls and non-spinal bone fractures.

Lastly, a 2002 study at the National Cheung Kung University Hospital in Tainan, Taiwan found that seniors who drank tea regularly built strong bones and decreased their risk of contracting osteoporosis. The study appears in the Archives of Internal Medicine.

Namely, individuals who drank two cups per day of black, green or oolong tea were discovered to have more solid bone material. Researchers point to the presence of fluoride, caffeine and phytoestrogen, the ingredients of which all contribute to bone mineral density and strength.

University researchers questioned 497 men and 540 women, aged 30 and older, about drinking tea, and all were administered a bone mineral density test. About 48.4 percent of the participants were tea drinkers for at least 10 years.

They reported drinking mostly green or oolong tea without milk, removing the calcium content of a dairy product. The study found those who drank tea steadily for more than ten years had the highest level of bone mineral density. Their level was 6.2 percent more than in those who did not habitually consume tea.

Regular physical exercise

The NIH, CDC and the U.S. Surgeon General asks senior patients to start an exercise regimen to prevent and treat osteoporosis and bone fractures. Physical exercise improves bone health and increases muscle strength, coordination and balance, leading to a reduction in falls and greater maximum overall health, the agencies say.

They say individuals who exercise regularly gain more peak bone mass, particularly “maximum bone density and strength” than those who don’t. There are two types of physical exercise: weight-bearing exercise and resistance exercise.

Individuals aged 40 and older are asked to consult their doctors before starting and to select exercise specialists qualified in physiology, physical education, physical therapy and other disciplines to lead activities.

Patients benefit when they engage the first variety, weight-bearing exercise, in which their bones and muscles “work against gravity.” These activities include walking, climbing stairs, dancing and playing tennis.

The second category, resistance exercises, use muscles to build muscle mass and bone. Examples include weight training/strength training with free weights or weight machines.

Other activities include Tai Chi, hiking, jogging and gardening.

Research shows that both weight-bearing and resistance exercise boosts the bone mineral density and strength of the spine and walking by itself enhances the status of the hip and spine in postmenopausal women and seniors aged 85 and older.

However, both groups of seniors must undergo an exam to determine the most suitable regimen for their physical ability and level of illness, the agencies say. Patients should test for muscle strength, range of motion, level of physical activity, fitness, gait and balance problems before embarking on a plan of exercise.

Seniors are asked to steer clear from activities that put them at risk for falling such as skiing and skating and “those with too much impact such as jogging and jumping rope”.

While certain exercises can benefit the hips, for instance, of postmenopausal women, they also can lead to fractures of the spine so their intensity and resistance may be need to be re-adjusted, researchers say.

Meanwhile, the agencies say, patients should not succumb to fear of falling and avoid exercise altogether. To help overcome fear, they caution seniors to achieve proper posture, to use handrails on staircases and bend from the hips and knees and not from the waist when lifting.

They also advise against seniors wearing slippery shoes; slouching when standing, walking or sitting at desks; moving too quickly; taking part in sports that lend to twisting such as golf and bending from the waist such as sit-ups or toe touches.

Non-weight-bearing exercise examples include bicycling and swimming but, while both build strong muscles and contribute to heart health, they are not effective for building bones, the agencies say.

The Surgeon General and guidelines from the American Heart Association recommend that all seniors aged 65 and older take part in moderate-intensity aerobic exercise for at least 30 minutes five days a week or vigorous-intensity activity for 20 minutes three days of the week.
Avoidance of tobacco and alcohol

The agencies forbid tobacco consumption among seniors, especially those with osteoporosis, declaring it harmful to the bones as well as for heart and lung health. Research finds one year of having quit smoking substantially increased bone mineral density in the femoral bones and hips in postmenopausal women.

Additionally, ending tobacco use has lowered the risk of hip fracture in female seniors after 10 years of such cessation as compared with younger adult women who continue smoking.

Researchers also say a female senior who drink two to three ounces of alcohol per day damages her skeleton. The same applies to drinking in younger women and men. Those who drink most heavily are more vulnerable to bone loss and fractures because malnourishment leads to a greater risk of falls.

Review of chronic illness medications

The NIH, CDC and the Surgeon General also warns seniors, their families and their doctors to perform a review of medications taken to treat a variety of chronic diseases associated with old age that lead to bone loss through a risk of developing osteoporosis or suffering fractures.

These include glucocorticoids or a class of medicines that treat a range of serious illnesses such as arthritis, Crohn’s disease, lupus and disorders of the lungs, kidney and liver, researchers say.

Other types of drugs that cause bone loss include treatment with anti-seizure drugs such as phenytoin, commercially known as Dilantin, and barbiturates; gonadtropin-releasing hormones used to treat endometriosis; excess use of aluminum-bearing antacids; cancer therapies, and; excess thyroid hormone.

Specifically, the use of the commercial drug Prilosec, also known as omeprazole to treat acid reflux disease, may ultimately lead to the onset of osteoporosis, 2002 research from the University of Minnesota shows.

When taken with calcium carbonate, Prilosec decreases calcium absorption in women aged 65 or older, which may lead to developing osteoporosis. The drug works by holding down the backflow of acids from the stomach to the esophagus. Still, the human body cannot process calcium without acid.

According to the study, which was presented at a yearly meeting of the American Geriatrics Society, out of a total of 18 women over aged 65 and taking Prilosec, about 16 had lowered calcium absorption levels.

The agencies urge seniors to speak with their physicians about whether to continue, stop or change medications with medical assistance or on their own.

Federal research projects that nearly 30 percent of individuals aged 65 and older, who stay at home, will fall at least once a year with the fall rate being higher in nursing homes and other senior long-term or short-term care facilities. Most falls will cause fractures with the most severe category being hip fractures.

Over 50 scientific studies published after 1988 have sought to address the question of whether a variety of medications cause these falls and injury though few have been designed in this manner. Many flaws in study design complicate the ability to make the connection between drugs and falls.

Despite such challenges, federal research has made important findings on the topic. Some have found that patients taking psychotropic drugs have twice the risk of falling and enduring fractures, compared with those not consuming such medicines.

As a result, physicians, pharmacists and nurses may prioritize reducing the use of psychotropic drugs by seniors in nursing homes or other forms of senior long-term or short-term care. Additionally, researchers and policymakers who advocate “aging in place” for seniors may lobby against the use of psychotropic drugs among elderly individuals who choose to stay at home.

Other studies have found that the use of nonsteroidal anti-inflammatory drugs is linked to falling and are expanding their examination of this class of medicines.

Most especially, researchers point to antidepressants, a class of drugs that have been connected by every major study to falls. Studies are focusing on the effects of selective serotonin such as 5-hydroxytryptamine, also known as 5-HT, and reuptake inhibitors and tricyclic antidepressants on falls.

Benzodiazepines with their long-term effects may impact falls through dosage rather than through drug half-life. Researchers are still determining the effects of drugs that treat heart conditions on falls.

Meanwhile, diuretics have been identified as a class of drugs not associated with falls and, in fact, thiazide diuretics, may avoid fractures by delaying the development of osteoporosis.

Medical testing

All seniors, most especially those aged 85 and older, must take an exam for the secondary causes of osteoporosis as part of a larger review of osteoporosis, the federal agencies say.

In general, a bone mineral density (BMD) test is considered the best exam for measuring bone health. The BMD test can recognize osteoporosis, determine one’s risk for fractures and measure a patient’s response to osteoporosis treatment.

The World Health Organization (WHO) has set definitions of units of standard deviations (SD) for DXA test results based on the peak bone mineral density of a healthy 30-year-old adult and a patient is assigned a T-score. A score of 0 is considered a BMD comparable with the norm for a healthy adult.

The more standard deviations (SD) there are below 0, shown as negative numbers, the lower your BMD and the greater risk of fracture. Bone density within the positive 1 or negative 1 range of the young adult mean is normal.

Low bone mass is indicated by a BMD score between 1 and 2.5 SD below the adult mean. Osteoporosis is defined as testing for a bone mineral density of 2.5 score or more below the average for young adults BMD for premenopausal women.

Severe osteoporosis is defined at more than 2.5 SD below the adult mean and in the incidence of one or more bone fractures. This same value can be used for both women and men.

Researchers particularly recommend that physicians diagnose osteoporosis in the proximal femur with the most common BMD test known as the dual energy X-ray absorptiometry or DXA test even though other sites and other methods of testing are effective and can be used to project fractures.

A patient’s bone mineral density can also be compared to that of an individual of the same age. This form of measure gives him or her a Z-score. Because a low BMD score is common among seniors, comparisons with the BMD of an individual of the same age can be misguiding. As a result, a diagnosis of osteoporosis or low bone mass is based on A T-score. Still, a Z-score can be useful for determining whether a disease causes bone loss.

While hip fracture prediction with bone mineral density and strength testing in itself is as valid as blood pressure reading to determine a risk for stroke, the value of the bone mineral density can be improved by other factors such as the biochemical indexes of bone resorption and fracture risk factors.

Factors outside of bone mineral density include age, previous fracture, premature menopause, a history of hip fracture and the use of oral corticosteroids. Physicians are encouraged to use a 10-year probability of fracture as the most effective measurement to determine intervention levels.

Treatments are available affordably for men and women if hip fracture probability over 10 years averages from 2 percent to 10 percent, depending on the age of patients.

Use of medical devices and therapies

Seniors can offset the risk of bone loss, bone fractures and osteoporosis by using medical devices and therapies other than medication. For example, federal research finds that hip protectors lower the risk of hip fracture among individuals most at risk for falls. Most hip protectors are reusable underwear that are worn over the hips.

One side of the piece of clothing is a thin layer of lightweight foam plastic. Hip protectors are worn by individuals with balance and posture problems and those who fall down and damage their hips as opposed to the more typical fall forward with hands and knees taking the hit.

However, clinical studies have found that at least one-third of seniors would not wear hip protectors or wore them for only short periods of time because of their lack of comfort or physical fit.

SOURCES:

“Australia Said Behind the Times in Recognition and Treatment of Osteoporosis,” Medical Week staff, April 14, 2002.

“Bone-Building Hormone Approved as Treatment for Postmenopausal Women With Osteoporosis,” Medical Week staff, August 5, 2002.

Borgstrom, F., Burlet, N., Cooper, C., Delmas, P.D., Kanis, J.A., Reginster, J.Y., Rizzoli, R, “European guidance for the diagnosis and management of osteoporosis in postmenopausal women,” Osteoporosis International, Vol. 19, No. 4, April 2008, pp. 399-428.

Bouxsein, M.L., “Determinants of skeletal fragility,” Best Practice Resident Clinical Rheumatology, Vol. 19, No. 6, December 2005, pp. 897-911.

Close, J.C., Lord, S.L., Menx, H.B., Sherrington, C., “What is the role of falls?” Best Practice Resident Clinical Rheumatology, Vol. 19, No. 6, December 2005, pp. 913-35.

Cumming, R.G., “Epidemiology of medication-related falls and fractures in the elderly,” Drugs Aging, Vol. 12, No. 1, January 1998, pp. 43-53.

“Doctor’s Office Can Help Motivate Women to Take Calcium Supplement, Osteoporosis News,” Osteoporosis News, Medical Week staff, July 26, 2004.

“Expert Says Most Are Unaware They Have Osteoporosis Until Suffering a Fracture,” Osteoporosis News, Medical Week staff, June 16, 2002.

“FDA Approves Once-a-Week Actonel for Postmenopausal Osteoporosis,” Osteoporosis News, Medical Week staff, June 2, 2002.

“Generic Version of Fosamax Approved for Treatment and Prevention of Osteoporosis,” Medical Week staff, May 5, 2002.

Hansen, L.B., McDermott, M.T., and Vondracek, S.F., “Osteoporosis risk in premenopausal women,” Pharmacotherapy, Vol. 29, No. 3, March 2009, pp. 305-17.

“High-Protein Diet, Calcium and Vitamin D Supplements Help Prevent Osteoporosis,” Osteoporosis News, Medical Week staff, April 7, 2002.

Janssen, H.C., Samson, M.M., Verhaar, H.J., “Vitamin D deficiency, muscle function and falls in elderly people,” American Journal of Clinical Nutrition, Vol. 75, No. 4, April 2002, pp. 611-5.

Kanis, J.A., “Diagnosis of osteoporosis and assessment of fracture risk,” Lancet, Vol. 359, No. 9321, June 1, 2002, pp. 1929-36.

“Long-Time Tea Drinkers Develop Stronger Bones, Reducing Osteoporosis Risk,” Medical Week staff, week of May 19, 2002.

National Institute’s of Health Osteoporosis and Related Bone Diseases National Resource Center, Bone Mass Measurement: What the Numbers Mean (patient factsheet guide), June 2015, https://www.niams.nih.gov/health_info/bone/bone_health bone_mass_measure.asp

National Institute’s of Health Osteoporosis and Related Bone Diseases National Resource Center, Exercise for Your Bone Health (patient factsheet guide), May 2015, https://www.niams.nih.gov/health_info/bone/Bone_Health/Exercise/default.asp

National Institute’s of Health Osteoporosis and Related Bone Diseases National Resource Center, Information for Patients About Paget’s Disease of Bone (patient factsheet guide), May 2015, https://www.niams.nih.gov/health_info/bone/pagets/patient_info.asp

National Institute’s of Health Osteoporosis and Related Bone Diseases National Resource Center, Once Is Enough: A Guide to Preventing Future Fractions (patient factsheet guide), April 2015, https://www.niams.nih.gov/health_info/bone/Osteoporosis/Fracture/default.asp,

“New Anabolic Drug Is Expected to Provide Important Option for Osteoporosis Patients,” Medical Week staff, May 12, 2002.

“Non-Surgical Procedure Can Aid Patients With Osteoporosis Suffering From Spinal Fractures,” Medical Week staff, April 21, 2002.

“Osteoporosis Patients Advised to Combine Calcium with Phosphorus,” Osteoporosis News, Osteoporosis News, Medical Week staff, June 9, 2002.

“Phase 1 Trial Begins on Oral Form of Calcitonin for Treatment of Osteoporosis,”Medical Week staff, April 28, 2002.

“Prilosec Decreases Calcium Absorption in Older Women, Increasing Risk of Osteoporosis,” Medical Week staff, May 26, 2002.

Ryan, Jill, National Osteoporosis Foundation, “National Osteoporosis Foundation releases new survey results during National Osteoporosis Awareness and Prevention Month,” (press release), May 2, 2011, Washington, D.C., (202) 721-6341, e-mail: [email protected], http://www.nof.org.

“Some Common Osteoporosis Drugs Thought to Cause Painful Jaw Decay in Rare Cases,” Osteoporosis News, Medical Week staff, May 10, 2002.

“Structural Network Inside Bones Can Deteriorate in Just One Year After Menopause,” Osteoporosis News, Medical Week staff, June 23, 2002.

U.S. Department of Health and Human Services, Office of the Surgeon General, The Surgeon General’s Report on Bone Health and Osteoporosis: What It Means To You, December 2015, https://www.niams.nih.gov/health_info/bone/SGR/surgeon_generals_report.asp

Vondracek, Sheryl F., Linnebar, Sunny A., “Diagnosis and management of osteoporosis in the older senior,” Clinical Intervention Aging, No. 4, 2009, pp. 121-136.
Vondracek, Sheryl F., Hansen, L.B., “Current approaches to the management of osteoporosis in men,” American Journal of Health-Systems Pharmacy, Vol. 61, No. 17, Sept. 2004, pp. 1801-11.

Proper Diet, Exercise, Smoking, Drinking Avoidance, Tests Promote Bone Health In Seniors, Federal Agencies Say (1 of 2)

by Vladimire Herard

A proper diet, physical exercise, avoidance of tobacco and alcohol, use of medical devices such as hip padding and medical testing preserve bone health in senior patients, various units of the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the U.S. Department of Health and Human Services’ (HHS) Surgeon General and researchers say.

The federal agencies, NIH and CDC, the U.S. Surgeon General and researchers released guides, a report and findings of research studies about maintaining bone health among senior citizens, advising for proper nutrition, regular exercise, shunning of smoking and drinking, the use of protective devices and therapies and undergoing medical exams to test bone strength and density.

Particularly, the NIH’s Osteoporosis and Related Bone Diseases National Resource Center, a national health care provider and patient informational and policy clearinghouse about bone health, works to secure its educational material with:

–the National Institute of Arthritis and Musculoskletal and Skin Diseases;
–the National Institute on Aging;
–the Eunice Kennedy Shriver National Institute of Child Health and Human Development;
–the National Institute of Dental and Craniofacial Research;
–the National Institute of Diabetes and Digestive and Kidney Diseases;
–the NIH Office of Research on Women’s Health and the HHS Office on Women’s Health, and;
–university and medical researchers.

The guides and report are titled Exercise for Your Bone Health, Once Is Enough: A Guide to Preventing Future Fractures, Information for Patients About Paget’s Disease of Bone, Bone Mass Measurement: What the Numbers Mean and the Surgeon General’s Report on Bone Health and Osteoporosis: What It Means To You.

This body of literature is aimed at instructing seniors, their families and the primary care, internal medicine and family practice physicians, endocrinologists, rheumatologists, orthopedic surgeons, neurologists, ear, nose and throat physicians treating them.

Bone Health and Factors

Human bone is ever-evolving and living tissue, composed of collagen, a soft, structured protein, and calcium phosphate, a strengthening and hardening mineral. Both collagen and calcium strengthen bone but also allow it to be flexible.

In the course of a person’s lifetime, old bone is disposed of (resorption) and new bone replaces it (formation). During his or her youth, a person’s new bone grows faster than the rate at which old bone is discarded.

Bone formation proceeds at a speed faster than resorption until a person’s skeleton reaches peak bone mass, which translates into “maximum bone density and strength” at age 30.

After that age, bone resorption starts to surpass bone formation. The loss of bone material is quickest in the earliest years of menopause but continues past this period.

Bone Diseases

After menopause in women and, to a lesser extent, in men, bone becomes more fragile or brittle and vulnerable to breakage or injury. Among the most common bone problems are bone fractures, osteoporosis, Paget’s disease and chronic illnesses with complications that impact bone health.

Osteoporosis, Fractures, Bone Deformities, Menopause

Osteoporosis, also known as porous bone, is a form of bone illness featuring low bone mass and structural decline of tissue, leading to more brittleness and a greater risk of fractures of the hip, spine and wrist. Called the “silent disease,” it is characterized as effecting bone loss without any symptoms.

In fact, despite a series of policy changes and laws affecting health care delivery to senior patients, some individuals may still not be aware that they have osteoporosis until their bones weaken severely to the point that any strain, bump or fall leads to a hip fracture or to the collapse of a vertebra and sometimes it is not even acknowledged then.

Such were the findings of a June 16, 2002 study by the University of California’s San Francisco School of Nursing Institute for Health and Aging that appeared in a journal Medical Week.

Additionally, researchers with Osteoporosis International found that, aside from osteoporosis affecting primarily women, of all osteoporosis patients in the hospital, 80 percent were white and 75 percent were over the age of 65 years.

The organization also found that osteoporosis costs billions of dollars nationally with the majority of the expense connected to hip fracture. The U.S. Surgeon General reports that it may cost $18 billion a year to treat fractures from osteoporosis. Most treatment for osteoporosis was covered by Medicare and the greatest cost borne was for nursing home cost, amounting to 59 percent of all dollars spent.

The National Osteoporosis Foundation and Harris Interactive, too, found that, while most senior participants in a survey meant to honor National Osteoporosis Awareness and Prevention Month in 2011 knew about osteoporosis, its risks and prevention efforts, about 34 percent did not know about the disease.

Still, 70 percent of women survey participants stated they thought the onset of osteoporosis could be avoided, though only 50 percent recognized physical exercise as a means of prevention and only 27 percent realized diet had an influence.

A collapsed vertebra can present as severe back pain, a loss of a person’s height or deformities of the spine such as kyphosis or a extremely stooped posture.

The onset of osteoporosis takes place when bone resorption begins too rapidly or the formation of bone happens too gradually. Osteoporosis is more likely to take place if a person did not peak in optimal bone mass during youth and young adulthood.

Nationwide, about 10 million persons suffer from osteoporosis and an additional 34 million have low bone mass, making it a public health threat for 44 million individuals total and increasing the chances of those with low bone mass of developing the disease. Half of all women and one in eight men over the age of 50 stand to experience an osteoporosis-related fracture at least once.

Unless they change their diet and lifestyle, the U.S. Surgeon General predicts that half of all individuals nationwide over the age 50 may suffer from fragile bones.

Every year, osteoporosis causes nearly two million fractures, the U.S. Surgeon General and the National Osteoporosis Foundation reported, including 2.6 million visits to the doctor’s office, 500,000 hospitalizations, 800,000 emergency room trips, 180,000 nursing home placements, 300,000 hip fractures, nearly 700,000 vertebral fractures, 250,000 wrist fractures and over 300,000 fractures in other parts in the human body, causing disability, pain and other health issues.

NIH and CDC researchers have identified several risk factors for developing osteoporosis. Some individuals hold many of these risk factors but others have none. They include gender, age, body size, ethnicity, family history, sex hormones, anorexia, drug use, a lack of physical exercise, smoking and drinking.

With respect to gender, a woman is more likely to develop osteoporosis than a man. Women have less bone mass and are more likely to lose bone material than men because they are more likely to undergo menopause, which causes changes in their bodies leading to this loss.

By contrast, men with osteoporosis make up one out of every five patients with osteoporosis. However, their level of ill health and risk of death are higher than that of chronically ill individuals without this disease.

When testing men for the risk of bone fracture and osteoporosis, researchers say physicians should evaluate the mineral density and strength of their senior patients’ bones. The most method is to use central dual energy X-ray absorptiometry.

Doctors must also factor in secondary causes for bone fracture or osteoporosis in men such as a reproductive health and hormonal condition known as hypogonadism. Drugs should be administered to senior male patients with a background of low-trauma fracture or severe bone loss.

Because of the links among proper nourishment, including daily intake of bone-building calcium and vitamin D, smoking, alcohol use, an exercise regimen and fall prevention and optimal bone health, researchers recommend that male senior patients and their physicians take these factors into consideration when treating men with osteoporosis or at risk for cultivating this illness.

They also urge male patients and doctors alike to administer appropriate drug therapy for all men in danger of bone fracture, including the use of the medication alendronate, deemed “first-line therapy” because of its effectiveness and mildness, and the “second-line therapy” drug teriparatide for managing osteoporosis in “high-risk men.”

Teriparatide is considered “second-line” because of its high cost, difficult administration routine and safety risks. Moreover, calcitonin and testosterone are also included in a doctor’s arsenal of solutions for managing the risk or onset for bone fracture and osteoporosis in men.

The second factor for bone fractures and osteoporosis is age. In both men and women, bones become less thick and weaker as they age. As a result, physicians must be mindful of the risks and the advantages of detecting and addressing osteoporosis in seniors.

Federal research finds that senior patients are not frequently tested enough for bone mineral density and strength and medications or other therapies are not prescribed often enough for them when they do present with bone disorders or the risks for them.

More data is needed on the safety and effectiveness of drugs and therapies in seniors for osteoporosis and bone fractures otherwise, making managing bone-related illness difficult.

Researchers say not enough is known about the effectiveness and safety risk of drugs, various bone-related diseases and costs so as to bridge the gap between the number of seniors at risk for such illness and the number actually being addressed.

As with elderly male bone disorder sufferers, researchers urge testing with central dual energy X-ray absorptiometry, which is for all seniors.

Researchers ask doctors to teach their senior patients to lead lives that encompass bone health, including a program of a proper diet, especially one rich in calcium and vitamin D, physical exercise and private home safety and security but free from smoking and drinking.

Facts and figures from the National Health and Nutrition Examination Survey (NHANES) demonstrate that the incidence of osteoporosis based on hip bone density was calculated at 4 percent for women aged 50 to 59 versus 44 percent for women aged 80 or older.

The NHANES survey finds that the number of seniors aged 65 and older will rise from the 36.8 million it was in 2004 to 54.6 million by the year 2020. In that time period, the number of senior aged 85 and older will jump from 5.1 million to 7.3 million. The incidence of hip fractures and their costs could increase by two to three times by the year 2040. Similar findings are made for seniors worldwide.

The danger of bone fractures rises with age. Hip fracture risk increases after age 70. Research shows that hip fractures were 1.6 per 1,000 years for female seniors aged 65 compared to 35.4 per 1,000 years for women aged 95 or older.

In 2004, there were about 329,000 hospital discharges for hip fractures with 125,000 taking place in patients aged 85 years and older — compared with 116,000 in patients aged 75 to 84 and 48,000 in patients between aged 65 and 74.

Researchers say bone fractures in general boost health care expenses and lead to an increased risk of illness and death for older seniors. After an event of hip fracture, half of all patients fully recover. Additionally, about 3 to 5 percent of patients die during their first hospital stay for hip fracture and about 20 percent to 40 percent in a year.

Data demonstrates that seniors with osteoporosis are not administered medications. A study of nursing home residents, aged 80 and older, with diagnosed osteoporosis or hip fracture showed that 69 percent of them were given calcium and 63 percent vitamin D but only 19 percent received a bisphosphonate. In total, about 36 percent were prescribed drugs or hip protectors for osteoporosis.

For the third factor of body size, small or petite women with thin bones are most endanger of developing bone disorders.

With the fourth factor of race and ethnicity, white and Asian women are most likely to develop bone fractures and osteoporosis than African-American and Hispanic women. The latter two racial groups have a lower but still relatively substantial risk of cultivating such diseases.

The fifth factor involves family history. Part of the risk for developing bone disorders is genetic. Senior patients whose parents suffered from bone fractures and osteoporosis, too, may share their fate with declining bone mass and a great risk of injury.

Six more factors are recognized as responsible for bone fractures and the development of osteoporosis, however, researchers say, with these, the odds can be reversed.

They include sex hormones with the unusual absence of menstrual periods, also known as amenorrhea, the low estrogen levels commonly known as menopause and low levels of the hormone testosterone in men; a high incidence of the eating disorder known as anoxeria because its resulting loss of calcium and vitamin D in the afflicted person’s diet; use of such drugs to treat chronic conditions such as glucocorticoids and some classes of anticonvulsants; a lack of physical exercise; cigarette smoking, and; abuse of alcohol.

Drugs and Other Therapies

A series of studies published in Medical Week in 2002 point to a number of medications and other therapies that treat osteoporosis and bone fractures, including a special class of drugs known as bisphosphonates such as Actonel, Fosamax, Actone, Boniva and Zometa, a commercial form of calcitonin known as Oratonin, a hormone known as Forteo, another treatment by the drug parathyroid hormone (PTH), and a therapy known as vertebroplasty.

Additionally, the Food and Drug Administration (FDA) has long approved the hormone estrogen and the medications alendronate, raloxifene, and risedronate to both prevent osteoporosis and to treat the disease. Alendronate is meant to treat osteoporosis in men. Both alendronate and risedronate are to be used for men and women with glucocorticoid-induced osteoporosis.

A separate set of research that appeared in Medical Week in 2002 finds that the structural network in bones can disintegrate in a year in early postmenopausal women.

Research discovered that the network, known as the trabecular architecture, can deteriorate even with a small amount of loss in bone mineral density, leading to skeletal fragility. The findings were brought before a meeting of the Endocrine Society in San Francisco.

The bisphosphonate drug Actonel, taken once a week, is meant to protect the trabecular architecture in early postmenopausal women, boost bone mineral density and to prevent and treat postmenopausal osteoporosis. Fosamax, too, is taken once a week to prevent and treat the disease in postmenopausal women and to stimulate bone mass in men with osteoporosis.

Bisphosphonates are the nonhormonal class of drugs that stem bone loss, increase bone mineral density and decrease the danger of fractures.

Research involved women within six months to five years after menopause who were administered with Actonel, a total of 12 participants, or a substitute, a total of 14 such participants, for a year. The women who took part in the study did not receive calcium supplements throughout that time period.

A review of hip bone biopsy samples demonstrated that, after one year, the 12 women taking the placebo were already found to have the deteriorated microarchitecture of trabecular bone even with only a small loss in the lumbar spine bone mineral density.

At the same time, the 14 women who received Actonel were able to restore trabecular bone microarchitecture and experienced greater lumbar spine bone mineral density.

The drug parathyroid hormone (PTH) is anabolic and triggers bone formation. This medication is more potent than some anti-resorptive therapies, which are meant to halt bone resorption.

The boost in bone density in two to three years amounts to 15 percent with PTH instead of 6 percent with its rival therapies. The results of research and clinical trials of PTH were reviewed by the American Association of Clinical Endocrinologists.

Yet another drug, Oratonin, is an oral form of calcitonin to treat osteoporosis, which was once only available by injection or in nasal spray form. Calcitonin is a hormone generated in the thyroid gland that decreases the amount of calcium and phosphate in the blood and blocks the resorption of bone, lowering the risk of fracture in an individual suffering from osteoporosis.

Additionally, patients with the disease and who are enduring spinal fractures are relieved from their pain with a procedure known as vertebroplasty. This procedure stabilizes a fractured bone, relieving a patient from pain and averting further damage if the procedure is conducted early enough. The results of research and clinical trials of vertebroplasty were examined by the Society of Cardiovascular and Interventional Radiology.

Lastly, the hormone Forteo, a natural bone-forming substance, is administered to men with osteoporosis through daily injections. Forteo works by triggering new bone-building activity by boosting the number and activity of bone-creating cells known as osteoblasts. The result is a reduced risk of bone fractures and an increase in bone mineral density and strength. A study of the hormone was published in the New England Journal of Medicine.

Paget’s disease

Paget’s disease, a chronic disorder that results in bone pain, swollen and deformed bones, fractures and arthritis near the joints, involves “excessive breakdown and formation” of bone tissues leading to weakened bones. Compared with osteoporosis, which affects all of the bones, Paget’s disease is localized and affects one or more bones.

The condition is caused by environmental factors and family medical history, particularly a slow-acting virus. Most especially, the disease afflicts seniors and individuals of northern European descent.

Symptoms include pain in any bone impacted by the disease or arthritis; headaches and hearing loss when the illness strikes the skull; pressure on nerves; increased head size; the bowing of a limb; curving of the spine; hip pain, and; damage to the cartilage of joints.

The illness is diagnosed using X-rays but can also be detected with an alkaline phosphatase blood test and bone scans. Complications include osteogenic sarcoma that is known as a rare form of bone cancer, arthritis, hearing loss, heart disease, kidney stones, nervous system problems, sarcoma, loose teeth and vision loss.

Paget’s disease is treated with calcium and vitamin D supplementation, physical exercise, the class of drugs known as bisphosphonates, calcitonin from the thyroid gland and surgery to correct bleeding, fractures, severe degenerative arthritis and bone deformity.

Chronic illnesses

However, other chronic illnesses can cause bone disorders. Vitamin D deficiency causes a number of diseases such as rickets and osteomalacia, which can lead to bone deformities and fractures. Renal osteodystrophy, a form of kidney disease, can cause fractures. Illnesses such as osteogenesis imperfecta leads to abnormal bone growth and easy breakage. Overactive glands can cause endocrine disorders.

Prevention and Bone Health Enhancement

In order to prevent osteoporosis and bone fractures and to promote bone health, the NIH, CDC and the U.S. Surgeon General recommend a proper diet; regular physical exercise; avoidance of tobacco and alcohol; a review of medications to treat chronic ailments that compromise bone wellness; medical testing, and; the use of medical devices and therapies such as hip padding or protectors to avert injury or recover from bone disorders.

The agencies ask seniors and their doctors to lower the risks of falls that hamper bone health. Preventing falls is a prime consideration for men and women with osteoporosis as accidents can cause bone fractures in the hip, wrist, spine or other parts of the human skeleton.

Osteoporosis patients are urged to pay attention to any alterations in their physical balance or gait and they must be ready to speak with their primary care, internal medicine and family practice physicians, endocrinologists, rheumatologists, orthopedic surgeons, neurologists, ear, nose and throat physicians about these changes.

After consulting with their doctors, senior patients and their families may be called upon to protect their bones through a variety of activities:

–private home safety and security efforts such as removing loose rugs or extension cords, fixing unstable staircases, installing grab bars in the bathroom and enhancing lighting;
–examining and, if need be, correcting their vision;
–determining whether they need canes, walkers and assistive devices;
–treating heart conditions that lead to falls such as orthostatic hypotension or arrhythmias, and;
–properly managing drugs that boost the danger of falls such as antipsychotic agents, benzodiazepines, anti-depressants, anti-hypertensives and diuretics.

Proper Diet

Senior patients are to consume a diet high in calcium, protein and vitamin D as these nutrients are proven to improve bone mineral density and strength, according to research by the federal agencies and Tufts University in Boston that has appeared in the American Journal of Clinical Nutrition.

If calcium and the other minerals and vitamins are lacking in the diet, their absence is linked to low bone mass, quick bone loss, high rates of fracture and the development of osteoporosis. National nutrition research finds that individuals of any age take in less than their recommended daily amount of calcium.

Aside from mineral supplements, the U.S. Surgeon General reports that seniors can increase their intake of calcium in certain foods such as almonds, baked beans, broccoli, ready-to-eat cereal, cheese, cheese pizza, cottage cheese, ice cream, lasagna, milk, fortified oatmeal, fortified orange juice, pudding, salmon, sardines, soy or rice milk, soybeans, spaghetti, tofu, turnip greens, fortified waffles and yogurt.

If possible, seniors may also increase their intake of other bone-building vitamins and minerals such as boron, collagen, dried plum, magnesium, especially magnesium citrate, manganese, silica, silicon, vitamin K2 and zinc.

And doctors are requested to play their role in convincing their patients to adopt sound nutritional habits for healthy bones. A 2002 study in the journal Menopause found that mere minutes of osteoporosis prevention education in the physician’s office prior to an appointment can encourage more women to take calcium or supplements.

For the study, a group of patients with the Women’s Health at the University of Medicine and Dentistry of New Jersey were subject to viewing a 10-minute osteoporosis education video before seeing their doctors. After watching the video, over 25 percent started their calcium supplements while only 4.9 percent of those who visited their physicians without watching the video did so.

Additionally, researchers ask patients to combine calcium and vitamin D to avoid the development of osteoporosis.

Home Safety, Managing Vision, Drugs, Physical Exercise Cut Back On A Senior’s Fall Risk, CDC, Specialists Say (Part 2 of 2)

Australian Group Exercise Program–Lord, et al.
This study evaluated a 12-month group exercise group for frail older adults. The program was tailored to each participant’s abilities. Overall, the fall rate was 22 percent lower among people who took part in the program, and 31 percent lower among participants who had fallen in the previous year, compared with those who were not in the program.
POPULATION: Ages ranged from ages 62 to 95 although nearly all were 70 years or older. Most study participants were female. Participants lived in retirement villages and most were independent.
GEOGRAPHIC LOCALE: Sydney and Wollongong, Australia
FOCUS: Increase participants’ strength, coordination, balance and gait, and increase their ability to carry out activities of daily living such as rising from chair and climbing stairs.
PROGRAM SETTING: Programs were conducted in common rooms in residential care community centers and senior centers within the retirement villages.
DURATION: One-hour classes were held twice a week for 12 months. The program consisted of 4 successive 3-month terms.
KEY ELEMENTS: Information was not provided by the principal investigator.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Stephen R. Lord, PhD Neuroscience Research. Australia Barker Street, Randwick Sydney NSW 2031, Australia Tel: +61 (2) 9399 1061 Fax: +61 (2) 9399 1005 e-mail: [email protected]

Yaktrax Walker — McKiernan.
This study tested the effectiveness of the Yaktrax Walker, a lightweight traction device that fits over shoes, to prevent falls among older adults when walking outdoors on ice and snow. During the winter months, participants in the Yaktrax intervention group were half as likely to slip and about 60 percent less likely to fall compared to the group that wore their usual winter footwear. Participants in the intervention group also experienced significantly fewer minor fall-related injuries.
POPULATION: Participants were community-dwelling adults aged 65 or older who had fallen at least once in the previous year. About 60 percent were female.
GEOGRAPHIC LOCALE: Rural central and northern Wisconsin, United States FOCUS: Using a traction device that fits on shoes to improve stability when walking on ice and snow.
PROGRAM SETTING: Participants used the Yaktrax Walker on their own in the community.
DURATION: This study took place during the winter of 2003-04.
KEY ELEMENTS: People must be able to safely put on and take off the Yaktrax Walker or leave the device on a dedicated pair of shoes or boots that are only worn out of doors. Shoes should be measured to assure proper fit of Yaktrax Walker. Yaktrax Walker must not be worn indoors. Yaktrax Walker should be inspected for breakage and replaced if broken.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Fergus Eoin McKiernan, MD Center for Bone Diseases Marshfield Clinic 1000 North Oak Avenue Marshfield, WI 54449, United States e-mail: [email protected]

Veterans Affairs Group Exercise Group — Rubenstein et al.
This study evaluated a structured group exercise program for fall-prone older men. During the 3-month program, participants were two-thirds less likely to fall compared with those who did not take part in the program. Note: This study calculated the fall rate as the number of falls per hour of physical activity.
POPULATION: All participants were aged 70 or older and lived in the community. All were males who had at least 1 of these fall risk factors: leg weakness, impaired gait, mobility, and/or balance; and had fallen 2 or more times in the previous 6 months.
GEOGRAPHIC LOCALE: Los Angeles, California, United States
FOCUS: Increase strength and endurance and improve mobility and balance using a low-to moderate-intensity group exercise program.
PROGRAM SETTING: The program was conducted at a Veterans Affairs ambulatory care center.
DURATION: Three 1 1/2-hour sessions a week for 12 weeks.
KEY ELEMENTS: Using a group format and providing a wide variety of exercise activities.
Focusing on strength, balance and endurance. Providing personal encouragement and reinforcement
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Laurence Z. Rubenstein, MD, MPH VA Medical Center, GRECC (11e) 16111 Plummer St. Sepulveda, CA 91343, United States Tel: 818-895-9311. Fax: 818-891-8181 e-mail: [email protected]

Falls Management Exercise (FaME) Intervention — Skelton et al.
This study examined the effectivenss of an individualized, tailored group and home-based exercise intervention designed to improve participants’ dynamic balance and core and leg strength, and to recover their ability to get down to and up from the floor. After 36 weeks, the fall rate in the exercise group was reduced by one-third. Over the entire study, which included a 50-week follow-up period, the fall rate was reduced by 54 percent.
POPULATION: Participants were women aged 65 or older, living independently, who had fallen 3 or more times in the previous year.
GEOGRAPHIC LOCALE: London, United Kingdom
FOCUS: Improve balance and strength
PROGRAM SETTING: Group classes were conducted at 4 locations in London in Community Leisure Centers (gym facilities that have rooms for exercise classes). Home exercises were performed in participants’ homes.
DURATION: The pre-exercise assessment lasted about 40 minutes. One-hour group classes were held once a week for 36 weeks. 30 minutes of home exercises were done twice a week.
KEY ELEMENTS: To be successful, the exercise program should last at least 36 weeks.It should include a minimum of 2 hours per week of combined group and home exercises. Exercise must be progressive, continually increasing in intensity, resistance, weight, and challenging balance. Exercises must be tailored to each individual’s needs and abilities, both in group classes and at home. It is desirable but not essential to include floor work to reduce fear of falling and improve falls efficacy.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information. Dr. Dawn Skelton Reader in Aging and Health School of Health, HealthQWest A236 Govan Mbeki Building Glasgow Caledonian University Cowcaddens Road, Glasgow G4 OBA, United Kingdom Tel: +44 (0) 141 331 8792 e-mail: [email protected]

Central Sydney Tai Chi Trial — Voukelatos, et al.
This study evaluated the effectiveness of a community-based Tai Chi program to reduce falls among people aged 60 or older. One-hour classes were offered once a week for 16 weeks in community settings by experienced instructors who taught their regular programs using several styles of Tai Chi. After the 24-week follow-up period, the fall rate among Tai Chi participants was one-third lower and the rate of multiple falls was 46 percent lower than the rates for participants who did not take Tai Chi.
POPULATION: Participants were healthy people aged 60 or older who lived in the community. About 84 percent were female.
GEOGRAPHIC LOCALE: Sydney, Australia
FOCUS: Improve balance and reduce falls.
PROGRAM SETTING: Tai Chi classes were conducted at community locations such as town halls and senior centers. Locations were chosen based on accessibility (e.g., accessible by public transportation, room accessible without climbing stairs), geographic diversity, and options for no- or low-cost sustainability after the study was completed.
DURATION: One-hour per week for 16 weeks.
KEY ELEMENTS: Limit class size to 12 people to maximize the attention each participant can get from the instructor. Incorporate relaxation and lowered center of gravity exercises into each class. It is important that participants maintain an upright (straight) posture at all times to reduce the risk of falling. Forms of Tai Chi that require participants to squat while moving or to get into positions that are not totally upright should be modified appropriately. Instructors need to be aware of participants’ comfort levels as well as any medical or physical conditions that may limit their ability to perform certain Tai Chi movements. Tai Chi movements should be introduced gradually so that participants are not exposed to too many new movements at once.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Alexander Voukelatos, PhD Sydney Southwest Area Health Promotion Service Level 9 (North), KGV building Missenden Road, Camperdown New South Wales 2050, Australia e-mail: [email protected]

Simplified Tai Chi — Wolf et al.
This study compared a 15-week program of Tai Chi classes that used 10 simplified movements, with a balance training program. After 4 months, the risk of falling more than once among participants in the Tai Chi classes was about half that of people in the comparison group. Participants reported that after the study they were better able to stop themselves from falling by using their environment and appropriate body maneuvers. After the study ended, almost half the participants chose to continue meeting informally to practice Tai Chi.
POPULATION: All were 70 years or older and lived in the community. Most study participants were female.
GEOGRAPHIC LOCALE: Atlanta, Georgia, United States
FOCUS: Improve strength, balance, walking speed, and other functional measures among seniors using Tai Chi.
PROGRAM SETTING: The program used facilities in a residential retirement community.
DURATION: The 15-week program included: Twice weekly 25-minute group sessions; Weekly 45-minute individual contact time with the instructor, and; Twice daily 15-minute individual practice sessions at home without an instructor.
KEY ELEMENTS: This program needs to be led by a very experienced Tai Chi grand master. No elements should be changed in order to replicate these results among seniors who are similar to study participants.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Steven L. Wolf, PhD, PT, FAPTA Department of Rehabilitation Medicine Emory University School of Medicine 1441 Clifton Road NE Atlanta, GA 30322, United States Tel: 404-712-4801 Fax: 404-712-5895 e-mail: [email protected]

HOME MODIFICATION INTERVENTIONS

The VIP Trial — Campbell et al.
This study looked at the effectiveness of 2 interventions to reduce falls and fall injuries in older people with poor vision. The home safety program consisted of a home hazard assessment by an occupational therapist followed by home modifications and recommendations for behavior change. The home exercise program consisted of a combination of strength and balance exercises (the Otago Exercise Program modified for people with poor vision) plus vitamin D supplements. Only the home safety program was effective in reducing falls. The home safety group had 61 percent fewer falls and 44 percent fewer injuries compared to those who received social visits.
POPULATION: Participants were community-dwelling seniors aged 75 or older with poor vision. Two-thirds of the participants were female.
GEOGRAPHIC LOCALE: Dunedin and Auckland, New Zealand
FOCUS: Assess and reduce home hazards and encourage changes in behavior.
PROGRAM SETTING: The program took place in participants’ homes of equipment that could lead to falls. The occupational therapist and participant then agreed on which recommendations to implement. The occupational therapist helped the participant obtain any necessary equipment and oversaw payment for the home modifications. Home modifications and equipment costing more than NZ$200 were funded by the local Board of Health and items costing less than this were funded by the participant or from research funds. The occupational therapist made a follow-up visit if equipment needed to be installed.
DURATION: The intervention consisted of 1 or 2 home visits. The first visit lasted about 2 hours. If the occupational therapist needed to approve new equipment, they made a second visit 2 to 3 weeks later. The second visit lasted about 45 minutes.
KEY ELEMENTS: The occupational therapist’s advice rather than the environmental changes was key. A trained and experienced occupational therapist is critical to the success of this intervention.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: A. John Campbell, MD Department of Medical and Surgical Sciences Dunedin School of Medicine Dunedin, New Zealand e-mail: [email protected]

Home Visits by an Occupational Therapist — Cumming et al.
This intervention used an occupational therapist (OT) who visited participants in their homes, identified environmental hazards and unsafe behaviors, and recommended home modifications and behavior changes. Fall rates were reduced by one-third but only among men and women who had experienced 1 or more falls in the year before the study.
POPULATION: All participants were 65 or older and lived in the community. More than half of the participants were female.
GEOGRAPHIC LOCALE: Sydney, Australia
FOCUS: Assess and reduce home hazards.
PROGRAM SETTING: The program was conducted in participants’ homes.
DURATION: One-hour home visit with a follow-up telephone call 2 weeks later. Total contact time was approximately 2 hours.
KEY ELEMENTS: Using an experienced occupational therapist is critical. These researchers emphasized that this study should not be used to justify widespread, untargeted home modification programs implemented by people who do not have skills in caring for older people.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Robert G. Cumming, PhD School of Public Health, Building A27 University of Sydney Sydney NSW 2006, Australia Tel: +61 (2) 9036 6407 Fax: +61 (2) 9351 5049 e-mail: [email protected]

Falls-HIT (Home Intervention Team) Program — Nikolaus, et al.
This intervention provided home visits to identify environmental hazards that can increase the risk of falling, provided advice about possible changes, offered assistance with home modification, and provided training in using safety devices and mobility aids. The fall rate for participants was reduced 31 percent. The intervention was most effective among those who had experienced 2 or more falls in the previous year; the fall rate for these participants was reduced 37 percent.
POPULATION: Participants were frail community-dwelling older adults who had been hospitalized for conditions unrelated to a fall, and then discharged to home. Participants showed functional decline, especially in mobility. All were 65 or older and lived in the community. Three-quarters were female.
GEOGRAPHIC LOCALE: Mid-sized town, Southern Germany
FOCUS: Assess and reduce fall hazards in participants’ homes.
PROGRAM SETTING: Intervention team members contacted patients once or twice while they were hospitalized to explain the program. The program took place in participants’ homes.
DURATION: The program consisted of 2 or more home visits, each lasting about 1 1/2 hours. After the participant was discharged from the hospital, 3 home visits typically were needed to provide advice on recommended home modifications and to teach the participant how to use safety devices and mobility aids. On average, the total individual contact time was 8 hours.
KEY ELEMENTS: Participants met all intervention team members at the hospital before they were discharged, which facilitated follow-up.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Thorsten Nikolaus, MD Medical Director/CEO Bethesda Geriatric Clinic and Professor of Geriatric Medicine University of Ulm Zollernring 26, 89073 Ulm, Germany Tel: +49 731 187 185 Fax: +49 731 187 389 e-mail: [email protected]

MULTIFACETED INTERVENTIONS

Stepping On — Clemson, et al.
This study used a series of small group sessions to teach fall prevention strategies to community-dwelling older adults. The fall rate among participants was reduced about 30 percent compared with those who did not receive the intervention. The intervention was especially effective for men. The fall rate among male participants was reduced almost two-thirds.
POPULATION: Participants were individuals who had fallen in the previous year or who were concerned about falling. All were 70 or older and lived in the community. Most study participants were female.
GEOGRAPHIC LOCALE: Sydney, Australia
FOCUS: Improve self-efficacy, empower participants to make better decisions and learn about fall prevention techniques, and make behavioral changes.
PROGRAM SETTING: Initial sessions were conducted in easily accessible community settings. Refreshments were provided before and after the sessions to give participants an opportunity to talk to each other and with the facilitators and content experts. Follow-up visits took place in the participants‘ homes.
DURATION: • Seven weekly 2-hour program sessions • A 1- to 11⁄2-hour home visit, 6 weeks after the final session • A 1-hour booster session 3 months after the final session
KEY ELEMENTS: Using content experts is critical. It is also important to let each expert know what is expected of them, to provide feedback, and to make sure each focuses on fall prevention. The Stepping On manual is essential for all program facilitators and provides a step-by-step guide to running the 7-week group program. It outlines topic areas and provides the background information for each content expert. Chapters include: Essential background information for understanding the conceptual underpinning of the program and the group process; Valuable content information for all the key fall prevention areas that can be used to train local experts participating in the program; A guide to useful resources; Handouts for group participants; Ideas on recruitment and evaluation, and; Work is ongoing to develop training workshops and certification for Stepping On program leaders.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Lindy Clemson, PhD Associate Professor in Aging, Head of Discipline (Occupational Therapy) Faculty of Health Sciences, The University of Sydney Cumberland Campus, PO Box 170 Lidcombe 1825, Australia Tel: +61 (2) 9351 9372 Fax: +61 (2) 9351 9166 E-mail: [email protected]

PROFET (Prevention of Falls in the Elderly Trial) — Close, et al.
This intervention provided medical assessments for fall risk factors with referrals to relevant services and an occupational therapy home hazard assessment with recommendations for home modifications. After 12 months, those in the intervention group were 60 percent less likely to fall once and 67 percent less likely to fall repeatedly (at least 3 times), compared with those who did not receive the intervention.
POPULATION: Participants were seniors who had been treated for a fall in a hospital emergency department. All were aged 65 or older and lived in the community. Two-thirds of participants were female.
GEOGRAPHIC LOCALE: London, United Kingdom
FOCUS: Identify medical risk factors and home hazards, and provide referrals and/or recommendations to reduce fall risk and improve home safety.
PROGRAM SETTING: The medical assessment took place in an outpatient hospital clinic. The occupational therapy assessment took place in participants’ homes.
DURATION: The average length of the medical assessment was 45 minutes. The average length of the home assessment was 60 minutes.
KEY ELEMENTS: For medication review and modification, a medical specialist rather than a general practitioner is recommended.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Jacqueline Close, MD Neuroscience Research Australia Barker Street, Randwick Sydney NSW 2031, Australia Tel: +61 (2) 9399 1055 Fax: +61 (2) 9399 1005 E-mail: [email protected]

Accident & Emergency Fallers — Davison, et al.
This multifaceted intervention was designed for people who fell repeatedly. Participants received a medical fall risk assessment by a geriatrician at the hospital and had in-home assessments by physical and occupational therapists. Each participant received an individualized intervention designed to reduce their fall risk factors. After 12 months, the fall rate in the intervention group was 36 percent lower than the rate in the comparison group.
POPULATION: Participants were men and women aged 65 or older. All had experienced at least 1 fall in the past year and also had been treated in the emergency department for another fall or fall injury. About three-quarters of participants were female.
GEOGRAPHIC LOCALE: Newcastle, United Kingdom
FOCUS: Identify and modify each participant’s fall risk factors.
PROGRAM SETTING: The medical assessment was conducted in a hospital and the physical therapy and home assessments were conducted in participants’ homes.
DURATION: On average, participants visited the hospital twice for the medical intervention. The initial hospital assessment took 1 hour and the medical intervention visit was 20 minutes. Participants received 2 physical therapy intervention visits; the initial physical therapy assessment took 45 minutes and the intervention lasted 15 minutes. The occupational therapy visit took 45 minutes and the follow-up visit about 1 month later lasted 20 minutes.
KEY ELEMENTS: Multifactorial assessments and interventions conducted by highly trained individuals in each of the 3 disciplines.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Dr. John Davison Falls and Syncope Service and Institute for Aging & Health Royal Victoria Infirmary Newcastle upon Tyne NEI 4LP, United Kingdom Fax: (+44) 191 222 5638 E-mail: [email protected]

The No Falls Intervention — Day, et al.
This study looked at the effectiveness of group-based exercise in preventing falls when used alone or in combination with vision improvement and/or home hazard reduction. The intervention components focused on increasing strength and balance, improving poor vision, and reducing home hazards. The group-based exercise was the most potent single intervention; when used alone, it reduced the fall rate by 20 percent. Falls were reduced further when vision improvement or home hazard reduction was combined with exercise. The most effective combination was the group-based exercise with both vision improvement and home hazard reduction. Participants who received all 3 components were one- third less likely to fall.
POPULATION: All participants were aged 70 and older and lived in the community. Sixty percent were female.
GEOGRAPHIC LOCALE: City of Whitehorse, Melbourne, Australia
FOCUS: Increase strength and balance, improve poor vision, and reduce home hazards.
PROGRAM SETTING: The exercise program was delivered in community settings such as exercise rooms in fitness centers and community health centers. The vision intervention was delivered via usual services available in the community. Participants went to their optometrist or ophthalmologist if they had one. If any further action was required, it was facilitated using normal services such as hospitals for cataract surgery, optometrists for new glasses, and general practitioners or ophthalmologists for medication if required. The home hazard intervention was conducted in participants’ homes.
DURATION: Exercise: Weekly 1-hour group classes for 15 weeks and 25 minutes of daily home exercises. Vision improvement: Duration depended on the specific intervention (such as cataract surgery or new glasses). Home hazard reduction: Duration depended on the length of time the home modifications were left in place by the participant.
KEY ELEMENTS: Although the most effective single component was the NoFalls exercise program, the complete program should be followed because partial implementation may not reduce falls.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Lesley Day, PhD, MPH Accident Research Centre Building 70, Monash University Wellington Road Clayton Victoria 3800, Australia Tel: +61 (3) 9905 1811 Fax: +61 (3) 9905 1809 E-mail: [email protected]

The SAFE Health Behavior and Exercise Intervention — Hornbrook, et al.
The Study of Accidental Falls in the Elderly (SAFE) health behavior intervention was a program of 4 group classes on how to prevent falls. The classes addressed environmental, behavioral, and physical risk factors and included exercise with instructions and supervised practice. The home safety portion included a home inspection with guidance and assistance in reducing fall hazards. Overall, participants were 15 percent less likely to fall compared with those who did not receive the intervention. Male participants showed the greatest benefit.
POPULATION: All were participants were 65 or older and lived in the community. About 60 percent of participants were female.
GEOGRAPHIC LOCALE: Portland, Oregon, and Vancouver, Washington, United States
FOCUS: Reduce risky behaviors, improve physical fitness through exercise, and reduce fall hazards in the home.
PROGRAM SETTING: No information was available on where risk education and group exercise classes took place. Home safety inspections were conducted in participants’ homes.
DURATION: Two home visits, each lasting about 15 minutes. Four weekly 11⁄2-hour classes (including 20 minutes of supervised exercise) over a 1-month period
KEY ELEMENTS: Information was not provided by the principal investigator.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Mark C. Hornbrook, PhD Chief Scientist The Center for Health Research, NW/HI/SE Kaiser Permanente Northwest 3800 North Interstate Avenue Portland, OR 97227-1110, United States Tel: 503-335-6746 Fax: 503-335-2428 E-mail: [email protected]

Multifactorial Fall Prevention Program — Salminen, et al.
This multifaceted fall intervention consisted of a geriatric fall risk assessment with counseling and guidance in fall prevention; home hazards assessment and modification; group and home-based exercise; group lectures on topics related to fall prevention; and monthly participation in a psychosocial group. The intervention did not reduce falls overall. However, falls were decreased 41 percent in participants who had experienced 3 or more falls in the previous year and 50 percent in participants with more symptoms of depression.
POPULATION: Participants were seniors aged 65 or older who lived in the community or in housing that provided occasional assistance, had no or little cognitive impairment, and had experienced at least 1 fall in the past year. Eighty- four percent of participants were female.
GEOGRAPHIC LOCALE: Pori, Finland
FOCUS: Assess and address each participant’s specific fall risk factors, improve physical fitness, provide information and counseling on fall prevention, assess and modify home hazards, and provide psychological support.
PROGRAM SETTING: The fall risk assessment, counseling, and group exercise classes were conducted in the Pori Health Center or at home for those participants living in assisted housing. Lectures and psychosocial groups were held in a senior center. The home-based exercises and home assessment were carried out in participants’ homes.
DURATION: • 45-minute fall risk assessment • 45-minute home hazard assessment • 45-minute information and counseling session • 45- to 50-minute group exercise class once every 2 weeks plus 25 minutes of exercise at home 3 times per week • 1-hour health lecture once a month • 1-hour psychosocial group session once a month.
KEY ELEMENTS: • Individual risk factor assessment, treatment, and/or referral by a physician. Exercise classes led by a trained physical therapist or physical therapy student, combined with at-home exercises tailored to each participant • Exercise intensity must increase progressively over time • Monthly lectures by various health professionals on topics related to • falling, followed by a question and answer period • Individual guidance on fall prevention • Home hazards assessment and written safety recommendations • Monthly psychosocial group sessions.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Marika J. Salminen, PhD Family Medicine Lemminkäisenkatu 1 FI-20014 University of Turku Turku, Finland E-mail: [email protected]

The Winchester Falls Project — Spice, et al.
This study evaluated the effectiveness of 2 fall interventions. The primary care intervention consisted of fall risk assessments by nurses followed by referrals to other professionals. The secondary care intervention involved multidisciplinary fall risk assessments (by a doctor, nurse, physical therapist, and occupational therapist), followed by appropriate interventions and follow-up if necessary. Only the secondary care intervention was effective in reducing falls. Compared to the group who received usual care, participants in the secondary care multidisciplinary intervention were half as likely to fall, a third less likely to sustain a fall-related fracture, and 55 percent less likely to die in the year following the intervention.
POPULATION: Participants were community-dwelling adults aged 65 or older who had sustained 2 or more falls in the previous year. About three- quarters were female.
GEOGRAPHIC LOCALE: Mid Hampshire, United Kingdom
FOCUS: Assess fall risk factors and provide individualized interventions.
PROGRAM SETTING: Baseline assessments were conducted in a multidisciplinary clinic with referrals for interventions and follow-up if necessary.
DURATION: Fall risk assessments took about 2 hours. The amount and duration of the follow-up interventions varied by the type of interventions received.
KEY ELEMENTS: Doctors, nurses, physical therapists, and occupational therapists used a structured in-depth assessment instrument.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Dr. Claire Spice Department of Medicine for Older People Portsmouth Hospitals NHS Trust Queen Alexandra Hospital Southwick Hill, Cosham PO6 3LY, United Kingdom E-mail: [email protected]porthosp.nhs.uk

Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) — Tinetti, et al.
This study used a tailored combination of intervention strategies based on an assessment of each participant’s fall risk factors. Participants were about 30 percent less likely to fall compared with people who did not receive the intervention.
POPULATION: Participants were members of a health maintenance organization. All were 70 or older and lived in the community. Most participants were female.
GEOGRAPHIC LOCALE: Farmington, Connecticut, United States
FOCUS: Identify and modify each participant’s risk factors.
PROGRAM SETTING: The intervention was delivered to participants in their homes.
DURATION: The intervention was conducted over a 3-month period. The amount and duration of contacts varied by the type of interventions received.
KEY ELEMENTS: The assessments need to be clearly linked to the intervention components. The minimum risk factor interventions include (1) postural blood pressure and behavioral recommendations; (2) medication review and reduction (especially psychoactive medications); (3) balance, strength, and gait assessments and interventions; and (4) environmental assessment and modification. It is essential that the progressive balance and strength exercise program includes both supervised and at-home (unsupervised) components.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Mary Tinetti, MD Department of Epidemiology and Public Health Yale University School of Medicine Internal Medicine-Geriatrics, PO Box 208025, New Haven, CT 06520-8025, United States Tel: 203-688-5238 Fax: 203-688-4209 E-mail: [email protected]

A Multifactorial Program — Wagner, et al.
This study tested a moderate-intensity intervention that used tailored strategies based on assessments of each participant’s risk factors. After 1 year, participants were 10 percent less likely to fall and 5 percent less likely to have an injurious fall, compared with people who received usual medical care.
POPULATION: All participants were 65 or older and lived in the community. About 60 percent of participants were female.
GEOGRAPHIC LOCALE: Seattle, Washington, United States
FOCUS: Reduce disability and/or falls by: improving physical fitness, modifying excessive alcohol use, improving home safety, reducing psychoactive medication use, and improving hearing and vision.
PROGRAM SETTING: Participants received the assessments and interventions from a nurse at local health maintenance organization (HMO) centers. Participants conducted a home assessment or had it done by a family member or volunteer.
DURATION: The initial visit consisted of a 1- to 11⁄2-hour interview. The length and number of subsequent sessions varied by the type of interventions selected for each participant.
KEY ELEMENTS: The nurse’s follow-up phone contacts and home visits may have had positive effects on participants’ health that were independent of the interventions for specific risk factors.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Edward H. Wagner, MD, MPH Group Health Research Institute 1730 Minor Avenue, Ste. 1290 Seattle, WA 98101, United States Tel: 206-287-2877. E-mail: [email protected]

SOURCES:

“Did You Know?” brochure, Active Rx Active Aging Centers, 201 E. Ogden Ave., Hinsdale, IL Corner of York and Ogden, (888) 960-4562.

“National Estimates of the 10 Leading Causes of Nonfatal Injuries Treated In Hospital Emergency Departments, United States,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Data Source: NEISS All Injury Program operated by the Consumer Product Safety Commission (CPSC), 2010.

Stevens, Judy A., PhD; A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults; Second Edition, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, (2010),https://www.cdc.gov/HomeandRecreationalSafety/pdf/CDC_Falls_Compendium_lowres.pdf and http://www.cms.gov/PrevntionGenInfo/Downloads/Exercise%20Re-port.pdf

Stevens, Judy A., PhD; and Burns, Elizabeth, MPH, A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults; Third Edition, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, (2015), https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/cdc_falls_compendium-2015-a.pdf

“Stopping Elderly Accidents, Deaths and Injuries” (STEADI) Tool Kit, Center for Disease Control and Prevention’s (CDC) Injury Center for health care providers, http://www.cdc.gov/injury/STEADI.

Home Safety, Managing Vision, Drugs, Physical Exercise Cut Back On A Senior’s Fall Risk, CDC, Specialists Say (Part 1 of 2)

by Vladimire Herard

Uncluttering his or her private home and spaces, checking vision needs, managing illnesses and medications and conducting physical exercise and therapy reduce a senior’s risk of falling and prevent injuries, the Centers for Disease Control and Prevention (CDC) says.

Through its suite of online and offline educational materials to instruct and guide seniors, their families and their physicians about fall risk and injury prevention, the CDC makes the following recommendations:

–Clear floors and other spaces in the home of debris to avoid accidents;

–Check and care for vision to improve spatial judgment;

–Manage chronic illnesses and medications with side effects that affect physical balance, and;

–Practice physical exercise and obtain physical therapy services to correct balance-related conditions.

Specifically, the CDC creates, releases and updates its “Stopping Elderly Accidents, Deaths and Injuries (STEADI) Tool Kit,” an online raft of instructional works that measures, treats and recommends solutions for seniors, their families and friends, based on the risk of falling.

The STEADI took kit can be found at the agency’s website at http://www.cdc.gov/injury/STEADI.

The federal agency also collaborates with the Centers for Medicare and Medicaid (CMS) and the RAND Corporation to make available “A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults,” a guidebook to teach public health physicians and senior care providers about 22 of the most effective, research-based falls prevention programs globally.

Editions of the compendium by researchers with the CDC’s National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention and the Home and Recreation Injury Prevention Team are available at the agency’s website at https://www.cdc.gov/HomeandRecreationalSafety/pdf/CDC_Falls_Compendium_lowres.pdf and http://www.cms.gov/PrevntionGenInfo/Downloads/Exercise%20Report.pdf and https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/cdc_falls_compendium-2015-a.pdf.

On the private sector side, physical therapy facilities offer one-on-one physical therapy, small group strength therapy and programs meant to address balance, cognitive function flexibility, mobility, strength and overall physical wellness and to improve the independence of senior patients.

These facilities focus on examining and treating neurological, orthopedic, vestibular and balance disorders that can lead to falls in seniors.

Federal research demonstrates the extent to which senior patients at risk for falls and injuries need physical therapy services: one out of three adults over the age of 65 fall annually and those who do are two to three times more likely to do so again. At that age, most adults lose 33 percent of their 30-year-old levels of strength.

Overall, seniors seek a sense of control over their lives and independence and falls can hamper their efforts to stay self-sufficient. Fall injuries can cause physical disability as well as a lack of independence and a lowered quality of life.

In 2000, the CDC reported, fall injuries cost the nation $19 billion and this figure rose to $34 billion in 2015. To reverse these trends would mean to comprehend that falls are not a prerequisite for aging and that scientifically-based prevention interventions can decrease their incidence.

Additionally, two-thirds of members of the Baby Boom generation, who have already begun to age in this decade, are now enduring chronic illnesses that restrict their physical capacities.

By the time, they reach age 74, 25 percent of the men and 66 percent of the women will not be able to hold a 10-pound bag of groceries, federal research shows.

STEADI Tool Kit Brochures, Material

Through its STEADI toolkit, the CDC provides a set of educational materials for physicians and senior long-term care providers and a separate collection for senior patients and their families.

For physicians, the agency releases an “algorithm flow chart for fall risk assessments and interventions; directions for conducting gait, strength and balance assessments; fact sheets about falls, medications and fall risk factors; a pocket guide for fall prevention algorithm and prevention; a summary checklist for fall risk factors; a wall chart for integrating fall prevention into practice; referral forms and recommended fall prevention classes; materials for talking with patients about fall prevention, and; instructions for measuring orthostatic blood pressure.”

For patients, the agency publishes a self-risk assessment brochure titled “Stay Independent”; a brochure titled “Postural Hypotension: What It Is and How To Manage It”; a brochure titled “What YOU Can Do To Prevent Falls: Proven Strategies To Prevent Falls”; a home safety brochure titled “Check for Safety: A Home Fall Prevention Checklist for Older Adult” by the CDC and the MetLife Foundation; and a one-page instructional handout on chair rise exercise.

Particularly with its “What YOU Can Do To Prevent Falls” brochure as part of the took kit, the CDC urges senior patients to commit to four actions to prevent falls: start a physical exercise program; allow a healthcare provider to review their medicines; have their vision examined, and; improve the safety and security of their homes.

For physical exercise, the agency explains that exercise reduces a senior patient’s chances of falling by making him or her physically stronger and imbuing in him and her a overall sense of mental and emotional well-being. The most successful forms of exercise that improve physical balance and motor coordination include Tai Chi.

Failing to maintain an exercise regimen promotes physical weakness and boosts a senior patient’s risk of falls, the CDC states in its brochure. Senior patients are asked to consult their primary care, family practice or internal medicine physician for the most suitable exercise program.

On the subject of medications, the agency requests that senior patients permit their doctors to review their drugs, including the over-the-counter prescriptions. These drugs include psychoactive medications such as benzodiazepines, antidepressants, nonsteroidal anti-inflammatory drugs, and antipsychotics and certain illnesses such as stroke, Alzheimer’s disease and Parkinson’s disease.

A class of drugs known as glucocorticoids and that treat several types of diseases such as arthritis, asthma, Crohn’s disease, lupus, and other diseases of the lungs, kidneys, and liver) can also weaken bone density, leading to falls and bone fractures.

Some types of medicinal therapy that, too, negatively impact bones include treatment with “anti-seizure drugs, such as phenytoin (Dilantin®) and barbiturates; gonadotropin releasing hormone (GnRH) analogs used to treat endometriosis; excessive use of aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone,” researchers say.

The CDC argues that, as patients age, medicines change the way they operate in their bodies. Some drugs, or a cocktail of them, can make a senior patient dizzy, which can lead to falling and injury.

With respect to vision, the agency instructs senior patients to have their sight examined by their optometrists and ophthalmologists at least once annually. The CDC says that seniors may wear the wrong glasses or may endure a condition like glaucoma or cataracts that restrict their ability to see, which, in turn, poses a danger for falling and injury.

In terms of home safety and security, the CDC teaches senior patients that, statistically, half of all falls and subsequent injuries take place in the home. To prevent falls, the agency recommends that seniors and their families be mindful of the following when making their private homes safer and more secure:

–Remove items that encourage tripping such as papers, books, clothes and shoes from the staircases and other areas in which they walk;
–Discard small throw rugs or use tape to keep them from slipping and causing a fall;
–Maintain items that are used most often in cabinets where they can easily reach without a step stool;
–Order the installation of grab bars near the toilet or in the tub or shower of their bathrooms;
–Apply non-slip mats in the tub and on the floors of showers;
–Enhance lighting in their home as they will need brighter lights for their vision as they age;
–Place light-weight curtains or shades in different rooms throughout the home to reduce glare;
–Request the installation of handrails and lights on all staircases;
–Put on shoes both inside and outside of the home, and;
–Do not go barefoot or wear slippers.

Vestibular, Balance Disorders

Many physical therapists, possibly with certification in mechanical diagnosis and therapy (MDT), provide orthopedic, neurological and vestibular consultation to prevent falls and injury risk among its patients.

In their offices, physical therapists and their staff may offer a complete balance, fall risk and strengthening program that local-area neurologists and ear/nose/throat (ENT) physicians may use.

Typically, the gamut of physical therapy services include arthritis/chronic pain, back pain, balance disorders, carpal tunnel syndrome, dizziness and arm, shoulder and leg pain, fracture, fibromyalgia, temporomandibular joint dysfunction (TMJ), neck pain, neuropathy, occupational injuries, Parkinson’s disease, pre- and post-surgical rehabilitation, sports injuries, sprains, strains and whiplash, stroke and multiple sclerosis.

For such offices, a referring physician base includes cardiologists, ear/nose/throat (ENT) physicians, family practice physicians, internal medicine physicians, neurologists, neurosurgeons, obstetrics/gynecologists, orthopedic surgeons, otoneurologists, pain medicine specialists, physiatrist, podiatrists and sports medicine specialists.

Before the staff can provide a patient with services for balance, fall risk and strength training, he or she must have his or her medical history examined. He or she must undergo a balance self-test, satisfying the following conditions:

–The patient may have fallen in the past year;
–The patient may have taken medications for two or more chronic illness: heart disease, hypertension, arthritis, anxiety or depression;
–The patient may have suffered a stroke or another neurological problem, impacting his or her balance;
–The patient may use a walker or wheelchair or may need assistance with his or her mobility, and;
–The patient must have had numbness or a loss of sensation in his or her legs or feet.

An audiologist begins a diagnosis of a senior patient at risk for falls and injury by testing his or her hearing and balance to evaluate the proper function of his or her inner ear balance system and hearing mechanisms.

If the audiologist discovers a problem, he or she will refer the patient for treatment whether it is vestibular therapy or medical/surgical remediation. The patient will be sent to an ear/nose/throat (ENT) specialist or a physical therapist. Physical therapy for balance disorders calls for training and certification to conduct the appropriate exercises and regimens.

A fully-equipped and functioning physical therapy center will use computerized equilibrium tests to review the sensory and motor elements of a patient’s balance system.

Sensory tests will investigate inner ears, eyes and joints that participate in balance control. Our motor tests will examine the patient’s ability to carry out coordinated movements, both voluntary and involuntary, to keep his or her balance.

The tests will discover the root cause of a patient’s balance problem and will form the base of a customized physical therapy program for him or her.

In particular, the patient may suffer from vestibular (inner ear) disorders, which are related to his or her balance. Vestibular disorders can lead to anxiety, difficulty concentrating, dizziness, fatigue, hearing changes, imbalance, nausea, vertigo and other symptoms.

Such symptoms may devastate the life or health of a patient, causing him or her to not function fully and rendering him or her incapable of working, maintaining ties with family and friends and keeping up a normal quality of life.

Vestibular disorders can stem from aging, allergies, head trauma, heart disease, nerve neuronitis (decreased nerve function), poisoning, viral infection and other illnesses of the inner ear.

Making a diagnosis and planning treatment for vestibular disorders is challenging, in part, because such illnesses are not invisible, making it hard for individuals to comprehend the attendant disabilities.

Senior patients are cautioned to seek out physicians and specialists with the proper credentials to appropriately diagnose and treat their balance disorders.

CDC’s Compendium

The CDC’s Compendium is targeted at providing public health groups and senior long-term care and short-term care facilities with the information they need to find the most appropriate fall prevention programs to suit the needs of seniors in particular communities.

The publication process for the Compendium began when the Centers for Medicare and Medicaid (CMS) assigned the RAND Corporation in 2003 to examine pre-existing research on fall prevention programs, which occurred by process of elimination.

RAND searched for literature and found 826 studies of which 95 qualified for further review because they met the following requirements: involved seniors aged 65 and older; used a randomized or controlled clinical study format; recognized falls as an outcome, and; calculated the number of falls three months before the start of a prevention program.

Out of the qualifying 95, about 57 cited falls as an outcome and 38 revealed the number of subjects who fell once or their monthly rates of falling. RAND singled out these 38 studies for further study and to decide on the success of their programs under the categories of physical exercise, education or awareness, environmental change or a combination of different types of solutions.

In reviewing the remaining 38 selected by RAND, CDC acknowledged those that had the following in common: involved community-dwelling seniors aged 65 or older; used a randomized or controlled clinical study format; recognized falls as an outcome, and; presented meaningfully successful fall prevention results.

The agency purged the collection of one study that focused on nursing home patients, four that did not prioritize falls and 25 that did not provide substantial outcomes. This left eight, two of which had to be combined because they represented the same study.

Then, the CDC found seven additional qualifying studies after RAND published its report on its findings. As a consequence, the first edition of the Compendium, which contained 14 studies released before Dec. 31, 2004, was published in 2008.

The first Compendium sets the format for the ones to follow, which include study summaries, intervention descriptions, summary tables, contact information, a bibliography and appendices.

The agency sought to update the original Compendium in 2009. A search of trials of fall prevention programs released between Jan. 1, 2005 and Dec. 31, 2009 turned up 86 studies. Two programs were scrapped because they were duplicated.

Of the total 84, the CDC trimmed off 20 that were not randomized controlled trials, 15 that did not center upon community-dwelling seniors aged 65 and older, 27 did not prioritize falls and 14 did not register meaningful successes in preventing falls. The remaining eight were published between January 2005 and December 2009 and were placed in the second edition of the Compendium in 2010.

In the second edition, the categories of fall prevention programs included exercise-based activities, home modifications and multifaceted interventions. The third edition added to two more categories — single interventions and clinical programs — to the pre-existing three groups.

The resulting 22 programs are aimed at addressing a variety of beneficiaries. Some are meant to accommodate the oldest of the elderly, some are designed for a special segment such as the blind and others are made for particular circumstances such as walking on ice and snow. The following summaries convey a portion of the basic information about the 22 programs as they appear in the second edition of the compendium.

EXERCISE-BASED INTERVENTIONS

Stay Safe, Stay Active — Barnett, et al.
This study used weekly structured group sessions of moderate-intensity exercise, held in community settings, with additional exercises performed at home. Participants were 40 percent less likely to fall and one-third less likely to suffer a fall-related injury compared with those who did not receive the intervention.
POPULATION: Participants were individuals at risk for falling because of lower limb weakness, poor balance, and/or slow reaction time. All were aged 67 or older and lived in the community. About two-thirds of participants were female.
GEOGRAPHIC LOCALE: Southwest Sidney, Australia
FOCUS: Improve balance and coordination, muscle strength, reaction time and aerobic capacity.
PROGRAM SETTING: Classes were conducted in local indoor lawn bowling and sports clubs that hosted community programs for various sports and exercise activities, comparable to United States: community exercise, sports and recreation facilities. Many lawn bowling and sports clubs also included other indoor attractions such as restaurants, meeting facilities and movies.
DURATION: A total of 37 1-hour classes were conducted once a week over a 1- year period.
KEY ELEMENTS: This study used health practitioners to assess and recruit participants. General practitioners are in an ideal position to both identify older people at risk of falls and to support their participation in an exercise program when appropriate. The program used existing services and facilities in the community so it is likely to be sustainable and transferable to other settings.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information; Anne Barnett, MPH Physiotherapy Department Bankstown Hospital, Locked Mailbag 1600 Tel: +61 (9) 722-7154, Fax: +61 (9) 722-7125, e-mail: [email protected]

The Otago Exercise Program — Campbell et al. and Robertson et al.
This intervention, tested in 4 randomized controlled trials and 1 controlled multi-center trial, was an individually tailored program of muscle-strengthening and balance-retraining exercises of increasing difficulty, combined with a walking program. This extensively tested fall prevention program is now used worldwide. Overall, the fall rate was reduced by 35 percent among program participants compared with those who did not take part. The program was equally effective for men and women. Participants aged 80 years and older who had fallen in the previous year showed the greatest benefit.
POPULATION: Participants were aged 65 to 97 years and lived in the community.
GEOGRAPHIC LOCALE: Dunedin, New Zealand
FOCUS: Improve strength and balance with a simple, easy-to-implement and affordable home-based exercise program.
PROGRAM SETTING: The program was conducted in participants’ homes and was intended for people who did not want to attend, or could not reach, a group exercise program or recreation facility.
DURATION: The exercises took about 30 minutes. Participants were encouraged to complete the exercises 3 times a week and to walk outside the home at least 2 times a week. Exercises then were continued on an ongoing basis. In 3 trials, the exercise program was prescribed for 1 year and in 1 trial was extended to 2 years.
KEY ELEMENTS: PTs should understand the research evidence on which the program is based and avoid adding or subtracting exercises from the set used in the trials, as this particular combination of exercises worked to reduce falls.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information; M. Clare Robertson, PhD Research Associate Professor Department of Medicine, Dunedin School of Medicine University of Otago, P.O. Box 913 Dunedin 9054, New Zealand Tel: +64 (3) 474 7007 extension 8508 Fax: +64 (3) 474 7641 e-mail: [email protected]

Erlangen Fitness Intervention — Freiberger, et al.
This study examined 2 interventions to reduce falls: a psychomotor intervention that focused on body awareness, body experience, and coordination; and a fitness intervention that focused on functional skills, strength, endurance, and flexibility. Both interventions included group classes, home-based exercises, and physical activity recommendations. Only the fitness intervention was effective in reducing falls. Compared to the control group, participants in the fitness group experienced 23 percent fewer falls.
POPULATION: The participants were community-dwelling, physically active people in very good health, aged 70 or older. Slightly more than half were male.
GEOGRAPHIC LOCALE: Erlangen, Germany
FOCUS: Improve functional skills, strength, endurance and flexibility.
PROGRAM SETTING: The group classes were conducted at the University of Erlangen-Nuremberg, Institute of Sport Science, and the home-based portion was carried out in participants’ homes.
DURATION: One-hour classes were held twice a week for 16 weeks. In addition, participants were instructed to perform selected exercises at home on a daily basis between sessions and after the program ended.
KEY ELEMENTS:
Strength, endurance and functional skill exercises, including balance and gait training, should increase in intensity over the duration of the program. Trainers must attend the program training.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Dr. Ellen Freiberger Institut fur Sportwissenschaft und Sport Friedrich-Alexander-Universitat Erlangen-Nurnberg Gebbertstrasse 123b, DE-91058, Erlangen, Germany Tel: +49 9131 852 5464 Fax: +49 9131 852 5002 e-mail: [email protected]

Tai Chi: Moving for Better Balance–Li, et al.
This study compared the effectiveness of a 6-month program of Tai Chi classes with a program of stretching exercises. Participants in the Tai Chi classes had fewer falls and fewer fall injuries, and their risk of falling was decreased 55 percent.
POPULATION: Participants were inactive seniors aged 70 or older. Three-quarters were female. All participants lived in the community.
GEOGRAPHIC LOCALE: Portland, Oregon, United States
FOCUS: Improve balance and physical performance with Tai Chi classes designed for older adults.
PROGRAM SETTING: The Tai Chi programs were conducted in community settings such as local senior centers and adult activity centers.
DURATION: One-hour classes were held 3 times a week for 26 weeks, followed by a 6-month period in which there were no organized classes.
KEY ELEMENTS:
Program settings can include facilities such as senior centers, adult activity centers and community centers. An average class size of 25 is ideal for effective learning and teaching. For this program to be successful, participants should attend Tai Chi classes at least 2 times a week and participate actively in class. Tai Chi can also be used in rehabilitative settings where the emphasis is on retraining balance in older adults.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Fuzhong Li, PhD Oregon Research Institute 1715 Franklin Boulevard Eugene, OR 97403, United States Tel: 541-484-2123 e-mail: [email protected]

Multi-Specialty Teams Help Seniors Manage Diabetes (Part 2 of 2)

Vision Impairments

Pharmacists, podiatrists, dentists and dental hygienists as well as optometrists and ophthalmologists are asked to examine diabetics for the most common diabetes-related eye diseases: retinopathy, double vision, vision fluctuations, cataracts, macular edema and ocular nerve palsy.

A comprehensive diabetic eye exam takes into consideration the following factors: visual acuity, visual fields, pupillary reaction, intraocular pressure, cranial nerves, a slit-lamp exam and a dilated retinal exam.

Diabetes is the condition most responsible for new incidence of blindness in adults aged 20 to 74 years of age. Retinopathy triggers 12,000 to 24,000 new cases annually. Diabetics are encouraged to care for their eyes by undergoing a complete vision exam yearly, including a dilated eye test with intervention if retinopathy is discovered.

Diabetics are 25 times more likely to develop blindness than those not afflicted with the condition. Particularly, diabetics who use cigarettes, eat poorly and do not control their blood sugar levels are at greater risk for cultivating eye conditions.

Because diabetes causes patients to heal slowly from wounds or injuries overall, eye conditions, including minor corneal scratches, ought to be taken seriously by optometrists and ophthalmologists.

Diabetes retinopathy is a diabetic eye complication caused by excess blood sugar damaging the blood vessels of the eye, leading to breakdowns, leaks or blockage.

This may lead to retinal hemorrhage and compromised delivery of oxygen to the retina, which may translate into the growth of deformed vessels. Such vessels are delicate and can break easily, resulting in the loss of vision.

One out of every 12 diabetics aged 40 years and older suffer from retinopathy. Research finds that aspirin use is safe in use for diabetics with retinopathy and the condition is treatable and preventable.

Poor blood sugar level control and a long history of diabetes can raise the risk of senior patients with type 1 and type 2 diabetes developing retinopathy. Thus, self-management of blood sugar, blood pressure and lipid can reduce or delay this risk by 76 percent in diabetics.

Early detection of retinopathy can cut back on the risk of retinopathy-related vision loss by 90 percent in diabetics. Still, half of all diabetics are not having their eyes examined or are found to have developed too advanced a stage of these eye conditions to be treated in time. Additionally, diabetics are in danger of contracting glaucoma and cataracts.

Enhanced therapy lessens the presence of retinopathy by 27 percent and retinal laser photocoagulation surgery can cut the risk from the most aggressive form of the illness, also known as proliferative diabetic retinopathy (PDR), to at least 4 percent.

Optometrists and ophthalmologists can supply such vision aids as simple hand magnifiers or optical devices for diabetics who have lost their sight to retinopathy. Eye care professionals can also seek to provide a comprehensive suite of care and services to allow visually-impaired diabetics to keep their dignity and control their diabetes.

Senior diabetics are at risk for developing cataracts, which represents a clouding of the eye lens with aging being the main cause of this condition. The lens focuses images that enter the eye onto the retina. A clouding would mean limited vision and more sensitivity to glare. More than half of seniors have cataracts.

Glaucoma is a condition damaging the optic nerve. The nerve carries images in the retina to the brain so obstruction of this transfer means the development of blind spots or field loss, which eventually leads to complete blindness.

A dilated eye exam, visual field testing, intraocular pressure testing and other exams provide a view of the optic nerve and can detect glaucoma early, making treatment possible.

With patients aged 40 years or older, about 2.2 million suffer from glaucoma while another 1.1 million don’t know they have the illness. African-American seniors are two times likely to develop glaucoma as their white peers.

Diabetics may complain about the onset of double imagery because of damage to the nerves from the brain to the eye. This warrants an immediate visit to the optometrist or ophthalmologist.

Double vision, an ocular complication, can be mistaken by a diabetic or a specialist other than an optometrist or ophthalmologist as stroke or another neurological condition, which can needlessly lead to radiological exams.

This complication may be due to mononeuropathy or damage to a single nerve. As a solution, third-nerve palsies take place with pupillary sparing in 80 percent of these cases. Most diabetics suffering from this condition experience healing within two to three months and double vision can be managed with special lenses.

Poor control of blood sugar levels can lead to fluctuation in vision. Poor blood sugar level control can cause fluid imbalance in the lens, which triggers the fluctuations.

When blood sugar levels are raised, the lens grows thicker and the resulting changes in vision may lead to nearsightedness or farsightedness. When blood sugar levels drop, the lens returns to its normal size. With inconsistent blood sugar level control, diabetes with glasses will find it hard to determine the best lenses to wear for their changing eyesight.

The NIH-CDC workgroup instructs specialists to ask diabetics the following questions about their eye health:

–Whether they are aware of the connection between diabetes and eye health, the risk of diabetic retinopathy, its responsibility for blindness and avoidance through sound blood sugar level control;

–Whether they know that, as diabetics, they are at risk for developing such eye conditions as cataracts and glaucoma and such symptoms as fluctuations in vision, double vision or dry eye;

–When they have last had a comprehensive dilated eye exam and whether they have one yearly and a regular eye screening to avoid blindness due to diabetic retinopathy;

–If they have reported eye symptoms to their primary care physicians and have a prescription for eyeglasses, contact lenses or vision aid, and;

–How often and long do they suffer from these eye symptoms and whether they report any changes in eyes or visions such as blurriness, spots, redness or pain to their primary care physicians, optometrists or ophthalmologists.

Dental Loss

Pharmacists, podiatrists, optometrists and ophthalmologists as well as dentists and dental hygienists are asked to check their senior diabetics for the following diabetes-related oral health conditions: changes in teeth, periodontal disease and oral candida (thrush).

A comprehensive oral exam will take teeth, gums, periodontal probing, intraoral lesions, infections or masses and insufficient saliva flow into consideration.

Diabetes can cause changes in the teeth and mouth. Dentists and dental hygienists are most concerned about how diabetes affects the health of gums and periodontal tissues.

Poor blood sugar level control is linked to gingivitis and other periodontal conditions. Symptoms of diabetes and dental illness include a neurosensory disorder known as burning mouth syndrome, problems in taste, abnormal wound healing and a fungal infection known as candidiasis.

Senior diabetics with oral health problems will note that they have a fruity breath, caused by a colorless, flammable, liquid substance known as acetone (a simple ketone used in nail polish), frequent xerostomia or dry mouth or a change in the thickness of their spit or saliva. This is dangerous as dry mouth can usher in an increase of dental decay.

Besides fruity breath, thickness in saliva, dry mouth and possible dental decay, xerostomia is also characterized by gum disease, especially red, swollen and bleeding ones or gums pulling from the teeth, pus between gums, loose teeth or change in bite or tooth position and candidal infection or thrush.

Dental problems in senior diabetics are connected with other discoveries such as a vast loss of fluids through excess urination, infection, a change in connective tissue and function, neurosensory malfunction, microvascular changes, drugs causing dry mouth and increased sugar concentration in saliva.

Cigarette use worsens these oral conditions, researchers say. However, often senior diabetics focus on other problems or complications tied to diabetes and oral care can be neglected. Aside from blood sugar level control, they say, sound oral hygiene can alleviate all of these problems.

Senior diabetics are two to three times more likely than non-diabetics to develop periodontal disease, such as periodonititis. Periodontal disease is an infectious, chronic, inflammatory illness that damages connective tissue and bones supporting teeth and leading to tooth loss.

Among individuals with type 1 and type 2 diabetes, periodontal disease is more likely to develop, especially more quickly and in a much more severe form than in non-diabetics. Research finds a powerful association between diabetes and periodontal disease.

Not only are diabetics more prone to periodontal disease but also this condition can make blood sugar level control harder. Oral care that includes treating periodontal disease may help diabetics control their blood sugar levels.

Research has found a relationship between an individual’s resistance to insulin and inflammatory disease. Swollen periodontal tissue, which can be as large as an adult’s palm in size, contains blood vessels and can be subject to ulcers. This infection may poison the blood with bacteria.

Such infection can cause the liver to produce “acute-phase proteins such as C-reative protein (CRP), serum amyloid A, and fibrinogen.” The level of these proteins can be raised in the blood of patients with periodonititis and have been known to damage other vital organs.

As a result, periodontal disease can ultimately lead to the development of other such illnesses as diabetes mellitus and heart disease.

The NIH-CDC workgroup says this can all be avoided by using periodontal probing by a dentist or dental hygienist as a diagnostic tool that can measure diabetics’ reactions to treatment with the following questions:

–Whether they are aware of the connection between poor control of blood sugar levels and gum disease and that oral care can control diabetes;

–Whether they practice sound dental hygiene such as brushing teeth after eating, flossing at least once daily and proper denture management;

–Whether they conduct monthly oral self-exams and contact their dentists or dental hygienists if they find signs of infection such as sore, swollen or bleeding gums, loose teeth and ulcers, and;

–Whether they experience symptoms that suggest infection such as bad taste, bad breath or pain and can determine when problems require medical attention.

Heart Conditions

Type 2 diabetics are twice to four times as likely to suffer from cardiovascular disease or endure a stroke than non-diabetics. Heart disease is the main cause of death for diabetics.

However, research in recent years have shown that there are clinical approaches that can prevent or delay the onset of complications of diabetes as well as the illness itself.

Some studies, such as the national Diabetes Control and Complications Trial (DCCT), demonstrate that blood sugar level control decreases the risk of microvascular disease in type 1 diabetics.

Namely, blood sugar level control translated into a 76 percent decrease in eye conditions, including 63 percent in retinopathy, a 54 percent drop in nephropathy and a 60 percent plunge in neuropathy.

The United Kingdom Diabetes Study (UKPDS) demonstrated that type 2 diabetics enhanced blood sugar level control from an A1C of 7.9 percent to that of 7.0 percent, leading to a decrease in the risk by 25 percent for microvascular disease; 17 percent to 21 percent for retinopathy, and; 24 percent to 33 percent for albuminaria, a disease in which the protein, albumin, is present in the urine.

Additionally, lower A1C also cut down the risk of macrovascular disease with a 16 percent decrease in heart disease and a 24 percent decrease in cataracts. The UK study also finds low blood sugar level control not only decreased diabetic complications but also led to blood pressure control.

The study concluded that “tight blood pressure” lessened the risk of retinopathy progression by 34 percent; vision loss by 47 percent; diabetes-related deaths by 32 percent; microvascular disease by 37 percent; heart failure by 56 percent, and; stroke by 44 percent.

Moreover, clinical trials like the Appropriate Blood Pressure Control in Diabetes Trial (ABCD) and Heart Outcomes Prevention Evaluation Study (HOPE) also demonstrates that an ACE inhibitor decreases the risk of heart failure, stroke or cardiovascular deaths by 25 percent to 30 percent in patients with type 2 diabetes and delays the development of kidney damage of diabetes.

Drug Therapy

Aside from pharmacists, podiatrists, optometrists and ophthalmologists, dentists and dental hygienists must confer with their senior diabetics for the following “drug management” issues: inappropriate drug choice, “underdosage, overdosage,” bad drug reactions and “drug interactions.”

Specialists must consult with their senior patients about strategies for managing their medications such as in their “use, monitoring treatment, self-treatment, over-the-counter (OTC) medications, selecting and using a blood sugar meter, cost control and coordination of care.”

Individuals most at risk for drug-related issues include those with severe long-term illnesses, take five or more medicines and those who see a variety of specialists. For professionals, this means complete reviews of drugs and their records, training of senior patients to comply with drug regimens and assessments of the way in which patients react to therapy to intervene properly and to coordinate and maintain plans of care.

The latest drugs and medical technologies give senior patients and physicians choices for treating diabetes and its complications. If not properly administered, however, they can lead to serious disease, disability or death.

Research in 2001 found that improper use of drugs nationally costs $177 billion a year in hospital re-admissions, extra therapy and visits to the doctor’s office, a boost from $76.5 billion in 1995.

Worse still, research averages that 218,000 drug-related deaths per year are due to misused drugs. Aside from inappropriate drug choice, “underdosage, overdosage,” bad drug reactions and “drug interactions,” researchers also examine untreated illnesses and drugs with no particular treatment goal.

Research also finds that over half of patients with chronic illness do not take their drugs appropriately. More than 60 percent of diabetics do not control their blood sugar levels. Of all high blood pressure and cholesterol patients, about 65 percent and 49 percent consecutively, are not able to reach their intended health goals.

As a result, researchers advise specialists to urge their senior patients to comply consistently with proper drug use directives and minimize lethal drug interactions and to track their conduct. These actions maximizes health outcomes and results in savings to the healthcare system, they say.

Diabetics ought to forge a relationship with a pharmacist who can supervise drug regimens, advise on how to self-administer drugs and inform them about other methods of controlling their diabetes.

The NIH-CDC workgroup prods specialists, especially pharmacists, to ask diabetics the following questions about their drug management strategies:

–Whether their drug routines are individualized for the best times to take these medications, avoiding side effects and poor drug interactions;

–Whether they use compliance aids, the proper dosage forms and a drug delivery system to effect proper drug use;

–Whether they are using nonprescription treatments such as vitamins, minerals, herbals, nutritional supplements or skin-care products, (Research finds that more than 57 percent of diabetics use alternative therapies.);

–How serious and urgent are their complaints, what is the appropriate level of self-administration warranted for the drugs they take and what warnings are there for the drugs they use;

–How much is a follow-up or a referral to another specialist warranted;

–Whether they use a blood sugar monitoring device and are properly trained to use it, knowing about the results, the correct actions to take and the appropriate times to seek help, and;

–Whether they know how to lower the costs of drugs and supplies through private insurers, prescription drug programs, Medicare and Medicaid, generic medications and coverage for referrals to other specialists.

Coordination of Care

Researchers acknowledge that comprehensive diabetic care is riddled with problems as it is provided by several specialists in different types of facilities. There may be changes in drug regimens when senior patients visit their physicians or at the time of severe illness or hospital stays.

When a patient stricken with numerous complications of diabetes and taking a cocktail of drugs to treat them, including over-the-counter medications, herbals and supplements, they and their specialists must practice careful self-administration and management.

Research shows that collaborative drug therapy management (CDTM), given by pharmacists and other specialists, revealed the myriad problems faced by patients’ in 65 percent of their drug routines.

Still, more research found that CDTM ended in decreased incidence of disease as well as lower costs linked to fewer doctors’ visits, emergency hospital visits and hospital stays.

Through coordinated care, all the specialists in a medical team as well as the patient can take advantage of a single point of contact to provide the appropriate drug regimens, instructions and essential tracking for effectiveness and drug interactions.

As a consequence, the NIH-CDC workgroup urge specialists to commit to the following in promoting the comprehensive diabetic care approach to addressing a patient’s medical needs:

–Encourage medical leadership to set up policies and procedures for quality diabetic care in a strategic plan;

–Recruit and consult with a designated diabetes coordinator and the care team;

–Instruct patients to perform self-management drug actions per the NDEP and ADA protocols;

–Rework the healthcare delivery system to allow for the use of registries and tracking mechanisms for appointments;

–Review charts for the office visits in the same system;

–Manage cases with a care coordinator using the same system;

–Make and back up medical decisions using flowsheets and electronic health records, and;

–Build relationships with local community organizations.

ADDITIONAL SOURCES:

American Academy of Ophthalmology, http://www.aao.org

American Academy of Optometry, http://www.aaopt.org

American Academy of Periodontology, http://www.perio.org

American Association of Clinical Endocrinologists, http://www.aace.com

American Association of Diabetes Educators, http://www.diabeteseducator.org

American College of Clinical Pharmacy, http://www.accp.com

American Dental Association, http://www.ada.org

American Dental Hygienists Association, http://www.adha.org

American Dietetic Association, http://www.eatright.org

American Optometric Association, http://www.aoa.org

American Pharmacists Association, http://www.aphanet.org

American Podiatric Medical Association, http://www.apma.org

American Public Health Association, http://www.apha.org

American Society of Health-System Pharmacists, http://www.ashp.org

HRSA Health Disparities Collaboratives, http://www.healthdisparities.net

National Association of Chain Drug Stores, http://www.nacds.org

National Community Pharmacists Association, http://www.ncpanet.org

National Diabetes Information Clearinghouse, http://diabetes.niddk.nih.gov

National Eye Institute, http://www.nei.nih.gov

National Heart, Lung and Blood Institute, http://www.nhlbi.nih.gov

National Institute of Dental and Craniofacial Research, http://www.nidcr.nih.gov

National Optometric Association, http://www.natoptassoc.org