Pain Management Options Based on the category of illness and their stage level of sickness
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.
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.
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: firstname.lastname@example.org
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@example.com
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.
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: firstname.lastname@example.org
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.
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@example.com
Pain Management Options Based on the category of illness and their stage level of sickness
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