Heart Failure, COPD, Diabetes and Hypertension Developing evidence - - PowerPoint PPT Presentation

Heart Failure, COPD, Diabetes and Hypertension

Developing evidence based therapeutic interventions to maximize the functional independence of at risk populations

1

Learning Objectives

• Gain a greater understanding of the causes, symptoms and

pathophysiology of heart failure, COPD, diabetes and hypertension

• Interpret common medications used to treat these conditions and

their possible side effects on therapy treatment, as well as medications that should be avoided with this patient population

• Discuss vital sign parameters, precautions, and contraindications

that can be used to guide clinical decision making when working with these patient populations.

• Utilize evidence‐based interventions designed to maximize

functional outcomes, increase independence, and improve quality

• f life
• Examine common lab tests performed with these patient

populations, learn the normal ranges for these lab tests, and the possible effects abnormal lab values may have on therapeutic interventions

• Explore methods to improve adherence to therapeutic

interventions as well as barriers to patient adherence

2

Actual therapist quotes

• “I’m spoiled, I work in the hospital so I don’t need

to take my patient’s vital signs”

• “I have told that patient what she needs to do, and

she is not doing it, so we need to discharge her”

• “It is not my job to know which medications my

patient is taking”

• “I have done everything I can with that patient, and

it’s not helping, so we need to discharge”

• “That patient is too sick to tolerate therapy, he/she

is not a good candidate for therapy”

• “But I just want to do therapy with my patients!”

3

Multiple Chronic Conditions

Is working with patients with multiple chronic conditions becoming the norm?

4

Multiple Chronic Conditions (MCC)

• 1 in 4 Americans has multiple chronic conditions 1.
• In the population of 65 and older, the number rises

to 3 in 4

• In the United States, around 71% of health care

spending involves patients with more than one chronic condition

• The risk of hospitalization, premature dying, and

receiving conflicting medical advice from multiple health professionals increases as the number of chronic conditions a person has increases 2

• Patients with MCC are the largest patient

population in the United States

5

Alarming Trend 3

Prevalence in 2008 Prevalence in 2015 0 to 1 chronic conditions 31.3% 27.8% 2 to 3 chronic conditions 32.7% 28.3% 4 to 5 chronic conditions 22.4% 24.3% 6 or more chronic conditions 13.6% 19.6%

6

Polypharmacy

• May be defined by a patient taking 4 or more
• medications. Causes could be a patient

receiving a large number of different medications by different providers, complexity

• f the patient’s problems requiring more than 4

medications

• Patients with MCC see an average of 13

different physicians each year, have 50 different prescriptions filled each year, and are 100 times more likely to have a preventable hospitalization each year. 1

7

Medication Review

• The medications a patient is taking can have a

direct effect on a patient’s ability to perform and progress with therapy treatments

• Common adverse drug reactions may include:
• Gastrointestinal Symptoms
• Dizziness and falls
• Sedation
• Confusion
• Depression
• Fatigue and weakness

How do each of these adverse effects effect what we do with our patients?

8

Medication Review

• Perform medication review with patient involvement

during therapy evaluations. This involves:

• Discuss the medications with your patients to assess their

understanding of what condition a particular medication is supposed to be treating.

• Assess for medication duplication
• Assess for medication compliance including how regularly a

patient is taking a medication. This can include questions such as what time do you take your morning meds, what do you use to help you remember to take your medications, what do you do if you miss a dose.

• Determine who is setting up the patient’s medications
• Flag medications that are known to have an increased risk
• f having an adverse effect on an older person

9

Role of therapists

Older adults experience changes in their ability to metabolize medications and may require adjustments in

• dosing. Other than therapy, who else spends as much

time with their patients and asks them to do as much as we ask them to do?

• Therapists can play a key role in this process by

assessing any changes in a patient’s function or cognition after a medication has been added or changed.

• Assessing ADLS/functional mobility/cognition when

medication changes occur. Notify physician of any adverse effects on mobility.

• Routinely ask your patients if they have had any

medication changes.

10

Beers Criteria 4

• Beers Criteria latest updates recently published in January

201978

• The American Geriatrics Society updated the Beers Criteria

in 2015. The original list was published in 2012. The purpose of the list is to educate clinicians and patients on possible adverse drug reactions that may occur in older adults.

• Included in the Beers Criteria are medications that should

be avoided in the geriatric population, referred to as Potentially Inappropriate Medications (PIM), medications to be used with caution, medications that should be used with caution in certain older adult populations (i.e. patients with heart failure or kidney failure), and medications with potential drug‐drug interactions in the

• lder adult population

11

First‐generation antihistamines

• Many patients with heart failure, COPD have difficulty

sleeping secondary to difficulty breathing and inability to lie flat in bed. Many patients may utilize diphenhydramine HCL or other first‐generation antihistamines such as Doxyalmine in order to sleep. These medications are catecholamines and are listed

• n the Beers criteria as a PIM in older adults due to

the possible side effects or possibly toxicity due to decreased rate of medication clearance. These may include confusion, memory loss, increased risk of falling, constipation, dry mouth.

• Pain medications that include “PM” in the name

contain the same ingredient (diphenhydramine HCL)12

NSAIDs

• Beers criteria advises that NSAIDS such as aspirin

(325 mg), ibuprofen, keto profen, meloxicam, naproxen be avoided for chronic use due to the possibility of gastrointestinal bleeding in at risk populations (>75 yo) . In patients with heart failure, it is advised that NSAIDs are used with caution in patients with asymptomatic heart failure, and avoided in patients with symptomatic heart failure secondary to they can promote fluid retention and exacerbate heart failure. 78

• NSAIDs have also been shown to increase a

person’s risk of developing heart failure , potential to increase mortality in older adults with heart failure

13

Aspirin

• Aspirin is routinely used as primary means
• f prevention of cardiac events.
• Beers Criteria lists aspirin as a medication to

be used with caution in older adults, as it may increase risk of GI bleed. The recommendation made is to use aspirin with caution in adults over the age of 70. 78

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Heart Failure

15

Heart Failure Statistics 5,6

• One out of five people will develop heart failure during

their lifetime

• More Medicare dollars are spent on the diagnosis and

treatment of heart failure than on any other disease

• Hospitals are penalized by CMS if patient with heart

failure is readmitted to the hospital within 30 days with same diagnosis

• Approximately 2/3 of patients with heart failure that

are hospitalized will be rehospitalized within one year. 30 day readmission rate is 25%

• According the Framington Heart Study, 80% of men and

70% of women under the age of 65 with heart failure die within 8 years

16

What is heart failure?

• Heart failure is a condition in which the function of the

heart steadily decreases due to a weakening of the heart muscle.

• As a result, the heart loses its ability to fill with or eject

blood

• Preferred terminology is heart failure, not congestive

heart failure as not all patients with heart failure will have congestion 7

• The American Heart Association and American College
• f Cardiology defined heart failure as a complex clinical

syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with blood or eject blood 6.

17

Terminology Review

• Ejection Fraction is an important term to

understand regarding heart failure. It refers to the portion of the total blood that is ejected from the heart chamber when the heart contracts. Some patients with heart failure have a reduced ejection fraction, while others have a preserved ejection fraction.

• Cardiac output is the total amount of blood that is

ejected by the heart over the course of a minute. It is a product of the stroke volume times the heart

• rate. Patients with both types of heart failure

(reduced ejection fraction, preserved ejection fraction) will have a reduced cardiac output.

18

Heart Failure video

19

Systolic Heart Failure

• Systolic heart failure is also known as HF with

reduced left ventricular ejection fraction (LVEF) as well as HF with left ventricular systolic dysfunction

• Systolic heart failure occurs when the heart muscle

can’t contract hard enough to squeeze out a sufficient amount of blood, resulting in a reduced ejection fraction. Think of the analogy of trying to squeeze water out of a water bottle and only using 2 fingers to do so.

• Systolic dysfunction usually begins in the left

ventricle and is usually due to MI, cardiomyopathy, myocarditis, or valvular heart disease 8

20

Diastolic Heart Failure

• Also known as HF with preserved LVEF
• Diastolic heart failure occurs when the heart is

unable to adequately fill with enough blood. This

• ccurs due to the ability of the heart muscle to

relax is decreased or slowed, making it difficult for the ventricle to fill with enough blood. Think of the water bottle analogy again, but this time you are unable to fill the water bottle with enough water to squeeze out an adequate amount.

• Patients with diastolic heart failure will have a

preserved ejection fraction, but will have a reduced stroke volume.

21

Left/Right Sided heart failure

• Heart failure typically begins in the left ventricle,

but may affect either the left side, the right side or both sides of the heart. 8

• With left sided heart failure, fluid is backed up into

the patient’s lungs leading to shortness of breath

• With right sided heart failure, fluid is backed up

into the periphery with patient exhibiting edema in the abdomen, legs and the feet

22

Causes 5

Most common cause of HF is Coronary Artery Disease, leading to Myocardial Infarction and ischemic cardiomyopathy

23

Causes

• Other causes include:
• systemic hypertension
• valvular heart disease
• severe renal failure
• constrictive pericarditis
• dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Infiltrative disorders
• Peripartum cardiomyopathy
• Myocarditis
• Infectious endocarditis
• arrhythmia

24

Diagnostic Criteria

• Cardinal symptoms include
• Weight gain of greater than 3 pounds

in one day

• Dyspnea
• Fatigue
• Exercise intolerance
• Fluid retention

25

Symptoms

• Classic symptom is dyspnea. Initially,

dyspnea occurs with activity and as HF worsens, dyspnea will occur at rest

• Fatigue
• Resting heart rate > 100 bpm
• Orthopnea
• Third heart sound
• Nocturia
• Cold extremities

26

Symptoms

• Pulmonary edema
• Peripheral edema
• Diaphoresis
• Global muscle atrophy
• Organ system dysfunction. Heart failure

begins as a single organ system problem, but progresses to a multiple

• rgan system problem as blood flow is

decreased

27

ACC/AHA Stage A and B “at risk” stages 6

Stage A Patients at risk of developing heart failure These are patients with a history of conditions that can put them at increased risk of developing heart failure such as CAD, hypertension, or DM Stage B Patients who have developed structural heart disease but have not shown signs/symptoms of heart failure This group includes those individuals who have had a previous cardiac incident such as an MI or LVH (left ventricular hypertrophy)

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Stage C and D

Stage C These are patients that have current or prior symptoms of heart failure with underlying structural disease of the heart These individuals are currently undergoing heart failure treatment Stage D These are individuals with advanced structural disease of the heart, marked symptoms of heart failure at rest. End‐ stage heart failure These are individuals with frequent heart failure hospitalizations, possible referral to hospice services

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NYHA Classification of Heart Failure 9

• Class I (mild) puts no limits on physical activity. Everyday

activity does not cause fatigue, shortness of breath, or

• palpitation. BNP 100‐300 pg/ml
• Class II (mild) shows slight limitation with physical activity.

Patient is comfortable at rest but may experience fatigue, shortness of breath, or palpitation with everyday activity. BNP 300‐599 pg/ml

• Class III (moderate) shows obvious limitation with physical
• activity. Patient shows no symptoms at rest but displays

fatigue, palpitations, and shortness of breath with less than

• rdinary activity. BNP 600‐899 pg/ml
• Class IV (severe) patient in discomfort with any physical
• activity. At rest, there are signs of cardiac insufficiency.

BNP >900 pg/ml

30

Precautions/Relative contraindication to exercise 9

• Monitor vital signs and general

symptoms at all times

• Therapist should note if there are any

specific precautions or contraindications from the physician

• Heart rate > 100 bpm in supine at rest
• Ventricular arrhythmia

*Keep risk versus benefit ratio in mind

31

Precautions/Relative Contraindications to exercise

• Class IV HF (patient has discomfort with any

physical activity and at rest; there are signs

• f cardiac insufficiency)
• Use of dobutamine (acute care)
• Body mass increase > 3 to 5 lbs over course
• f 1 to 3 days
• Systolic blood pressure decreases with

exercise

• Systolic blood pressure > 180 mm hg or

diastolic blood pressure > 110 mm hg81

32

Absolute Contraindications to Exercise 10

• New onset of atrial fibrillation
• Uncontrolled Diabetes *
• Acute illness or fever
• Thrombophlebitis or embolism
• Pericarditis or myocarditis
• Moderate to severe aortic stenosis
• Further reduction in exercise tolerance, or

dyspnea at rest, or upon exertion over the last few days

• Exercise‐training induced hypotension

33

Patient Evaluation—Invest time in patient history

• History should include cardiac history. Document date of

diagnosis and classification (I‐IV) if available and any cardiac events, cardiac surgeries

• Diagnostic tests performed‐ blood tests, EKG,

echocardiogram, peak VO2 to determine peak exercise intensity

• Symptoms
• Sleep disturbance/quality of sleep, nocturia, sleep apnea,

how many wakings/night, number of pillows used, is patient able to sleep in bed?

• Respiratory status, use of oxygen, cpap
• Medical management including dietary restrictions, alcohol

consumption

• Medication Review

34

Medications used to treat heart failure

Diuretics

• Thiazide diuretics11 Examples include chlorothiazide,

chlorthalidone, hydrochlorothiazide, indapamide,

• metolazone. Possible side effects include hyponatremia,

hypokalemia, decline in renal function, gout, or hyperglycemia

• Loop diuretics. Examples include bumetanide,

furosemide, torsemide. Possible side effects include hypokalemia, hyponatremia, low magnesium levels, and high levels of calcium. These can lead to weakness and possible abnormal heart rhythms

• Potassium sparing diuretics. Examples include amiloride,

triamterene, spironolactone. Side effects can include feeling faint, dizzy, confused, sleepy, and hyperkalemia.

35

Medications used in HF treatment

ACE inhibitors ACE inhibitors are used in the treatment of heart failure as a vasodilator, helping to improve blood flow and decrease the work load on the heart. Examples include enalapril, lisinopril, and captopril Side effects of ACE inhibitors can include low blood pressure, low white blood cell count, and kidney or liver problems

36

Medications used in HF treatment

Angiotensin II Receptor Blockers (ARBS)

ARBS have many of the same effects as ACE inhibitors, but may work well for patients that have difficulty tolerating ACE inhibitors. Examples include losartan, irbesartan, and valsartan May work well with patients with chronic kidney disease Side effects can include low blood pressure, elevated potassium levels, muscle or joint pain, dizziness, drowsiness, headache, and nausea/vomiting

37

Beta Blockers

• Examples include propranolol, metoprolol,

acebutolol, atenolol

• Side effects can include fatigue, cold hands and feet,

weight gain. Less common side effects can include shortness of breath, trouble sleeping, and depression

• Beta blockers are good for the management of

diastolic heart failure by decreasing the heart rate and allowing the ventricles to fill with more blood between contractions

• Should be avoided in patients with asthma secondary

to medication may trigger asthma attacks

• May block signs of low blood sugar in patients with

diabetes, including increased heart rate. Diabetic patients should monitor blood sugar

38

Calcium Channel Blockers

• Examples include amlodipine, diltiazem,

verapamil, felodipine

• Calcium channel blockers work by relaxing

blood vessels, increasing blood supply, and decreasing work load on the heart

• Side effects can include constipation,

headaches, palpitations, dizziness, rash, drowsiness, flushing, swelling in lower extremities, nausea

39

Beers Criteria 4

• Medication included in the Beers Criteria as PIM in older

adults include disopyramide, as it may induce heart failure in older adults.

• Dronedarone should be avoided in patients with recently

decompensated heart failure

• Digoxin listed as having questionable effects on patients

with heart failure, may be associated with increased mortality in older adults with heart failure. Most recent update to AGS Beers Criteria recommends digoxin not be used as a first line medication, and when it is used, dosages should be below .125 mg.

• Amiodarone is a medication used to maintain normal

heart rhythm, but has greater toxicities than other medications like it. However, it may a reasonable first‐line medication in patients who also have heart failure or left ventricular hypertrophy

40

Patient Evaluation

• Past medical history
• Depression is common with this population affecting up

to 40% of patients with chronic HF with clinical depression and up to 75% of patients with chronic HF reporting elevated depressive symptoms 12. Be sure to screen for depression (PHQ 2 or PHQ 9)

• Additionally, approximately 20 to 30% of patients with

chronic HF also have COPD 13

• Patient centered goals
• Functional limitations, ADL assistance required
• Living environment, number of stairs to enter home

as well as within home, handrails, grab bars in bathroom, caregivers

41

Lab Values in Heart Failure 13,14

• Elevated BUN levels > 45 mg/dl at discharge from

hospitalization related to increased readmission rate. Elevated levels indicate decreased renal blood flow

• Increased Creatinine levels also indicate decreased

renal blood flow

• Hyponatremia defined as serum sodium levels

concentration less than 130 mmol, one study demonstrated 33.7% of patients with heart failure had hyponatremia.

• Hyponatremia has been shown by numerous studies to be

indicative of increased mortality risk.

• Patients with hyponatremia also have been shown to have

longer hospital stays

42

Lab Values

• BNP 15
• BNP is B‐type natriuretic peptide
• The strongest independent predictor of

heart failure.

• Substances that are released into the

blood stream when the heart is stretched and is working hard

• Used to detect, diagnose, and evaluate

the severity of heart failure

• Levels are increased in heart failure,

correlate to NYHA classification

43

Pro BNP

• NT‐Pro BNP 76
• Similar to BNP, as it is a substance present in the

blood stream produced when the heart is stretched

• r strained.
• NT‐Pro BNP is a precursor to BNP, and has a longer

half life.

• Median values, NT‐Pro BNP loosely correlated with

NYHA heart failure classes:

• Class I: 377
• Class II: 1223
• Class III: 3130
• Class IV: not provided

44

Evaluation

• BMI, body weight measurements needed daily (assess

patient’s ability to step on and balance on the scale)

• Arousal and attention
• Assistive and adaptive devices
• Balance in sitting and standing. Retrospective study

determined 94.7% of patients with HF in a home health setting were at risk for falls (16)

• Cardiorespiratory function and endurance. Monitor the

following at rest, in sitting and standing, with ADLs, during and after gait, and after a rest period

• Blood pressure, heart sounds, heart rate, borg rating of

perceived exertion, O2 saturation levels

• Assess inspiratory muscle strength as indicated using an

inspirometer

45

Evaluation

• Circulation, assess dorsalis pedis/radial

pulses

• Strength
• Range of motion
• Gait
• Functional mobility
• Posture
• Self care/ ADLs

46

Outcome Measures

• Assess patient health literacy regarding heart failure
• Dutch Heart Failure Knowledge scale or the Atlanta Heart

Failure Knowledge Scale

• Assess cardiopulmonary endurance and function:
• 6 MWT, Borg RPE scale , 10 meter incremental shuttle‐

walk test, 2 MWT, 2 minute step test, stair climbing ability

• Assess balance:
• Berg Balance Scale, Dynamic Gait Index
• Quality of Life:
• Disease specific questionnaire include Kansas City

Cardiomyopathy Questionnaire, Minnesota Living with Heart Failure Questionnaire (need permission from McMasters University), Chronic Heart Failure Questionnaire

47

Exercise Guidelines

• Review relative and absolute

contraindications to exercise.

• Supervised exercise programs have

been shown to reduce mortality in patients with heart failure.

• Current clinical standard for exercise

programs for patients with heart failure is moderate‐intensity aerobic exercise.

48

Monitoring response to exercise, use of heart rate max

• Unless your patient has participated in

exercise testing and metabolic gas analysis, you cannot rely on heart rate as a reliable tool to monitor exercise response. This is due to many cardiac medications blunting a heart rate response to exercise.

• Utilizing Borg’s Rate of Perceived Exertion

(RPE) or Rate of Dyspnea to monitor patient’s response to exercise.

49

Exercise Guidelines

• All exercises should be tailored to the patients

individual level of tolerance with maintenance

• f appropriate vital signs.
• Compromised patients can begin with

intervals of 5 to 10 minutes of exercise, 2‐3 times per week. Progress minutes of exercise gradually, as tolerated, to 20 to 30 minutes, 3

• r more times per week. Educate patient on

self monitoring of blood pressure, heart rate,

• xygen saturation, and Borg RPE. 9

50

Exercise Guidelines

• A combination of strength training along with interval training

has been reported to be beneficial 17

• Strength training for upper and lower extremities and trunk

using light weights, resistance band, weight machines or body resistance begin with low resistance and high repetitions, avoiding the Valsalva maneuver

• May begin strength training with 1 set and progress to 3 sets
• f each exercise, performing 10 to 15 repetitions 2 to 3 days

per week

• Once patient able to lift a weight 10 to 15 repetitions without

muscular fatigue, increase amount of weight lifted to an amount the patient can lift only 8 to 10 reps without having to stop due to muscular fatigue

• Older persons with heart failure have an increased risk of

skeletal fracture (e.g. hip fracture) and require supervision or restrictions for exercise modalities that can cause increased risk for falls 18

51

Monitoring for worsening of Symptoms during therapeutic interventions

• The goal is to identify worsening of symptoms as early as

possible, refer back to physician with worsening of symptoms.

• Vital signs must be monitored before, during, and after

therapy treatments and progression of treatments. If patient doesn’t have the expected vital sign reaction to exercise, this information needs to be reported to the patient’s physician

• Monitoring body weight with each therapy session. You

should know your patient’s daily “dry weight” with each therapy session

• Lung auscultation is also helpful. Listen for the development
• r worsening of crackles.
• Assessing heart sounds is also helpful. Listening for the

development or worsening of S3 heart sound.

52

Aerobic training

• Patients can initially work at 40 to 50 % of VO2

max, progressing to working at 60 to 80% of VO2 max. Utilizing Borg’s RPE exertion, initially patients should work at around 10‐14/20, progressing to working at 15‐16/20

• Moderate intensity aerobic training has strong

evidence to support use in therapy programs to decrease mortality in patients with heart failure.

• Protocols include a frequency of 3 to 5 times

per week, with a duration of 20 to 45 minutes

• f continuous exercise or interval training

53

Interval Training

• Many patients with heart failure are unable to

tolerate continuous exercise. These patients may benefit from interval training in one session, or even possible multiple sessions over the course of a day if your setting allows (Long term care)

• Optimal protocol appears to consist of short

intervals with passive recovery.

• A randomized study conducted in France used a

protocol with short intervals (30 seconds) interspersed with passive recovery time. Patients were better able to tolerate exercise, increase their total exercise time without compromising training time spent at >85% VO2 max 19

54

Is High Intensity Exercise safe/more effective than moderate intensity exercise?

• A systematic review was conducted in 2013 that looked at

high intensity interval training and found there was insufficient evidence to support high intensity interval training 20.

• In another study conducted in Norway, group‐based high

intensity aerobic interval training demonstrated improvement in functional capacity and quality of life. The study included 80 patients with stable chronic heart failure who performed high intensity interval training twice a week for 65 to 80 minutes for 16 weeks. At 4 months, the exercise group showed an improvement in the 6 minute walk test by 58 meters versus the control group showed a decline of 15

• meters. At 12 months, the exercise group showed an

improvement of 41 meters versus the control group showed a decline of 20 meters 22.

55

Inspiratory Muscle Training

• Patients with heart failure can experience

weakness of respiratory muscles, as well as increased airway resistance. Signs can include dyspnea, especially with exertion. Patients may experience early onset of fatigue with exercise training, and patients may benefit from inspiratory muscle training. 24

• Due to changes in ventricular function, reduced

lung compliance, increased airway resistance, patients with HF have an altered breathing

• pattern. This could lead to patient’s experiencing

increased respiratory muscle fatigue, leading to decreased activity and exercise tolerance

56

Inspiratory Muscle training

• Protocols include performing inspiration at 30% max

inspiratory pressure (Pimax) initially, progressing gradually to 60% Pimax for two 15 minute sessions daily, or 30 minutes once daily

• Gradually increase reps, taking rest breaks as needed, with

multiple studies having subjects performing 30 minutes

• daily. Instructions are to take rest breaks as needed, but

perform as many reps as possible during time frame

• Devices such as the respiratory muscle trainer (Respironics

Health) can be used. Various small diameter orifices are used to provide resistance during inhalation

• If your patient also has a history of COPD, be sure to

include expiratory muscle training in your therapy program to avoid trapping of air.

57

Aquatic Therapy 25

• During swimming, the hydrostatic pressure compresses

superficial veins, particularly in the lower extremities and the abdomen, causing a blood volume shift to the chest and heart

• Decompensated heart failure is an absolute

contraindication to aquatic therapy

• Patient with severe HF should remain in upright position,

and submerge body in water no deeper than the xiphoid process.

• Obtain physician’s clearance, as well as recommendations

for water temperature and time spent in pool.

• Patient should be closely monitored for cardiac symptoms

and changes in vital signs.

58

Referrals to other disciplines

• Social services for any equipment needs,

community resources

• Back to physician if patient has an abnormal

response to exercise

• Smoking cessation program if necessary
• Nutritionist/Dietician for fluid, calorie, fat and

sodium reduced diet

• Mental health professional if there are

psychological issues (depression)

• Sleep specialist if sleep apnea is present
• Cardiac Rehab program

59

Patient Education in Heart Failure

• The HF Society of American Guidelines

recommends ongoing education due to the lack of efficacy of a single session

• Education must be a routine part of all therapy

visits, targeted to health literacy level of the patient, and post‐teaching patient understanding should be assessed 26

• Additional Patient Education includes edema

management via lower extremity elevation, sleeping position to alleviate/decrease orthopnea, educate on dietary changes such as sodium restrictions/fluid restrictions, fall prevention

60

Chronic Obstructive Pulmonary Disorder

61

Copd

COPD is a collective term for any disease process that blocks or disrupts the passage of air through the lungs over time. Three diseases are recognized to be included within the term: asthma, emphysema and chronic bronchitis

62

We will discuss two main types of COPD

• Emphysema decreases airflow through the

actual destruction of lung tissue. Over time, the elastic tissues of the alveolar membranes become damaged and permanent distention of air spaces occurs.

• Chronic bronchitis decreases airflow due to

inflammation in the bronchial tubes with increased mucus production. This inflammation and mucus gland hyperplasia are due to chronic irritation

• Most patients with COPD present with a

combination of emphysema and chronic bronchitis

63

COPD video

64

COPD

X‐ray imaging of the lungs of a patient with COPD often show hyperinflated lungs and a flattened diaphragm Patient with COPD

• ften present with a

barrel chest. In addition to the flattening of the diaphragm, the diaphragm also weakens, losing it’s ability to contract

65

Functional Consequences

• Functional consequences of both types of

COPD include:

• Expiratory airflow is limited
• Patients experience dynamic
• hyperinflation. Due to the difficulty with

expiration, patients with COPD begin to inhale before they have fully exhaled.

• Elastic load of the respiratory system is

increased and reduces the performance of the respiratory muscles.

66

Signs and Symptoms

• Main signs and symptoms are SOB and

decreased capacity for physical activity. Other signs and symptoms include productive coughing, non productive coughing, loss of appetite, weight loss, skeletal muscle atrophy, respiratory muscle weakness, and increased fatigue

67

Global Initiative for Obstructive Lung Disease (GOLD) classifies COPD into 4 stages 27

• Mild COPD: mild limitation to airflow. Patients may or

may not be aware of abnormal lung function at this time. FEV1 > 80% predicted

• Moderately severe COPD: patients may start feeling

symptoms of shortness of breath (SOB), coughing, and coughing phlegm during exertion. FEV1 > 50% to < 80%

• Severe COPD: patients continue to complain of SOB and

are more limited in activities of daily living (ADLs). May present with increased fatigue and feelings of tiredness FEV1 > 30% to <50%

• Very severe COPD: severe reduction in air flow, which can

affect the cardiovascular system. May require supplemental oxygen. FEV1 < 30%

68

Causes

The most common causes are years of smoking, exposure to second hand smoke or chemical irritants. Can also be caused by irreversible airway

• inflammation. 28 95% of cases are due to

years of cigarette smoking.

69

Risk Factors

• cigarette smoking
• breathing chemical fumes
• dust or air pollution over a long period of

time

• secondhand smoke exposure
• history of several severe lung infections
• severe viral pneumonia early in life
• allergies
• genetics (i.e. antiprotease deficiency)

70

Precautions

• Frequent pulse oximetry should be used to monitor for

adequate oxygen levels, especially if patient is using supplemental oxygen

• Patients hospitalized for exacerbations of COPD are at

increased risk for deep vein thrombosis (DVT) and pulmonary embolism

• Adverse effects of medications used to treat COPD include

tachycardia and cardiac rhythm disturbances in susceptible patients (with beta 2 agonists), atrial and ventricular arrhythmias (with methylxanthines), and myopathy and decreased bone density ( with long term corticosteroids) 28

• Follow vital sign parameters established by patient’s

physician or your organization

71

Precautions

• Whole‐body exercise often causes patients with

COPD to become dyspneic and stop exercise before the exercising muscles and circulatory system reach their critical limits

• Avoid isometric resistance exercise
• Avoid outdoor exercise when weather is very hot,

humid, or cold

72

Patient Evaluation

• History of present illness/injury, reason for
• referral. Is patient having an exacerbation, or is

COPD stable?

• Smoking history? Is the patient currently

smoking?

• Is there a productive cough present? How long

has the cough been present? How often does the patient become short of breath?

• Medical treatment. Use of oxygen therapy,

inhalers/bronchodilators, smoking cessation programs, history of pulmonary rehab program participation

73

Patient Evaluation

• Sleep disturbance: wakings per night due to dyspnea, number of

pillows patient needs to sleep due to orthopnea, CPAP use, has patient undergone a sleep study? Symptoms of COPD can be accentuated during sleep, and risk of nocturnal death is a possibility

• Respiratory status, document use of oxygen
• Past medical history, comorbid diagnoses. Cardiovascular

disease is the most frequent disease coexisting with COPD. Anxiety and depression are also highly prevalent co‐occurring in patients with COPD. Lung cancer is also frequently seen with COPD and is the most common cause of death in patients with

• COPD. Pneumonia occurs frequently with COPD
• A good set of vital signs needs to be taken with every therapy

visit including BP, O2 sats, Temperature, RR, HR, Borg RPE, lung sounds, and heart sounds

74

Patient Evaluation

• Manometer can be used to determine maximal

inspiratory pressure and maximal expiratory pressure

• Note breathing pattern, diaphragmatic breathing, use
• f accessory muscles. Also, note if patient has a

preferred “breathlessness” position

• Assess cough, four stages of cough, productive cough,

color, consistency, and amount of sputum

• Observe for edema in extremities, clubbing of fingers
• Social/occupational history. What are the patient’s

goals? Functional limitations, ADL status, living environment including number of stairs, floors, with whom does the patient live, caregivers, etc.

75

Patient Evaluation

• Diagnostic tests completed may include
• Arterial blood gases (ABG)
• Complete blood count (CBC)
• Chest x‐ray, Chest CT
• Ventilation perfusion scan
• EKG
• Pulmonary functions tests will include the following

along with additional tests: forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), tidal volume, vital capacity, peak expiratory air flow

• Nocturnal oximetry

76

Lab Values 29

• Commonly referred to as ABG, arterial blood gases is a

blood test which can be used to see how well your lungs are functioning. This test measures the amount

• f oxygen, carbon dioxide, bicarbonate, and ph of the

blood.

• Low blood levels of oxygen is referred to as hypoxia.

Mild hypoxia is paO2 60 to 80 mm, moderate is paO2 is 40 to 60 mm, and severe is < 40 mm.

• Normal blood ph is 7.35 to 7.45, normal partial

pressure of oxygen is 80 to 100 mm hg, normal partial pressure of carbon dioxide is 38 to 42 mm hg, and normal bicarbonate is 22‐26 mEq/l.

• Lower blood ph may be indicative of higher carbon

dioxide levels (hypercapnia).

77

Relevant Tests and Measures

• Height, weight, BMI
• Measurement of chest girth
• Arousal, attention, and cognition
• Balance assessment
• Cardiorespiratory function and endurance
• 6 MWT
• 2 MWT
• 2 Minute Step Test
• stair climbing ability
• Borg Rating of Perceived Exertion
• Borg Rating of Dyspnea

78

Relevant Tests and Measures

• Functional mobility.
• Gait
• Assess for need for assistive device. Rollator

walker has been shown to show clinically relevant improvements with sedentary patients with the 6 MWT as compared to use of unaided 6 MWT 30

• Muscle strength
• Range of motion
• Self Care/ADLs
• What happens to patient’s breathing when

performing ADL requiring use of upper extremities? How does this affect patient’s ability to use accessory muscles to assist with breathing?

79

Relevant Tests and Measures

• Assess viability of diaphragm
• Place your finger tips just below the patient’s

xyphoid process. Ask them to sniff 3 times. You should be able to feel the diaphragm contract underneath your fingertips if the diaphragm is viable.

• Also, observe patient’s breathing pattern. Note

if the abdomen is rising and falling with each breath, or if they are using accessory muscles for breathing

• Note lowest point of patient’s breathing

pattern, diaphragmatic, middle chest, upper chest

80

Ventilatory Response Index (VRI)

• Great objective tool that can be used to

quantify breathlessness

• Have patient count from 1 to 15 in 8
• seconds. You can tap or snap to keep time
• Count the number of breaths the patient

has to take.

• 0 to 4 scale depending upon the number of

breaths the patient has to take

81

Ventilatory Response Index

Able to count to 15 in a single breath, no additional breaths taken 1 Able to count to 15 with one additional breath 2 Able to count to 15 with two additional breaths 3 Able to count to 15 with three additional breaths 4 Able to count to 15 with four additional breaths

82

Prognosis

• COPD is one of the leading causes of morbidity and

mortality in the United States.

• The BODE (Body mass index, degree of airflow

Obstruction, Dyspnea, Exercise capacity) index can be used to assess risk of mortality in patients with COPD.

31

• Smoking cessation is important for improved prognosis.
• There is a concern that supplemental oxygen may cause

patients with COPD to develop what is known as

• xygen‐induced hypercapnia. However, supplemental
• xygen, when indicated, has been shown to improve
• survival. Recommend O2 sats be maintained at 88 to

92%79

83

Prognosis

• Malnutrition, cor pulmonale, hypercapnia, and

resting pulse > 100 are indicators of a poor prognosis.

• Weight loss of >10% in past 6 months also poor

prognostic indicator

• O2 Sats < 88% on oxygen
• Factors that have been found to be predictive of

hospital readmission:

• Prior hospitalization
• use of oral corticosteroids
• use of long‐term oxygen therapy
• poor health‐related quality of life
• lack of routine of physical activity

84

Common medications used to treat COPD 32

• Bronchodilators. The purpose of bronchodilators is

to relax the smooth muscles of the lungs so that more air can move in and out.

• 3 types
• Beta2‐agonists: increase airway patency through

smooth muscle relaxation. There are two types, rescue and long acting. Rescue inhalers include albuterol and albuterol sulfate (Proventil, Ventolin, ProAir) and long acting include Serevent, Brovana, and Perforomist

• Anticholinergic Agents: increase airway patency by

preventing bronchoconstriction. Examples include Atrovent (short acting) and Spiriva (long acting).

• Combination beta2‐agonists and anticholinergic

agents.

85

Bronchodilators

• Patients will be prescribed a rescue inhaler first, but if

they are needing their rescue inhaler more than two times per week, they will be prescribed a long acting bronchodilator.

• Rescue inhalers are also known as short acting

inhalers

• The purpose of long acting bronchodilator is to

control symptoms, not for quick relief of symptoms

• Side effects of bronchodilators can include

tachycardia and other arrhythmias, trembling/shakiness, nervousness, and headaches

86

Glucocorticosteroids/Corticosteroids

• Anti‐inflammatory agents. Act by preventing

inflammatory‐induced bronchoconstriction by inhibiting inflammatory cells.

• Examples include Aerobid, Budesonide (Pulmicort),

fluticasone (Flovent), ciclesonide (Alvesco), beclomethasone (Qvar), and mometasone (Asmanex)

• Not used to control acute inflammation, used for

long term symptom control

• Side effects are few, and may include development
• f thrush. Rinsing the mouth after use of these

medications can help decrease the risk of thrush 32.

87

Other Combination Drugs

• Advair: combination between fluticasone, a

corticosteroid and salmeterol, a long acting, beta agonist bronchodilator.

• Symbicort: contains formortor, a long acting,

beta‐agonist bronchodilator and budesonide, a corticosteroid

• Combivent (inhaler) or DuoNeb (nebulizer).

Contains two bronchodilators, albuterol and ipratropium (Atrovent).

• Trelegy has 3 medications included: long acting

beta 2 agonist, corticosteroid, and a long acting anticholinergic agent.

88

Medications used to promote mucus clearing

• Mucolytics: reduce the viscosity of the

mucus, an example includes

• acetylcysteine. Side effects are rare, but

can include gi bleeding. They should not be used in patients with history of stomach ulcers

• Expectorants: Increase the volume and

hydration of secretions. Examples include

• guaifenesin. Side effects include can

possibly induce coughing, N/V, or diarrhea

89

Therapy medication related goals:

• If patient experiences dyspnea with activity or

therapy treatment, patient should be educated to time performance of therapeutic activities after use

• f rescue inhaler (as prescribed)
• Medication goals can be incorporated into therapy
• treatments. Examples include:
• PT: patient to be independent with use of rescue

inhaler in order to control dyspnea with ambulation to increase ambulation endurance and return to community ambulation distances.

• OT: patient to improve fine motor skills in order

to allow independent use of rescue inhalers, nebulizer including medication vial

90

Referrals to other disciplines

• Respiratory therapist for airway management
• Smoking cessation counselor
• Back to physician if oxygen saturation levels are not

maintained and supplemental oxygen or other medical management is warranted. Notify physician if vital sign response to activity is not as expected

• Support groups for psychological and emotional

support

• Social work for availability of community resources
• Mental health professional if depression is present
• Pulmonary rehab

***Effective COPD management depends upon multidisciplinary communication and collaboration

91

Effective Therapeutic Interventions

92

General Guidelines

• There is a high level of evidence that

therapy programs with patients with COPD aid recovery from exacerbations

• f COPD and prevent reoccurrence
• Treatment interventions are based on

minimizing additional damage to remaining lung tissue, increasing the amount of gas exchange during respiration, and improving quality of life and physical activity.

93

Aerobic Exercise Training

• As with heart failure, patients can initially work

at an intensity of 40 to 50 % of VO2 max, progressing to working at 60 to 80% of VO2

• max. Utilizing Borg’s RPE exertion, initially

patients should work at around 10‐14/20, progressing to working at 15‐16/20

• As with heart failure, compromised patients can

benefit from interval training. Begin with 5 to 10 minutes of interval or continuous exercise, and progress to 20 to 30 minutes of exercise 3 to 5 times per week

94

Programs to increase Physical Activity

• Patients with COPD will need to be educated on programs

to increase physical activity. These programs may help to decrease incidence of hospital admissions as well as improve mortality

• Study conducted in which patients who were hospitalized

for exacerbation of COPD wore an accelerometer (measures movement by measuring acceleration forces) for the first 30 days after hospitalization

• Patients with increased minutes of physical activity

(average 114 minutes)had a lower rate of hospital readmission than those with lower minutes of physical activity (average 42 minutes)

• Patient who were eventually rehospitalized had a gradual

decline in physical activity, whereas those who were not readmitted had a gradual increase in physical activity 38

95

Strength and Resistance training programs

• Patients with COPD are going to experience muscle

wasting and benefit from strength and resistance training programs

• RT programs in addition to an ET program can lead to

better results than an endurance based program alone in regards to improvements in strength and overall function

• As with heart failure, initiate RT programs with higher

reps and lower resistance.

• Start with one set of 10 to 15 reps, can progress to 3

sets performing 5 to 10 exercises utilizing major muscle groups.

• As patient acclimates to strength training, increase

resistance to a level that a patient can perform only 8 to 10 repetitions due to muscular fatigue

• Educate patient to perform 2, preferably 3 times per

week.

96

Strength and Resistance Training Programs 39,40

• Strength and resistance training programs may be a

good alternative for patients that are experiencing severe dyspnea, as it can result in decreased dyspnea when compared to endurance training

• A systematic review conducted in 2015 looked at

the effects of RT versus ET in patients with COPD. Outcome measures that were studied included quality of life, ADLs, dyspnea, possible harm, and

• mortality. The result of their study showed no

clinically significant difference between RT and ET in patients with COPD in regards to the outcomes

• listed. Therefore, RT may be a good alternative for

patients with COPD and should be considered when developing exercise programs

97

Breathing Exercises

• Incorporate breathing exercises into your therapy plan of
• care. Utilize breathing exercise devices as applicable
• Breathing exercises can include pursed lip breathing,

diaphragmatic breathing if viable, paced breathing. Pursed lip breathing has the strongest level of evidence to support its use.

• Position your patient in a position to help them succeed,

depending upon the viability of their diaphragm 35

• Posterior pelvic tilt, arms at side, and forward head

posture helps to facilitate the muscle fibers of the diaphragm

• Anterior pelvic tilt, arms up in a “hold em up” position,

and head neutral/extended helps to facilitate the upper and middle chest fibers

98

Pursed Lip Breathing

• Cue patient to breathe in through the nose and out

through pursed lips.

• Educate patient on exhale to inhale ratio of 2:1.

Count out loud with patient inhale 1…2… exhale 1…2…3…4…

• Can incorporate diaphragm if it is viable!!
• The purpose of pursed lip breathing is it provides

positive pressure to pop open any closed alveoli.

• Pursed lip breathing has been shown to reduce HR,

BP, and RR and promote relaxation if done progressively slower

99

Inhale 1..2… Exhale 1..2..3..4

100

Pursed Lip Breathing

• Teach them to breathe at rest initially, then with
• activity. Don’t assume that the skill will carry over

to activity.

• It is a learned skill which requires practice. Instruct

patient to perform in various positions including supine, sitting, standing, walking, stair climbing, during ADLs and with functional mobility.

• Patients will require repeated training in order for

patient to master.

• Therapists can use items such as kazoos, pinwheels,
• r bubbles to facilitate pursed lip breathing

101

Flutter Valve

• Used to help loosen secretions from the chest

wall so that the patient can cough up secretions easier.

• There is a ball at the end of the valve that

vibrates the air.

• It’s not used for muscle training, but solely used

for secretion management

• Make sure patient exhales completely when

using this device

102

Acapella Device

• Similar to a flutter valve, it also has a ball at

the end of the valve to vibrate the air to loosen secretions

• The added benefit of the Acapella Device is

that it adds resistance for expiratory muscle training

• Many hospitals will issue patients with COPD
• ne of these devices, so be sure to ask your

patients about it.

103

Pranayama Breathing Exercises Efficacy in COPD

• Pranayama is a specific set of breathing exercises within

yoga with emphasis on controlled breathing

• Study completed in India studied the effects of

Pranayama breathing on BODE index and the COPD Assessment test score (CAT) 36

• Four types of pranayama breathing were used. Patients

performed 2 sessions for 30 minutes each session

• Study showed an significant improvement in CAT

scores, but no change in FEV. Demonstrates use of Pranayama breathing can have an effect on subjective experience of health, disease severity, and functional status without a change in FEV.

104

Breathlessness Position

• Most of the time, your patient will know what

their best position to relieve breathlessness is. Typically, this is the position that you will often see your patient sitting or standing in.

• The diaphragm has two main jobs, one is for

breathing and the other is for posture. The idea behind the breathlessness position is to eliminate the role of the diaphragm for posture so that your patient can utilize the diaphragm just for breathing. It is the most useful when used in conjunction with PLB.

105

Coughing Techniques

Assessment of cough

• 4 stages to a cough
• Inspiration
• Glottal closure
• Increased abdominal and thoracic pressure
• Forced exhale

If patient coughs something up, note color, amount, viscosity, odor, and energy expenditure

106

Coughing Techniques

• When working on facilitating coughing

technique, be sure to work on it within 15 minutes of patient utilizing inhaler or nebulizer. This is when the airways are the widest and patient is most likely to get mucus out

• Make sure patient is well hydrated
• Have patient in a seated, well supported

position

• Use devices as needed to facilitate moving air

and sputum

107

Facilitating Inhale 37

• To facilitate inhale, position the patient for

success:

• Trunk in extension
• Have patient place arms above the

head as much as possible

• Have patient position head in extension
• Have patient look upward

108

Facilitating Exhale

• Have patient flex the trunk to help

“Squeeze” the cough out

• Have patient bring the arms down to the

side, can additionally have patient bring the arms into the costal angle to assist with forced exhalation

• Have patient put their head in a flexed

position

• Have the patient look downward

109

Inspiratory Muscle Training

• Inspiratory muscle training can be performed in

the management of COPD to strengthen inspiratory musculature, increase exercise tolerance, and decrease exertional dyspnea

• Inspiratory muscle training can be performed

utilizing incentive spirometer or respiratory muscle trainer.

• Patients with COPD need to be trained to

perform full inhalation, followed by a full exhalation to avoid trapping of air.

110

Is your patient too dyspneic to tolerate aerobic or strengthening exercises?

• A Cochrane review of 16 studies revealed breathing

exercises can be effective if used alone for patients too dyspneic to tolerate other forms of exercise :

• They looked at studies that utilized breathing exercises

included pursed‐lip breathing, diaphragmatic breathing, pranayama yoga breathing ( timed breathing with focus

• n exhalation), and computerized feedback that allowed

patients to slow respiratory rate and increase exhalation time.

• Patient showed increased functional exercise capacity as

measured by the 6 MWT, but showed no change in dyspnea or health‐related quality of life. 35

• As patient improves, he/she may be better able to

tolerate strength and endurance training programs 111

Breathing Exercises and Anxiety and Depression 41

• Controlled breathing exercises have been shown to

have a positive effect on anxiety and depression in patients hospitalized with COPD. A randomized controlled trial was conducted in Spain in which the breathing‐intervention group received twice daily PT including pursed‐lip breathing, relaxation exercises, and active expiration. The outcomes that were measured included dyspnea, anxiety and depression, quality of life, maximum inspiratory and expiratory pressure, hand grip strength, and sleep quality. The treatment group showed significant improvement in functional and psychological variables and the control group showed a deterioration.

112

Vicious Cycle

113

Pulmonary Rehab Programs

• Pulmonary rehab programs have been shown to

reduce hospital readmission rate after a hospitalization due to COPD. Utilization is low with reasons for non adherence including transportation issues, patient refusals, and full time employment.

• Home based pulmonary rehab programs have been

studied and have been found to be a safe, feasible, and effective treatment program for those patients who are unable to attend traditional pulmonary rehab programs due to geographic or functional constraints.

• Patients need to be educated on the benefits of

pulmonary rehab programs. 42,43

114

Other Interventions

• Aquatic exercise has been shown to be safe for

patients with COPD and may show an improvement in a patient’s endurance and quality

• f life
• A 2012 systematic review showed there is little

evidence to support or refute the use of manual therapy in patients with COPD

• Study completed looking at high frequency NMES

versus strength training

• No difference in exercise performance and was

found to be equally as effective as strength training.

• The authors concluded that HF‐NMES may be a

good alternative for those patients experiencing dyspnea limiting exercise performance 45

115

Lower Body Ergometer Study 46

• A study was completed in Canada involving 22

patients with COPD. The researchers had the intervention group complete single leg use of a lower body ergometer 3 times a week, 15 minutes each leg for a period of 6 weeks. They compared them to the control group who rode the ergometers utilizing both pedals 3 times a week for 30 minutes for a period of 6 weeks. The treatment group was found to have greater improvements in peak oxygen uptake.

116

Patient education

• In 2014, CMS added acute exacerbations of COPD

as an additional diagnosis that hospitals will be penalized for if patients are readmitted within 30

• days. Patient education along with programs to

enhance adherence are an important part of decreasing rehospitalization rates.

• Smoking cessation is the number one treatment

strategy in the management of COPD.

117

118

Patient education continued

• Use of the motivational intervention known as the 5 R’s

might help:

• 1. Relevance, encourage patient to discuss why quitting

is personally relevant

• 2. Risks, ask the patient to identify possible negative

consequences of tobacco use

• 3. Rewards, ask the patient to identify the possible

benefits of quitting tobacco use

• 4. Roadblocks, ask the patient to identify possible

barriers or impediments to quitting smoking

• 5. Repetition, the motivational intervention should be

repeated every time an unmotivated patient has an encounter with a clinician. Patients should be educated that most people make repeated quit attempts before they are successful 47

Tele health

• Preventative home self‐monitoring using telehealth

technology may reduce hospital admissions and help to promote patient responsibility in handling their

• wn disease 49
• A pilot study conducted in Norway in which each

participant received an individualized training program consisting of regular exercise on a treadmill 3 times per week and strength training. They had weekly videoconferences with a

• physiotherapist. The patients showed a 27%

decrease in COPD‐related hospital costs due to decreased admissions and shorter lengths of stay

119

Type 2 Diabetes Mellitus

120

Pathophysiology of Type 2 Diabetes (DM2)

• It has also been called non insulin dependent

diabetes mellitus, adult onset diabetes . However, these terms are not used anymore secondary to many Type 2 diabetics requiring the use of insulin and many juvenile patients developing Type 2 DM

• The pancreas, liver, adipose tissue and skeletal

muscle are all involved in the pathogenesis of

• diabetes. Numerous organs are harmed by DM2

including, but not limited to, the heart and blood vessels, kidneys, eyes, nerves, brain, and skin.

121

Pathophysiology

• Results from the inability of the muscle cells to

respond to insulin properly, as well as a decreased compensatory insulin secretion 50

• Hyperglycemia and hyperinsulinemia generate
• xidants linked to cellular injury.
• Chronic hyperglycemia and hyperinsulinemia

initiate organ damage especially to the eyes, kidneys, nerves, heart, and blood vessels.

• Complications associated with DM2 include

hypertension, hyperlipidemia, cardiovascular disease, microvascular disease, neuropathic disease, increased susceptibility to infection, poor healing due to capillary damage and immune cell dysfunction, diabetic foot ulcers

122

Prevalence/Future Predictions

• The World Health Organization considers the

prevalence of DM2 to be at epidemic proportions 51

• More than 90% of people in the United

States classified as diabetic have DM2

• Lifetime risk estimates that one in three

persons born after 2000 will develop DM2, and in high risk ethnic groups the number may be closer to 50% 50

123

Diagnostic Criteria

• The American Diabetes Association (ADA)

recommends the use of four criteria in the diagnosis of DM2 50

• Glycated hemoglobin (A1C) value of 6.5 %
• r higher
• Fasting plasma glucose > 126 mg/dl
• 2 hour plasma glucose > 200 mg/dl during

a glucose tolerance test utilizing 75 g of glucose

• Classic symptoms of hyperglycemia ( ie

polyuria, polydipsia, unexplained weight loss) or a hyperglycemic crisis with a random plasma glucose > 200 mg/dl

124

Diagnostic Criteria for Pre‐ Diabetes

• Pre‐diabetes is diagnosed by the

following 50

• A1C of 5.7 to 6.4 %
• Fasting plasma glucose of 100 to

125 mg/dl

• 2‐hour post load glucose of 140 to

199 mg/dl

125

Risk Factors

• Obesity
• Metabolic syndrome
• Polycystic ovarian syndrome
• Pregnancy
• Dietary factors including increased processed

meat consumption, sweetened beverage consumption, high dietary glycemic index, low cereal fiber intake, low magnesium intake

50

• Sedentary lifestyle
• Smoking

126

Risk Factors

• Race/ethnicity
• African Americans, Hispanics
• Lower socioeconomic status
• Genetic influences
• In identical twins over age 40, there is over

70% concordance within a year of DM2 developing in one twin 51

• Hormonal excess diseases such as a

glucagonoma, acromegaly, Cushing syndrome, and pheochromocytoma

• Genetic syndromes such as hyperlipidemias,

myotonic dystrophy, and lipoatrophy 50,52

127

Precautions

• Patients with DM2 are at an increased risk for injury and acute

adverse events and should be monitored carefully during exercise

• Patients with DM2 may develop hyperosmolar hyperglycemia.

Patient can develop this condition due to severe dehydration after infection such as UTI, pneumonia. Signs/Symptoms can include confusion, aphasia, seizures or coma

• Patients with blood glucose > 250 mg/dl should use caution,

consult with physician. Check urine for presence of ketones.

• If ketones present in the urine, this is indicative that the body

doesn’t have enough insulin to control blood sugar. Exercising with high level of ketones may lead to ketoacidosis.

• Guidelines: if blood sugar > 250, exercise with caution. Blood

sugar > 300 hold exercise

128

Precautions

• If blood glucose is < 100 mg/dl, these

precautionary steps should be taken

• Increase carbohydrate intake before

exercise

• Decrease insulin dose before exercise
• Decrease insulin dose after exercise
• Glucose‐rich snacks (foods with high

glycemic index) should be readily available in the event the patient should exhibit hypoglycemic symptoms

129

Signs/Symptoms of Hypoglycemia

• Inappropriate profuse sweating (diaphoresis)
• Rapid onset of fatigue
• Loss of muscle tone or feeling weak
• Confusion/impaired cognitive function
• Blurred vision
• Shakiness/trembling
• ***If your patient is prone to hypoglycemia,

encourage patient to check and report blood sugar prior to exercise session

130

Precautions

• Vital signs should be monitored before, during, and

after exertion; review parameters

• Stop exercise if patient exhibits difficulty breathing,

chest pain, unusual fatigue, dizziness, nausea, or exhibits signs/symptoms of hypo or hyperglycemia

• Patients with DM2 should be screened for orthostatic

hypotension, as many patients with DM2 develop DM‐ induced autonomic neuropathy

• Encourage patients to wear shoes that fit well and have

plenty of room for the toes, always wear socks with their shoes, avoid exercise in bare feet. Inspect shoes for cracks in the soles, bunching of material, and wrinkles in the lining. Instruct patients to inspect their feet daily. Examine feet of patients with diabetic skin changes prior to each exercise session.

131

Patient Evaluation

• Mechanism of injury or etiology of illness
• Medical management
• Diagnostic test completed. 53 Tests may include
• Urinalysis for glucose, protein, or ketones
• Urine albumin/creatinine ratio and

microalbumin

• Blood lipid profile (total cholesterol, LDL,

HDL, triglycerides)

• Fasting, random, and postprandial blood

glucose

• HbA1c level
• Blood urea nitrogen (BUN) and creatinine
• Semmes Weinstein Monofilament testing

132

Patient Evaluation

• Sleep disturbances, document number of

wakings/night. If patient is obese, document if sleep apnea has been diagnosed

• Respiratory status, does patient need supplemental
• xygen
• Past medical history. Patients with DM2 have an

increased risk of hearing impairment, obstructive sleep apnea, fractures, cognitive impairment,

• depression. 54 Patients with DM2 have a

significantly increased risk for hip fracture

• Any barriers to learning?
• *patients with DM2 are at increased risk of

dementia

133

Patient Evaluation

• Social/occupational history
• Patient’s goals
• Vocation/avocation
• Living environment
• Presence of stairs
• Who does the patient live with
• Does patient require caregivers?

134

Patient Evaluation

• Past medical history, comorbid diagnoses
• Functional limitations/ assistance with

ADLs

• Use of assistive devices, adaptive

equipment

• Balance
• Gait
• Assess pedal pulses and lower extremity

filling time

135

Common medications used to treat diabetes

• Some patients with DM2 can effectively be

managed with effective meal planning and exercise alone.

• Some patients will be prescribed oral

medications, some will be prescribed insulin, and some patients with be prescribed a combination of both medications.

• Knowledge of medications is key when working

with patients with DM2. Timing of diabetic medications and therapeutic interventions need to be optimized to have the desired outcome 55

136

Oral Medications (most common)

• There are 9 different classes of oral medications used to treat
• DM2. During this course, we will discuss the most common types.
• Sulfonylureas. Examples include Glipizide, Glyburide, Glimepiride.

These stimulate the pancreatic beta cells to increase insulin

• secretion. Side effects can include hypoglycemia.
• Biguanides. Examples include Metformin. These work by

decreasing the glucose production in the liver and decrease the resistance of the body to insulin in the periphery. Side effects can include low blood sugar, can cause lactic acidosis (signs include tiredness, difficulty breathing, weakness, unusual muscle pain, unusual sleepiness)

• Thiazolidinediones. Examples include rosiglitazone (Avandia)

and pioglitazone (Actos). These work by decreasing glucose production in the liver and improving sensitivity to insulin in adipose tissue. Some of these medications can increase risk of heart disease. Side effects include headache, weight gain, muscle pain

137

138

Non‐Insulin Injectable Medications

• Trulicity
• It is a once a week injectable medication that is a glucagon‐like

peptide 1 receptor agonist. It helps by slowing down the release of glucose from the liver and helps the pancreas release insulin in response to high blood glucose levels.

• Side effects can include inflammation of the pancreas, low

blood sugar, or severe stomach problems.

Insulin Medications

• Used when oral medications fail to achieve

blood sugar goals for patients with DM2, or when patients have a comorbidity that prevents the use of an oral agent.

• Types of insulin medications include rapid‐

acting, short‐acting, intermediate‐acting, long‐acting and various combinations.

• Possible side effects of insulin medications

include low blood sugar, pain, and injection site redness, pain, or swelling.

139

Insulin Medications 55

Type Brand Names Onset Peak Duration

Rapid‐Acting Novolog, Apidra and Humalog 15 minutes 30 to 60m 1 to 3 hours Short‐Acting Humulin R, Novolin R 30 to 60 minutes 2 to 4 h 5 to 8 hours Intermediate‐ Acting Humulin N, Novolin N 1 to 3 hours 8 hours 12 to 16 hours Long‐Acting Levemir, Lantus 1 hour Peakless 20 to 26 h Pre‐mixed inter/short Humulin 70/30, Novolin 70/30 30 to 60 m varies 10 to 16 h Pre‐mixed inter/rapid Humalog 75/25, Humalog 50/50 10 to 15 m varies 10 to 16 h Pre‐mixed Inter/rapid Novolog 70/30 5 to 15 m varies 10 to 16 h

140

AGS Beers Criteria 4

• Beers criteria lists sliding scale insulin as

potentially inappropriate when short or rapid acting insulin is used as the sole medication in hyperglycemia medication.

• This is due to the increased risk of

hypoglycemia

• This does not apply when used in

conjunction with other insulin medications, such as long acting insulins or additional short or rapid acting insulins.

141

AGS Beers Criteria

• Long duration Sulfonylureas have a prolonged half‐

life in older adults. An example includes Chlorpropamide, and its use can cause prolonged hypoglycemia

• Glyburide, glimepiride(added 2019)78 also have a

higher risk of severe prolonged hypoglycemia in

• lder adults
• Beers Criteria also lists medications that should be

avoided or dosages reduced in patients with decreased kidney function. Decreased kidney function is routinely seen in patients with DM2, and this list of medications should be reviewed if working with patients in this population.

142

Effective Therapeutic Interventions

143

Exercise Guidelines

• The ACSM and the ADA recommend an exercise

program for patients with DM2 that consists of the following: 50

• Initially, patients with DM2 should aim for aerobic

exercise training (ET) sessions at least 3 days per week with no more than 2 consecutive days between sessions

• Aim for 150 minutes of exercise per week of at least

moderate intensity, such as brisk walking

• Gradually progress exercise intensity and minutes

per week to minimize risk of injury and to enhance compliance

• Types of aerobic physical activity include any

activities that include any form that uses large muscle groups, increases heart rate and perceived exertion to moderate levels

144

Resistance Exercise Guidelines

• Progressive resistance exercise (PRE) training at least 2

days per week, but preferably 3 times per week

• Resistance exercises should be light to moderate

intensity in order to achieve gains in strength or improvement in glycemic control.

• Blood glucose control has been shown to be

enhanced with resistance training, even as low as 23% 1RM, 56

• Include in each exercise session 5 to 10 exercises that

involve major muscle groups

• 10 to 15 repetitions to near fatigue in each set
• Gradually progress to heavier weights that can be

lifted only 8 to 10 times per set

145

Exercise Guidelines

• Incorporate a weight control program

that involves, exercise, diet, and behavioral modifications for weight management

146

Additional Benefits of exercise

• Benefits of exercise programs
• Aerobic exercise has been reported to improve

insulin sensitivity in DM2 patients even without changes in body composition

• A single exercise session has been shown to

improve blood pressure for a 24 hour period in patients with DM2 58

• Reductions in fat mass and central adiposity and

increased muscle strength and fitness reveal a reduction in HbA1c after exercise training

• Regular exercise has been shown to reduce the risk
• f cardiovascular disease, which is the leading cause
• f death in patients with DM2, irrespective of

weight loss or glucose control

147

Referrals to other disciplines

• Podiatrist for toenail clippings and fitting

for therapeutic shoes and inserts

• Nutritionist for dietary therapy
• Wound specialist, as indicated
• Nursing for education, management and

testing equipment

• Back to physician for any unresolved

medical concerns or new problems

148

Hypertension

149

Hypertension Facts 59,60

• Hypertension is the most common primary

diagnosis in the United States.

• Hypertension affects 46% of the adult US

population

• 15% of deaths associated with coronary artery

disease are contributable to elevated blood pressure (formerly known as prehypertension)

• Twenty‐two percent of people with hypertension

do not even know that they have it.

150

Defining Hypertension 63

BP Classification Systolic Blood Pressure in mmHg Diastolic Blood Pressure in mmHg Normal <120 <80 Elevated 120‐129 <80 Stage 1 Hypertension 130‐139 80‐89 Stage 2 Hypertension 140 or higher 90 or higher Hypertensive Crisis (immediate medical consult advised) Higher than 180 Higher than 120

151

Blood Pressure Management Guidelines

• According to the latest recommendations made by the 8th

Joint National Committee (2014), there is concern about previous blood pressure management guidelines (maintaining blood pressure < 140 systolic and <80 diastolic). The concern is that older patients may experience orthostatic symptoms, which can put them at greater risk of falling. The new recommendation made by the JNC8 is maintaining BP <150 systolic and <80 to 90

• diastolic. 61
• However, in 2015 the American Heart Association,

American College of Cardiology, and the American Society

• f Hypertension realized a scientific statement

recommending blood pressure readings be maintained at <140 systolic and <90 in uncomplicated hypertension 62

• On November 13th, 2017, the American heart Association

and the American College of Cardiology released new guidelines as outlined in the following slide. 63

152

Causes

• In 90 to 95% of cases, hypertension has no specific
• cause. In these cases, it is known as essential,

idiopathic, or primary hypertension.

• In 5 to 10% of cases, hypertension is secondary to a

chronic illness, including genetic syndromes, renal failure, or endocrine disorders such as Cushing

• Syndrome. In these cases, it is referred to as

secondary hypertension

• Presence of HTN and DM2 are both major risk

factors in cardiovascular disease and have additive effects on mortality and morbidity 59,60

153

Risk Factors 60

• Age (over 45 for men and 55 for women).

Prevalence is greater than 50% in Americans

• ver the age of 60
• Overweight/ high BMI (25 and higher).

Excessive weight carried around the abdomen

• African American ethnicity
• Sedentary lifestyle
• High dietary sodium intake (over 2300 mg, or

about 1 teaspoon per day)

154

Risk Factors

• More than moderate alcohol consumption

averaging more than 2 drinks per day for men or more than 1 drink per day for women

• Mental stress/anxiety
• Family history
• Smoking
• Certain chronic conditions such as kidney

disease or sleep apnea

155

Pathophysiology

• In older adults, hypertension is primarily

due to increased systemic vascular resistance, such as what is seen in arterial stiffening and endothelial dysfunction. In contrast, hypertension in younger and middle‐aged patients is usually due to increased cardiac output and increased sympathetic innervation

• As we age, the loss of arterial

compliance is a normal part of the aging process

156

Anti Hypertensive Drug Therapy

• Diuretic
• Beta Blocker
• Calcium Channel Blockers
• Angiotension‐Converting Enzyme Inhibitor

(ACEI)

• Angiotension II Receptor Blockers (ARBS)

157

Beers Criteria

• Beers Criteria lists peripheral alpha‐1 blockers

such as Doxazosin, Prazosin, and Terazosin as PIM medications in the treatment of hypertension due to high risk of orthostatic

• hypotension. These medications may also

aggravate incontinence in older women.

• Also listed as PIM are central alpha blockers,

such as Clonidine, Guanabenz, Guanfacine, Methyldopa, or Reserpine, as these medications may cause bradycardia and orthostatic hypotension

158

Beers Criteria

• Beers criteria also lists medications that

may have a potential drug to drug interaction.

• ACEIs used in conjunction with potassium

sparing diuretics, such as Amiloride or triamterene, can increase the risk of

• hyperkalemia. The recommendation is

made that this combination of drugs be reserved for patients that have experienced hypokalemia when taking an ACEI.

159

Lifestyle Modifications to Control HTN

• Exercise
• Dietary Changes
• Moderate Alcohol Consumption
• Smoking Cessation

160

Precautions/Contraindications

• If symptoms of headache or dizziness

develop during treatment, hold treatment, recheck vital signs, and notify physician if appropriate

• Acute systemic illness or fever
• Uncontrolled atrial or ventricular arrhythmias
• Uncontrolled sinus tachycardia greater than

120 beats/min

• Patients with clinical retinopathy should

avoid high‐impact exercise, head‐down positions, and using the Val‐Salva maneuver

161

Measurement guidelines

• An inaccurate measurement of blood

pressure can lead to a patient being falsely diagnosed with hypertension or falsely classified as not having hypertension. Additionally, an inaccurate blood pressure reading can lead to faulty clinical decisions in the therapy world, including (but not limited to) how a patient is reacting to a progression

• f an exercise program or if a therapist

should progress resistance, etc. with an exercise program 65

162

Measurement guidelines

• Measurement of blood pressure gives therapists a lot
• f information. A correct measurement of blood

pressure can give a therapist an idea of a patient’s baseline cardiovascular status. It can also give you an idea of how a patient responds to exercise and activity, which in turn can help to guide clinical decisions including using blood pressure response as a gauge to determine a patient’s reaction to treatment

• As therapists are moving towards being primary health

care providers, it is crucial for therapists to include an accurate measurement of blood pressure, as well as using blood pressure to gauge a patient’s response to treatment.

163

Controlling for Error in blood pressure measurement

• Correct technique for measuring blood pressure
• Make sure the cuff size is appropriate. This is the single

most common mistake when checking blood pressure. Utilize guide on the cuff to determine if cuff is

• appropriate. If patient’s arm is too large, you can

measure the blood pressure on the forearm. Also, the cuff should be not be more than 80% of the patient’s upper arm length

• Make sure patient is seated with back supported, legs

uncrossed, and the arm is at the level of the heart. If the arm is below the heart, the reading will measure higher than it is. If the arm is above the heart, the reading will measure lower than it is. The therapist should support patient’s arm at the level of the heart with the patient’s arm relaxed, as muscular contractions can raise blood pressure

164

Controlling for error

• The cuff should be placed against the patient’s bare
• arm. Do not just roll up the patient’s sleeve, as it may

cause a tourniquet effect and alter the blood pressure measurement reading. Studies have shown that performing bp measurement over clothing can impact a systolic blood pressure reading

• The cuff should be placed at least one inch above the

elbow crease, so that the bell of the stethoscope can be placed over the area where the brachial artery is the most palpable without being covered by the blood pressure cuff.

• The blood pressure can be measured at the forearm if

necessary to maintain the correct size measurements of the cuff. Be sure your documentation reflects the site of measurement, as the systolic reading can be up to 20 mm hg higher than the upper arm measurement

165

Controlling for error

• Make sure the patient is allowed to rest 3 to 5

minutes before checking blood pressure.

• Ask the patient to remain quiet, talking can

increase the systolic measurement by 10 to 15 mm hg

• Full bladder. Blood pressure is lower when your

bladder is empty

• Stress or anxiety can also increase blood pressure

measurements.

• Alcohol and caffeine can also alter blood pressure

measurements

166

Standardized Technique

• It is recommended that more than one measurement

be taken in order to increase accuracy, and the average

• f the readings should be used. It is also recommended

that blood pressure be taken in both arms during an initial assessment, as most people will have a different measurement in each arm. The arm that had the highest reading is the one subsequent blood pressure measurements should be taken on in the future.

• In order to avoid overinflating the cuff, the therapist

can palpate the radial pulse and inflate the cuff 30 mmhg above when the pulse was last palpaple. This can also be done by listening for the point in which the pulse is no longer audible as you incrementally inflate the cuff.

167

Standardized Technique

• If a patient has a PICC line in the upper arm, blood

pressure measurement should be avoided in that arm

• If patient has a dialysis shunt or AV fistula in the upper

arm, blood pressure should be taken in the opposite

• arm. This is to avoid blood clotting or possible trauma
• Blood pressure measurement should be taken in the
• pposite arm when a patient has had a mastectomy on
• ne side, although there is limited evidence that the

tourniquet effect of the blood pressure cuff can cause an increase in lymphedema.

168

Blood Pressure response to activity

• A normal response to activity is an increase of 10

mm hg of the systolic pressure for every 1 MET of

• activity. Light activity (leisurely walking,

standing/performing basic ADLs) is 3 METs. Moderate activity (walking at a brisk pace, heavy cleaning such as mopping, washing windows) is 6 METS, and vigorous activity (hiking, participation in sports, shoveling) is greater than 6 METs.

• MET levels in a particular patient is relative to that

patient’s current health status. A patient with severe COPD, heart failure may be working at a vigorous level while performing just basic ADLs. 169

Orthostatic Hypotension 62

• Defined as a 20 mm hg or greater drop in systolic

pressure or a 10 mm hg drop in diastolic pressure after going from lying to standing.

• Potential adverse event in older adults that can

contribute to fall risk. It occurs in 30% in population

• ver age of 70. 77
• Increased risk with use of alpha blockers and

combination alpha‐beta blockers with diuretics and nitrates

• Recent cohort study (2017) of 11,429 adults found that

assessing blood pressure within one minute of standing was most strongly related to dizziness and individual adverse outcomes. Recommendation per this study is to update the guidelines for OH to be assessed within the first minute after standing.

170

Lifestyle interventions Recommended by the JNC on Prevention, Detecting, evaluation, and treatment of high blood pressure 60

• Weight loss to manage obesity
• DASH diet Dietary Approaches to Stop

Hypertension (reduced sodium, increased potassium)

• Regular aerobic exercise
• Smoking cessation
• Limiting alcohol consumption
• Self measured BP monitoring

171

Therapeutic Interventions

• BP should be under control before

initiating an exercise program, especially when resistive exercises are involved

• Resting bp > 180/110 in an absolute

contraindication and >160/100 is a relative contraindication when performing resistance exercises

172

Therapeutic Interventions

• Monitor BP on a regular basis during

therapeutic interventions. Stop exercise if:

• Systolic bp fails to rise > 20 mm hg after

initiating exercise ***

• Systolic BP falls expectantly more than 10

mm hg

• Exercise related symptoms such as chest

discomfort, palpitations, lightheadedness, or shortness of breath are experienced by

• patient. These could be a sign of exercise‐

related distress

173

Therapeutic Interventions

• To avoid an exaggerated BP response to

exercise, warm up with a 5 to 10 minute period

• f light aerobic exercise before increasing

intensity

• Avoid heavy resistance with most older

patients, especially with patients with known history of osteoporosis

• Educate patient on Val Salva, instruct patient to

avoid Val Salva during exercise, this is especially important for patients with a history of

• rthostatic hypotension

174

Therapeutic Interventions

• Perform an extended cooling down period.

Avoid stopping exercise suddenly as this can cause patients to be at higher risk for

• rthostatic hypotension
• Cryotherapy can create an increase in BP due

to vasoconstriction, use caution with patients with hypertension and discontinue if patient has an increase in blood pressure with use

175

Aerobic Exercise Training

• Multiple studies have shown a reduction in resting

systolic and diastolic BP in patients participating in an aerobic exercise training program.

• Health education programs coupled with aerobic

exercise training programs have been shown to significantly reduce resting systolic BP

176

Resistance Training

• Resistance training should initially be coupled with

aerobic training in order to offset the increased arterial stiffness due to increased pulse wave velocity that has been reported with isolated resistance training 65

• Intensity in older adults should be light to moderate

to prevent an increase in arterial stiffness

• Resistance training may cause systolic BP to fall up to

10 mmhg during the first hour after a resistance exercise training session

177

Improving Adherence to Therapeutic Interventions

Identifying barriers to adherence, establishing programs that promote adherence, and designing patient education programs that promote adherence

178

Adherence

• Non adherence to health care recommendations is a

huge problem. It can not only be frustrating to therapist’s, but can impact a patient’s health in many

• ways. A primary reason for rehospitalization in heart

failure is non adherence to health care recommendations 67

• Health behavior change in patients with chronic

diseases is difficult. Compliance with recommendations is low, despite numerous benefits of increasing physically active and exercise

• Clinicians need to assess a patient’s perceived barriers

to change, as well as a patient’s readiness and willingness to change a behavior.

• Additionally, clinicians need to assess a patient’s health

literacy, and the extent to which a patient understands the information the clinician is providing them. Tools are available to assess health literacy, and the “teach back” process is useful in determining patient understanding

179

Improving Adherence with Depression

• As many as 50% of patients with a chronic illness suffer from

depression, so screening for depression is an important part

• f therapy treatment. This can be completed utilizing scales

such as the PHQ‐9, with all members of the health care team aware of the results of the depression screening.

• Studies have shown that there is a correlation between

symptoms of depression and decreased self care activities such as exercise adherence. Patients who exhibit symptoms

• f depression will require additional support to promote

exercise adherence

• Make therapy relevant to patient’s work, family, hobbies,

ability to live independently, reduce pain, increase level of independence, and maintain mobility.

• Educate patient on benefits of physical activity to improve

depressive symptoms

180

Assessing Health Literacy

• Factors that may negatively impact a

patient’s health literacy include fewer years

• f schooling, old age, and greater number of

years living with chronic illness 68

• Patients with low health literacy have a

higher rate of diabetes, hypertension, depressive symptoms, and physical

• limitations. Older adults with low health

literacy also have a higher incidence of heart failure 69

181

Transtheoretical Model (TTM)of Health Behavior Change 71

• Gives clinicians a model to assess a patient’s

willingness to change a health behavior and provides strategies to help patients to change health behaviors.

• TTM allows clinicians to match interventions with

the stage of change a patient is currently

• experiencing. TTM has been shown to improve

patient adherence by targeting interventions to a patient’s stage of change rather than mismatching interventions to a patient’s current stage of change.

• 4 main constructs: stages of change, self‐efficacy,

decisional balance, and processes of change

182

Stages of Change

• Stages of change. Outlines the stages of change in a 5

stage process. Stages can be linear, however, most of the time the stages are cyclical with patients often reverting to previous stages before the change becomes stable.

• First stage is precontemplation. These patients are not

physically active and are not considering becoming physically active.

• Contemplation. These patients are not physically

active, but are contemplating becoming physically active within the next 6 months.

• Preparation. These patients are irregularly active, and

intend to become physically active in the immediate future

• Action. These patients have been physically active for

a period of 6 months

• Maintenance. These patients have been physically

active for a period greater than 6 months

183

Assessing a patient’s stage of change

• Note instances of non‐adherence during history taking, or

through observation of patient’s living environment (if applicable) or in patient’s medical history.

• Use a 0 to 10 scale. Ask the patient, how willing are you to

change (i.e. become more physically active), with 0 equal to not at all willing to 10 equal to willing to change right now.

• If response is 7 or more, the patient is ready to act and is in
• ne of the later stages of change
• If response is 4 to 6, patient may be in the contemplation
• stage. Help the patient to weigh the pros and cons of

change

• If response is 1 to 3, patient may not be ready to change and

may be in the pre contemplation stage. Tailored patient education should be a primary intervention at this stage 184

Self‐efficacy

• Self efficacy is the extent to which an individual

believes they are capable of carrying out a behavioral change

• Many studies have found that self‐efficacy is the most

important factor in health behavior change

• Patients need to be provided with physical activity

experiences in which they are able to succeed. However, avoid making activities too easy in which there isn’t any challenge.

• Train patients on setting realistic, but moderately

challenging goals. Achieving goals helps to increase self‐efficacy. Additionally, if a patient is overly

• ptimistic with his or her goals, it can lead to

disappoint when the goal is not achieved and lead to non adherence

• Discuss perceived barriers to adherence and possible

solutions to overcoming barriers

185

Identifying Barriers to Adherence

• A patient’s current level of self‐efficacy is related to

his or her perceived barriers to adherence. If a patient does not believe they have the ability to change his or her behavior due to a perceived (or actual) barrier, then behavior change is not likely

• Common barriers to adherence
• Socioeconomic challenges
• lack of access to health care
• lack of transportation to medical appointments
• low health literacy
• conflicting medical information given to patients

from different health care providers

• psychosocial comorbidities

186

Decisional Balance

• This reflects the individuals process of weighing the pros

and cons of behavior change. A patient’s health literacy and perceived/actual barriers to adherence are an integral part of the process of decisional balance

• The idea behind decisional balance is a patient will initiate

a change (i.e. become more physically active) if the perceived pros of a change (participating in an exercise program) outweigh the costs (barriers) of initiating the change (exercising)

• Patients in the contemplation and precontemplation

stages of change perceive more barriers (cons) to change than benefits (pros) of changing

• The cross‐over point, or balance point, in which a patient

perceives more pros than cons to behavior change occurs in the preparation stage

187

Strategies to help patients move through the decisional balance stage

• Patient education is a key PROCESS during this
• stage. It is a process, and not simply telling a

patient he or she needs to change. Education should be tailored to patient centered goals.

• Providing patient with educational material
• utlining benefits of physical activity may be

beneficial

• Work with patient on creating a “pros and cons”
• list. Writing a list versus just discussing a list

has been shown to be more effective

188

Creating a Pros and Cons list with your patient

• Using a note card, ask the patient to write down

benefits of becoming more physically active.

• Ask the patient to leave the note card in a place that

can be reviewed several times a day.

• If the patient is unable to write down 3 to 5 reasons

(assessing health literacy), educate the patient.

• Identify what is important to the patient (patient‐

centered goals), and tailor education to allow patient to see how that goal can be enhanced by therapy interventions.

• Work with your patient to determine if barriers are

actual or perceived. If you perceive a strong enough benefit (pro), the barriers to change can be dissolved.

189

Processes of Change

• Strategies and processes used to support efforts to

progress through the stages of change

• Strategies and processes used vary based on the

stage of change a patient is in.

• According to the TTM, there are 10 distinct

processes a patient goes through when making a health behavior change that are internally focused

• n emotions, values, and cognition. There are 5

cognitive processes, and 5 behavioral processes.

• In general, patients in the earlier stages of change

tend to place greater emphasis on cognitive processes, and patients in the later stages place greater emphasis on behavioral processes.

190

Cognitive Processes of Change

Cognitive Processes Consciousness Raising Seeking new information about exercise Dramatic Relief Experience and express intense feelings about being inactive Environmental Re‐evaluation Assess how being inactive affects physical and social environment Self re‐ evaluation Re‐appraise values about inactivity Social‐ liberation Develops awareness and acceptance of active lifestyle

191

Behavioral Processes of change

Behavioral Processes Counter Conditioning Substitute alternate behaviors for sedentary

• nes

Helping relationships Use support from others to be more active Reinforcement management Changes contingencies, reward physical activity Self‐liberation Choose and commit to being more active; believe that change is possible Stimulus control Controls situations and cues that support inactivity

192

What we can do to help a patient through the process of change

• Education is not limited to a single session of therapy.

Education is an ongoing process that involves the input

• f the patient.
• Help patient by discussing barriers to adherence, and

problem solve with patients on how to help remove these barriers. 72

• Step 1: describe the barrier to exercise
• Step 2: help the patient to brainstorm a possible solution
• Step 3: ask the patient to list the pros and cons of each

possible solution

• Step 4: patient should choose the best option to be

implemented for a certain amount of time

• Step 5: evaluate the results. If the option didn’t work,

the process should be repeated

193

Helping a patient through the process of change

• Involve significant people in patient’s life. Educate

family and caregivers on providing positive reinforcement to patients, avoid negative

• reinforcement. Involve family members in exercise

program.

• Clinicians should demonstrate unconditional

acceptance of the patient’s behaviors. Watch your non verbal communication, as well as verbal communication.

• Partner with your patient, display empathy and avoid

judging a patient’s behavior (or avoid obvious signs of judgment).

• Become more coach‐like, and less expert‐like.

194

Improving Adherence

• A study published in the Journal Of Geriatric PT in

2016 assessed the impact of weekly telephone calls placed after discharge to patients in balance program 73

• Phone calls were made by support staff, not the

treating therapist

• Each telephone call lasted approximately 15

minutes and included a list of standardized questions

• Patients were encouraged to comply with home

exercise program during telephone call intervention

195

Questions that were asked

• Are you doing your exercises as suggested? If

not, what changes have you made to the exercises and why?

• Are you having any difficulty with the exercises?
• Are you keeping your exercise log as requested?
• Have you had any falls this week? Any near

falls?

• We want to encourage you to keep up with your

exercise program. I will be calling you each week to check on your progress and to see if you need any assistance

196

Results of their study

• Both groups were assessed with the Berg Balance

Scale at 4 weeks, 8 weeks, and 12 weeks after discharge

• Both groups showed the same amount of

improvement in the Berg Balance Scale score at the 4 week mark, but the no telephone call group plateaued at this point while the telephone call group continued to improve

• At the end of the 12 week period, the telephone

group showed a clinically meaningful improvement in Berg Balance Scale score (6.3 points) while the no telephone call group did not (3.9 points)

197

Exercise Study

• Researchers in Australia examined the results of

participation in the “Lift for Life” program. Program consisted of two supervised, 45 to 60 minute programs and one unsupervised program each week for a period of 8 weeks. Participants also received counseling at the 2 month, 4 month, and 6th month time point on overcoming physical barriers to exercise. Participants in program demonstrated greater improvements in HbA1c at 12 months compared to a standard exercise program 74

198

Final Thoughts

• Know your patient’s history. Take the time to

review patient’s medical history prior to performing treatments

• Monitor your patient’s vital signs. Repeat vital sign

measurements as necessary during treatment.

• Know your facilities vital sign parameters and any

patient‐specific parameters established by the physician

• Contact the patient’s physician as needed when the

response to therapy isn’t as expected.

• Know your patient’s current medication list. This

has a huge impact on your therapy treatments.

199

Final Thoughts

• Patients with multiple chronic conditions are

quickly becoming the norm in therapy treatment. Having an understanding of the patient’s medical condition will help guide your therapeutic interventions.

• You are a valuable asset to your patients, their

families, their physicians, and the organization for which you work. You are on the front lines, challenging your patient’s functional status on a significant level, and you may be the first to catch an adverse reaction to a medication or a treatment. Your actions may help to prevent a hospitalization

• r decline in medical status.

200