Senior Health

Back Symptoms Affect Function in the Elderly

Age and health burden have been associated with back symptoms and functional limitations in previous studies; however, little data addresses how back symptoms impact overall physical disability, the proportion of disability attributable to back symptoms, or the association between site-specific back symptoms and functional limitations in people older than age 70.

In a study designed to determine the relationship between back symptoms and limitations in performing specific functional activities, 1,007 surviving members (ages 70-100) of the Framingham Heart Study provided information on whether they experienced pain, aching or stiffness in any joints on most days. Subjects also identified the location of their problem by selecting its location from a picture of the back regions that clearly defined the neck, upper back, midback and lower back.

Subjects were also asked about whether they had any difficulty performing one or more of nine functional skills: standing in one place for approximately 15 minutes; walking one-half mile; stooping, crouching or kneeling; lifting a 10-pound object off the floor; putting on socks or stockings; getting in and out of a car; pushing or pulling a large object (i.e., a living room chair); reaching or extending the arms above shoulder level; and writing, handling

or fingering small objects. Functional limitation when performing any of the nine activities was determined if the subject stated that he or she experienced considerable difficulty performing the activity or was unable to perform it altogether. The proportion of the study population with a particular functional limitation that they attributed to back symptoms was also determined.

Results: Most subjects reported problems performing at least one functional activity, and limitations were more than twice as common in those with back symptoms than those without such symptoms. Back symptoms accounted for a significant proportion of functional limitations (43%-63% of limitations), particularly for activities such as standing in one place for approximately 15 minutes and pushing or pulling a large object. The association between back symptoms and functional limitations proved stronger in women than in men.

Edmond SL, Felson DT. Function and back symptoms in older adults. Journal of the American Geriatrics Society December 2003;51(12):1702-09.

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Recognizing Neurologic-Based Pain in the Elderly

Pain in the elderly population is often attributed to chronic musculoskeletal conditions such as osteoarthritis. Health care practitioners must remain wary of other conditions that may cause widespread pain, particularly if such pain has neuropathic features (allodynia, hyperpathia or hyperalgesia).

This article presents a case report of an elderly patient presenting with widespread pain attributed to thalamic pain syndrome, otherwise known as central post-stroke pain (CPSP). Discussion of the basic characteristics of neuropathic pain and testing techniques are presented to help clinicians identify patients presenting with this condition. Included in the case report is a discussion of the patient�s:

* chief complaint;
* mental status examination;
* physical examination;
* diagnostic imaging and laboratory test results;
* differential diagnoses; and
* treatment options.

The author emphasizes the role of the chiropractor in correct diagnosis and referral and continued chiropractic support and follow-up in the form of musculoskeletal treatment for residual discomfort. He also stresses the importance of this case report in illustrating nonmusculoskeletal conditions that may present as musculoskeletal pain.

Specific Risk Factors Predict Functional Decline in Elderly Women

It has been estimated that more than 20% of Americans aged 65 and older live with a disability. Functional declines in the elderly have been associated with age and socioeconomic status, but modifiable risk factors have yet to be determined - a shortcoming that may have prompted this study.

A volunteer sample of 6,632 community-residing women was recruited to identify modifiable predictors of functional decline.

Functional decline was defined as inability over a four-year interval to perform one or more of five "vigorous" activities (household chores; heavy housework; shopping; climbing stairs; or walking 2-3 blocks), or one or more of eight "basic" activities (getting in/out of bed; turning faucets on/off; getting in/out of a car; dressing oneself; washing and drying entire body; bending down; preparing one's own meals; or lifting a full cup/glass to one�s mouth).

Of the 10 potential risk factors studied, eight proved significant predictors of functional decline in terms of ability to perform at least one of the five vigorous activities or one of the eight basic activities. The authors present a clinically useful prediction tool for functional decline based upon the following eight modifiable risk factors:

* slow gait (< 1 meter per second on a 6 meter course);
* use of short-acting benzodiazepines;
* geriatric Depression Scale rating of > 6;
* exercise levels lower than 448 kcal per week;
* obesity measured as body mass index > 29;
* weak grip strength (< 15 kg average);
* use of long-acting benzodiazepines; and
* visual acuity worse than 20/40.

Conclusion: Functional decline may be attributable to specific risk factors responsive to short-term intervention. The authors suggest that by "using eight modifiable predictors that can be identified at a single office visit, clinicians can identify older women at risk for functional decline."

Sarkisian CA, Liu H, Gutierrez PR, et al. Modifiable risk factors predict functional decline among older women: a prospectively validated clinical prediction tool. Journal of the American Geriatrics Society, Feb. 2000:48, pp170-78.

Involvement in Activities Improves Function in Elderly

It is estimated that 250,000 hip fractures occur in the United States each year, affecting primarily Caucasian females between the ages of 85 and 95. Most do not regain their previous level of functioning, and many become permanently institutionalized in nursing homes.

Twenty women who were admitted to a rehabilitation facility after suffering hip fractures were separated into two groups for study purposes. The first group (10 subjects) received intervention based on a biomechanical approach. This model asserts that improvement in physical function will result in improvement in overall function, as assessed by predetermined outcomes such as strength and flexibility. The second group of 10 subjects received intervention based on occupational adaptation. This model focuses on the improvement of the patient based upon parameters of daily activities (i.e., cooking, cleaning, sewing, etc.) and the adaptation program made with each individual patient.

Results showed no significant difference in improvement of patients receiving biomechanical intervention compared with those receiving adaptation intervention. However, both groups improved during the course of care, suggesting that a sense of involvement in the rehabilitation process and participation in activities of interest are therapeutic.

Buddenberg LA, Schkade JK. Special feature: a comparison of occupational therapy intervention approaches for older patients after hip fracture. Topics in Geriatric Rehabilitation, June 1998;13(4), pp52-68.

Pain Management and Disability in the Elderly

As the number of people 65 years of age and older increases, the need for appropriate pain-management strategies becomes more critical. Although a high proportion of the elderly population reports musculoskeletal pain and physical disability, very little research has examined the potential association between the two.

Eight hundred and eighty-seven community-dwelling senior citizens in Ontario, Canada completed a postal questionnaire which assessed the presence of musculoskeletal pain (self-reported pain in joints, muscles or bones) and the amount of difficulty performing three or more routine activities (eating, walking, reaching, gripping, etc.)

Of the study participants, 644 (72.7%) reported musculoskeletal pain, and 500 (56.5%) were classified as having a physical disability. A significantly higher percentage of patients reporting pain were identified as having a disability, compared to patients who reported no pain (68.6% vs. 24.1%).

These results emphasize the need for competent management of pain and its underlying causative disorders. The valuable information in this article can be used to develop educational and preventative programs designed to promote more active and healthy lives in the geriatric community.

Scudds RJ, Robertson JMcD. Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens. Pain, April 1998;75, pp229-35.

Management of Chronic Pain in the Elderly

Pain is recognized as a complex experience derived from sensory stimuli and influenced by individual memory, expectations and emotions. In older people, arthritis, bone and joint disorders, degenerative back dysfunction, and other chronic conditions can cause debilitating pain and frustration.

This position paper by the American Geriatric Society outlines clinical practice guidelines for managing chronic pain in the elderly population. Recommendations for appropriate case management are presented in a comprehensive, concise format focusing on:

* pain assessment and classification;
* conservative intervention techniques;
* exercise recommendations;
* pros and cons of pharmacologic therapy; and
* the importance of patient education.

Included throughout the paper are informative tables, charts, records and scales that can be utilized in clinical practice. Classifying chronic pain in pathophysiologic terms can help determine prognosis and an appropriate course of care. The information presented in this paper can serve as a valuable tool for clinicians managing geriatric patients.

AGS Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons.Journal of the American Geriatric Society, 1998;46, pp635-51.