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Aging with a Spinal Cord Injury

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Osteoporosis due to loss of calcium. Muscles lose strength and coordination ... Osteoporosis universal. 22% in first 3 months. Continual linear loss for at ... – PowerPoint PPT presentation

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Title: Aging with a Spinal Cord Injury


1
Aging with a Spinal Cord Injury
  • Suzanne L. Groah, MD, MSPH
  • Brenda Gilmore, RRTC SCI Life Consultant

2
What Does Aging Mean?
3
Aging Processes
  • Physiologic changes
  • Changing social roles
  • Self-realization

4
Aging Issues
  • Medical changes
  • Functional changes
  • Socioeconomic changes
  • Support changes
  • Varies with genetics, body habitus, lifestyle,
    general state of health

5
What Doesnt Aging Mean?
  • Disease and aging are synonymous
  • Older are less physically active
  • Older are less mentally active
  • Diminished quality of life

6
What is Normal Aging?
7
Normal Aging Cardiovascular
  • Decreased stroke volume
  • Decreased ability to maintain vessel tone
  • Gradual increase in sBP and dBP
  • Related to loss of arterial elasticity
  • Increased orthostasis
  • Increased syncope related to micturition

8
Normal Aging Pulmonary
  • Decline in
  • Vital capacity
  • Maximum voluntary ventilation
  • Expiratory flow rate
  • Forced expiratory ventilation

9
Normal Aging Pulmonary
  • Decreased lung compliance
  • Inability to expand on inspiration
  • Loss of flexibility of chest wall
  • Decreased muscle strength in chest
  • Restriction of pulmonary function

10
Normal Aging Integument
  • Loss of subcutaneous tissue
  • Thinning of skin
  • Loss of elasticity of skin
  • Skin tears and bruising more common

11
Normal Aging Gastrointestinal
  • Transit time increases
  • Incomplete absorption of medications
  • Overabsorption of medications
  • Excessive water reabsorption (due to prolonged
    transit time)
  • Dilated colon
  • Rectal fissures
  • Hemorrhoids
  • Decreased force/coordination of smooth muscle
    contraction of colon

12
Normal Aging Nervous System
  • CNS
  • Neurons slowly lost from 24 years
  • Decrease in short term memory
  • Loss of speed and motor activities
  • Slowed rate of central information processing

13
Normal Aging Nervous System
  • PNS
  • Decline in conduction velocity
  • 60 reduction in vibratory sense in LE
  • 20 reduction in reaction time
  • Decreased balance
  • Decreased strength
  • Decreased coordination
  • Decreased agility

14
Normal Aging - Musculoskeletal
  • Osteoporosis due to loss of calcium
  • Muscles lose strength and coordination
  • Joint capsules tighten and lose flexibility
  • Contractures may develop
  • Lean muscle replaced with adipose
  • Athletic build changes to overweight with
    protruding abdomen and stooped posture
  • Degenerative joint changes universal in WB joints
    by 60 years

15
Normal Aging - Musculoskeletal
  • Muscle changes
  • Decrease in muscle mass
  • Decrease in muscle fiber size
  • Decrease number of myofibrils
  • Reduced concentration of mitochondrial enzymes
  • Occur regardless of activity level

16
Normal Aging - Musculoskeletal
  • Muscle changes
  • Muscle strength declines 20-30 by 60 years
  • Maximum power output declines 45 after 50 years

17
Normal Aging Endocrine
  • Reduction of hormones responsible for repair of
    cellular tissues
  • hGH
  • Testosterone
  • Reduction in or effectiveness of insulin and
    insulin like growth factor
  • Cellular and humeral decline in immune response

18
Normal Aging Renal
  • Loss of glomeruli
  • Renal insufficiency

19
After the Doom and Gloom
  • Large functional reserve for each organ

20
How Does Spinal Cord Injury Factor In?
21
Aging Changes
  • Variations in the rate of decline for different
    organ systems in the body
  • 60 decline pulmonary function
  • 15 decline nerve conduction velocity

22
Functional Phases During the Aging Process with
SCI
  • Acute restoration phase
  • Maintenance phase
  • Decline phase

23
Functional Phases During the Aging Process with
SCI
  • Acute restoration phase
  • Immediately after SCI
  • Regains maximal functional return
  • Maintenance phase
  • Variable in length
  • Stable level of function
  • Decline phase
  • Result of degenerative effects of overuse and
    physiologic changes

24
Functional Decline After SCI
  • Variable and depends on
  • Genetics
  • Life style
  • Level of injury
  • Age
  • Weight
  • Health history
  • Level of support
  • Comorbidities

25
Functional Decline After SCI
  • May begin as early as 10-15 years post-SCI
  • 93 of those 15 years post-SCI had experienced
    functional decline

26
Functional Decline After SCI
  • Impact of age at injury
  • Age at SCI during or prior to adolescence
  • Maintenance phase of 20 years
  • 55 years old at time of SCI
  • Maintenance phase of 5-7 years

27
Summary of Craig Collaborative Aging Study
28
Craig Collaborative Aging Study
  • Purpose
  • Evaluate the health and functional status of
    people living with long-term SCI
  • Inclusion criteria
  • Injured between 1943 - 1970
  • Between 15 - 55 yo at time of injury
  • Located in 13 county catchment area
  • Admitted within one year of SCI
  • Survival at least 1 year

29
Participants
  • 834 met criteria
  • 2/3 with paraplegia, 1/3 with tetraplegia
  • Most injured in late teens and early 20s
  • 412 survivors
  • 282 participated in 1990
  • 227 re-recruited in 1993
  • Classification by neurologic level of injury

30
Neurologic Groups
31
Changes by System as an Individual Ages with
Spinal Cord Injury
32
Aging with SCI Pulmonary
  • Normal Aging
  • Decreased compliance
  • Decreased muscle strength in chest
  • Restriction of pulmonary function
  • Affects of SCI
  • Restrictive lung disease due to muscle paralysis
  • May have obstructive component due to airway
    hyperreactivity

33
CCAS with SCI - Pulmonary
  • Natural reduction in lung function with age
  • Chest infections
  • More common in TetraABC than ParaABC and All Ds
  • More common in youngest age group and those with
    shorter duration of injury
  • Sleep apnea

34
Aging with SCI - Gastrointestinal
  • Normal Aging
  • Transit time increases
  • Excessive water reabsorption
  • Decreased force/coordination of smooth muscle
    contraction of colon
  • Affects of SCI
  • Reduction in natural bowel contractions
  • Decreased colonic motility
  • Prolonged colonic transit
  • Decreased colonic compliance
  • Diminished tolerance for certain foods

35
CCAS with SCI - Gastrointestinal
  • 74 with hemorrhoids
  • more common in ParaABCs and TetraABCs
  • incidence increases with age and duration of
    injury
  • 43 with abdominal distention
  • 43 autonomic dysreflexia related to bowel
  • 20 with difficult bowel evacuation
  • Gallbladder disease greater in SCI
  • Problems increase with time since injury

36
Aging with SCI Endocrine
  • Normal Aging
  • Reduction of
  • hGH
  • Testosterone
  • Reduction of insulin
  • Cellular and humeral decline in immune response
  • Affects of SCI
  • Reduced GH
  • Reduced testosterone
  • Impaired glucose tolerance
  • Reduced capacity to maintain lean tissue
  • Increased insulin resistance
  • Impaired calcium metabolism
  • Reduced cellular repair

37
Aging with SCI - Endocrine
  • Diabetes
  • 4x more common in men with SCI
  • Obesity more common
  • Obesity without overweight
  • Dyslipidemia
  • 40 had low HDL cholesterol
  • gt70 paraplegics need treatment according to NCEP
    guidelines

38
Aging with SCI - Musculoskeletal
  • Normal Aging
  • Osteoporosis
  • Muscles lose strength
  • Joint capsules tighten
  • Contractures
  • Lean muscle replaced with adipose
  • Degenerative joint changes in WB joints
  • Decreased flexibility
  • Affects of SCI
  • Osteoporosis universal
  • Joint capsules tighten
  • Change in body composition
  • UE pain/overuse
  • Increases with time
  • Peripheral nerve entrapment

39
Aging with SCI - Musculoskeletal
  • 2/3 have compressive neuropathy in UE
  • gt50 with median neuropathy
  • 25 bilateral
  • Overuse syndromes
  • DJD
  • Rotator cuff tendinitis
  • Subacromial bursitis
  • Capsulitis

40
Aging with SCI - Musculoskeletal
  • Osteoporosis universal
  • 22 in first 3 months
  • Continual linear loss for at least 2 years
  • Greatest in areas of paralysis
  • Spine BMD may be unchanged or even gt
  • Fractures 6 after SCI
  • Most occur in femur
  • Around the knee

41
Aging with SCI - Musculoskeletal
  • Scoliosis universal in peds (97)
  • Approx 50 in adults

42
CCAS with SCI - Musculoskeletal
  • Joint pain stiffness
  • Highest in ParaABC than both TetraABC and All Ds
  • Increased with increasing duration of injury

43
Aging with SCI - Integument
  • Normal Aging
  • Epidermis thins
  • Skin becomes less flexible
  • Delayed wound healing
  • Affects of SCI
  • Thinning of SQ over WB surfaces
  • Thinning of skin
  • Loss of elasticity
  • Skin at risk of breakdown and harder to heal
  • Body composition changes

44
Aging with SCI - Integument
  • Pressure sores
  • Most common cause of morbidity
  • Incidence increased with increasing age
  • Decubitus ulcer rate increases with time since
    injury

45
Aging with SCI - Genitourinary
  • Normal Aging
  • Renal function declines with age
  • Loss of glomeruli
  • Renal insufficiency
  • Affects of SCI
  • UTIs
  • Most common cause of morbidity
  • More common in TetraABCs than ParaABCs or All
    Ds

46
Aging with SCI - Nervous System
  • Normal Aging
  • ? conduction velocity
  • ? vibratory sense
  • ? reaction time
  • ? balance
  • ? strength
  • ? coordination
  • ? agility
  • ? fine coordination
  • ?entrapment neuropathies
  • Affects of Aging
  • Motor sensory changes
  • 3 times more common in All Ds
  • More common in oldest and those with longest
    duration of injury

47
Aging with SCI - Cardiovascular
  • Normal Aging
  • Decreased stroke volume
  • Decreased ability to maintain vessel tone
  • Gradual increase in sBP and dBP
  • Increased orthostasis
  • Increased syncope related to micturition
  • Affects of SCI
  • Risk of CVD higher due to SCI

48
Aging with SCI - Cardiovascular
  • Normal Aging
  • ? incidence of heart disease
  • ? blood pressure
  • ? cholesterol levels
  • ? glucose tolerance
  • Affects of SCI
  • Risk of CVD higher due to SCI
  • Predisposition to lipid and carbohydrate
    metabolism abnormalities

49
More on CVD After SCI
50
Epidemiology of CVD
  • CVD is 1 cause of death in US
  • 1993 CVD mortality rate 163 per 100,000
  • 1993 CHD mortality rate 95 per 100,000
  • 28.6 decline in mortality due to MI
  • 84.6 of mortality due to MI in 65yo

51
Reversible Risk Factors for CVD
  • Hypertension
  • Low HDL cholesterol
  • Hypercholesterolemia
  • Hypertriglyceridemia
  • High lipoprotein A
  • Tobacco use
  • Sedentary lifestyle
  • Abdominal obesity
  • Diabetes mellitus
  • Hyperinsulinemia

52
Irreversible Risk Factors for CVD
  • Male gender
  • FHx premature CVD
  • H/O CVD
  • H/O occlusive peripheral vascular disease
  • H/O cerebrovascular disease

53
Cholesterol Level by Neurologic Group
54
Serum Lipids
  • Cholesterol significantly higher in ParaABCs and
    All Ds than TetraABCs
  • HDL significantly lower in TetraABCs than All
    Ds
  • HDL decreased significantly in ParaABCs and
    TetraABCs over time

55
Cumulative probability of CHD
56
Relative Risk of CHD
57
CVD and CHD Mortality
  • 33 total deaths
  • CVD mortality rate 42
  • CHD mortality rate 33
  • CVD case fatality rate 22
  • CHD case fatality rate 17

58
Epidemiology of CHD and CVD
  • General population
  • CVD 1 COD
  • CHD prevalence 12.7-22
  • CHD accounts for 51.2 of CVD mortality
  • 17 CVD mortality in lt65 yo
  • Long-term SCI
  • CVD 1 COD
  • CHD prevalence 15
  • CHD accounts for 79 of CVD mortality
  • 64 CVD mortality in lt65 yo

59
CHD in SCI
  • CHD incidence increases with
  • age
  • duration of injury
  • Risk of CHD is higher in ParaABCs and All Ds
    than TetraABCs
  • Why?

60
What is Accelerated Aging?
61
Is Aging Accelerated in SCI?
62
Impact of SCI on Aging
  • Individual is young at the time of injury
  • Immediate reduction in some of the functional
    reserve and capacity
  • Some body systems experience more rapid decline

63
Life Expectancy
64
Is Aging Accelerated in SCI?
65
Disability Knowledge and Skills
  • Brenda Gilmore, BFA

66
Barriers for People with Disabilities
67
Goals
  • To raise awareness of some of the common barriers
    experienced by people with disabilities
  • To provide strategies to overcome these barriers

68
Types of Barriers
  • Environmental
  • Structural
  • Attitudinal

69
Environmental Barriers
  • Transportation
  • Availability
  • Timeliness
  • Cost

70
Strategy
  • Be flexible
  • Time allotted for appointments
  • Tardiness beyond patients control

71
Office accessibility
  • Parking
  • Elevators and doorways
  • Examination rooms
  • Diagnostic Equipment
  • Staff communication

72
Strategy
  • Make the experience easy for the patient
  • Inform patient of office layout
  • Prepare for patients appointment by adjusting
    barriers
  • Ask patient how best you can help

73
Structural Barriers
  • Structure of health care policies and procedures
  • Limitation of visits
  • Limitation of durable medical equipment coverage
  • Referrals to specialists
  • Length of time spent with health care provider

74
Strategy
  • Allow adequate time for the patients visit
  • Provide easy method for referrals

75
Attitudinal Barriers
  • Lack of provider knowledge about SCI
  • Lack of attention to issues other than SCI
  • Preventive screenings, sexuality, exercise,
    wellness

76
Strategy
  • Speak to SCI patient as an intelligent adult
  • Counsel and address SCI patients total well being

77
Communication with people with disabilities
78
Goals
  • To identify communication issues and needs when
    interacting with people with disabilities
  • To determine critical communication skills
  • To identify strategies to improve communication
    with individuals who have disabilities

79
Attitudes and behaviors
  • Person with a disability is a person first, a
    patient second, and an individual with special
    needs third
  • Dont make assumptions or jump to quick
    conclusions about the reasons they come to see
    you
  • Approach the individual with a disability just
    like everyone else

80
Attitudes and Behaviors (continued)
  • Dont make assumptions about the social life of
    people with disabilities
  • Do not automatically provide assistance
  • Make sure you look at and talk directly to the
    person with a disability

81
Use of appropriate terminology
  • Awareness of language and terminology is critical
    for the development of a trusting relationship
    between the individual with a disability and the
    healthcare provider
  • In the medical community it is not uncommon to
    identify people by their condition as if that
    constitutes their whole identity.

82
Terminology (continued)
  • Identify communication issues when interacting
    with people with disabilities
  • Overview of communication issues (e.g. speech
    impairments, general attitude and behavior)
  • Define and describe critical communication skills
  • Group suggestions to improve communication with
    people with disabilities compare with
    suggestions made by consumers with disabilities

83
Communication ground rules
  • Offering assistance
  • Introduce yourself and offer assistance.
  • Don't be offended if your assistance is not
    needed.
  • Ask how you can help and follow instructions.
  • Be courteous, but NOT condescending.
  • Assist when necessary or requested, but do not
    discourage their active participation

84
Introductions and General Communication Rules
  • Use a normal tone of voice when extending a
    verbal welcome. Do not raise your voice unless
    requested.
  • When introduced to a person with a disability, it
    is appropriate to offer to shake hands.

85
  • Shaking hands with the left hand is acceptable.
  • For those who cannot shake hands, touch the
    person on the shoulder or arm to welcome and
    acknowledge their presence.

86
Rules (continued)
  • Treat adults in a manner befitting adults
  • When addressing a person who uses a wheelchair,
    never lean on the person's wheelchair since the
    chair is part of his or her personal space

87
  • Offer assistance in a respectful and sensitive
    manner If your offer for assistance is declined
    do not proceed to assist. If the offer is
    accepted, listen and accept instructions.
  • When talking with a person with a disability,
    look at and speak directly to that person and not
    through a personal assistant or family

88
  • When offering help with bags or carrying items
    inquire whether you may help
  • Do not hand a cane or crutches unless the
    individual requests this.
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