Thanks to John L. Evarts for thoughtful recommendations and emotional and technical support and to Geri Richards Hall, PhD, ARNP, CNS, FAAN, for providing resources and expert input. This chapter is dedicated to the memory of my father, Herschel A. Cooper, who showed me what graceful aging looks like, and to my mother, Delma P. Cooper, for her ongoing interest in my work.
There is a certain part of us that lives outside of time. Perhaps we become aware of our age only at exceptional moments and most of the time we are ageless.
Milan Kundera in Immortality , 1990
Treatment Guidelines for Use with Geriatric Hand Patients
Schedule the treatment at the patient’s “good” time, which is often midmorning or early afternoon.
Try not to rush older patients. If you do, they may actually slow down.
Eliminate or minimize interferences and ambient stimuli.
Simplify strap requirements on orthoses; permanently secure one end of each strap to the orthosis; color-code the ends of straps; mark where straps should meet; and simplify overall numbers of orthoses, devices, exercises, and instructions.
Talking with Elderly Hand Patients
The following suggestions may improve communication effectiveness with elderly people:
Do not use baby talk. Do not call the patient “sweetie” or “honey.”
Do not shout. Shouting distorts speech perception and also may embarrass the patient. Lower your voice and face the patient directly.
If the patient has traditional learning and memory problems, focus on activities of daily living.
Express interest in the person. If the patient is given an opportunity to tell about his or her life, you may find yourself fascinated by a remarkable or moving story.
Why Special Considerations Are Needed with Elderly Hand Patients
A 78-year-old woman sustained a comminuted displaced left distal radius fracture. She underwent open reduction and internal fixation with plating, using a dorsal approach. Because of edema, her physician initially immobilized her hand in a plaster slab that was held in place with bias stockinette. She arrived at her first therapy visit with two long pieces of drinking straws that she had shoved longitudinally under the dorsal stockinette. The straws were covered inside and out with a residue of chocolate milk. She had significant dorsal hand edema, with definitive pressure areas, like crevices, under the straws. She said she had inserted the straws because her stockinette wrapping felt tight.
Such bizarre behavior typically raises a therapist’s suspicion that the patient may have cognitive problems that would interfere with follow-through. A patient who is cognitively normal may lack good clinical judgment, or, worse, a patient may have both cognitive impairment and poor judgment. This chapter helps hand therapists distinguish between the two. It begins by exploring the phenomenon of aging as it may influence the appropriateness and effectiveness of hand therapy. Recommendations for cognitive screening are provided, and special treatment implications are considered. The goal of this chapter is to sensitize hand therapists to the process of aging to promote their patients’ successful aging, to foster patient-centered care for elderly hand therapy patients, and to thereby maximize our clinical efficacy with older patients.
Ageism and Age Identity
Our societal values reflect stereotypes that promote gerontophobia, or fear of aging. This fosters age bias. Advertising media bombards us with images of youth and beauty and promotion of cosmetic surgery. These messages reinforce negative perceptions about aging: older people are both implicitly and explicitly devalued. Social distance and age segregation further compound the problem.
Age identity has various dimensions, including one’s subjective age, others’ view of one’s age, one’s desired age, one’s desired longevity, and one’s perceived old age. As people age, their subjective age increases, but not in a one-to-one ratio. Most older people think of themselves as younger than their actual age. It is uplifting to learn that people often believe that they are perceived by others to be the age they feel rather than their true age.
Aging and Body Image
Cultural standards for female beauty are associated with youthful characteristics. Our media are glutted with young, attractive, thin women promoting products developed to defy chronologic age. An external fixator, incisional scarring, or hand deformity can aggravate existing issues of cosmesis in older patients.
By conservative estimates, approximately 500,000 elderly people experience abuse each year. Older people who live with family are at greater risk, with women being more vulnerable than men to abuse that may be physical, financial, or psychological. In the United States, the prevalence of elder abuse is 1% to 10%. Many cases go unidentified, and only about 1 out of 13 cases gets reported.
Spiral fractures and transverse or oblique midshaft digital fractures might raise suspicion of physical abuse, whereas flexion or extension contractures may indicate physical neglect. Victims may be afraid to report their abuse because of the fear of being placed in a nursing home.
Stereotypes of elderly people commonly include the notion of incompetence. This may contribute to the use of baby talk when communicating with older persons. Talking too loudly, using a higher pitch, and choosing words that normally are used with pets and babies may also occur. These condescending behaviors should be avoided, but keep in mind that it can take awareness and practice to change such habits.
Therapists should become aware of their attitudes toward elderly patients. One study of physical therapists found less aggressive goals associated with negative attitudes about aging. Underestimating patients’ potentials based on their age could deprive them of opportunities to maximize their function and independence.
Although we may know what old age looks like, most of us do not know what it feels like. We should make special efforts to treat and connect with older patients as people, not as numbers or ages. For instance, it is obvious that many older hand patients put time and thought into their appearance before coming to therapy. When appropriate, it can be very effective to sincerely compliment an older patient on his or her appearance. Also, do not call elderly patients “young lady” or “young man.” Instead, ask what your patient wants to be called. A name is considered by some to be an important symbol of their personhood.
Figure 134-1 is a photograph of my twin great aunts taken when they were 98 years old. Although both had medical problems, they still lived together in an apartment until they were nearly 100 years old. Both were widowed. Relatives assisted them with errands and appointments. Their physician sent them birthday cards and showed interest in them as human beings, which probably had a favorable effect on their health and well-being.
Statistics on Aging
The older population consists of people who are at least 65 years of age. In 2006, they numbered 37.3 million and constituted 12.47% of the U.S. population. In 2030, 71.5 million Americans will be 65 years of age or older, and they will represent 20% of the population. Approximately 6000 people reach the age of 65 every day, and this number will grow to 10,000 per day in the year 2012. People who are older than 85 years of age make up the segment of our population that is growing most rapidly.
A larger geriatric population will result in a greater proportion of geriatric hand therapy patients. Learning about the unique features of older patients will enable us to individualize effective treatment programs. Although accommodating their special needs may prolong the initial treatment, it can increase therapist effectiveness, improve patient compliance, and produce a more successful clinical outcome.
Changes Associated with Aging
Nonelderly caregivers have difficulty imagining what it is really like to be elderly. Six million elderly people residing in the community (i.e., not in nursing homes or other assisted-care facilities) experience difficulty with at least one activity of personal care and more than 7 million experience difficulty with at least one activity of home management. Because we all stand a chance of someday being elderly, any improvements that we make for older people today may benefit us tomorrow.
Skin, Soft Tissue, and Wound-Healing Changes Associated with Aging
Age-related changes in skin predispose older people to injury after even minimal trauma. Age also contributes to slower healing. Changes include reduced dermal thickness and decreased contact of and adherence between the dermis and epidermis. Physiologic changes demonstrated in animal models include reduced cellular proliferation, altered wound metabolism, and altered remodeling of collagen. Such findings help to explain the increased incidence of skin wounds in the elderly.
Dryness and loss of skin turgor, lower overall strength of incisional wounds, and higher dehiscence rates occur with aging. Skin tears among institutionalized elderly people appear to occur most frequently in the forearm, with the hand, elbow, and arm being the next most common locations.
The elderly can heal successfully, although age causes them to heal more slowly. Other concomitant medical conditions, such as vascular disease, steroid use, and cardiopulmonary disease, which are seen more often in older patients, also can slow the healing process.
Slight mechanical traumas that may occur with dressing removal, especially adhesive dressings, pose potential for injury because of skin vulnerability associated with aging. Orthosis edges may be more problematic as a result of the fragility of older skin.
The therapist should remove dressings with extreme care and touch the patient very gently. Soft, wide orthosis straps should be selected and orthosis edges should be padded to minimize shearing forces on the skin. Conservative guidelines for skin checking should be provided. The therapist should use extra care with routine clinic equipment such as treatment table edges and exercise equipment handles.
Muscle Changes Associated with Aging
Muscle strength tends to be stable through age 50. It decreases by 15% per decade from age 50 to 70, and again by 30% from age 70 to 80. By 80 years of age, people have lost almost half of their motor neurons, motor units, muscle fibers, muscle strength, and muscle mass. Additional age-related neuropathic changes are associated with cell apoptosis and motor neuron death, apparently independent of the patient’s activity level.
Hand atrophy associated with aging tends to affect the interosseous and thenar muscles. Loss of muscle mass may explain the reduction of grip strength noted with aging. There are changes in muscle fiber type as well as motor neuron abnormalities.
Immobilization itself has significant negative effects on skeletal muscle. Immobilization causes shortened muscle length with segmental necrosis at muscle fiber ends, with myofibril contracture. This may result in partial denervation or may predispose the involved muscles to atrophy. Interestingly, immobilization can even lead to changes in muscle fiber type.
Decreased muscle strength results in reduced capacity for physical activity and may contribute to functional dependence. Because it may also increase one’s risk of injury, care should be used in testing. On a brighter note, clinical study has demonstrated that the hand muscles of elderly subjects can be strengthened by a training program. Also, aerobic training in even very elderly people (older than the age of 80) has been shown to increase their maximal aerobic power, thereby promoting functional independence.
Sensibility Changes Associated with Aging
Studies have demonstrated age-related changes in sensibility, including the touch/pressure threshold. The degree of deterioration of tactile acuity may vary among subjects. Interestingly, blind elderly subjects were found to have better acuity in a digit used for reading Braille, but not at other sites. Individual differences may result from changes in circulation, thinning of receptors, or age-related disease or trauma.
Adult norms should not be applied to an elderly population unless they are age specific. Sensory changes may make it difficult to perform fine-motor tasks such as manipulating orthosis straps or dynamic components. In addition, therapists should be extra cautious with guidelines for monitoring orthosis edges, strap tightness, or other possible pressure spots.
Neuromuscular Changes Associated with Aging
Sensorimotor decline may be among the most apparent changes associated with aging. Motor function such as finger-tapping, sensory perception, and central processing are slowed with age. Speed-based psychomotor skills reach their peak at approximately 20 years of age and tend to decline thereafter. Skills used infrequently are most affected by age.
Essential tremor is a common movement disorder that manifests with intentional use of the extremity. It may also be called intention tremor or action tremor . The cause is not known, but its incidence increases with age. Stress or emotional situations can exacerbate its severity.
Resting tremor typically is seen among patients with Parkinson’s disease. Resting hand tremor is described as pill – rolling; it lessens with hand activity. Like essential tremor, resting tremor also worsens with emotional stress.
Older patients may be slower in most of their behaviors, which can be challenging to a busy therapist with a full schedule. Older people may have difficulty ignoring irrelevant stimuli such as dialogue among therapists, ambient noise, and other interruptions. The therapist can try to help the patient focus by eliminating distractions and by redirecting, talking, and touching.
Therapists should make an extra effort to establish a good rapport with their older patients. Because stress has negative effects on cognitive processing, motor tone, and movement quality, therapists should try to communicate in stress-relieving ways. Instructions or demonstrations must not be overcomplicated. Humor is helpful but should be used with sensitivity and discretion.
The stressful demands and unfamiliar surroundings of a busy hand clinic may exacerbate a person’s tremor. A therapist may notice essential tremor as a patient dons or doffs an orthosis. A calming environment should be provided, and any tendency to rush the patient should be minimized.
People with problems with motor tone may have an unsteady gait, which may further increase their risk of falling. Interestingly, having a decreased grip strength is reported to be a risk factor for minor injuries after a fall. Obstacles that could cause a fall should be eliminated, and assistance with ambulation should be provided as appropriate.
Physiologic Changes Associated with Aging
Chronic degenerative disease has surpassed infectious disease as the major health threat in our nation. Hypertension, arthritis, and heart disease are the most prevalent chronic conditions of the elderly. Significant hearing loss affects approximately 20% to 50% of people older than 65 years of age and results in significant emotional and social problems, including communication barriers that dramatically affect their quality of life. Changes in temporal organization associated with aging can interrupt the sleep–wake cycle and can be extremely problematic.
Most people who are 65 years of age or older have at least one chronic condition; 95% have some degree of cataracts; 50% have neurologic problems, the most common cause of limited function in the elderly ; 48% have hypertension; 47% have arthritis; 32% have hearing impairments; 29% have heart disease; 16% have diabetes; 16% have orthopedic problems; 14% have sinusitis; and 9% have visual impairment.
Osteoarthritis is the most common arthritic condition occurring in older people and is a leading cause of disability among adults in the United States. Most older individuals demonstrate some radiographic changes indicative of osteoarthritis. As many as 80% of people older than 65 years of age may have significant pain that is caused by osteoarthritis and limits their function and activity level.
Rheumatoid arthritis, a debilitating condition, affects women two to three times more often than men, with frequency increasing for people older than 65 years of age. More than 90% of people with rheumatoid arthritis have clinical involvement of the hands.
Osteoporosis is a skeletal disease associated with low bone mass and microarchitectural deterioration of the bone. It results in fragile bone and higher susceptibility to sustaining a fracture. Osteoporosis causes approximately 1.5 million fractures yearly; 250,000 of these are wrist fractures. Osteoporosis affects between one third and one half of all women who are menopausal. After the age of 50, a woman has a 40% chance of incurring an osteoporotic fracture at some time.
Arthritis can contribute to a decrease in grip strength and fine-motor skills, areas already affected by aging. Orthotic application and strap management by the patient may be doubly difficult in these situations.
When treating a patient whose hearing is impaired, the therapist should sit directly facing the patient to promote lipreading. The therapist must speak clearly and slowly. In cases in which patients have both sensory and physical problems, it can be difficult to discern whether their limitation is a result of physical or cognitive causes.
Functional Changes Associated with Aging
Physical performance generally improves into the middle of the second decade and then decreases as people age. Capacity for physical work also decreases with age, as people experience more chronic conditions that limit their activity level. This decline in physiologic status limits function and raises the morbidity associated with chronic diseases.
Mental impairment limits the self-sufficiency of 3.3 million elderly people in the United States. Another 2.5 million older people live alone despite their need for a caregiver.
The concept of staying active has been described in phenomenologic research as an attitude; the consequence of staying active is movement. Older people who maintain a physically active lifestyle demonstrate less functional decline mentally and physically than those who are not active. Low levels of social activity have been identified as a precursor to mortality. Therefore, the hand therapist should look for ways to sustain elderly hand patients’ activity levels while they recover from upper extremity injuries.
The treatment space itself may pose problems. Doors may be heavy to open, and doorways may not be wide enough to accommodate wheelchairs. Waiting areas should be free of obstacles or types of carpets that challenge ambulation with assistive devices because these obstacles might even cause falls. Lighting should be good.
Orthotic use may limit a person’s ability to drive safely. Because there can be medical-legal issues of driving while wearing a hand orthosis, this difficult question should be referred to the physician to answer.
Pain Associated with Aging
Pain is a common problem with profound effects on the elderly population’s quality of life and ability to function. Pain is reported to be both highly prevalent and undertreated in the older population. Musculoskeletal causes, especially osteoarthritis, predominate. Pain is associated with diseases accompanying aging, such as cancer and neuromuscular disorders. From 25% to 50% of elderly people in the community and 45% to 80% of residents in nursing homes have significant pain.
Simply not reporting pain does not mean that pain is not occurring. Older patients who want to please the caregiver may not report their pain, may have stoic attitudes about pain and aging, or may not feel permitted to express their pain. They might hesitate to discuss their pain because they do not want to be perceived as pests or because of the fear of diagnostic tests or possible medication-related side effects.
Pain in the elderly can result in depression, limited socialization, disturbance of sleep, and problems with ambulation, all of which contribute to increased cost and use of health-care services. Pain can result in deconditioning and poor gait, leading to falls; polypharmacy; greater cognitive dysfunction; and even malnutrition. Pain can significantly degrade the quality of life of residents in long-term care facilities.
Pain or its treatment may worsen a person’s cognitive status. Pain leading to inactivity and immobility may contribute to or result in depression and worsening pain, establishing a vicious cycle that may be hard to break. Therapists can converse with patients about pain and instruct them to report any pain associated with their therapy. A report of pain by the elderly should not be underestimated.
Loneliness Associated with Aging
Loneliness is a common finding among the elderly, with women reporting greater loneliness than men, which is probably related to outliving their spouses. Lonely people are diagnosed with Alzheimer’s disease twice as often as people who are not lonely. This finding reflects the negative impact of social isolation that many older people experience.
Hand therapy sessions provide opportunities to explore elderly patients’ functional levels and to promote their engagement in social activities. Patient involvement in goal setting is a starting point. Incorporating their interests into the treatment process can help to reconnect them with meaningful and rewarding ways to fill their days. For example, a hand therapy patient who enjoys knitting may be encouraged to participate in a knitting group where friends can be made.
Depression and Suicide Associated with Aging
The elderly population has the highest risk of suicide. Depression is actually the most common functional disorder of the elderly, affecting 17% to 37% of this population. Signs of depression, which may be vague, include anorexia, apathy, fatigue, self-neglect, weight loss, social withdrawal, sleep disturbance, decreased involvement in activities, and hopelessness.
Physical disability is strongly associated with depressive disorders. Because pain contributes to depression, hand patients who are in pain may be at heightened risk of experiencing depression.
I have been moved by the frequency with which older hand patients reveal tearfully that they are grieving for a deceased spouse or have recently experienced some other personal loss. The clinical problem necessitating hand therapy may heighten their emotionality, their loneliness, or simply their need for a caring listener.
Treatment of depression has been shown to improve the physical functioning of elderly adults. Because physical activity has associated psychological benefits, every effort should be made to restore patients’ preinjury levels of physical activity. Regular physical exercise that is safe for patients should be strongly encouraged ( Fig. 134-2 ).