GERINOTES Academy of Geriatric Physical erapy

Th is Issue President’s Message

Editor’s Note

Policy Talk: Post-acute Care Payment is Changing

My Opinion: Productivity, an Ambiguous but Widely Sighted Monster

Debility and Functional Decline in Long-term Care Facilities: Are We Part of the Problem?

A Multi-disciplinary Event to Celebrate Falls Prevention Awareness Day National Fall Prevention Awareness Day Celebrations RIC RIAT PH Knowledge Translation – What Is It? E YS G IC F A Persistent Postural Perceptual Dizziness in the O L Elderly: A Theoretical Hypothesis for a Y T Missed Diagnosis in the Underserved Population M H

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Impact or LSVT-BIG on Functional Outcomes R

in a Patient with Parkinson’s Disease: A Case Study D A

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External Gait Cues: Improving Gait in Persons with Y

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Parkinson’s Disease

GET LIT A

m n o Core Values: Measurement in Older Adults e ti ri ia ca c n so 3D Pharmacology: Management of Depression, Ph s ys py A Delirium, and Dementia in Older Adults ical Thera

January 2019 | Volume 26, No. 1 TABLE OF CONTENTS

President’s Message...... 3 Knowledge Translation – What Is It?...... 16 Greg Hartley Mariana Wingood, Mary Milidonis

Editor’s Note...... 4 Persistent Postural Perceptual Dizziness in Michele Stanley the Elderly: A Theoretical Hypothesis for a Missed Diagnosis in the Underserved Population...... 18 Policy Talk: Post-acute Care Payment is Changing...... 5 Jeffrey R. Guild Ellen R. Strunk Impact or LSVT-BIG on Functional Outcomes in My Opinion: Productivity, an Ambiguous a Patient with Parkinson’s Disease: A Case Study...... 20 but Widely Sighted Monster...... 9 Blake A. Hampton, Niamh Tunney, Daryll Dubal Gabriel Alain External Gait Cues: Improving Gait in Persons Debility and Functional Decline in Long-term with Parkinson’s Disease...... 24 Care Facilities: Are We Part of the Problem?...... 11 Alex Piersanti Heidi Sue Moyer GET LIT A Multi-disciplinary Event to Celebrate Core Values: Measurement in Older Adults...... 26 Falls Prevention Awareness Day...... 13 Carole Lewis, Valerie Carter Bonnie L. Rogulj, DeAnn Taylor 3D Pharmacology: Management of Depression, National Fall Prevention Delirium, and Dementia in Older Adults...... 28 Awareness Day Celebrations...... 14 Roslyn D. Burton Mariana Wingood

Publication Title: GeriNotes Statement of Frequency: 5x/year; January, May, July, September, and November Authorized Organization’s Name and Address: Academy of Orthopaedic Physical Therapy, APTA, Inc. For Academy of Geriatric Physical Therapy, APTA., 2920 East Avenue South, Suite 200, La Crosse, WI 54601-7202 Newsletter Deadlines: March 10, May 10, July 10, September 10, November 10 Editorial Statement: GeriNotes is the official magazine of the Academy of Geriatric Physical Therapy. It is not, however, a peer-reviewed publication. Opinions expressed­ by the authors­ are their own and do not necessarily reflect the views of the Academy of Geriatric Physical Therapy, APTA. The Edi­­tor reserves the right to edit manuscripts­ as neces­ sary­ for publication. Copyright 2019 by the Academy of Geriatric Physical Therapy, APTA. All advertisements that appear in or accompany GeriNotes are accepted on the basis of confor­ ­ma­tion to ethical physi­­cal therapy standards, but acceptance does not imply endorsement by the Academy of Geriatric Physical Therapy, APTA.

IN HONOR/MEMORIAM FUND Each of us, as we pass through life, is supported, assisted and nurtured by others. There is no better way to make a lasting tribute to these individuals than by making a memorial or honorary contribution in the individual’s name. The Academy of Geriatric Physical Therapy has established such a fund which supports geriatric research. Send contributions to: The Academy of Geriatric Physical Therapy | 3510 East Washington Avenue | Madison, WI 53704 Also, when sending a contribution, please include the individual’s name and any other person you would like notified about your contribu- tion. If you are honoring someone, a letter will be sent to that person, and if you are memorializing someone, the surviving family will be notified of your contribution. In the field of geriatric physical therapy, we receive many rewards from our patients, associates, and our mentors. A commemorative gift to the Academy of Geriatric Physical Therapy In Honor/Memoriam Fund is a wonderful expressive memorial. President’s Message

Greg Hartley, PT, DPT

Our collec- or various other government agencies (1) AGPT provides education that en- tive voice mat- on a wide variety of proposed rules and hances practice by producing value, ters. As many of regulations. In 2018, AGPT submitted empowering advocates, and promoting you are aware, comments to HHS on the proposed the use of evidence informed practice; Reader’s Digest rules for SNF PPS, IRF PPS, and Home (2) AGPT attracts, engages, and mobilizes published an Health PPS; IMPACT Act implementa- physical therapists, physical therapist article (Septem- tion; proposed opioid rules for residents assistants, and students serving aging ber 2018) titled in long-term care; and a letter to the adults; and “14 Exercises to editor of the New York Times regarding (3) AGPT builds relationships to expand Never Do After an article they published titled, “Costly its influence and the reach of physical Age 50.” The Rehab for Dying is on the Rise at Nurs- therapy. article was misleading and full of age- ing Homes, a Study Says” (https://www. ist information. It quickly generated nytimes.com/2018/10/12/business/ There are several objectives and a backlash among therapists on social nursing-home-residents-rehabilitation- strategies embedded within each goal. media, prompting a combined response therapy.html). The AGPT’s comments Transparency (information sharing, from the AGPT and APTA (https://ge- are always aligned with our mission communication), collaboration (inter- riatricspt.org/news/index.cfm?#n428). to improve access to promote physical nal and external partnerships), advo- Within a few hours of receiving the let- therapist best practice and to advocate cacy (anti-ageism, payment and policy), ter to the editor from APTA and AGPT, for optimal aging. These comments are evidence-based practice and education, Reader’s Digest retitled the article to in the public domain but are admittedly and health promotion/prevention/well- “Exercises You Should Modify If You’re difficult to find. The AGPT has begun ness and themes in each of the strategies. Over 50” (https://www.rd.com/health/ posting our comments to our own web- I am excited to get to work on this bold fitness/exercises-to-modify-over-50/). site in an effort to inform our members and energetic plan. Implementation of While the title changed, most of the of all of our advocacy work. Look for the plan will require many volunteers. content did not. Thankfully, Reader’s them in the News Section (https://geri- Some activities do not require a long- Digest invited APTA, AGPT, and indi- atricspt.org/news/). term commitment and are quick tasks. vidual physical therapists to write a fol- This commitment to transparency Some tasks require ongoing commit- low-up article that was later published and advocacy is directly related to the tee work, while others will be handled as “Myths You Shouldn’t Believe About Academy’s 2019-2021 strategic plan. In by short-term task forces or micro- Fitness Over 50” (https://www.rd.com/ early October 2018, AGPT leadership volunteers (volunteers who commit to health/fitness/myths-shouldnt-believe- met to develop a new strategic plan, one quick task). Please watch for calls fitness-after-50/). I am very proud of including a revised vision and mission. for volunteers and check the website our members and the PT/PTA com- The vision, mission, and overall goals frequently. We cannot achieve our vision munity at large for speaking up against will be presented to the membership without your help! the original ageist article and supporting for endorsement during the member’s With that, I would like to thank the our response and the subsequent follow- meeting at CSM this month. Members members who volunteered their time to up article. This series of events is perfect received information about the new develop this language and plan. I am example of how we can work together language and strategic plan in eNews, inspired by all of you. Your dedication and have a broad societal impact. email, and on the website. The proposed to the AGPT, APTA, and aging adults While the Reader’s Digest articles vision, “Embracing aging and empower- is admirable. I cannot wait to see where got mainstream and widespread atten- ing adults to move, engage, and live well,” this takes us! And let us know how you tion, there are many examples of activ- describes a vision of the Academy’s out- can help by going to https://geriatricspt. ism AGPT participates in on behalf ward facing societal role in the future. org/volunteer/index.cfm. of its members and aging adults. This The proposed mission, “Building a com- form of advocacy occurs quite regularly munity that advances the profession of but is often less visible. Examples of this physical therapy to optimize the experience include comments submitted by AGPT of aging,” defines the Academy’s internal to the Department of Health and Hu- approach to reach the goals and ulti- man Services (HHS), the Centers for mately, the vision. There are 3 primary Medicare and Medicaid Services (CMS), goals in the 2-year plan. They are:

GeriNotes, Vol. 26, No. 1 2019 3 Editor's Note

Michele Stanley, PT, DPT

HAPPY One of the missions of GeriNotes GET LIT, the popular and KT NEW YEAR! I is to illustrate the works and projects of based regular column by Carole Lewis keep thinking the component SIGs of the Academy of and Valerie Carter returns this month that I should Geriatric PT. Balance and Falls related to talk about CORE values evidence (as come up with problems are not only the bread and in trunk strength not religion or ethics), a witty regular butter for lots of PT practices, the Bal- they will continue this topic in the next column name… ance and Falls SIG is one of the biggest GeriNotes as well (May issue). In follow- but I haven’t, and busiest components of our group. don’t, not even Read about how many members cel- up responses to the GET LIT series on sure that it is a ebrated Fall Awareness Prevention Day the evidence in treating PD, there is a resolution. Clearly, it has not been (FPAD) – and get some ideas for com- case report on using the LSVT approach a priority in the one year that I have munity education and service projects and a literature review specific to gait enjoyed this editor’s position. What that you/your clinic can institute for cueing strategies when working with has been a priority has been increasing next September FPAD or October’s PT persons with Parkinson’s disease. the number of new authors published month. Fall(s) are the ultimate 4 let- (that aren’t a school assignment-based ter word for our older clients but also • Still looking for therapists who work submission, although I’m always happy for institutions that serve elders. Heidi within an Emergency Department to to read and consider those as well). Suc- Moyer presents some thoughts on how collaborate on an article in an upcom- cess. With this issue that number rises we approach this problem ing issue: share informal case studies, to 8 new authors and I’m delighted with Knowledge Translation (KT): a fan- structure, and competency required the information those colleagues have cy way to express the process that moves shared and challenged us with. In that ideas and techniques from research labs for this practice, productivity issues. vein, please read the op/ed piece on pro- to clinical settings and integration into • Do you have a wellness or fitness- ductivity from Gabe Alaine, one of our professional practice. GeriNotes, along based practice? A future issue would newest colleagues. What a good lead-in with JGPT (journal of the Academy like to focus on this aspect of physical that is to an understanding how we got of Geriatric Physical Therapy) and the therapy and your stories would be to the position as an industry/profession Academy is committed to fostering KT welcomed. that now looks at a different measure of to improve the functional evidence- • Hey, all you VA residency peeps! value: MIPS, PDPM, PDGM. Do you based interactions of physical therapy Word on the street is that many of understand this new alphabet soup? If professionals and their clients. Mary you are starting or involved in some not, one of your New Year resolutions Milidonis and Marianna Wingood pro- pretty amazing projects – share the should be to read Ellen Strunk’s expla- vide a simple explanation of the process. details! Articles duly referenced in nations. Like it, or not, value based In follow-up, you will see a more in- payment systems are coming on hard teractive and cooperative approach by AMA style between 900-2700 words starting this month, depending on your the Academy publications that I hope are welcomed. Maybe we can do an practice setting. that you will find useful. One way to issue highlighting the VA’s role in car- Are you a member of the Listserv? expedite this is to recruit and encour- ing for our aging and amazing vets? Subscribing is a great way to get not age recognized opinion leaders (content • PTAs – we would like to highlight only regular updates from Ellen but experts) who will write an article or a PTA with advanced proficiency or also to participate in all the discussion, commentary for GeriNotes that includes other certifications in every issue - tips, frustrations that are sure to be ex- implications/applications of one or more nominate yourself or a colleague and pressed as the new payment systems are articles featured in the corresponding we will interview and share your story. implemented. Our listserv is moderated edition of the JGPT; the publications • Does your personal resolution include so it remains spam-free; when you re- editors resolve to coordinate at least getting healthier and/or changing quest to join the listserv make sure that some content in 1 to 2 issues each/year. your exercise routine in 2019? Are you give not only your email but also Watch for the initial attempt in both of your real name and credentials so that the July publications. IF there is an area you a personal trainer….or have you you are automatically vetted. Academy in which you are knowledgeable and ever used one? Write about it! If the of Geriatrics APTA listserv website at passionate (and would like to produce thought of writing intimidates you, http://health.groups.yahoo.com/group/ thoughtful commentary on) – contact I’ll interview you. Michele Stanley: geriatricspt/ an editor! We want to hear from you! [email protected] 4 GeriNotes, Vol. 26, No. 1 2019 Policy Talk: Post-acute Care Payment is Changing

Ellen R. Strunk, PT, MS

By the time you are reading this when they released an Advanced Notice repeatedly called on CMS to eliminate article, there will be less than 12 months of Proposed Rulemaking (ANPRM) the number of therapy visits as a before the post-acute care environment asking stakeholders for feedback on a payment factor since they believe it is forever changed. Skilled nursing payment system they called the Resident “creates financial incentives that distract facilities (SNFs), home health agencies Classification System Version 1 (RCS- agencies from focusing on patient (HHAs), and inpatient rehabilitation 1). The provider community responded characteristics.” Their research supports facilities (IRFs) all received news in their in mass to the proposal, and a year later, a model that increases “payments for final rules that, while not unexpected, is CMS formally proposed a new model medically complex patients and lowering likely overwhelming to many. called the Patient-Drive Payment Model payments for patients who receive (PDPM). The PDPM was finalized on rehabilitation therapy unrelated to their SKILLED NURSING FACILITY’S July 31, 2018. care needs.”2 PATIENT-DRIVEN PAYMENT The PDPM is a fundamental shift In July 2017, CMS released its MODEL (PDPM) from the RUGs system used today and proposed rule for HHAs for calendar On July 31, 2018, the Centers for will replace it entirely. The CMS’s intent year 2018 displaying an “early” version Medicare and Medicaid Services (CMS) with the new model was to pay providers of the PDGM. At the time it was called published the Prospective Payment System based on patient characteristics instead the ‘Home Health Groupings Model’ (PPS) and Consolidated Billing for Skilled of the number of therapy days and (HHGM). Like the current PDGM, Nursing Facilities (SNF) Final Rule for minutes. In fact, the number of therapy HHGM aimed to classify patients by Fiscal Year (FY) 2019. The rule finalized days and minutes will not have any admission source, principle diagnosis, CMS’s proposal to replace the current influence over how much a SNF is paid. and certain functional OASIS items. SNF PPS Resource Utilization Group Under the new system, patients will be One key difference between the two (RUGs) with a new payment model assigned a Case Mix Group (CMG) models was that HHGM was estimated called the Patient-Driven Payment using 5 components: physical therapy to decrease payments to HHAs by Model (PDPM) beginning on October (PT), occupational therapy (OT), speech $950 million, an amount that would 1, 2019. language pathology (SLP), nursing, and be devastating to many providers and Therapists who have practiced in non-therapy ancillaries (Table 1). patients. The PDGM, on the other the SNF setting for any length of time hand, is required to be done in a budget- have not been immune to the criticism HOME HEALTH AGENCY’S neutral manner. However, it does of the RUGs payment system. Perhaps PATIENT-DRIVEN GROUPER include “assumptions about behavior those reading this article may have MODEL (PDGM) changes that could occur as a result of voiced their own criticism of the model On October 31, 2018, the CMS the implementation of the 30-day unit because it ties payment to the volume published the CY 2019 Home Health of payment and a change to the case-mix of therapy minutes delivered. For years, Prospective Payment System Rate Update methodology.”3 policymakers have complained about and CY 2020 Case-Mix Adjustment Like PDPM, the new Home Health how the system might incentivize a level Methodology Refinements. The rule model is designed to classify the patient of therapy that is not warranted in an finalized CMS’s proposal to replace the using only clinical characteristics and effort to receive a higher payment. In current Home Health Resource Groups other patient information components 2016, CMS began releasing public use (HHRGs) with a new payment model (Table 2). Under the new payment files of SNF payments and utilization. called the Patient-Driven Group Model model, the unit of payment for home They illustrated that a significant (PDGM) beginning on January 1, 2020. health services will also move from a 60- number of patients’ therapy time was Like their colleagues in the SNF, day period to a 30-day period. within 10 minutes of the lowest possible home health therapists have experienced threshold that would still allow the SNF the criticisms related to therapy visits and INPATIENT REHABILITATION’S to receive that payment, prompting the the HHRG level. The HHRG payment FUNCTIONAL INDEPENDENCE Deputy Administrator at the time to is influenced by the number of therapy MEASURE (FIM™) refer the issue to the Recovery Auditor visits delivered over the course of a 60- The final rule for FY2019 Inpatient Contractors for further investigation.1 day episode: as the number of therapy Rehabilitation Facilities (IRFs) included Others have criticized the fact that visits increases, so does the payment to some good news for providers related the nursing and nontherapy ancillary the home health agency. And like the to documentation requirements. In its payment was underfunded. The CMS RUG’s analyses, the Medicare Payment effort to reduce regulatory burden on responded to those criticisms in June 2017 Advisory Commission (MedPAC) has rehabilitation providers and physicians, GeriNotes, Vol. 26, No. 1 2019 5 Table 1. Components Used in the Patient-Driven Payment Method Per Diem Component Patient Characteristics Payment Primary reason for SNF Stay falls into 1 of Functional Status using Section GG Beginning with 4 categories: Early and Late-Loss Abilities: Day 21, per diem (1) Major Joint Replacement or Spinal Surgery payment amount PT (2) Non-orthopedic Surgery or Acute Neuro (1) Self-Care GG0130: 3 items decreases by 3% (3) Other Orthopedic (2) Mobility GG0170: 8 items every 7 days (4) Medical Management Primary reason for SNF Stay falls into 1 of Functional Status using Section GG Beginning with 4 categories: Early and Late-Loss Abilities: Day 21, per diem (1) Major Joint Replacement or Spinal Surgery payment amount OT (2) Non-orthopedic Surgery or Acute Neuro (1) Self-Care GG0130: 3 items decreases by 3% (3) Other Orthopedic (2) Mobility GG0170: 8 items every 7 days (4) Medical Management Primary reason for SNF stay falls into 1 of • Cognitive Status Per diem payment 2 categories: • Presence of swallowing disorder and/ is the same for all SLP (1) Acute Neuro or mechanically altered diet covered days (2) Non-Neuro • Presence of other SLP comorbidities • Clinical information from the SNF Functional Status using Section GG Per diem payment stay using MDS data Early and Late-Loss Abilities: is the same for all • Extensive services received covered days Nursing • Presence of depression (1) Self-Care GG0130: 2 items • Number of restorative nursing (2) Mobility GG0170: 5 items services received • Number and type of comorbidities present • Extensive service used Per diem payment Non-therapy is the same for all Ancillaries covered days Abbreviations: SNF, skilled nursing facility; PT, physical therapist; OT, occupational therapist; SLP, speech language pathology; MDS, minimum data set

there were several revisions to the Improving Medicare Post-Acute Care will not change just because the way coverage criteria to include allowing the Transformation (IMPACT) Act (Policy that SNFs, HHAs, and IRFs get paid is post-admission physician evaluation to Talk in the September 2018 GeriNotes). changing. count as one of the weekly required face- One of the domains called for by the Will facilities and agencies have a to-face visits; allowing the rehabilitation IMPACT Act was function. In October new incentive to decrease the amount physician to lead the interdisciplinary 2016, IRFs began collecting Section GG of therapy provided? Or will other team meeting remotely; removal of self-care and mobility items. Center for providers, such as restorative nursing the admission order documentation Medicare and Medicaid Services intends aides or therapy aides replace therapists requirement since it is duplicative of to use these items to assign patients into since they cost less than therapists other admission requirements. a Case-Mix Group (CMG) for payment and therapist assistants? Providers The final rule for IRF also purposes under the IRF PPS beginning should be very cautious of either of announced that beginning on or with discharges on or after October 1, these approaches because functional after October 1, 2019, the FIM™ 2019. They will incorporate two full outcomes will likely suffer. Therapists instrument and the associated Function years of data (FY 2017 and FY 2018) should remind their colleagues and Modifiers will be removed from the IRF into the analyses used to review the their facilities/agencies that each of Patient Assessment Instrument (PAI). CMG definitions, and stakeholders will the PAC settings are still required to Therapists working in this setting may have an opportunity to comment on participate in their respective Quality be concerned about that since it has that analysis in future rulemaking. Reporting Programs (QRP) and Value- been a cornerstone of the IRF-PAI as Based Purchasing (VBP) programs. well as a method of measuring functional IS THERAPY GOING AWAY IN Therapy programs and effective patient outcomes between and among IRF POST-ACUTE CARE? care delivery have a direct impact on facilities nationally. However, CMS The short answer is no. Might it many of these quality measures (Table pointed to the fact that under the IRF look different than it does today? Yes. 3). Therapists working in post-acute Quality Reporting Program (QRP), they The patients being seen in the post-acute care should become familiar with the began collecting a number of patient care setting require and benefit from measures in their setting and begin assessment items mandated by the the provision of therapy services. That discussing with colleagues and facility/ 6 GeriNotes, Vol. 26, No. 1 2019 Table 2. Components Used in the Patient-Driven Group Model Admission The Primary Reason for Functional Comor- Timing* Clinical Grouping# LUPA ^^ Source^ the HH episode is: Level~ bidities ** Musculoskeletal PT, OT, or ST for Lo, Med, Hi >/=2 Stroke Rehabilitation Lo, Med, Hi >/=2 /=2 /=2 /=2 Medication Management, Teaching and Assessment Commu- None Early or (MMTA): nity or Low Late Assessment, Evaluation, Teaching and Medication Institutional Management for: High MMTA – Surgical Aftercare Surgical aftercare Lo, Med, Hi >/=2 /=2 /=2 /=2 /=2 /=2 /=2

agency administrators how therapy can Physical Therapy, the Home Health and feedback on what you need to contribute to the outcomes and overall Section, HPA The Catalyst section, and prepare. Contact us at geriatrics@ quality of care to the patients they serve. the APTA will be partnering to bring geriatricspt.org. members more information and more As I stated in the last issue of ARE YOU READY? resources about PDPM, PDGM, and GeriNotes, therapy services have been This article is just an overview of the looming Uniform Post-Acute Care paid on volume for too many years: eg, the changes to come. Over the next (UPAC) payment model that is sure to the number of visits made, the number 12 months, the Academy of Geriatric follow. We welcome your suggestions of minutes provided, the number of GeriNotes, Vol. 26, No. 1 2019 7 Table 3. Post-acute Care Quality Reporting Programs SETTING QUALITY REPORTING PROGRAM “COMPARE” WEBSITES https://www.cms.gov/Medicare/Quality-Initia- https://www.medicare.gov/nursinghomecompare / tives-Patient-Assessment-Instruments/Nursing- Data/About.html#quality OfResidentCareData- Skilled Nursing HomeQualityInits/Skilled-Nursing-Facility-Qual- Collection Facility ity-Reporting-Program/SNF-Quality-Reporting- Program-Measures-and-T echnical-Information. html https://www.cms.gov/Medicare/Quality-Initia- https://www.medicare.gov/HomeHealthCompare/ Home Health tives-Patient-Assessment-Instruments/Home- Data/Patient-Care-Star-Ratings.html Agency HealthQualityInits/Home-Health-Quality-Mea- sures.html https://www.cms.gov/Medicare/Quality-Initiatives- https://www.medicare.gov/inpatientrehabilitation- Inpatient Rehab Patient-Assessment-Instruments/IRF-Quality- facilitycompare /#about/theData Facilities Reporting/IRF-Quality-Reporting-Program-Mea- sures-Information-.html

codes recorded. Some therapists have Reporting Requirements; Home OTHER RESOURCE never worked in a time when minutes, Infusion Therapy Requirements; Strunk ER. Policy Talk: Have you heard? visits, units, and days were not a focus and Training Requirements for Functional Outcome Measures are here. and point of discussion in the therapy Surveyors of National Accrediting GeriNotes. 2018;25(4):9-13. workplace. These changes in payment Organizations. https://federalregister. – while uncomfortable and uncertain gov/d/2018-24145. Accessed – may help therapists to begin to October 31, 2018. understand what effective care is and for whom. We must not lose sight of the fact that the effectiveness of our clinical skills in these settings will still be important to a SNF, HHA, and IRF. Are you ready?

REFERENCES 1. Centers for Medicare and Medicaid Congratulationsto the following Services. CMS releases Skilled Nursing Facility utilization and candidates who will take office at the payment data. https://www.cms. gov/newsroom/press-releases/cms- AGPT Member Meeting at CSM 2019 releases-skilled-nursing-facility- utilization-and-payment-data. in Washington, DC! Accessed November 11, 2018. 2. Medicare Payment Advisory Treasurer – Kate Brewer Commission. Home health care Directors – Ken Miller and Sue Wenker services: Assessment payment Nominating Committee – Lucy Jones adequacy and updating payments. http://www.medpac.gov/docs/ We also congratulate the following SIG officers: default-source/reports/mar18_ BFSIG Chair – Jennifer Vincenzo medpac_ch9_sec.pdf?sfvrsn=0. BFSIG Vice Chair – Shweta Subramani Accessed November 29, 2018. BFSIG Secretary – Heidi Moyer 3. Department of Health and Human BHSIG Chair – Sherri Betz Services. 42 CFR Parts 409, 424, BHSIG Vice Chair – Andi Morgenthaler 484, 486, and 488. Medicare BHSIG Secretary – Virginia Renegar and Medicaid Programs; CY BHSIG Nominating Committee – Amy Wagner 2019 Home Health Prospective HPWSIG Chair – Gina Pariser Payment System Rate Update and CMHSIG Chair – Christine Childers CY 2020 Case-Mix Adjustment Methodology Refinements; Home A big Thank You to all the candidates who participated in Health Value-Based Purchasing this year’s election and to the members who voted! Model; Home Health Quality 8 GeriNotes, Vol. 26, No. 1 2019 My Opinion: Productivity, an Ambiguous but Widely Sighted Monster

Gabriel Alain, PT, DPT

As a recent graduate who came to use the Nu-Step, I wanted to ambu- was not on my case load. Even one of the from a non-traditional background (Fi- late with my patient as I felt the sensory aides complained to my supervisor be- nance), I cannot help but notice current input from full weight bearing through cause now she would have to get the pa- practice cultures in place which, in my the kinetic chain would be far superior tient out of bed when lunch time rolled opinion, are hampering our ability to than a seated activity. Can the Nu-Step around. I was dumbfounded. I told my provide meaningful patient care. In my be made into a challenging interven- supervisor “Respectfully, if the situation experience as a physical therapist, it tion? Absolutely. However, in my opin- were to occur again I would do it again.” seems our profession is eager to use or ion it becomes exceedingly difficult to If the concern of productivity has caused pioneer new ways of thinking but quick document, keep an activity skilled while us to forget about basic human respect to move on without refinement. Previ- hands free, and maintain patient safety especially during the last few months of ously as an analyst I often found most at the same time. Therapists should not life, we are in a scary place. value was realized not through discovery have to forgo what I deem is clinically I frequently encountered having 30 but through optimization. This is my necessary in the name of productivity. minutes to complete a progress note yet call to action to optimize productivity Perhaps my most disappointing ex- the patient had 5 goals that needed to and more importantly, standardize it. perience regarding productivity was in be examined. Could I have looked at Productivity only measures billable time the case of a patient who was previously previous treatment notes done by an- at this time. It does not measure what is on my case load who I will refer to as other therapist to save myself time and done during those minutes, only wheth- Patient A. Patient A was in long-term fill in goal progress instead of examin- er or not minutes were filled. I think care and had an inoperable brain tumor ing it for myself? Sure. Is that ethical to one of productivities greatest ironies is that presented with stroke like symp- the patient and 3rd party payers who its total blindness to quality. In a skilled toms as it continued to grow. Symptoms are expecting a skilled service? I do not nursing facility (SNF) setting when a pa- included severe expressive aphasia and think so. What quality of documenta- tient walks to the rehabilitation gym and hemiplegia. I had just finished seeing tion can be expected in situations like then is treated with 1 lb ankle weighted another patient and as I was returning to these? I see these types of situations LAQs, this is considered productive. But the gym, I saw Patient A who was clearly quite often. I think productivity often for who? People go their whole career in some sort of distress and unsuccessful pushes therapists to pursue submaximal treating this way and would be seen by in communicating his need to nearby interventions. Sometimes the therapists a hiring manager as “highly productive.” personnel. Patient A’s eyes lit up when are at fault, sometimes it is the expected My own gut reaction is to say “well the he saw me and I began trying to figure productivity requirements for the given therapist should know better and use out what it was the patient needed. It setting, sometimes it is both. I realize a time in a more challenging manner.” took about 10 minutes to figure out solution to this will require a multi-fac- This is not always the case, though. what the patient wanted but when I eted approach as it is quite the monster During one of my clinical rotations finally pieced it together and figured we are dealing with. But rather than just at a SNF setting, the therapists were out Patient A wanted to return back going after the monster, it seems more tasked with finishing 90% of the note, to his room and take a nap, the patient reasonable to first define what everyone regardless of its type, before leaving the pumped his fist in the air and I received wants to call it. Once defined I believe patients room or the intervention was a handshake. No staff was available so I it will become clearer as to what thera- finished. Documentation was done on proceeded to transfer Patient A from the pist “true” productivity expectations are an IPad. I felt myself being strong-armed wheelchair to the bed. Once the patient across the board and how they can be into situations I had no desire being in. was positioned and well supported his better managed. I think market forces For example, in some situations I was eyes began to tear, he gave a clear and will also dictate what is and what is not hands on with patients for the major- audible “Wow” and I received another reasonable. ity of the treatment yet I still needed to handshake. Who knew sufficient back Every facility defines productivity find time to finish documentation so I support and communication could go differently. Some allow nuances such could meet productivity requirements. such a long way. It was my pleasure to as mandatory meetings, patient family I found myself using equipment like have helped out and an emotional mo- phone calls, etc. to be written off and the Nu-Step (nothing against it) so my ment for both of us. However just 2 not affect productivity. Other facilities hands could be free and I could type. hours later I was reprimanded by my su- are rigid and do not allow deductions to This would be fine except I did not want pervisor for helping Patient A because he lost time. Some facilities require evalua- GeriNotes, Vol. 26, No. 1 2019 9 tors maintain 60% productivity, others health professionals. Directors, rehab define productivity so we can better de- require 92%. The percentages do no managers, and other hiring managers fine the value being provided to patients. matter, only what they are constituted should be actively looking for a more of. I would not be surprised if productiv- comprehensive way of monitoring pro- ity was defined this second as say: bill- ductivity. After all productivity takes Gabriel Alain, PT, able time with deductions for manda- no consideration of patient outcomes, DPT, is a recent tory meetings, phone calls, and repeated denied insurance reimbursement, or pa- graduate from Mar- patient non-compliance. Some facilities tient satisfaction just to name a few. We shall University. He would probably find themselves to have as therapists should also be looking for previously was a fi- been requesting over 100% productivity opportunities to prove how we continue nancial professional from their therapists. to provide value across the spectrum that trading equities and Let me be clear the aim of this writ- often goes unmeasured. If I have an op- derivatives. He will ing is not to complain about what is be- portunity to spend an extra 15 minutes be the incoming resident to the National ing asked of therapists, but to sound the with a patient that is not billable but Church Residences/OSU Geriatric Resi- warning bells. Payments are not growing they go home happy and refer just one dency Program from 2018-2019. He and insurance continues to increase the new patient to the facility, I just made may be contacted at Gabriel.n.alain@ amount of documentation required for the facility thousands of dollars. Yet by gmail.com. reimbursement. Standardizing produc- current metrics, I was unproductive. We tivity should be in the interest of all can do better! Let’s standardize how we

CMS Releases New Resource to Prevent All Cause Harm in Nursing Homes

On behalf of The Centers for Medicare & Medicaid Services (CMS) and the Quality Innovation Network National Coordinating Center, we are excited to share a new resource with you: a Change Package to prevent all cause harm in nursing homes: https://qioprogram.org/all-cause-harm-prevention-nursing-homes

We're all living longer, and we need our healthspan to keep up with our lifespan. Right now our lifespan is exceeding our health span, especially when it comes to our brains. That can be done not only with pharmaceuticals and drugs, which we're working on, but it starts with you. Take care of your body, brain and mind—that staying healthy and staving off disease begins with you.

—Rudy Tanzi, Harvard Professor of Neurology and a co-discoverer of early- onset familial Alzheimer's genes and the link between herpes and Alzheimer's disease when asked what one thing he would change about aging in America https://www.nextavenue.org/rudy-tanzi/ Accessed December 5, 2018.

10 GeriNotes, Vol. 26, No. 1 2019 Debility and Functional Decline in Long-term Care Facilities: Are We Part of the Problem?

Heidi Sue Moyer, PT, DPT

Members of the Academy of Geri- within the facility. The function appears Psychometric validation studies atric Physical Therapists see themselves unchanged. The patient denies falls and within long-term care populations are as champions for aging and older adults. facility records support this claim. De- limited for several reasons. First, many We serve others, we advocate for oth- creased balance performance is demon- residents have a diagnosis of dementia or ers, we teach others, we challenge oth- strated by the test, but function appears other cognitive decline, classifying them ers. How often do we take a step back unchanged; the patient was ambulatory as a “special/at risk population” which re- and re-evaluate ourselves? The more we without a device before and seems to be quires additional protections in terms of place ourselves in the spotlight, the more functioning the same (the patient’s sub- enrolling and participating in a research criticism and speculation we will face. A jective report supports your subjective study. This often requires additional con- solid self-re-evaluation might save us a assessment). sent both from the patient and his or her little bit of trouble in the long run, par- As a result of the failed balance test, power of attorney. This may make attri- ticularly in our clinical tool use. you recommend that the patient use tion during the recruiting process very A Combined Section Meeting pre- a wheelchair to decrease the risk of fall high. Next, this population has a high sentation by the Balance and Falls SIG within your facility. Now the patient prevalence of comorbid conditions. In tackled the topic of falls and balance is demonstrating depression-like symp- many research trials, a health control assessment and management in long- toms, has withdrawn from social ac- cohort is required for best evidence, but term care facility (LTCF) residents. The tivities at the facilities, and her physical this is not a possibility in this place. In- presentation detailed that little evidence performance is declining. Consider these dividuals come to live in LTCF due to supporting this area exists within this following questions: complications and functional decline unique subgroup of the older adult pop- from comorbidities. Quality of the re- ulation. Consequently, physical thera- 1. Was that the best outcome assessment search study may be compromised by the pists are selecting outcome measures that to use? volatile health of these residents that re- are not psychometrically supported for 2. Was there another option in terms of sults in hospitalizations or death during use in this population. While an out- activity limitations? the usual course of the 6- to 12-month come measure may be clinically relevant 3. What else could be in place to prevent follow-up. Finally, the predominant for a specific disease pathology during an events such as this? culture of the LTCF is the reduction evaluation, it might not be statistically of injuries. Yes, fall prevention is key to supported to detect change in the LTCF Use of outcome measures that are prevent resulting fall-related injuries and population due to limited research. inappropriate for use in a setting that further physical and functional decline. Consider this scenario: You evalu- were not validated may place residents at Literature has shown that alarms, protec- ate an individual living on the long- risk of creating a self-fulfilling prophecy tive gear, and other “preventative” mea- term side of a LTCF who was recently and propagating a fear of falling in indi- sures do not actually prevent falls: physi- hospitalized for 2 days following a ter- viduals who previously were not at risk. cal therapy intervention does! rible sinus infection (a new medication We as clinicians think they are at risk of Barriers are not going to disappear caused orthostatic hypotension, result- falling, therefore we limit mobility, fur- anytime soon. Our management and ap- ing in an ER visit). During evaluation, thermore perpetuating deconditioning proach to addressing these barriers must you use an outcome measure that is not and weakness, and then: they Fall. What change. While counties with different valid within the LTCF population but is if the clinician had chosen an outcome health care models have been able to per- highly supported in community dwell- measure that was validated in the SNF form RCTs in this population, our own ers. This individual has been a facility setting? If therapists recommend limited system is not conducive for conducting resident for 5 years and going home will activity for a patient, and in realty said a study such as this. Physical therapists, not be an option anytime soon. Your as- patient was safe to be mobile within the as a profession, should consider the value sessment tells you that the patient is at facility because we are lacking the tools that “lesser quality” studies (case studies, a moderate fall risk. While they move to accurately measure this, then we as case series, cohort studies, etc) could pro- slowly, the resident demonstrates no loss therapists are a prime component of this vide. Health status changes are typically of balance, no safety awareness deficits, problem. Physical therapists should be rapid; the standard 12-month follow-up and is compliant with all safety protocols promoting mobility, not demoting it. time used with community dwellers may GeriNotes, Vol. 26, No. 1 2019 11 not be appropriate. It is a disservice to idence-based practice within the LTCF our profession and our LTCF patients population. Therapists have to facilitate Heidi Sue Moyer, when functional studies are not consid- the propagation of a culture of mobil- PT, DPT, graduated ered because usual research design can- ity within the facility, which challenges many of the policies in place in many from Angelo State not be achieved. facilities already. We have to continue to University in May This a multi-faceted problem that advocate for our patients even if it is not 2016 and is based requires intervention from a multitude the popular opinion. Complacency by out of Chicago, IL. of angles. Our values are in place, but the therapist is dangerous for the health She serves in several the execution is not solid yet. We have of these individuals and makes us com- roles such as East- to ensure that the literature reflects ev- plicit in their functional decline. ern Regional Coordinator and Illinois Co-chair for the AGPT state advocate program, Clinical Liaison for the AGPT Balance and Falls SIG, a committee member on the GeriEdge Task Force, Pitch your story ideas to the and also holds various commitments and positions within the Gerontological So- GeriNotes Editor ciety of America. She can be reached for Meet at the AGPT booth in the Exhibit Hall at CSM on Friday questions or further information on this from 11:30 -12:30. You can even volunteer at the same time. topic at [email protected] The AGPT CSM Booth Volunteer sign-up is available at https://geriatricspt.org/csm Volunteering at the Booth is a great way to connect with your peers, help out the Academy, and be registered to win a free year's membership.

AGPT State Advocates AGPT has State Advocates working locally in 48 states, advocating for older adults, promoting geriatric-related issues, courses, meetings, AGPT SIGs, and being a liaison between AGPT and state chapters.

Find your State Advocate contact info online at www.geriatricspt.org/ Select “Members” tab, then “Contact Your State Advocate” or http://geriatricspt.org/members/state-advocates/index.cfm .

We are actively looking for new State Advocates in Alaska and South Dakota, plus looking to share duties with current State Advocates in: California, Hawaii, Montana, North Dakota, and Utah. Additional positions may be opening in 2019.

Interested, or want more info about the program? Contact Beth Black at [email protected] and Heidi Moyer, moyerheidis@gmail. com, AGPT State Advocate Regional Coordinators.

12 GeriNotes, Vol. 26, No. 1 2019 A Multi-disciplinary Event to Celebrate Falls Prevention Awareness Day

Bonnie L. Rogulj, PT, DPT; DeAnn Taylor, SPT

On September 8, 2018, the Uni- The activities available to partici- tance, the participant then performed versity of St. Augustine for Health Sci- pants consisted of an educational section the dual-task of tossing a beanbag into ences (USAHS) hosted an event titled, offering a multitude of health-related the cornhole board. A maze was created Don’t Be Trippin’. The event was created education hand-outs, an evidence-based for participants to navigate with a variety to celebrate national Falls Prevention health screening, a fall risk scavenger of obstacles, including pumpkins, scat- Awareness Day (FPAD) 2018. The hunt, balance-themed games, a maze tered leaves decor, step boxes ranging in event was created by Doctor of Physi- with obstacles and dual-cognitive task, height from 2 to 6 inches, compressed cal Therapy Student, DeAnn Taylor, and raffle prize drawings. Doctor of foam pads, and cones. The maze was and Instructor, Bonnie L. Rogulj, PT, physical therapy students performed constructed with tables and further chal- DPT, GCS. The event hosted over health screenings that consisted of lenged participants by using tape to 70 community-dwelling older adults, providing each participant a copy of create multi-directional arrows on the multi-disciplinary health care provid- the STEADI Fall Risk Checklist and ground, which allowed patients to use cognition in order to navigate their ap- ers, community organizations and busi- Questionnaire, vitals assessment (blood propriate path. nesses, and over 80 physical and occupa- pressure, pulse rate, respiratory rate, The event Don’t Be Trippin’ was cre- tional student volunteers. oxygen saturation), grip strength mea- ated to celebrate FPAD 2018. The cel- On arrival, community-dwelling sured with a hand-held dynamometer, ebration allowed for community mem- older adult participants were provided Timed Up and Go (TUG) test, and the bers, students, health care providers, a passport that included a list of the 30-Second Chair Stand Test (30CST). The participants were provided educa- organizations, and businesses to unite available event resources and activities. tion regarding their performance on the for a worthy cause. The event promoted Participants were greeted by various health screenings, based on normative health, safety, education, and attempted health care providers, community or- values and ranges per evidence. The to positively impact the lives of all who ganizations, and businesses that repre- scavenger hunt designed by a physi- participated. sent health and fall prevention within cal therapist and occupational thera- St. John’s County, located in northern pist resembled a typical home’s living Florida. Health care providers in at- room. The set-up included multiple fall tendance included physical therapists, Bonnie L. Rogulj, risks that participants were instructed to PT, DPT, GCS, occupational therapists, pharmacists, vi- identify. The fall risk hazards located sion specialists. completed her Doc- within the room included a lost pair of tor of Physical Ther- glasses (poor vision), scattered medica- apy degree at Old tion bottles (medication management Dominion Univer- and polypharmacy), slippers (improper sity and completed footwear), a bathrobe placed on the a geriatric residency floor (potentially hazardous clothing), at Brooks Institute of Higher Learning. throw rug, low-level cushioned couch, She is a board-certified geriatric special- vacuum with extended cord, a glass ist (GCS), Stepping On Instructor, and with spilled liquid content, and scattered Mental Health First Aid Instructor. She clutter. The event provided games to is a licensed Physical Therapist and challenge participants’ balance that were Doctor of Physical Therapy program decorated with a fall theme that corre- Instructor at the University of St. Augus- lated with the event décor. The games tine for Health Sciences. included a scarecrow reach station that resembled the Functional Reach Test and cornhole toss station. The cornhole toss challenged participants to stand in advancing balance positions, marked by tape on the floor, located at progres- sive distances from the cornhole boards. DeAnn Taylor, Bonnie Rogulj With each progressive position and dis- GeriNotes, Vol. 26, No. 1 2019 13 National Fall Prevention Awareness Day Celebrations

Mariana Wingood, PT, DPT

National Fall Prevention Awareness collaboration between 6 DPT Programs handout: “6 steps to Prevent a Fall.” Day (NFPAD) occurs every year on the in Georgia (faculty and students) and Therapists engaged in conversations first day of fall and every year members multiple clinical and community part- on fall prevention throughout the of the Balance and Falls SIG are actively ners. As of October 31, 2018, a total week with visitors to the hospital involved in various fall prevention com- of 681 individuals were screened for fall and patients and family members. munity events. This year members risk using the CDC STEADI initiative. partnered with fall prevention coali- NEW YORK: tions, other health care providers, home IDAHO: Had multiple NFPAD events: improvement experts, meal sites, exer- Southeastern Idaho Public Health cise experts, and various senior service collaborated with community partners (1) “Don’t” Fall Festival: held in con- agencies. Together they put on various as well as faculty and students from junction with fitness department’s events including presentations, health Idaho State University (ISU) to hold “Active Aging Week” activities. The fairs, screenings, and workshops. Here their 7th Annual “Humpty Dumpty” festival activities included: is a short summary of some of their suc- Falls Prevention Health Fair. The health • Pumpkin Painting with a casual vi- cess stories: fair included various health stations to sion exam to educate participants determine fall risks and how to prevent a of vision check-ups and its impor- ALABAMA: fall. The student health disciplines from tance to fall prevention. Had a couple of events, including: ISU included dietetics, occupational • Apple Picking instructing on safe therapy, physical therapy, and health use of step stools and reachers to (1) The Alabama State University Physi- education. The participatory health sta- demonstrate safety at home. cal Therapy Program participated in tions focused on walking tests, foot • Mummy Wrap was a fun game the Successful Aging Initiative Con- checks, getting back up safely from a fall, that allowed therapists to screen ference where they screened over balance tests, nutrition and hydration attendees for balance issues. 200 older adults. evaluation, exercises to prevent falls, and • Matching card game included (2) Infirmary Health, a non-profit navigating a room with fall risk factors. educational material about home health care system, screened over safety and fall prevention pre- 100 older adults at 4 senior centers NEW JERSEY: sented in a fun and entertaining in south Alabama during the week Held a Fall Prevention Community format. of NFPAD. Event at the Senior Appreciation Day • Throw Away the Throw Rug Fair in Freehold, NJ. The event was a which had attendees tossing har- FLORIDA: multi-university and community col- vest themed rugs into garbage The University of St. Augustine laboration that included a proclamation cans to stress the tripping hazard for Health Sciences hosted an event presented by Governor Murphy, fall- that throw rugs present. titled “Don’t Be Trippin”. The event prevention screening, and distribution • The last table included educational was an interdisciplinary health event of 150 promotional bags (containing fall prevention materials and free that involved community organizations/ education regarding fall prevention and night lights along with Apple Ci- businesses as well as physical and oc- exercise). der and Cider Donuts! Event was cupational student volunteers. For more held between 1:00 pm and 2:00 information read the article titled “A NEW MEXICO: pm and had about 45 attendees. Multi-Disciplinary Event to Celebrate Held two separate events: (2) A free Stepping On Program: with Falls Prevention Awareness Day.” 16 community members partici- (1) There was a “Fall Fiesta,” an event pated. GEORGIA AND that included community screen- (3) A Fall Prevention Initiative that SOUTH CAROLINA: ings based on the CDC STEADI included sending the community Physical therapists in Georgia and and interdisciplinary collaboration members the ABC test. The 85 South Carolina collaborated on an as well as education. that responded received a fall risk amazing dual-state effort. They support- (2) A physical therapist organized a classification (low, moderate, and ed fall prevention via the STOP Falls week of fall prevention education high fall risk) and recommendations (Screening One-Thousand Older Adults at Rust Medical Center in Rio Ran- based on the classification. The low to Prevent Falls) initiative. The impetus cho, with flyers around the hospi- fall risk residents were encouraged behind the initiative was to honor the tal promoting the event. Handouts to participate in a variety of fitness father of a Georgia physical therapy edu- included the CDC’s “Stay Inde- classes located within the commu- cator who passed away this year related pendent,” “What You can Do to nity. Moderate fall risk members to the consequences of a fall and support Prevent Falls,” “Check for Safety,” were requested to participate in NFPAD. The STOP Falls is the result of and National Center on Aging’s the Otago fall prevention program 14 GeriNotes, Vol. 26, No. 1 2019 with an outpatient physical thera- and how these relate to the daily tasks (2) Week long social media post with pist. High fall risk group members they perform. Students also demonstrat- tips on how to help prevent fall. were offered a home assessment ed various methods for getting up after a (3) A video series, first with a balance from occupational therapist and the fall and practiced with those participants test and then subsequent short vid- Otago fall prevention program from who wanted to give it a try. eos on balance exercises that you can a physical therapist. work on at home to improve your TENNESSEE: balance and decrease your falls risk. NORTH CAROLINA: Completed a week-long event at a (4) The University of Wisconsin in Provided state-wide community local health center/assisted living facility. Madison involved its DPT students services learning opportunities for Physi- This included a daily stand up meeting with Occupational Therapy, Nurs- cal Therapy and Physical Therapy As- and a Fall Festival. The meeting was an ing, Pharmacists, and Safe Com- sistant students as well as fall prevention interdisciplinary effort that had repre- munities Organization to put on an activities. This included multiple fall sentation from each department, includ- event titled “Only Leaves Should prevention presentations, educational ing maintenance, housekeeping, dietary, Fall.” The event included an educa- opportunities including floor transfers recreation, nursing, and of course all tion program (luncheon) and Falls demonstration, screenings, and indi- of the therapies. The Fall Festival con- Risk Screenings. During the event vidualized recommendations based on sisted of fun activities including walking the students manned the screening screening results. an obstacle course with fall mats and stations and acted as buddies for the oxygen tubing, throw the throw rugs, sit participants. The buddies accom- OREGON: stand from a variety of chairs and stools, pany the participants to the various The Providence Hospital Network Bingo (with fall-prevention prizes such stations, help record the results, and hosted 10 free events. The events fea- as non-ski socks and night lights), and then use their motivational inter- tured a 1-hour education class taught by more. viewing skills to foster the partici- Physical Therapists, Occupational Ther- pants development of a plan. apists, and Pharmacists. Followed by a TEXAS: Tai Chi or Strong for Life exercise dem- Had two different screening events, VERMONT: onstration/class. Pharmacists educated one at the Age Well Brazos Health Fair Hosted their annual Vermont Stay about fall risk increasing medications and one at the Austin Speech Labs. and performed individualized medica- Steady Events, this included providing tion reviews. Vendors, such as Tunstall WASHINGTON: educational material via a fun game of medical alert devices and representatives Hosted fall prevention screening Bingo, a community screening, and rec- from our local Providence Optimal Ag- events at local Senior Center. They used ommendations based on the STEADI. ing caregiver service, were also present. the STEADI for screenings and recom- Their education and screening sites in- Providence Hospital Network provid- mendations. cluded Senior Centers, Meal Sites, and ed all participants with a mobility kit, ALF. The events were run by Physical which included a paper bag filled with WISCONSIN: Therapists with assistance from physical a water bottle, non-skid slipper socks, a Hosted multiple events including: therapy students and members of the pen, and nightlight. Vermont Falls Coalition. (1) An exercise class with balance screen- PENNSYLVANIA: ing and other community-based Thank you to everyone who par- The faculty members and students balance screenings using Timed Up ticipated, you all made a difference in from the Gannon University DPT pro- and Go, 4 step balance test, Self- someone’s life. gram participated in a local event where selected Walking Speed, and 5xSit- If you have any questions regarding they focused on gait speed, sit to stand, to-Stand. Individuals were provided the event, how to be involved, or what to and fall recovery. Students provided with recommendations based on do better for next year, feel free to e-mail handouts with explanations of the tests the results. me at [email protected].

STRICTLY PROFESSIONAL Let's meet for a think Enthusiastic journal editor1 seeks passionate geriatric clinicians for knowledge translation, evidence-informed practice, and life-long learning. Must be curious, enjoy professional growth, and be tolerant of Tables, Charts and Graphs. Participation in Journal Club2 a plus! Apathetic individuals and wiseacres need not apply. Rekindle the fire! Check out your next issue of the Journal of Geriatric Physical Therapy (JGPT).

1. Leslie Allison, PT, PhD; Editor-in-Chief, JGPT. You can contact me with suggestions about how the JGPT can support advanced clinical practice at [email protected] 2. Contact Marianna Wingood, PT, DPT, to learn about how you can join other engaged clinicians to participate in Jour- nal Club: [email protected]

GeriNotes, Vol. 26, No. 1 2019 15 Knowledge Translation- What Is It?

Mariana Wingood, PT, DPT; Mary Milidonis, PT, PhD

Knowledge translation (KT) is an to Action framework (KTA).5,6 The KTA encouraged to adopt example frame- under-used tool that has the power and the OMRU detail all stages of KT works such as KTA to implement the to significantly improve our practice. intervention and address the greatest highest level of evidence. Using these Knowledge translation helps with syn- number of barriers to EBP.6 frameworks will help improve knowl- thesis, dissemination, exchange, and ap- Using the KTA, framework clini- edge implementation and EBP, resulting plication of evidence into patient care. cians, managers, and educators can assist in tremendous advancement in both The primary goals are to improve pa- with overcoming barriers to EBP.7 The clinical knowledge and skills. Such im- tient health as well as the effectiveness of initiation of the framework occurs when provements will lead to enhanced pa- health care.1 It is the solution to many an individual identifies and recognizes tient outcome, a primary motivator for clinical difficulties that stem from one the knowledge gap and/or issue.7 The many clinicians and clinics. major problem--lack of evidence imple- next step is either one or both cycles of mentation. Currently it can take more KTA, known as Knowledge Creation REFERENCES than 17 years to get evidence into prac- and Action Cycle.7 Knowledge Creation 1. Moore JL, Carpenter J, Doyle tice, demonstrating that traditional edu- includes knowledge inquiry, synthesis, AM, et al. Development, imple- cational methods of infusing research and composes clinical tools.7 While the mentation, and use of a process to into practice have not worked.2 Action Cycle includes problem iden- promote knowledge translation in Knowledge translations can be di- tification; identifying, reviewing, and rehabilitation. Arch Phys Med Reha- vided into two parts: knowledge devel- selecting knowledge; adapting knowl- bil. 2018;99(1):82-90. opment and knowledge implementation edge to local context; assessing barriers 2. Blair M. Getting evidence into (includes review and sustainability).1,3 to knowledge use; selection, tailoring, practice--implementation science Implementation is the most common- implementing interventions; monitor- for pediatricians. Arch Dis Child. ly used component and includes both ing knowledge use; outcome evaluation; 2014;99(4):307-309. education and decision aids to ease and sustained knowledge use.7 During 3. Moore AE, Straus SE, Kasperavicius the application of the research into an the implementation process, barriers are D, et al. Knowledge translation individual’s clinical practice. A recent identified and overcome, this allows for tools in preventive health care. Can Cochrane review identified the benefits the knowledge to be applied to local Fam Physician. 2017;63(11):853- of decision aids; these include improv- practice.7 The finalized implementation 858. 4. Stacey D, Légaré F, Lewis K, et ing patient and clinician knowledge of model may take several cycles of both al. Decision aids for people facing options, increased participation in deci- Knowledge Creation and Action Cycle, health treatment or screening deci- sion making, increased awareness of risk highlighting that this is not a linear sions. Cochrane Database Syst Rev. and/or benefit, and increased likelihood pathway. 2017;(4):CD001431. of patient-clinician discussion about the The application of the KTA pro- 5. Yen IH, Anderson LA. Built en- decision.4 cess within physical therapy has been 8,9 vironment and mobility of old- Research has identified several bar- published in two case reports. One er adults: important policy and riers to implementation including time, case report details a series of 3 educa- practice efforts. J Am Geriatr Soc. access to literature, and critical appraisal tional workshops for 8 physical thera- 2012;60(5):951-956. skills. Additional factors that affect the pists working within a skilled nursing 6. Hudon A, Gervais MJ, Hunt 8 use of evidence-based practice (EBP) facility. The primary objective of the M. The contribution of conceptual include attitude toward research, educa- KTA application was to improve use of frameworks to knowledge transla- tion about EBP, exposure to EBP, confi- EBP while respecting time constraints tion interventions in physical thera- 8 dence in EBP, years in clinical practice and productivity pressure. In the sec- py. Phys Ther. 2015;95(4):630-639. (newer grads use more EBP), and attain- ond case report, the authors used a 7. Field B, Booth A, Ilott I, Gerrish 1 ment of a post-graduate degree. multicomponent interactive continuing K. Using the Knowledge to Ac- To overcome these barriers the education process that involved both re- tion Framework in practice: a cita- World Health Organization (WHO) has search and practice to successfully imple- tion analysis and systematic review. identified 9 knowledge translation mod- ment gait and balance assessments.9 Implement Sci. 2014;9:172. els that relate to healthy aging. Three These two case studies are prime 8. Sibley KM, Salbach NM. Apply- of those models are found in physical examples of successful application of ing knowledge translation theory therapy and include Promoting Action KTA. They created a positive change to physical therapy research and on Research Implementation in Health in physical therapist’s beliefs, attitudes, practice in balance and gait as- Services (PARHIS), Ottawa Model of skills, and clinical practice guideline sessment: case report. Phys Ther. Research Use (OMRU), and Knowledge awareness.8-10 Clinicians and clinics are 2015;95(4):579-587. 16 GeriNotes, Vol. 26, No. 1 2019 9. Schreiber J, Perry S, Downey P, Mary Milidonis, PT, Williamson A. Implementation of PhD, is an Associate For more on related topics innovative continuing education Professor and Direc- program focused on translation of tor of Gerontology to this month's GeriNotes, knowledge into clinical practice. J Certificates in the check out the first issue of Phys Ther Educ. 2013;27(3):63-71. Doctor of Physical the Journal of Geriatric 10. Bérubé MÈ, Poitras S, Bastien M, Therapy Program at Physical Therapy (JGPT) for 2 Laliberté LA, Lacharité A, Gross Cleveland State Uni- more articles related to DP. Strategies to translate knowl- versity. She teaches courses in geriat- balance and falls and edge related to common musculo- rics, gerontology, and musculoskeletal skeletal conditions into physiother- physical therapy. Her current research 2 related to MCI apy practice: a systematic review. includes health literacy tool impact, in- and dementia. Physiotherapy. 2018;104(1):1-8. tergenerational communication strate- gies, and predictors of satisfaction in at risk populations. Happy Reading! Mariana Wingood, PT, DPT, GCS, CEEAA, is a physi- The AGPT CSM Booth Volunteer cal therapist at Uni- versity of Vermont sign-up is available at Inpatient Rehab https://geriatricspt.org/csm Department. She is also the Balance and Volunteering at the Booth is a great way to connect with Falls SIG Chair who is very enthusiastic your peers, help out the Academy, and be registered about fall prevention as well as knowl- edge translation/implementation. to win a free year's membership.

Academy of Geriatric Physical Therapy is pleased to announce Physical Therapy and the Aging Adult Monograph Series now available in the APTA Learning Center! TOPICS INCLUDE: Assistive Devices, Adaptive Equipment, Orthotics, and Wheeled Mobility for the Older Adult Management of Falls and Fall Prevention in Older Adults Bariatric Obesity in the Older Adult Tool Kit for the Prevention of Diabetic Foot Ulcers Biopsychosocial and Environmental Aspects of Aging Breast Cancer Related Lymphedema End of Life Ethics To order your electronic copy visit http://learningcenter.apta.org

GeriNotes, Vol. 26, No. 1 2019 17 Persistent Postural Perceptual Dizziness in the Elderly: A Theoretical Hypothesis for a Missed Diagnosis in an Underserved Population

Jeffrey R. Guild, PT, DPT

INTRODUCTION 80s with the disorder, this is very few falling with or without a history of falls Persistent postural perceptual dizzi- compared to younger individuals.4 This compared to those without a fear of fall- ness (PPPD) is a chronic functional neu- age factor is also true in clinical practice ing.15 Common presentations in older ro-otologic disorder1 usually triggered in vestibular and balance specialty clin- people of dizziness,11,12 fear of falling,13 by a vestibular2-4 or medical event or ics where these younger individuals with activity avoidance behavior with fear of hospitalization resulting in a maladap- PPPD represent a large percentage of falling,14 and gait abnormalities with fear tive non-spinning dizziness and percep- the clientele, possibly the second most of falling15 are similar to presentations tion of unsteadiness. Persistent postural common vestibular disorder in these of PPPD. perceptual dizziness exists independent specialized practices.9 Studies seeking diagnostic causes of of a lesion or other disease.1 Persistent The purpose of this article is to ask dizziness in the elderly do not mention postural perceptual dizziness is a combi- a basic question about PPPD and to PPPD as a possible cause,16-18 even for nation of diagnoses such as chronic sub- explore possible answers. Why would studies with inclusion criteria down to jective dizziness, phobic postural vertigo, this common vestibular disorder occur age 50, well within the age-range com- space-motion discomfort, visual vertigo, predominantly when people are in their monly associated with PPPD.16,17 More- and others.1,5 30s, 40s, and 50s, and prevalence reduce over, in a recent multidisciplinary study Clinicians who specialize in ves- dramatically over the age of 70? This consisting of a geriatrician, vestibular tibular or balance disorders may think article proposes a theoretical hypothesis neuroscientist, psychologist, and exer- of individuals with PPPD as the 40 to this question to promote discussion cise physiologist who sought to identify year old working full-time and raising and debate. causes of dizziness in a cohort of 424 a family whose world has been turned individuals over the age of 50, 23% had upside-down after an initial vestibular PROBLEM an unrecognized reason for their dizzi- event. They find themselves in a chronic Most of the research about PPPD ness; in 18%, anxiety or depression were state of dizziness and anxiety2-4 that is performed in otolaryngology/vestibu- considered the cause.16 Given the high lasts for months and years4 resulting in lar/neurological specialty practices and rates of PPPD in specialty clinics,9 is it fear-avoidance of daily life activities.4,6,7 research departments.4,7-9 This makes possible PPPD would be present in 41% Seemingly unrelated symptoms such as sense given the specialty of the disorder. of those over the age of 50 with uniden- shortness of breath, palpitations, and However, since specialty clinics tend to tified causes of dizziness or dizziness la- abdominal symptoms7 add complexity receive referrals from other providers, beled as caused by anxiety or depression? to the disorder. Elaborate gait abnor- there is a risk that certain populations malities1,7 that reduce with increased gait could be missed and not referred out by HYPOTHESIS velocity and distraction6,7 tend to leave primary and secondary providers. Those Why would PPPD have minimal health care providers and families think- providers less familiar with the disorder prevalence over the age of 70? Is there ing the patient is malingering or in need of PPPD may miss this diagnosis in pop- a neurological, physiological, or psy- of help from a psychologist. Since PPPD ulations with common symptoms that chological difference between younger is a functional disorder that is indepen- are similar to PPPD, such as the elderly. individuals and those over the age of dent of any lesion or disease,1 it does not A third of 70 year olds and over 70 that would prevent elderly people show up on traditional medical tests,8 half of people by age 85 experience the from getting PPPD? This is certainly resulting in patients seeing several spe- symptoms of dizziness or vertigo.11,12 a possibility worth studying. However, cialists.1,9 However, very recent imaging Prevalence of fear of falling in the elderly since acute vestibular events are known studies have shown the physical evidence ranges widely between 21% and 85%.13 to trigger PPPD,1-5 is there a possibility that PPPD is a functional neurological Studies consistently support that 50% that PPPD is even more prevalent over disorder with observable changes to the of older people with a fear of falling the age of 70 since vestibular events are cerebral cortex.3,10 have not even experienced a fall.13 Activ- more common for this age group?11,12 Persistent postural perceptual diz- ity avoidance behavior is significantly This article hypothesizes the pos- ziness is most prevalent among people higher amongst elders with a fear of sibility that PPPD is being missed in in their 30s, 40s, and 50s.2,4,9 Although falling14 and gait abnormalities are sig- clinics and research facilities that do research does identify people into their nificantly higher for those with a fear of not specialize in vestibular or balance 18 GeriNotes, Vol. 26, No. 1 2019 disorders since PPPD is usually identi- to treatment if there is a lack of increased gait velocity and dual-tasking, fied in specialty tertiary care centers. In retention or understanding of the and elaborate movements beyond typical practice, neurologists, otolaryngologists, information provided about the di- furniture walking often seen in geriat- geriatricians, and internal medicine spe- agnosis. In other words, age is often ric populations. Physical therapists who cialists usually refer individuals to ves- blamed by the elderly themselves. work in geriatric settings have a trained tibular or balance clinics when there (4) Treatment of PPPD for those over eye for this population; these clini- is a presentation of dizziness, balance the age of 70 may need a little more cians could be prime to identify these problems, anxiety, and abnormal behav- of a hands-on approach. Some ves- subtleties. Moreover, the addition of case ior of a previously young and healthy tibular clinicians may see younger studies from clinicians would help con- individual. These same symptoms in the patients with PPPD once every 2 to tribute to the growing body of literature elderly may be easily interpreted as fear 3 weeks. Geriatric populations with about PPPD. of falling, gait abnormalities due to fear this diagnosis may need a higher of falling, or simply another older indi- frequency. Reasons for increased fre- CONCLUSION vidual with dizziness, balance problems, quency may be related to higher fall Theoretically PPPD could be a and anxiety about falling. risk due to other physical limita- diagnosis overlooked in the geriatric tions and more consistent repeated population because of similarities to Difference in Persistent Postural positive reinforcement that symp- complaints of dizziness, fear of falling, Perceptual Dizziness between toms are an actual diagnosis not and gait abnormalities. Fear of falling 13 Younger vs. Older Populations necessarily related to age. Cognitive by itself is associated with fall risk, Persistent postural perceptual dizzi- and memory deficits may limit the activity avoidance, and physical and 13,14 ness may present slightly differently for efficacy of cognitive behavioral ap- health decline. Persistent postural those over the age of 70 compared to proaches that is so successful at perceptual dizziness is a diagnosis worth younger populations: the onset of treatment in younger investigating for those over the age of populations. Cognitive behavioral 70. Presentation of PPPD in an older (1) Persistent postural perceptual dizzi- therapy may need to be repeated person may slightly differ due to ad- ditional complexities and comorbidities ness is not associated with fall risk throughout the entire spell of ill- of the elderly; basic diagnostic criteria of despite the perception of imbal- ness. PPPD would still apply to those over age ance.7 Those with PPPD over the 50. Treatment for PPPD is specific to age of 70 may actually be at high SOLUTION include cognitive behavioral-type ther- risk for falls and injury since fear Given a theoretical possibility that apy, vestibular rehabilitation, possibly of falling in the elderly is associated PPPD may be more prevalent than cur- selective serotonin reuptake inhibitors, with increased fall risk13 and de- rently recognized in those over the age and serotonin norepinephrine reuptake creased physical activity and physi- of 70, this could be an interesting area inhibitors.1 Correctly identifying this cal health.13,14 to investigate with slight variations in diagnosis in older people could dra- (2) The perception of a lack of balance research and more awareness in clinical matically help many people live a better due to PPPD in the elderly may be practice. Specialists investigating preva- quality of life, prevent physical/health mixed with actual balance impair- lence of PPPD might collaborate with decline, and prevent falls. ments due to vestibular dysfunction, geriatric researchers to address incidence proprioceptive loss, physical decline, and prevalence of PPPD over the age of REFERENCES strength deficits, and other medical 65 or 70 specifically. Could the 41% of 1. Popkirov S, Staab JP, Stone J. Per- complexities more common in older unknown causes of dizziness or dizziness sistent postural-perceptual dizziness compared to younger populations. due to anxiety or depression for those (PPPD): a common, characteristic This may make the diagnosis and over the age of 50 be reduced if PPPD is and treatable cause of chronic dizzi- treatment of PPPD in an older part of a list of causes of dizziness? This ness. Pract Neurol. 2017;18(1):5-13. person more complex and difficult. type of research could bring awareness to 2. Yan Z, Cui L, Yu T, Liang H, Wang Y, This is especially true since comor- those who work in geriatric populations Chen C. Analysis of the characteris- bidities can co-occur with PPPD and allow more people to be identified, tics of persistent postural-perceptual and the presence of a comorbid referred, and treated. dizziness: A clinical-based study in structural, metabolic, or psychologi- Clinicians can contribute to the China. Int J Audiol. 2017;56(1):33- cal condition does not forestall the solution as well. Recognition of signs 37. diagnosis of PPPD.1 and symptoms of PPPD and reflection 3. Wurthmann S, Naegel S, Stein- (3) Cognitive behavioral therapy at the on how that likely presents in an older berg BS, et al. Cerebral gray matter onset of treatment for PPPD (and person can aid clinicians to identify, changes in persistent postural per- usually so efficacious with PPPD9,19) treat, and help older individuals suffer- ceptual dizziness. J Psychosom Res. may have a more mixed affect in a ing from PPPD. Subtle clues to differ- 2017;103:95-101. person surrounded by peers with entiate an older individual with PPPD 4. Huppert D, Strupp M, Rettinger N, similar challenges and who accepts from their dizzy and anxious peers may Hecht J, Brandt T. Phobic postural his or her functional status due to include autonomic symptoms with ves- vertigo. A long-term follow-up (5 to age changes. Cognitive and memory tibular stimulation, improved balance, 15 years) of 106 patients. J Neurol. deficits may also increase challenges and reduced gait abnormalities with 2005;252(5):564-569. GeriNotes, Vol. 26, No. 1 2019 19 5. Staab JP, Eckhardt-Henn A, Ho- Neurosci. 2015;9:334. of vestibular disorder in older peo- rii A, et al. Diagnostic criteria for 11. Jönsson R, Sixt E, Landahl S, Rosen- ple who experience dizziness. Front persistent postural-perceptual diz- hall U. Prevalence of dizziness and Neurol. 2015;6:268. ziness (PPPD): Consensus docu- vertigo in an urban elderly popula- 18. Maarsingh OR, Dros J, Schellevis ment of the committee for the Clas- tion. J Vestib Res. 2004;14(1):47-52. FG, et al. Causes of persistent diz- sification of Vestibular Disorders 12. Oghalai JS, Manolidis S, Barth ziness in elderly patients in primary of the Bárány Society. J Vestib Res. JL, Stewart MG, Jenkins HA. care. Ann Fam Med. 2010;8(3):196- 2017;27(4):191-208. Unrecognized benign paroxysmal 205. 6. Wuehr M, Pradhan C, Novozhilov positional vertigo in elderly pa- 19. Shaaf H, Hesse G. Patients with S, et al. Inadequate interaction be- tients. Otoaryngol Head Neck Surg. long-lasting dizziness: a follow- tween open-and closed-loop postur- 2000;122(5):630-634. up after neurotological and psy- al control in phobic postural verti- 13. Scheffer AC, Schuurmans MJ, van chotherapeutic inpatient treat- go. J Neurol . 2013;260:1314-1323. Dijk N, van der Hooft T, de Rooij ment after a period of at least 7. Schniepp R, Wuehr M, Huth S, SE. Fear of falling: measurement 1 year. Eur Arch Otorhinolaryngol. Pradhan C, Brandt T, Jahn K. Gait strategy, prevalence, risk factors and characteristic of patients with pho- consequences among older persons. 2015;272(6):1529-1535. bic postural vertigo: effects of fear of Age Ageing. 2008;37(1):19-24. falling, attention, and visual input. J 14. Choi K, Jeon GS, Cho SI. Prospec- Neurol. 2014;261(4):738-746. tive study on the impact of fear of Jeffrey R. Guild, 8. Bittar RS, Lins EM. Clinical charac- falling on functional decline among PT, DPT, CSCS, is teristics of patients with persistent community dwelling elderly wom- founder and owner Braz J Int J Environ Res Public Health postural-perceptual dizziness. en. . of Optimove Physi- Otorhinolaryngol. 2015;81(3):276- 2017;14(5). pii: E469. cal Therapy & Well- 282. 15. Makino K, Makizako H, Doi T, et ness, LLC, a prac- 9. Obermann M, Bock E, Sabev N, et al. Fear of falling and gait param- tice in the Dallas al. Long-term outcome of vertigo eters in older adults with and with- Fort-Worth area that and dizziness associated disorders out fall history. Geriatr Gerontol Int. following treatment in specialized 2017;17(12):2455-2459. specializes in outpatient neurological tertiary care: the Dizziness and Ver- 16. Menant JC, Migliaccio AA, Stur- physical therapy with a subspecialty in tigo Registry (DiVeR) Study. J Neu- nieks DL, et al. Reducing the bur- vestibular and balance and falls, as well rol. 2015;262(9):2083-2091. den of dizziness in middle-aged as complex movement problems. He 10. Indovina I, Riccelli R, Chiarella and older people: A multifacto- welcomes feedback and questions and G, et al. Role of the insula and rial, tailored, single-blind random- can be reached at J.Guild@OptimoveD- vestibular system in patients with ized controlled trial. PLoS Med. FW.com and Optimove can be followed chronic subjective dizziness: An 2018;15(7):e1002620. at https://OptimoveDFW.com and on fMRI study using sound evoked 17. Chau AT, Menant JC, Hübner PP, its blog page at https://optimovedfw. vestibular stimulation. Front Behav Lord SR, Migliaccio AA. Prevalence com/blog/.

Impact of LSVT- BIG on Functional Outcomes in a Patient with Parkinson’s Disease: A Case Study

Blake A. Hampton, PT, DPT; Niamh Tunney, PT, DPT, MS; Daryll Dubal, PT, BSPT

INTRODUCTION health-related quality of life, strength, intensive treatment with a focus on Parkinson’s disease (PD) is a de- balance, and gait speed for patients with generalized recalibration in sensory per- bilitating condition affecting between PD, and high-intensity exercise has been ception of normal amplitude of move- 4.1 and 4.6 million individuals over the shown to improve corticomotor excit- ments.3,4 Research is limited on the im- age of 50, making it the second most ability in PD.1,2 pact the LSVT-BIG program has on PD common neurodegenerative disorder af- LSVT-BIG emphasizes training with regard to mobility and function. ter Alzheimer’s disease.1 Exercise has a movement amplitude as a single treat- Evidence supports an increase in gait beneficial effect on physical functioning, ment parameter through high effort, velocity and cadence, a decrease brady- 20 GeriNotes, Vol. 26, No. 1 2019 kinesia in upper and lower limb move- his prior level of function with decreased assessed using a number of measures ments,5 improved balance function,6 and risk of falling. In addition, the patient recommended as reasonable or reason- enhanced motor learning, but the ability states that he would like to reduce his able to recommend by the PDEDGE to transfer skills to automatic routines neck and low back pain. task force for use with individuals with is impaired.7 However, not all evidence PD presenting in Hoehn and Yahr Stage supports the superiority of LSVT-BIG PHYSICAL EXAMINATION III.11 From the recommended list the over other approaches in managing PD.8 The patient was screened for readi- following were used: 5 repetition Sit to Therefore, the impact of the LSVT-BIG ness to start the LSVT-BIG program by Stand, 30 second Sit to Stand, 6-Min- program must be explored in order to an LSVT certified physical therapist. ute Walk Test, Functional Reach Test, ensure efficacy of the intervention in Mr. J was alert and oriented to person, Timed Up and Go (TUG) test, Tinetti meeting its stated goals, and effective place, and time and was able to follow 1 Performance Oriented Mobility Assess- use of health care resources. The pur- to 2 step commands. Mild hypophonia ment (POMA), and the 10-Meter Walk pose of this case study is to determine was noted throughout the physical ex- test.11 As proposed by Dibble et al, mul- the impact of LSVT-BIG on functional amination. Vision and hearing presented tiple measures of balance function were outcomes in a patient with PD. within normal limits with the use of pre- used to predict fall risk for Mr. J.12 Refer scription glasses. Light touch and pain to Table 1 for initial and discharge scores CASE DESCRIPTION sensations were intact bilaterally in both on these measures. This case study presents a 69-year- the upper and lower extremities. Muscle old male diagnosed with Idiopathic Par- strength was 4-/5 for all major muscle ASSESSMENT kinsonism in 2010, presenting in Hoehn groups of bilateral lower extremities.10 The clinical impression was that and Yahr Stage III, indicating bilateral The patient also presented with mod- the patient would benefit from the disease; mild to moderate disability with erate bradykinesia, hypokinesia, and LSVT-BIG rehabilitation program. The impaired postural reflexes; physically in- minimal cogwheel rigidity. The patient patient’s impairments included general- 9 dependent. He was referred to the out- reported 2/10 neck pain at rest and 8/10 ized muscle weakness of bilateral lower patient physical therapy department of a low back pain during ambulation greater extremities, impaired dynamic standing skilled nursing facility after having 3 falls than 400 feet (0/10 at rest) on the verbal balance, impaired reactive postural con- in the 2 weeks prior to the start of care pain rating scale (VPRS). trol responses/balance recovery, impaired for the LSVT-BIG program. coordination, bradykinesia, hypokinesia, Activity Limitations/Participation hypophonia, and micrographia. These Patient History and Interview Restrictions all contributed to increased fall risk Medical History The patient required moderate as- and activity limitations in bed mobil- Cellulitis, debility, respiratory fail- sistance to safely transition from supine ity, transfers, and ambulation. Goals for ure, diabetes mellitus (Type II), Par- to sitting with verbal cues. He required this patient during the 4-week program kinson’s disease, dementia, previous supervision to safely perform a sit to were established: (1) increase gait veloc- cerebrovascular accident, hypertension, stand transfer from a chair with arms, ity to 2ft per second or greater without congestive heart failure, nephrolithiasis, and required stand by assistance dur- an assistive device on even surfaces; (2) obesity, and sleep apnea. These condi- ing gait with a rolling walker for safe increase his Tinetti score to 27 out of tions had been managed with prescribed ambulation for more than 150 feet on 28 to lower fall risk; (3) decrease fall medication and previous physical ther- level surfaces. frequency to 0 falls per week for 12 apy for several years including a short- weeks; (4) complete supine to sit transfer term inpatient rehabilitation admission Outcome Measures at a level of modified independence; (5) to the same skilled nursing facility. The patient’s static and dynamic decrease TUG score to 13 seconds or less standing balance, gait, and fall risk were Social History without use of an assistive device; and Retired and lives with his wife in a single story home with 7 steps to enter, Table 1. Outcome Measure Data handrails on both sides. Outcome Measure Initial Evaluation Score Discharge Score Current Level of Function Independent with basic activities Timed Up and Go 23 seconds with AD 10 seconds without AD of daily living, ambulates in his home Tinetti 23/28 with AD 28/28 without AD independently using a rolling walker, and outdoors with supervision using a Functional Reach 10 inches 20 inches rolling walker for up to 400 feet. Patient 30 second sit to stand 12 repetitions 15 repetitions was able to ambulate without an assistive device on occasions for short distances 5 time sit to stand 18 seconds 9 seconds indoors independently and was able to 6-minute walk test 480 ft with AD 600 ft without AD ascend/descend the stairs in and out of his home with the use of handrails and 10-meter walk test 22 seconds (.45m/sec) 6 seconds (1.67m/sec) support from his wife. The patient’s with AD without AD stated goal for therapy was to return to Abbreviation: AD, assistive device GeriNotes, Vol. 26, No. 1 2019 21 (6) improve endurance to be able am- were: getting out of a recliner, mak- Gait/Stairs bulate 600 feet in 6 minutes to increase ing a drink and carrying it without Observational gait analysis at 4 the score of his 6-Minute Walk Test with spilling, and getting out of the car. weeks showed improvements in stride decreased complaints of low back pain. length, velocity, sequencing, and weight During each 1-hour, one-on-one shifting during all phases of the gait INTERVENTION session, Mr. J was constantly encour- cycle. Furthermore, the patient was able The patient continued his estab- aged to focus on how it feels and what to ambulate 300 feet safely while using lished regimen of Sinemet® without ad- it looks like to move big and work with a rolling walker, and was able to safely justment while in the LSVT-BIG pro- an effort of at least 80% of the maximal ascend/descend 7 stairs requiring super- gram. The patient did not receive any workload. vision and bilateral handrails. other form of physical rehabilitation The daily homework consisted of while participating in the LSVT-BIG Daily Maximal Exercises, the 5 Func- Bed Mobility program. The participant engaged in tional Component Movements, walking After 4 weeks of the LSVT-BIG the 4-week LSVT-BIG training protocol BIG, and a carryover assignment (as- program, the patient was able to per- administered by an LSVT-BIG certified signed daily and relates to the person’s form supine to sit with modified inde- physical therapist as defined by LSVT- plans for the day). The patient selected pendence (secondary to increased time BIG Global Inc.4 The high intensity of part of a Hierarchy Tasks to use as required to complete transfer) and sit to 4 LSVT-BIG is predefined by a training his carryover task. Mrs. J was trained stand transfers from the edge of the bed mode of 16 individual 1-hour sessions 4 to provide cues throughout the home independently. At the end of the 4-week consecutive days a week for 4 weeks and program and she was able to cue with program, the patient reported that he an independent home training program. 100% accuracy by the end of the 15th no longer considered it difficult to get Each treatment session consisted of: session on all exercises required in the out of bed. home training program. Training was 1. Seven Maximal Daily Exercises: adapted weekly by increasing volume or Strength 2 maximum sustained movements intensity of the exercises. The Functional After completion of the 4-week pro- and 5 repetitive directional move- Component Movements and Hierarchy tocol, the patient’s gross lower extremity ments (3 multidirectional, balanc- Tasks did not change throughout his strength was also increased at discharge ing movements involving inter-limb program in response to the patients which was hypothesized to be related coordination and 2 intra-limb coor- expressed desire to achieve mastery of to improve motor unit recruitment and dination movements). During the these specific movements and tasks. coordination, as resistance training to maximal daily exercises, movements Throughout the program, movement achieve muscle hypertrophy is not in- were shaped by modeling, and use was calibrated by highlighting the rela- corporated in the LSVT-BIG protocol. of tactile, visual, verbal, auditory, tionship between increased movement and proprioceptive cues to create big effort and normal motor output ulti- DISCUSSION movements with good quality. mately allowing big movements to feel The patient in this case report dem- 2. Five Functional Component Move- more normal and matching perception onstrated improvements on several out- to reality. Instructions and explanations ments (1 of which is sit to stand; come measures, and in activities not the other 4 are chosen by the patient were kept to a minimum to reduce the captured on outcome measures, after and can be part task relating to a cognitive demand of the session. Sensory completing 4 weeks of LSVT-BIG train- hierarchy task): The purpose of these recalibration was achieved by focusing ing. Consistent with the Berlin LSVT- movements is to over-learn familiar the patient’s attention on how it felt to BIG Study, we saw increases in the commonly used and salient everyday move big during everyday activities and TUG and 10-meter walk tests.13 Farley movements. This encourages compli- probing for the feedback that people in et al posited that patients with PD in ance with the home exercise program his life provided regarding his bigger and carryover to daily tasks facilitat- movements. It is important to note that Hoehn and Yahr Stage III, and possibly ing sensory recalibration. The other 4 the patient only participated in 15 of the Stage II, were limited in their capacity Functional Component Movements 16 1-hour, one-on-one sessions due to to spontaneously generate increased ve- 5 selected by the patient were: stand the supervising physical therapist being locity. However, in this case study the and reach, walk and turn, rolling in unable to administer the last training patient substantial improvements in gait bed, and putting on the seatbelt in session. velocity. the car. Observed increases in Tinetti 3. Walking BIG: The patient practiced RESULTS POMA score, Functional Reach Test, Walking BIG during every session Outcome Measures and 10-meter walk test all exceeded the with an emphasis on increasing stride Data were obtained at initial evalu- minimal detectable change (MDC), and length, improving posture, and in- ation before training started and after 4 the patient achieved a discharge score creasing arm swing. weeks of LSVT-BIG training at the 15th of 10 seconds for TUG (a 13 second 4. 1-3 Hierarchy Tasks (more complex session. Results of all outcome measures decrease from baseline). salient activities-multi-step function- are listed in Table 1. After 4 weeks, It is important to note that Mr. al activities): The Hierarchy Tasks performance on all of the outcome mea- J met his stated personal goals, but were also selected by the patient and sures for gait and balance improved. these changes were not captured on the 22 GeriNotes, Vol. 26, No. 1 2019 outcome measures used. He became BIG study. Arch Phys Med Rehabil. independent in rising from his recliner, 2014;95(5):996-999. Blake A. Hampton, pouring a glass of water, carrying the 4. LSVT Global, Inc. LSVT BIG PT, DPT, CSCS, is a water and returning to sitting in his Training and Certification Workshop staff physical thera- recliner without spilling, getting in and Manual. Tucson, AZ: LSVT Glob- out of his car independently, and walk- al, Inc; 2013. pist at Dekalb Medi- ing at a speed similar to his wife to be 5. Farley BG, Koshland GF. Training cal and an adjunct able to keep up with her when out in the BIG to move faster: the application faculty member at community. These achievements reflect of the speed-amplitude relation as Mercer University a change in Mr. J’s quality of life that a rehabilitation strategy for people in Atlanta, GA. His could have been captured by a quality of with Parkinson’s disease. Exp Brain clinical practice area is rehabilitation of life outcome measure such as the PDQ- Res. 2005;167(3):462-467. individuals with neuromusculoskeletal 6. Janssens J, Malfroid K, Nyffeler T, 39 as recommended by the PDEDGE conditions and persistent pain. He is Bohlhalter S, Vanbellingen T. Ap- task force.11 The patient was able to residency trained in the field of ortho- plication of LSVT BIG interven- achieve all of his goals and was indepen- pedics and is a Board Certified Strength tion to address gait, balance, bed dent without use of his assistive device and Conditioning Specialist. His teach- mobility, and dexterity in people at discharge and at 12-week follow-up. ing emphasizes clinical application of with Parkinson’s disease: a case se- exercise programming. Mr. J only completed 15/16 of ries. Phys Ther. 2014;94(7):1014- the supervised sessions. However, in a 1023. Niamh Tunney, PT, study comparing the established 4-week 7. Ebersbach G, Grust U, Ebersbach DPT, MS, is a Clini- protocol to a shorter 2-week 10 session A, Wegner B, Gandor F, Kuhn AA. cal Associate Profes- protocol similar motor improvements Amplitude-oriented exercise in Par- 7 sor in the Depart- were noted. kinson’s diease: a randomized study ment of Physical Future studies into the efficacy of comparing LSVT-BIG and a short LSVT-BIG program for individuals with training protocol. J Neural Transm Therapy at Mercer PD should examine the long-term ben- (Vienna). 2015;122(2):253-256. University in Atlan- efits on gait speed, gait amplitude, stride 8. Dashtipour K, Johnson E, Kani ta, GA. Her clinical length, arm swing, functional mobility C, et al. Effect of exercise on mo- practice area is the rehabilitation of transitions, and quality of life. tor and nonmotor symptoms of individuals with chronic stroke, and Parkinson’s disease. Parkinsons Dis. her teaching emphasizes neuro-rehabil- CONCLUSION 2015;2015:586378. itation. In conclusion, this case study dem- 9. Goetz CG, Poewe W, Rascol O, onstrates the significant impact LSVT- et al. Movement Disorder Society Daryll Dubal, PT, BIG training had on this patient in the Task Force study on the Hoehn BSPT, is a staff areas of gait, balance, bed mobility, and and Yahr staging scale: status and physical therapist functional mobility as well as decreased recommendations. Mov Disord. at Life Care Center fall risk, and supports the efficacy of 2004;19(9):1020-1028. of Lawrenceville in LSVT-BIG on functional outcomes in 10. Kendall FP, McCreary EK, Provance Lawrenceville, GA. patients with PD. PG, Rodgers MM, Roman WA. He is responsible for Muscles, Testing, and Function with providing care for a REFERENCES Posture and Pain. 5th ed. Balti- variety of neurologic and musculoskel- more, MD: Lippincott Williams & 1. Salgado S, Williams N, Kotian etal impairments in a geriatric popula- Wilkins; 2005:19-24. R, Salgado M. An evidence-based tion in an extended care facility and is 11. Neurology Section, APTA. Parkin- exercise regimen for patients with LSVT-BIG certified specializing in the son EDGE Task Force: Recommen- mild to moderate Parkinson’s dis- treatment of Parkinson’s disease in an dations by Disease Severity. www. ease. Brain Sci. 2013;3(1):87-100. outpatient program at the same facility. neuropt.org. Accessed November 2. Fisher BE, Wu AD, Salem GJ, 30, 2017. et al. The effect of exercise train- 12. Dibble LE, Christensen JD, Ballard ing in improving motor perfor- J, K Foreman B. Diagnosis of fall mance and corticomotor excitabil- risk in Parkinson disease: an analysis ity in people with early Parkinson’s of individual and collective clini- disease. Arch Phys Med Rehabil. cal balance test interpretation. Phys 2008;89(7):1221-1229. Ther. 2008;88(3):323-332. 3. Ebersbach G, Ebersbach A, Gandor 13. Ebersbach G, Ebersbach A, Edler F, Wegner B, Wissel J, Kupsch A. D, et al. Comparing exercise in Impact of physical exercise on reac- Parkinson’s disease—the Berlin tion time in patients with Parkin- LSVT BIG study. Mov Disord. son’s disease—data from the Berlin 2010;25(12):1902-1908. GeriNotes, Vol. 26, No. 1 2019 23 External Gait Cues: Improving Gait in Persons with Parkinson’s Disease

Alex Piersanti, PT, DPT

INTRODUCTION posed that visual and auditory cueing meta-analyses and 206 participants from Background and Purpose strategies are successful in improving the RCTs and case study. Males were Parkinson’s disease (PD) affects gait because the recruited neural path- 37.5% of the participants and 62.5% about 3.3% of adults over the age of ways may bypass the basal ganglia.6 were female. Ages ranged from 30 to 84 65 making it the second most common Currently, it is unknown which years old. neurodegenerative disorder in this age external cueing strategy is most effec- group.1,2 Parkinson’s disease results from tive in improving gait in those with PD. Intervention Characteristics a degeneration in dopamine produc- The purpose of this literature review is Eleven of the 12 articles investi- ing cells in the substantia nigra within to evaluate the effectiveness of different gated the effects of auditory cues on the basal ganglia in the brian.3 Due to cueing strategies on spatiotemporal gait gait characteristics.2,6-11,13-16 Nine articles the lack of curative treatment options, characteristics in those with PD and investigated the effects of visual cues there is a rising economic burden on to suggest an evidence-based guide for on gait characteristics2,6,7,10-14,16 and 4 both patients and payers.4 In the United clinicians to improve practice strategies. articles investigated the effects of tactile States, approximately $14.4 billion was cues on gait characteristics.2,13,14,16 Two spent on medical costs associated with METHODS studies investigated the effects of audi- PD in 2010 which equates to about Search Strategy and Eligibility Criteria tory and visual combination cueing on $22,800 per patient per year.4 This cost A literature review completed be- gait characteristics.10,16 is projected to grow substantially in the tween September 2017 and February The frequency of interventions in coming years.4 2018 was conducted using the search en- the included studies ranged from 20- to Parkinson’s disease presents with gines PubMed, CINAHL, MEDLINE, 40-minute sessions, 3 to 5 times per many motor and non-motor symptoms and Sports Discuss. Studies were includ- week. The duration of the interventions that can severely impact functional mo- ed in the literature review if they: (1) ranged from 1 session to 8 weeks. bility to varying degrees. The 4 cardinal evaluated the effects of visual, auditory, features of PD include resting tremors, vibrotactile, or a combination of cues Gait Characteristic Outcomes rigidity, akinesia, and postural instabil- on gait in individuals with PD; (2) in- Stride length ity.1 More recently, gait disturbance has cluded evaluation of spatiotemporal gait Five studies evaluated the effects been suggested as a fifth cardinal fea- characteristics; (3) were written between of external cueing on stride length.6-10 ture.5 Gait disturbances in those with 2004 and 2018; (4) were written in the Three studies used visual cues,6,7,10 5 PD include stooped posture, freezing English language; and (5) were available studies used auditory cues,6-10 and 1 of gait (FOG), festination, shuffling in full text. Studies were excluded if study used combination cues.10 Articles steps, shortened stride length, increased they: (1) did not involve external cues to that evaluated the effects of external cadence, and falling1,5 that are thought affect gait, (2) were not available in the cueing on stride length found that both to stem from the loss of postural reflexes English language, or (3) were not avail- visual and auditory cueing improved associated with PD.1 able in full text. stride length by 9% to 25%.6,8,9 Most motor and non-motor symp- toms that result from PD can be treated RESULTS Step length effectively through pharmacological in- Literature Search Results Four studies evaluated the effects terventions, however, gait disturbances Following an extensive search, 473 of external cueing on step length.2,7,11,12 have a poor response to pharmacological articles were identified. Duplicates were Four studies used visual cues2,7,11,12 and treatment and are usually altogether in- deleted, inclusion/exclusion criteria 3 studies used auditory cues.2,7,11 Results effective.2 External cueing is often used were applied, and the remaining articles show that visual cueing is more effective as a non-pharmacological treatment for were screened for relevance by title and at improving step length. gait disturbances in PD. Visual, audi- abstract. Twelve studies were included tory, and vibrotactile cueing have been within this review: 2 systematic reviews, Cadence used clinically to improve gait kinemat- 1 meta-analysis, 8 randomized control Five studies evaluated the effects of ics in those with PD.2 Cueing has espe- trials (RCTs), and 1 case study. external cueing on cadence.2,6-8,10 Four cially shown significant improvements studies used visual cues,2,6,7,10 5 studies in balance that has led to reduced fall Participant Characteristics used auditory cues,2,6-8,10 and 1 study risk, reduced FOG, decreased cadence, The total number of participants used combination cueing.10 Overall, ca- and improvements in stride length.2 A in all studies was 1,754 including 1,528 dence improved with the use of auditory study by Suteerawattananon et al pro- participants from systematic reviews and cues by 12% to 21%.6,8 24 GeriNotes, Vol. 26, No. 1 2019 Gait initiation/Freezing of gait during treat- Four studies assessed the effective- ment sessions. Visual6,10 ness of external cueing on gait initia- In certain situ- Stride length tion and FOG.11,13-15 Three studies used ations, it may Auditory7-10 visual cues,11,13,14 4 studies used auditory be more fea- cues,11,13-15 and 2 studies used vibrotac- sible to use one tile cues.13,14 Results show that auditory cueing strategy Step length Visual2, 7,11, 12 cueing decreased start hesitation from over another 15 31.7% to 3.3%. One article found that due to resourc- Cadence Auditory2,6-8,10 Gait the use of fixed delay or countdown cue- es, space, and Disturbance(s) ing is most beneficial when using visual time. Each 11, 13,14 cueing.13 clinician must Visual Gait Initiation/ use their clini- FOG Gait speed cal judgement Auditory15 Eight studies evaluated the ef- to determine fectiveness of external cues on gait the appropriate Auditory2, Gait Speed 6-10, 12, 16 speed.2,6-10,12,16 Six studies used visual cueing strategy cues,2,6,7,10,12,16 7 studies used auditory based on the cues,2,6-10,16 and 2 studies used combina- patient’s limita- Figure 1. tion cues.10,16 Overall, the articles found tion, response that there was a 16% to 19% improve- to cueing, and tive at improving gait in those with PD. ment in gait speed with the use of audi- environment. It should be emphasized that there are a tory cueing.6,8,9 In one study, 85.7% of wide variety of useful cueing strategies participants reported they walked faster Experimental Design and including some of the strategies men- with the use of the auditory pacer.9 Study Limitations tioned in this article. Clinicians should External cueing strategies are cheap, select the most appropriate cueing strat- DISCUSSION easy to implement, and effective at im- egy for their patient based on the pa- Gait abnormalities are one of the proving gait in those with PD. Clini- tient’s presentation, goals, response to most detrimental functional limitations cians, such as physical therapists, occu- treatment interventions, caregiver sup- experienced by those with PD.6 Gait pational therapists, and nurses can use port, and living environment. Cueing this information to help guide treatment disturbances may lead to a decline in strategies are a low cost and low risk sessions and patient/caregiver education. functional mobility, loss of indepen- intervention; clinicians can confidently Caregiver training on specific strategies dence, and decreased quality of life apply these techniques. may increase carryover into the commu- (QoL). The purpose of this literature Suggestions for further research in- nity or home environment and promote review was to evaluate the effectiveness clude determining the relationship be- longer carry-over. However, the progres- of different cueing strategies on key tween improved gait and increased QoL, sive nature of PD cannot be ignored gait disturbances in those with PD. optimal parameters of external cueing when discussing long-term retention of Although differences in testing facilities strategies, and long-term carry-over of gait improvements. and study protocols made comparison external cueing strategies on improving This study has several limitations. of results difficult, some conclusions can gait. This literature review examined 12 ar- be drawn. ticles from 2004 to 2018 that included ACKNOWLEDGEMENT Results indicate that visual cues a case study, RCTs, systematic reviews, The author acknowledges Maggie are most effective in improving step and meta-analysis. Application of in- 2,7,11,12 Schumacher, PT, DPT, GCS, for her length. Auditory cues are most ef- clusion and exclusion criteria limited thoughtful contributions throughout fective in improving cadence and gait the number of articles reviewed. Sev- 2,6-10,12,15,16 speed. Both visual and audi- eral studies had small sample sizes that the editing process. tory cueing strategies have similar im- may have affected generalization of the REFERENCES pacts on improving stride length and results. Interpretation of results may 6-11,13-15 gait initiation. Vibrotactile cueing be limited due to the diversity of trial 1. Chen P, Wang R, Liou D, Shaw J. strategies were not found to improve gait designs, treatment protocols, and study Gait disorders in Parkinson’s dis- characteristics within this review. Figure parameters. It is difficult to generalize ease: assessment and management. 1 provides a clinical decision-making functional carry-over outside of the test- Int J Gerontol. 2013;7(4):189-193. flow chart based on the results of this ing environment due to variability in 2. Rocha PA, Porfirio GM, Ferraz HB, review. practice setting, clinicians, and available Trevisani VF. Effects of external These results may assist clinicians in resources for patients and clinicians. cues on gait parameters of Par- making evidence-based decisions when kinson’s disease patients: a system- selecting the appropriate cueing strategy. CONCLUSION AND atic review. Clin Neurol Neurosurg. For example, if a clinician evaluates that SUGGESTIONS FOR 2014;124:127-134. doi: 10.1016/j. a patient’s most significant gait distur- FUTURE RESEARCH clineuro.2014.06.026. bance is shortened step length, the clini- It can be concluded that external 3. Jankovic J. Parkinson’s disease: cian may choose a visual cueing strategy cueing strategies are safe, easy, and effec- clinical features and diagno- GeriNotes, Vol. 26, No. 1 2019 25 sis. J Neurol Neurosurg Psychiatry. administration of auditory cueing 15. Delval A, Moreau C, Bleuse S, et al. 2008;79(4):368-376. to improve gait in people with Auditory cueing of gait initiation 4. Kowal SL, Dall TM, Chakrabarti R, Parkinson’s disease. Clin Rehabil. in Parkinson’s disease patients with Storm MV, Jain A. The current and 2009;23(12):1078-1085. freezing of gait. Clin Neurophysiol. projected economic burden of Par- 10. Spaulding SJ, Barber B, Colby 2014;125(8):1675-1681. kinson’s disease in the United States. M, Cormack B, Mick T, Jenkins 16. Lim I, van Wegen E, de Goede C, Mov Disord. 2013;28(3):311-318. ME. Cueing and gait improvement et al. Effects of external rhythmical 5. Okuma Y. Freezing of gait in among people with Parkinson’s dis- cueing on gait in patients with Par- Parkinson’s disease. J Neurol. ease: A meta-analysis. Arch Phys kinson’s disease: a systematic review. 2006;253(Suppl):VII27-32. Med Rehabil. 2013;94(3):562-570. Clin Rehabil. 2005;19(7):695-713. doi:10.1007/s00415-00607007-2. doi:10.1016/j.apmr.2012.10.026. 17. Shen X, Wong-Yu IS, Mak MK. 6. Suteerawattananon M, Morris 11. Jiang Y, Norman KE. Effects of visual Effects of exercise on falls, balance, GS, Etnyre BR, Jankovic J, Pro- and auditory cues on gait initiation and gait ability in Parkinson’s dis- tas EJ. Effects of visual and audi- in people with Parkinson’s disease. ease. Neurorehabil Neural Repair. tory cues on gait in individuals Clin Rehabil. 2006;20(1):36-45. with Parkinson’s disease. J Neu- 12. Sidaway B, Anderson J, Daniel- 2015;30(6):512-552. rol Sci. 2004;219(1-2):63-69. son G, Martin L, Smith G. Ef- doi:10.1016/j.jns.2003.12.007. fects of long-term gait training us- 7. De Icco R, Tassorelli C, Berra E, ing visual cues in an individual Alexandra Piesanti, Bolla M, Pacchetti C, Sandrinin G. with Parkinson disease. Phys Ther. PT, DPT, is origi- Acute and chronic effect of acoustic 2006;86(2):186-194. nally from Palatine, and visual cues on gait training in 13. Lu C, Amundsen Huffmaster SL, IL, and earned her Parkinson’s disease: a randomized, Tuite PJ, Vachon JM, MacKin- Doctor of Physical controlled study. Parkinsons Dis. non CD. Effect of cue timing Therapy from Car- 2015;2015:978590. and modality on gait initiation in 8. Ford MP, Malone LA, Nyikos Parkinson disease with freezing roll University in I, Yelisetty R, Bickel CS. Gait of gait. Arch Phys Med Rehabil. 2017. She recently training with progressive external 2017;98(7):1291-1299. completed the Creighton University- auditory cueing in persons with 14. McCandless PJ, Evans BJ, Janssen Hillcrest Geriatric Physical Therapy Parkinson’s disease. Arch Phys Med J, Selfe J, Churchill A, Richards J. Residency and plans to take the GCS Rehabil. 2010;91(8):1255-1261. Effect of three cueing devices for exam in 2019. Alexandra is currently doi:10.1016/j.apmr.2010.04.012. people with Parkinson’s disease with working in the home health setting in 9. Bryant MS, Rintala DH, Lai EC, gait initiation difficulties. Gait Pos- Nebraska. She can be reached at alexpi- Protas EJ. An evaluation of self- ture. 2016;44:7-11. [email protected].

GET LITerature Core Values: Measurement in Older Adults

Carole Lewis, PT, DPT; Valerie Carter, PT, DPT

No therapist would deny the im- importance of addressing this area. As measures that are both feasible and safe portance of core strength in our older strength experts, we are well positioned in the older population? patients. A strong core can help prevent to screen for core strength deficits, just The prone bridge test, also known back pain,1 balance issues,2 and problems as we routinely test upper and lower as the plank, has been shown to be a with functional mobility.3 However, few extremity strength. The question for valid and reliable test for abdominal older adults seek out specific exercises us is: how do we go about testing core muscle performance in younger adults,4,5 to strengthen their core or realize the strength? Do we have valid, reliable but has not been examined in older 26 GeriNotes, Vol. 26, No. 1 2019 adults until recently. In 2018, Dr. Rich- long as possible. In Bohannon’s study, 4. Schellenberg KL, Lang JM, Chan ard Bohannon filled this gap by publish- the participants were given up to 3 KM, Burnham RS. A clinical tool ing a study in the Journal of Bodywork warnings if they deviated from a neutral for office assessment of lumbar spine and Movement Therapies entitled, “The position; timing ended when the posi- stabilization endurance: prone and prone bridge test: Performance, validity, tion could no longer be maintained. supine bridge maneuvers. Am J Phys and reliability among older and younger For patients who cannot tolerate Med Rehabil. 2007;86(5):380-386. adults.”6 It was a descriptive study of the prone position, there is an alternative 5. Czaprowski D, Atelltowicz A, Ge- 120 participants, 60 younger (20-35 based on the work of Ito.7 The partici- bicka A, et al. Abdominal muscle years old) and 60 older (60-79 years old) pant is positioned in supine and lifts the EMG-activity during bridge exercises that looked at validity and reliability of head and shoulder blades off of the mat. on stable and unstable surfaces. Phys the test. Participants were timed in the In Ito’s study (average age 45.3 years), Ther Sport. 2014;15:162-168. prone bridge to their maximal ability; participants held their hips and knees 6. Bohannon RW, Steffl M, Glenney they reported their perceived rating of in 90° of flexion. However, this position SS, et al. The prone bridge test: exertion at the beginning and the end can be modified for older adults to a Performance, validity and reliability of the test. The timed test was repeated hooklying position, knees flexed, and among older and younger adults. J 5 to 9 days later. The participants’ feet on the mat. The average hold time Bodyw Mov Ther. 2018;22(2):385- height, weight, and waist circumference for healthy controls in men was 182.6 389. were measured. They also completed the seconds and 85.1 seconds in women. 7. Ito T, Shirado O, Suzuki H, Taka- Veterans Specific Activity Questionnaire Ito’s work also included testing of trunk hashi M, Kaneda K, Strax TE. Lum- to assess their fitness level, the Rapid extensor endurance performed in a prac- bar trunk muscle endurance testing: Assessment of Physical Activity to as- tical way. Subjects were positioned prone an inexpensive alternative Arch Phys sess their exercise participation, and an- with a small pillow under the abdomen Med Rehabil. 1996;77(1):75-79. swered questions regarding usual activity to neutralize the lumbar spine position. with abdominal exercises including the They were asked to lift the sternum off plank. of the mat with their arms at their sides. The researchers found that the av- Average hold time for healthy controls Carole Lewis, PT, erage prone bridge time for the older in men was 208.2 seconds and 128.4 DPT, GCS, GTC, adults was 126.1 seconds, significantly seconds in women. While this study did MPA, MSG, PhD, higher than averages that have been not test the older population specifically, FSOAE, FAPTA, is reported previously for younger par- it nevertheless gives us a reference point the president of ticipants. They reported that the sample for testing abdominal flexor and exten- GREAT Seminars of participants may have had an above sor strength with a safe, feasible, and and Books and Great average level of fitness and exercise par- reliable method. Seminars Online ticipation. It is imperative to have measures in (www.greatseminarsandbooks.com and Better prone bridge time was sig- our toolbox that are both reproducible www.greatseminarsonline.com). She is nificantly correlated with higher fitness and practical. These are simple tools for a consultant with Pivot Physical Therapy levels, more exercise participation and core strength that you could consider and has her own private practice. She is more regular performance of abdominal using for your older patients. Improving Editor-in-Chief of Topics in Geriatric Re- exercise. Ratings of perceived exertion core strength is also of vital importance. habilitation and an adjunct professor in were higher at the end of the test than In our next GET LITerature column, George Washington University’s College the beginning; those who reported lower we will explore many interventions for of Medicine. exertion at the beginning held the bridge improving core strength. longer. These findings contribute to the Valerie Carter PT, validity of the prone bridge as a measure REFERENCES DPT, NCS, is a of core strength. 1. Chang WD, Lin HY, Lai PT. Core board-certified Neu- Test-retest reliability had an ICC of strength training for patients with rological Specialist 0.915, confirming that the prone bridge chronic low back pain. J Phys Ther and a Clinical Pro- is a reliable measure for both younger Sci. 2015;27(3):619-622. fessor in the Physical and older adults. Bohannon’s study al- 2. Kahle N, Tevald M. Core muscle Therapy at Northern lows us to use this tool with new confi- strengthening’s improvement of bal- Arizona University. dence as a valid and reliable measure for ance performance in community- She and her husband own and operate older patients. dwelling older adults: a pilot study. Carter Rehabilitation and Wellness Cen- The prone bridge is a simple ma- J Aging Phys Act. 2014;22(1):65-73. ter an outpatient physical therapy clinic neuver to test and requires no special 3. Granacher U, Lacroix A, Muehlbauer in Flagstaff, AZ, which has a neurologi- equipment. Clients should be instructed T, Roettger K, Gollhofer A. Effects of cal client focus with a particular interest from a prone position to keep only their core instability strength training on in persons with Parkinson’s disease. She forearms and toes in contact with the trunk muscle strength, spinal mobil- also lectures for Great Seminars. mat. In response to the tester’s command ity, dynamic balance and functional “go,” they should keep their head, neck, mobility in older adults. Gerontology. back, and hips in a neutral position as 2013;59(2):105-113. GeriNotes, Vol. 26, No. 1 2019 27 3D Pharmacology: Management of Depression, Delirium, and Dementia in Older Adults

Roslyn D. Burton, PT, DPT

INTRODUCTION The purpose of this article is to and prednisone are used to address in- Depression, delirium, and dementia identify common pharmacological inter- flammation in the body but it is believed are geriatric syndromes commonly seen ventions to address depression, delirium, that these medications may lower sero- in clinical practice with the aging adult. and dementia but also identify drug tonin levels.10 Serotonin is a substance These cognitive impairments negatively classes that are linked to, precipitate, produced in the body that influences impact social capacity, functional inde- and/or exacerbate symptoms of these 3 mood and emotional responses.11 It is pendence, and may contribute to other cognitive geriatric syndromes. In addi- hypothesized that lower levels of sero- geriatric syndromes such as urinary in- tion, a clinical drug chart is presented tonin can present as depressive symp- continence, frailty, and falls that are with a non-exhaustive list of these medi- toms such as confusion, agitation, poor 1 associated with poor outcomes. It is cations that are also listed on the 2015 insight, and self neglect.11 Finally, anti- estimated that about 25% of older adults American Geriatrics Society Beers Crite- hypertensive agents are linked to depres- experience some form of cognitive im- ria as potentially inappropriate medica- sive symptoms, specifically alpha agonist 2 pairment and it is suggested that the tions for the aging adult. and rauwolfia alkaloid drug classes. Al- incidence will increase as older adults are pha agonists such as Clonidine12 low- 3 living longer. In fact, older adults may DEPRESSION ers norepinephrine-a neurotransmitter have one or more cognitive impairments It is estimated that the rate of de- that heightens arousal and attention. If as they may coexist with each other or pression in community dwelling older norepinephrine levels are decreased, an be a risk factor for another. For example, adults ranges from 1% to 5% but in- opposite mood effect may ensue. Reser- depression may predispose a person to creases to 11.5% and 13.5% in older pine, a rauwolfia alkaloid, also decreases mild cognitive impairment; delirium adults who require home health care and serotonin and norepinephrine leading may be a precursor to dementia4 and de- hospital care, respectively.6 The Diag- to the presentation of depressive symp- pressive type behavioral symptoms may nostic and Statistical Manual for Mental toms.13 In order to manage depressive be expressed in people with delirium Disorders Fifth Edition (DSM-5) pub- symptoms in older adults, several types and/or dementia,4,5 all of which may lished by the American Psychiatric As- of medications are available. require pharmacologic interventions. sociation states that symptoms such as Pharmacological interventions for There are several pharmacologic in- mood disorder, loss of interest in activi- depression are antidepressant medica- terventions that aim to prevent, reverse, ties, hopelessness, insomnia, fatigue or tion, specifically second generation an- slow progression, and/or treat behavioral loss of energy, feelings of worthlessness, 14 symptoms seen in these cognitive im- tidepressants. Second generation an- and decreased ability to think or concen- pairments. However, there are also medi- tidepressant such as, selective serotonin trate must persist for at least 2 weeks for reuptake inhibitors (SSRIs), selective cations that are linked to, precipitate, 7 and/or exacerbate symptoms of depres- a major depressive disorder diagnosis. serotonin and norepinephrine reuptake sion, delirium, and dementia. As a prac- However, medications may contribute inhibitors (SNRIs), norepinephrine and titioner of choice and patient advocate, to depressive symptoms that the older dopamine reuptake inhibitors (NDRIs), it is vital for physical therapists to iden- adult may express. These medications and noradrenergic and specific seroto- tify not only the current pharmacologic include benzodiazepines, corticosteroids, nergic (NaSSA) are more commonly 15 interventions for cognitive impairments and antihypertensive agents. used. It is hypothesized that reuptake but medications that may yield adverse Benzodiazepines, which typically inhibitors prevent reabsorption of the effects for the aging adult who are at risk end in “-pam”, are psychoactive drugs correlating neurotransmitter (ie, sero- or have one or more of these cognitive used to promote sleep and decrease anxi- tonin, norepinephrine, and dopamine) 8 geriatric syndromes. Although medica- ety in older adults. Examples of these back into the nerve cell. As a result, tion prescription is outside our scope of drugs include clonazepam, diazepam, the neurotransmitter is increased in the practice, awareness of pharmacological flurazepam, and lorazepam. These are body to help regulate mood and emo- interventions that contribute to behav- long-acting benzodiazepines and remain tional response.11 ioral symptoms (ie, confusion, agitation, in the older adult’s body longer due to The most commonly used reuptake poor insight, self-neglect) seen in the decreased drug metabolism. As a result, inhibitor, SSRIs, are divided into First older adult with cognitive impairment there is an increased drug effect that Line Agents and Second Line Agents may help guide treatment strategies, re- may manifest as feelings of depression.9 with First Line Agents being the drug ferrals, and/or discharge planning. Corticosteroids such as dexamethasone of choice. First Line Agents have lower 28 GeriNotes, Vol. 26, No. 1 2019 potential for adverse drug effects and system effect of all available NSAIDs.9 the disease progresses, older adults may better response toward depressive symp- Finally benzodiazepines, (short and long demonstrate behavioral symptoms such toms.14,15 These medications include Ser- acting) and corticosteroids (ie, pred- as immediate and remote memory loss, traline and Escitalopram.14 Second line nisone, dexamethasone) are associated decreased reasoning and judgment, de- SSRIs such as Fluoxetine and Paroxetine, with inducing or worsening delirium creased ability to recognize people and are not initially used because of their type symptoms.9,10,19 objects, word finding difficulty, agitation long half-life and high anticholinergic Many symptoms of delirium such and irritability, delusion and hallucina- effects respectively, which may lead to as hallucination, delusion, and agitat- tions, nervousness, and anxiety which 4,10,23,24 adverse effects in the older adult.9,15 ed behavior are similar to psychosis; interfere with daily function. Selective serotonin and norepinephrine therefore, antipsychotics are typically Several medications are thought 20 reuptake inhibitors such as Venlafaxine used as pharmacological interventions. to exacerbate behavioral symptoms of and NDRIs such as Bupropion enhance Antipsychotics are categorized as first dementia by increasing confusion and delirium. These include Dopamine pro- activity of serotonin/norepinephrine and generation and second generation with moters, Levodopa and Amantadine, of- norepinephrine/dopamine respectively second generation antipsychotics having ten use to treat Parkinsonism.9 Muscle to affect mood.15,16 Finally Mirtazapine, lower risk for adverse effects, thus more 21 relaxants and Antispasmodics, Soma and a NaSSA, increases the activity of nor- widely used. Atropine, result in anticholinergic effects 17 Although second generation anti- adrenaline and serotonin in the brain and sedation that are not tolerated well thereby regulating mood response. It is psychotics have lower adverse effects, clinicians should be aware they may by older adults thus increasing confu- important to specify that all antidepres- sion.9 As mentioned earlier, medications sants may cause side effects (ie, falls, cause diabetes mellitus, hypotension, 21 with Anticholinergics properties such as 14 and weight gain in older adults. Second nausea, weight gain) but the antide- Benadryl and Meclizine9,19 do the same. pressants noted above demonstrate lower generation antipsychotics include Que- tiapine and Risperidone.18,21 The first Corticosteroids, prednisone, and dexa- adverse effects in the older adult. methasone may cause corticosteroid- generation medication such as Haldol induced reversible dementia resulting may also be used but it is associated with DELIRIUM in impaired memory, attention, con- extrapyramidal side effects, ie, dystonia, It is estimated that 6% to 56% centration, and mental speed.10 Finally akinesia, and dyskinesia.18 of hospitalized older adults experience benzodiazepines, especially long-acting, It is important to note that delirium delirium. It is described as a sudden may accumulate in the body and lead is a risk factor for subsequent develop- onset of cognitive impairments that in- to exacerbation of impaired memory.9 ment of dementia and people with de- clude fluctuating course of conscious- It is found that these medications may mentia may have episodes of delirium.21 ness, short attention span, distractibility, render adverse effects in older adults and Accordingly, it is paramount to differ- impaired short-term memory, and dis- if a clinician or caregiver notices sudden entiate between delirium and dementia 18 increased confusion in an older adult orientation. The cause is multifactorial because the use of antipsychotics in but may be attributed to surgery, acute with dementia these medications may people with dementia may increase the be the culprit. medical illness, and medications. Medi- risk of stroke and death.18 This further cations that are linked to, precipitate, Currently, dementia is not curable underscores the necessity to understand but there are pharmacologic interven- and/or exacerbate delirious symptoms pharmacological interventions in older are those with anticholinergic properties, tions aim to improve cognitive func- adults with cognitive impairment to bet- tion and treat behavioral symptoms. antidepressants, analgesics, benzodiaz- ter identify medications that may yield Acetylcholinesterase inhibitors such as epines, and corticosteroids. adverse events. It creates an opportunity Donepezil and Galantamine prevent the Anticholinergics affect the activity to be advocates for our patients who may breakdown of acetylcholine. This in- of acetylcholine which is a neurotrans- be at risk of severe medical consequences creases acetylcholine levels in the brain, mitter involved with learning and mem- due to medication. subsequently reducing behavioral symp- ory. Antihistamines, such as Benadryl toms of dementia.25 N-methyl-D-aspar- and Meclizine, contain anticholinergic DEMENTIA tate receptor antagonist (NMDA) such properties that may lead to confusion, There are several types of dementia as Memantine is a cognition-enhancing nervousness, and drowsiness in the older (ie, Alzheimer’s, Lewy Body, vascular) medication and is found to address agi- 19 adult. Amitriptyline and Doxepin are but it is estimated that 1 out of 10 tation, aggression, and delusional symp- first generation antidepressants that have adults 65 and older, have Alzheimer’s toms seen in those with dementia.26 strong anticholinergic effects leading to dementia, the most common type.22 Finally, long term use of SSRIs such as similar delirious symptoms.19 Other The American Psychiatric Association Citalopram may delay the progression of medications associated with delirium (APA) has termed dementia under a mild cognitive impairment to Alzheim- are analgesics that include opioids and broader category, Major Neurocognitive er’s dementia27 as well as treat agitation nonsteroidal anti-inflammatory drugs Disorder, in an effort to include all types and delusion.28 (NSAIDs) used to address pain. De- of dementia. Although not an expecta- merol, an opioid, converts to an anticho- tion of the APA, it may help decrease AMERICAN GERIATRICS linergic metabolite leading to delirious the stigma associated with the term SOCIETY BEERS CRITERIA 2015 symptoms and indomethacin is thought dementia.23 Dementia is progressive and The American Geriatrics Society to have the most adverse central nervous irreversible with an insidious onset. As Beers Criteria is an evidenced-based GeriNotes, Vol. 26, No. 1 2019 29 clinical tool originally conceived by the reduction and internal fixation, left total discontinued by the geriatrician and late geriatrician, Mark H. Beers who hip arthroplasty, and major neurocogni- the neurologist replaced Carbidopa/le- researched medications that led to del- tive disorder. Upon hospital admission, vodopa with a Rotigotine patch, a do- eterious side effects in older adults. The he was found to have bradycardia, hy- pamine agonist, which has a lower risk tool compiles potentially inappropriate potension, dehydration, and an age in- for confusion and mental disturbances medication use in older adults, which determinate nondisplaced comminuted by addressing emotional symptoms, ie, are associated with poor health out- C7 fracture. The veteran was oriented to depression, apathy, and anxiety.30 comes. The criteria list the disease or his name but not time nor place and met syndrome followed by the potentially criteria for delirium based on the Confu- CONCLUSION inappropriate drug, rationale, recom- sion Assessment Method (CAM).29 His Depression, delirium, and dementia mendation, quality of evidence, and the medications included Mirtazapine, Car- are cognitive impairments that the older strength of recommendation as decided bidopa/levodopa, Tamsulosin, Ibupro- adult may experience. As a practitio- by the Beers expert panel.19 The 2018 fen, Atorvastatin Calcium, Alendronate, ner of choice, it is vital that physical Beers Criteria edition is currently under Aspirin, Calcium/Vitamin D, Cholecal- therapists understand the current phar- review. Table 1 summarizes drug classes ciferol, Quetiapine, and Haldol. macologic interventions for cognitive previously mentioned in this article that This case demonstrates a quintes- impairments but also identify medica- are linked to, precipitate, and/or exacer- sential example of delirium, depression, tions that are linked to, precipitate, bate symptoms of depression, delirium, and dementia co-existing. In addition and/or exacerbate symptoms of these and dementia but are also listed on the to the current CAM screen for delirium geriatric syndromes. In this manner, 2015 Beers Criteria. Please note that and personal history of dementia, one we can continue to be advocates for the generic or brand names are listed in the can deduct a history of depressive symp- aging adult by initiating a discussion or table. These medications should cue the toms due to use of the antidepressant, investigating medications that render clinician to closely monitor and/or fur- Mirtazapine. Another vital component adverse effects that may affect our plan ther investigate their use in older adults. from this case is that he was on two of care. It provides an opportunity for antipsychotics. It is known that antipsy- physical therapists to continue to be CASE SCENARIO chotics may lead to stroke or death in part of the interprofessional team serv- A 70-year-old veteran presented to older adults who have dementia.18 Fur- ing a special growing population. This the hospital from the nursing home thermore, he was on a dopamine pro- article provided an overview of common due to a fall and altered mental status. moter, which is thought to exacerbate pharmacologic interventions as well as a He was a former financial investor, avid symptoms of confusion and delirium. clinical drug chart to help practitioners runner, and divorced. Over a period of This case exemplifies the importance of identify potentially inappropriate medi- 3 years, he transitioned from living in a understanding medications that carry cations related to depression, delirium, private home, to an assisted living facil- adverse effects in older adults with de- and dementia in the older adult. ity, and finally to a nursing home due to pression, delirium, and dementia. It mental and functional decline. He had a should facilitate a discussion with the ACKNOWLEDGEMENT maternal history of dementia and a per- interprofessional team on risk versus I would like to acknowledge men- sonal history of Parkinson’s disease, os- benefits of medications in older adults. tors and colleagues from the Residency teoporosis, osteoarthritis, right hip open In this case, the antipsychotics were in Geriatric Physical Therapy at the

Table 1. Depression, Delirium, and Dementia (3D) Clinical Drug Chart. This table show medications (generic or brand) that are linked to, precipitate, and/or exacerbate 3D symptoms and listed on the 2015 American Geriatrics Society Beers Criteria. It is recommended to avoid antipsychotics in older adults with dementia. Anticholinergics Sedatives Antispasmodic/ Analgesics Antihypertensives Antidepressants (antihistamines) (benzodiazepines) Muscle Relaxants (First generation) Benadryl Demerol Diazepam Clonidine Soma Amitriptyline Meclizine Fortal Flurazepam Reserpine Doxepin Atropine Skelaxin Dayhist Indomethacin Ativan Norpace Norpramin

Phenadoz Naproxen Oxazepam Guanabenz Amoxapine Oxybutynin (2nd generation and 2nd Hydroxyzine Daypro Quazepam Aldomet Robaxin line agent) Fluoxetine Zymine Feldene Halcion Tenex Paroxetine Paraflex

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GERINOTES US Postage 2920 East Avenue South, Suite 200 PAID La Crosse, WI 54601-7202 LMC 54601

Get plugged into the AGPT! The AGPT Member’s meeting and SIG member meetings at CSM 2019 are the perfect starting spot to explore your options. Put them on your calendar today! AGPT Member’s Meeting Thursday, January 24, 2019 - 6:30 - 8 pm in the Marriott Marquis 8 SIG Member Meetings in Marriott Gallery Place Thursday, January 24, 2019 9 - 10 am - Residency and Fellowship 10 - 11 am - Health Promotion and Wellness Friday, January 25, 2019 3 - 4 pm - Global Health for Aging Adults 4 - 5 pm - Cognitive and Mental Health Saturday, January 26, 2019 7 - 8 am - Bone Health 10 - 11 am - Balance and Falls