Disability – CGS 2011 & NICE

1  Determine whether a specific decline in functioning (e.g., social, physical, emotional) is a disability for that specific patient.

  • Impairment: any loss or abnormality of psychological, physiological, or anatomical structure or function
  • Disability: any restriction or lack of ability to perform an activity within the range considered normal for a human being
  • Handicap: the disadvantage for an individual arising due to impairment and disability
    • Limits or prevents the fulfillment of an individual’s normal role as determined by society and depends on age, sex, social, and cultural factors
    • Changes the individual’s relationship with the physical and social environment

2  Screen elderly patients for disability risks (e.g., falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.

According to Canadian research, five types of chronic illness contribute largely to disability in people aged over 65 years:

  • Foot problems
  • Arthritis
  • Cognitive impairment
  • Heart problems
  • Vision

Other common or important problems are:

In frail elderly people, a marked decline in physical and mental function can result from apparently small insults. This has been called the “domino” effect, with a small initial insult leading to a cascade of adverse events.

Main risk factors for functional disability in elderly people in the community were:
  • lack of schooling, rented housing, chronic diseases, arthritis
  • chronic diseases, arthritis, diabetes,visual impairment, obesity,
  • poor self-perceived health, cognitive impairment, depression,
  • slow gait, sedentary lifestyle, tiredness while performing daily activities, and
  • limited diversity in social relations.

3  In patients with chronic physical problems (e.g., arthritis, multiple sclerosis) or mental problems (e.g., depression), assess for and diagnose disability when it is present.

The World Health Organization has defined disability as the following:

“Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus disability is a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in which he or she lives.”

Section 10 (1) of the Code defines “disability” as follows:
“because of disability” means for the reason that the person has or has had, or is believed to have or have had,

  1. any degree of physical disability, infirmity, malformation or disfigurement that is caused by bodily injury, birth defect or illness and, without limiting the generality of the foregoing, includes diabetes mellitus, epilepsy, a brain injury, any degree of paralysis, amputation, lack of physical co-ordination, blindness or visual impediment, deafness or hearing impediment, muteness or speech impediment, or physical reliance on a guide dog or other animal or on a wheelchair or other remedial appliance or device,
  2. a condition of mental impairment or a developmental disability,
  3. a learning disability, or a dysfunction in one or more of the processes involved in understanding or using symbols or spoken language,
  4. a mental disorder, or
  5. an injury or disability for which benefits were claimed or received under the insurance plan established under theWorkplace Safety and Insurance Act, 1997

4  In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).

Assessment of a frail or disabled person requires evaluation of:
  • The damaged system.
  • Other body systems.
  • Medication – including polypharmacy.
  • Communication.
  • Cognition/mood.
  • Function (such as ability to perform daily living activities):
    • Activities of daily living (ADLs) – eating/dressing/toileting/mobility.
    • Instrumental activities of daily living (IADLs) – dealing with medication/finances/housework/transportation.
  • Environment – both the immediate environment (clothes and housing) and the locality (shops and social facilities).
  • Formal and informal supports.
  • Social and economic welfare.

Assessment by a specialist geriatrician and/or a multidisciplinary team specialising in elderly care can be useful.

A marked decline in function can be due to relatively small physiological insults, which may result in a frail older person being wrongly labelled as “unable to cope”. Bear in mind that early comprehensive geriatric assessment and appropriate treatment may enable such patients to regain lost function.


 Comprehensive Geriatric assessment:- read more in the Elderly post
  • Memory: MCI vs dementia – MMSE / MOCA
    • BPSD (Behavioural and Psychological Symptoms of Dementia)- SMART approach
    • Safety – remove patient to safe environment
    • Medical – perform an organic workup to treat reversible causes; reduce medication load
    • Assess competency – decisions regarding personal care, finances, driving; protect assets
    • Rest, nutrition, hydration ensured; address problems with pain, ambulation, vision, hearing, constipation
    • Trial of medication – cholinesterase inhibitor/antipsychotic/antidepressant/ mood stabilizer
  • Mood – Depression (MSIGECAPS) – PHQ-9 or geriatric depression scale
  • Appetite & wt loss inquiries – Cancer screening
  • Bowel and bladder functions – incontinence is common in geriatrics
  • Falls, vision, hearing, postural HoTN, vertigo
  • Meds – prevent polypharmacy
  • Social Hx: Born, Education, Job
    • ADLs and IADLs
    • supports, POA, advance directives

5  For disabled patients, offer a multi-faceted approach (e.g., orthotics, lifestyle modification, time off work, community support ) to minimize the impact of the disability and prevent further functional deterioration.

Important aspects of management are:

  • Treatment of unstable medical conditions and any treatable problems contributing to the disability.
  • Reviewing drug treatment (including polypharmacy).
  • Early mobilisation.
  • Nutritional support.
  • Comprehensive rehabilitation.

Who should be involved in management?

  • A multidisciplinary approach can be helpful. This has been shown to be beneficial, eg following stroke and fractured neck of femur. Geriatric day hospitals have been shown to be beneficial in providing care to elderly people with functional decline, although a Cochrane review found they may not have any clear advantage over other forms of comprehensive elderly medical services.
  • “Hospital at home” schemes have also been devised, although a Cochrane review found little evidence that they improved functional ability.
  • “Case management” by community matrons is a recent development in the care of elderly patients and those with long-term conditions. A recent review of this strategy concluded that this provision is at an early stage of development, and needs to develop effective links with a range of local services. The financial viability of this service is not clear.

6  In patients at risk for disability (e.g., those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (e.g., exercises, braces, counselling, work modification).

Prevention

The National Service Framework states that there is strong evidence of benefit to older people from:

  • Increasing physical activity.
  • Improved diet and nutrition.
  • Immunisation and management programmes for influenza.
Exercise

Adapted exercise is beneficial for strength, mobility and balance, and may reduce the risk of falls. This applies even to frail older people. Indirectly, physical activity may also increase wellbeing, social activity and mental health.

Evidence on the role of exercise in preventing disability
  • physical exercise interventions reported positive outcomes for disability
  • physical activity can protect against the risk of hip fracture among community-dwelling older adults.
    • This may be via increased levels of vitamin D, or through the improvement of bone quality.
  • a single question about a fall in the previous year is a method of identifying those who will benefit most.
    • middle-aged and elderly people who are sedentary could be invited to participate in lifestyle interventions including a prescription for exercise.
How much exercise?
  • The goal is to work towards 30 minutes of at least moderate-intensity physical activity on at least five days of the week.
  • Two 15-minute periods of moderate activity daily may be a good way to start. If that is too much, take a ‘little and often’ approach, advising a gradual increase starting with just three minutes.
  • The ideal is a combination of endurance exercises, strength exercises and stretching/balance/co-ordination exercises.
  • It is never too late to start, and any activity is better than none.
  • Adequate warm-up is important, and safe exercises/movement patterns should be chosen.
Nutrition
  • Elderly people have relatively more body fat and less lean body mass, resulting in lower metabolic rates.
    • Therefore, calorie needs are reduced, so the diet needs proportionately more protein, essential fats and micronutrients.
    • Improving nutritional status (adequate calories and protein) can help to reduce sarcopenia and frailty in the elderly.
  • Avoiding obesity is also beneficial.
  • Aim to meet minimum nutritional requirements, provide adequate dietary fibre, and address specific disease risks such as cardiovascular disease, stroke, diabetes and osteoporosis.
  • Vitamin D may help prevent muscle weakness, falls and fractures, but adequate doses must be used.
  • Oral health and provision of dental treatment are important.
  • Hospital nutrition – Age UK has campaigned for greater awareness of the problem of malnutrition in hospitalised elderly patients. Practical steps have been suggested, eg a ‘red tray’ system to indicate which patients need assistance at mealtimes.
  • Folic acid ± vitamin B12 has been suggested as possibly benefiting cognitive function in elderly people. However, a Cochrane review concluded that there is no consistent evidence either way, and more research is needed.

Fall Prevention

(Timed) Get-up-and-Go Test (for mobility and falls assessment):
  • Person stands from a seated position and walks a distance of 3m (10 ft), turns, and walks back to the chair and sits down.
  • < 10 sec is mobile, no impairment
  • > 30 sec is significant impairment
NICE has identified four interventions with evidence-based effectiveness:
  • Strength and balance training.
  • Home hazard intervention and follow-up.
  • Medication review.
  • Cardiac pacing where indicated.
Methods deemed ineffective or with an equivocal evidence base include:
  • Brisk walking (may be hazardous in postmenopausal women).
  • Low-intensity exercise combined with continence training.
  • Cognitive and behavioural interventions.
  • Referral for visual disturbance (but should not be discouraged on grounds of good practice).
  • Vitamin D (may help to improve bone strength and risk of falling but uncertainty over contribution that it makes to fracture reduction means NICE refrains from making a firm recommendation at the moment).
  • Hip protectors (equivocal results in trials).
Provision of aids and appliances
  • OT and the provision of aids can improve the quality of life.
    • Home adjustments such as grip rails, stair lifts and removal of dangers such as loose carpets or inappropriate footwear can be helpful.
  • Aids should be used to make the most of impaired vision or hearing.
    • Glasses, low vision aids such as magnifying glasses, large-print materials, talking clocks and watches, telephones with large numbers, audio books, safety measures, such as raised-dot dials on kitchen equipment, may all be helpful.
    • Hearing aids can greatly improve quality of life.
  • Adapted safety devices may be needed (eg flashing light on telephone or smoke alarm).
Treat contributing causes

Do not assume that age-related disability is untreatable. Look for and treat contributing problems (where feasible), such as:

  • Uncontrolled cardiac, respiratory or metabolic disease, eg heart failure, hypothyroidism.
  • Reversible causes of hearing loss, eg wax.
  • Potentially treatable neurological disease, eg tumours.

7  Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan).

Social and environmental interventions – These may reduce the impact of the disability – for example:
  • Financial support – eg access to benefits and grants.
  • Social support – eg day centres, social activities and befriending.
  • Housing support – appropriate accommodation can support independence and increase functional ability.
Pain management
  • Persistent pain in elderly patients is not simply a chronologically older version of younger pain. They suggest that interventions such as a ‘mindfulness-based stress reduction programme’ can be helpful.
  • Appropriate exercise can be part of pain management in some conditions, eg osteoarthritis.

References:

For Disabled Patients: (the key is a multi-faceted approach)

Conservative:

  • Those who are employed will need time off work.
  • Impaired mood will need counseling (eg CBT) and community programs.
  • Pain will need to be controlled using the WHO Pain Ladder
  • Mobility needs to include orthotic, walker, or wheelchair (O/T)
  • Appropriate exercises to prevent further decline (P/T)

Non-conservative:

  • Medications, injections, dialysis etc
  • Surgery, ECT

For at risk for disability:
(targeted preventative maneuvers are not as effective as multi-faceted approaches)

  • Influenza and Pneumococcal Vaccine for seniors
  • Reducing or eliminating offending medications
  • Improving visual acuity
  • Improving footwear, or referral to podiatry
  • Use of adaptive devices, such as arm supports, protective rails, walking aids
  • Balance exercises, coupled with moderate physical activities -> careful with recommending too much physical activity as this may increase the risk for disability); Core stabilization.
  • Socialization
  • Hip protectors for the frail elderly -> but best to avoid the fall, rather than the impact of the fall
  • Improve the home environment: better lighting, fixing damaged floors, etc.
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Posted in 28 Disability, 99 Priority Topics, FM 99 priority topics, Others

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