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December 2002


Soothing Hands

By Cynthia Cooper, MFA, MA, OTR/L, CHT


Older people are living longer. In 2010, 56 million Americans will be at least 60, and 6 million will be at least 85.1 The population growing most rapidly consists of people who are over 85. Thus, hand therapists will be treating larger numbers of geriatric patients. While it may take longer to treat some elderly patients effectively, adjusting treatment to meet their needs will maximize clinical effectiveness.2

PAIN AND DEPRESSION

Pain is a very common problem among the elderly and it profoundly affects their quality of life and ability to function. Musculoskeletal causes, especially osteoarthritis, are the most common.3 Pain is common with diseases associated with aging, such as neuromuscular problems and cancer, and can contribute to depression, sleep disturbance, limited socialization, and problems with ambulation. It can lead to deconditioning, falls, and polypharmacy.

Depression is the most common functional disorder among the elderly and it affects up to 25% of this population. Signs of depression can be vague but might include apathy, fatigue, self-neglect, weight loss, social withdrawal, sleep disturbance, decreased involvement in activities, and hopelessness.4 Because pain contributes to depression, hand patients who are in pain may be at risk of becoming depressed. Because physical activity has associated psychological benefits, every effort should be made to restore patients’ preinjury levels of physical activity.

HEALING AND MUSCLE STRENGTH

Older people are more vulnerable to injury and are slower to heal after minimal trauma.5,6 Soft tissue changes may include loss of dermal thickness, and less contact of and decreased adherence between the dermis and epidermis. Animal models have demonstrated reduced cellular proliferation, altered wound metabolism, and altered collagen remodeling. Dryness and loss of skin turgor are associated with aging, as are lower strength of incisional wounds and higher dehiscence rates.6 Skin tears occur most frequently in the forearms of elderly people.

Concomitant medical conditions that are seen more often in the elderly can also slow the healing process. These include vascular disease, steroid use, or cardiopulmonary disease.6 Even slight mechanical traumas that may happen with dressing changes can cause injury due to skin vulnerability. Splint edges should be monitored closely to protect fragile older skin. Guidelines for skin checking should be very conservative.

Muscle strength can decrease by 15% per decade from age 50 to age 70, and decreases further by 30% from age 70 to age 80. By the age of 80, people may have lost about half of their motor units, motor neurons, muscle fibers, muscle strength, and muscle mass.5,7 Age-related hand atrophy primarily affects the interosseous and thenar muscles, which explains the reduction of grip strength observed with aging.

Immobilization itself has significant negative effects on skeletal muscle, causing shortened muscle length, segmental necrosis at muscle fiber ends, and myofibril contracture, and may contribute to partial denervation or atrophy.8 The good news is that clinical studies show elderly patients’ hand muscles can be strengthened by training.9

SENSIBILITY AND PHYSIOLOGIC STATUS

The severity of sensory deterioration in tactile acuity may vary among patients. Individual differences may be related to changes in circulation, thinning of receptors, or age-related disease or trauma.10 Therefore, adult norms should not be applied to an elderly population.11

Sensory changes may make it difficult to manipulate splint straps. In such situations, treatment suggestions are to keep dexterity demands to a minimum, and to simplify strapping on splints. Secure one end of each strap to the splint, use colors to code the ends of straps, and put visual marks where straps should meet.

The sensorimotor skills used least frequently are the ones most affected by age. Older patients may be slower in many behaviors, and this can be challenging to a therapist who may have a busy schedule.12 The elderly may have difficulty ignoring irrelevant stimuli. Therapists should make an extra effort to establish a good rapport with their older patients and should try to convey information in stress-relieving ways. Treatment suggestions are to allow extra time to treat patients, to avoid interruptions, and to try not to rush elderly patients.

Most people who are 65 or older have at least one chronic condition.1 Neurologic problems are the most common cause of reduced function in the elderly; 49% have arthritis; 37% have hypertension; 32% have hearing impairments; 30% have heart disease; 17% have cataracts; 17% have sinusitis; 16% have orthopedic problems; 9% have visual impairment; and 9% have diabetes.1

Arthritis, hearing loss, and hypertension are among the most prevalent chronic conditions of the elderly. Hearing loss affects about 40% of people over 75, resulting in communication barriers that dramatically impact their quality of life.13 Changes in temporal organization associated with aging can disturb the sleep-wake cycle and this can be extremely problematic.14

Osteoarthritis is the most common arthritic condition occurring in older people, and most elderly people display radio- graphic evidence of osteoarthritis. Rheumatoid arthritis is a very debilitating diagnosis that affects two to three times more females than males, and the frequency increases for people over 65 years of age.15 More than 90% of people who do have rheumatoid arthritis have clinical involvement of their hands.16

Osteoporosis is the cause of more than 1 million fractures yearly. It affects one third to one half of all postmenopausal women. There is a 40% chance that a woman will have an osteoporotic fracture after the age of 50.17

Some treatment suggestions are to schedule treatment at a time that is best for the patient, avoid shouting, and ask if the patient can see well. If so, use visual aids.

COGNITION AND ALZHEIMER’S DISEASE

Cognitive declines typically associated with normal aging tend to be minimal. Elderly adults frequently comment on their memory loss, and this generally includes losing items and forgetting names or everyday events. They may be slower to learn in unfamiliar situations or to process new information. However, they may respond well to suggestions of adaptive strategies including appointment books or reminder notes. Short-term memory is likely to be worse if the content seems irrelevant to the patient.

In these cases, one treatment suggestion is to simplify the numbers of exercises, splints, and home instructions for patients. Physical practice with simultaneous writing and verbalizing of instructions may also enhance learning.

Alzheimer’s disease is the most common cause of dementia, and aging itself is the highest indicator for Alzheimer’s disease to occur. Cardiovascular accident is the second most common cause.18

The disease may occur in 3% of those 65 to 74, in 19% of those 75 to 84, and in 47% of people 85 and older. Approximately 50% of 90-year-olds are clinically demented. Factors that may quicken the onset of dementia include drugs, nutrition, and cardiovascular disease.19

In the case of cognitive impairment, some treatment suggestions are to avoid using baby talk or calling the patient “sweetie” or “honey.” Speak in simple sentences and convey only one piece of information with each sentence. If the patient has memory problems, focus their home program on activities of daily living, and, if need be, recruit the assistance of a more patient colleague.

CONCLUSION The efficacy of therapists can be challenged by the unique problems posed by some older hand patients. Despite this, it is essential for therapists to reinforce their dignity. Using strategies such as those presented here may promote successful clinical results with older patients, resulting in an increased sense of competence for patients, as well as for therapists.

Cynthia Cooper, MFA, MA, OTR/L, CHT, is clinical research coordinator for occupational and physical therapy at Mayo Clinic Hospital, Phoenix, and an assistant professor of physical medicine and rehabilitation at Mayo Medical School in Rochester, Minn.

REFERENCES
  2. Champlin L. “Eldercare” goal: integrate health, social needs. Geriatrics. 1991;46(8):67-70.
  3. Cooper C. The geriatric hand patient: special treatment considerations. In: Mackin EJ, Callahan AD, Skirven T, Schneider LH, Osterman AL, eds. Rehabilitation of the Hand and Upper Extremity. St Louis: Mosby; 2002:1949-1958.
  4. Ferrell BA. Pain management in elderly people. J Am Geriatr Soc. 1991;39:64-73.
  5. Moore KA, Babyak MA, Wood CE, et al. The association between physical activity and depression in older depressed adults. Journal of Aging and Physical Activity. 1999;6:55-61.
  6. Buckwalter JA, Woo SLY, Goldberg VM, et al. Current concepts review: soft-tissue aging and musculoskeletal function. J Bone Joint Surg Am. 1993;75:1533-1548.
  7. Gerstein AD, Phillips TJ, Rogers GS, Gilchrest BA. Wound healing and aging. Dermatol Clin. 1993;11:749-757.
  8. Booth FW, Weeden SH, Tseng BS. Effect of aging on human skeletal muscle and motor function. Med Sci Sports Exerc. 1994;26:556-560.
  9. Gordon T, Pattullo MC. Plasticity of muscle fiber and motor unit types. Exerc Sport Sci Rev. 1993;21:331-362.
  10. Keen DA, Yue GH, Enoka RM. Training-related enhancement in the control of motor output in elderly humans. J Appl Physiol. 1994;77:2648-2658.
  11. Stevens JC, Cruz LA. Spatial acuity of touch: ubiquitous decline with aging revealed by repeated threshold testing. Somatosens Mot Res. 1996;13(1):1-10.
  12. Desrosiers J, Hebert R, Bravo G, Dutil E. Hand sensibility of healthy older people. J Am Geriatr Soc. 1996;44:974-978.
  13. Cooper C. Maximizing therapist effectiveness with geriatric hand patients. J Hand Ther. 1993;6:205-208.
  14. Keller BK, Morton JL, Thomas VS, Potter JF. The effect of visual and hearing impairments on functional status. J Am Geriatr Soc. 1999;47:1319-1325.
  15. Reynolds CF, Jennings R, Hoch CC, et al. Daytime sleepiness in the healthy “old old”: a comparison with young adults. J Am Geriatr Soc. 1991;39:957-962.
  16. Nesher G, Moore TL, Zuckner J. Rheumatoid arthritis in the elderly. J Am Geriatr Soc. 1991;39:284-294.
  17. Dellhag B, Burckhardt CS. Predictors of hand function in patients with rheumatoid arthritis. Arthritis Care and Research. 1996;8(1):16-20.
  18. Licata AA. Therapies for symptomatic primary osteoporosis. Geriatrics. 1991;46(11):62-67.
  19. Mungas D. In-office mental status testing: a practical guide. Geriatrics. 1991;46(7):4-66.
  20. Goodwin JS. Geriatric ideology: the myth of the myth of senility. J Am Geriatr Soc. 1991;39:627-631.

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