A Good Enough Daughter:
Caring for Your Elderly Parent While Taking Care of Yourself Copyright © Gwynne E. Morgan 1 May 2008
Chapter III: Falls & Fitness in the Elderly
It’s a Tuesday morning at the Hebrew Rehabilitation Center in Boston, MA and Mina Gold, dressed in a flowered jersey warm up suit, is seated on an exercise machine, flexing and straightening her legs against weighted resistance, keeping the soles of her feet perpendicular to the ceiling. Gold, is working on the hamstring muscles at the back of her thighs, as part of an exercise regimen to increase strength, balance and mobility in her upper and lower extremities. Nearby, the exercise physiologist checks her posture, and occasionally adjusts the machine, adding resistance pound by pound.
The only unusual aspect of this scene is that Mina Gold is 95 years old. She is working out, as she does three times a week, as a part of the ten year old “Circle of Fitness” program at the Hebrew Rehabilitation Center, a Boston nursing home and rehabilitation affiliate of Harvard Medical School’s department of geriatric medicine. The program is designed to build strength and restore balance and flexibility to frail elderly residents at this residential facility. That’s right, build and restore. Hebrew Rehab and Harvard are part of a rising tide of researchers, gerontologists, nutritionists and exercise physiologists who maintain that proper exercise and nutrition, including vitamin supplements, can go far to prevent falls and frailty in the elderly population and help many frail elders regain strength, balance and mobility.
Certainly, Mina Gold is a believer. She says she, her adult son and daughter have all noticed that her balance and walking have improved since she began the fitness program. Gold came to live at Hebrew Rehab a year ago after a bad fall in her Connecticut apartment led to hospitalization and stays in a rehabilitation facility and a nursing home. The fall had occurred in the most mundane circumstances: bending to pick up her purse where it lay on the floor, she had lost her balance and toppled over, landing on her forehead.
Gold, who is legally blind, says that she is slowly regaining her confidence and learning to find her way without fear since she began her exercise regimen. This morning she will spend about an hour in the gym, first warming up for 15 minutes on the NuStep recumbent stepper, a bike-like machine which is slightly reclined to take pressure off the spine, and then moving along the specially-designed Keiser resistance machines --leg-press, chest press, knee and leg extension equipment-- as well as machines which strengthen the upper and lower back, all under the watchful eye of Maureen Connerty, the exercise physiologist.
Connerty explains that the specialized Keiser exercise equipment, developed in response to research done by “Circle of Fitness" founder Dr. Maria F. Singh, allows the professional staff to increase resistance in more manageable increments than on machines found in local fitness clubs. “That means that frail seniors get a good work out and experience success without injuring themselves. Mina is one of our best clients, and has been able to substantially increase her strength and resistance. I can see her confidence grow as her strength and balance improve.”
The importance of such an exercise regimen for our elderly parents has become increasingly clear. A spate of studies, conducted over the past three decades by geriatricians and researchers around the globe, points to a common conclusion: When old people fall down, they do more than break bones; they begin to die. Falls are frequently fatal to the old, and represent horrendous health care costs to the systems that treat them if they live. Even for those who survive a fall, the accident usually represents a turning point, after which the quality of their lives deteriorates dramatically, both physically and psychologically.
The impact of falls on the elderly population is not news. A decade ago, researchers at Washington University School of Medicine noted that about one-third of people over age 65 fall at least once a year and that in about 10 to 15 percent of the cases, these falls result in injuries such as fractures of the hip or other bones.
Of the elderly who break a hip during a fall—one of the most common injuries—one-quarter die within the year. Three out of four of the fallen never recover the quality of life they had before the fall, according to the U.S. National Safety Council. The 12 million elderly Americans who fall down every year result in 10,000 fall-related deaths and about $20 billion in medical costs.
Not quantified are the psychological costs, including loss of confidence, withdrawal, depression and a host of physical maladies associated with inactivity. Sometimes it is not the fall itself that does the damage, but rather the mindset created by the fall. People who have fallen fear that they will fall again and rein in their activity in response to that fear. Ironically, it is not their motion, but their lack of motion, that leads to further physical deterioration.
“Use it or lose it.” “Prepare rather than repair.” We all know that we need to exercise. All the catch phrases point to the truism that consistent exercise impacts how long and how well we will live. And yet studies show that about one-third of all American adults participate in no form of physical exercise. Not surprisingly, the prevalence of inactivity is greatest among the old.
Researchers now believe that regular exercise can help to prevent falls, and can begin at any age, even by the so-called “old elderly,” those above the age of 85. Of course, being physically prepared for a healthy old age is the best bet.
We’ve been hearing for years that exercise helps people live longer. Recently, there’s been an effort to quantify how much longer an exercising elder can live. Late in 2005, using data from the Framingham (MA) Heart Study, which has followed more than 50,000 Bay State residents for 46 years, researchers determined that higher levels of physical activity added one to three years to life expectancy—regardless of age, gender or other existing health problems. Moderate to highly active persons also lived more years without cardiovascular disease, so that presumably their quality of life was better.
“The role that physical activity plays in cardiovascular risk management should be emphasized to achieve a worldwide implementation of an active pattern of life,” the researchers concluded. “Our study suggests that following an active lifestyle is an effective way to achieve healthy aging.”
There is evidence that regular exercise benefits the mind as well as the body. Swedish researchers reported in early 2006 that exercising in middle age not only keeps weight down and hearts healthy but can also cut the risk of developing Alzheimer’s disease, the most common form of dementia in the elderly, particularly in high risk persons. People in mid-life who exercised at least twice a week had about a 60 percent lower risk of suffering from dementia than more sedentary people.
Scientists at Sweden’s Karolinska Institute’s Aging Research Center tracked the mental health people between the ages of 65-79 whose leisure activities were monitored for fifteen years. They discovered that the active group, who participated in physical activity like walking or bicycling that caused sweating and strained breathing, was less likely to suffer from Alzheimer’s.
Given these findings, researchers suggest that the huge financial investment expended on treating fallen elders could be better spent on preventive measures such as encouraging t older people to take weight-bearing, and other exercise. and in providing post-fall care. “Ensuring older people are not discharged too early from the hospital and (that they) get the care and support they need at home are crucial steps that could reduce (fall) risk,” British researcher Paul Scuffman wrote in the Journal of Epidemiology and Community Health.
The story of Merton Bergman, a strapping 6 ‘ retired salesman, who shares the gym with Mrs. Gold on a recent morning, underscores the vital roles of regular exercise and professional oversight in fall recovery and confidence-building. Today, Bergman, 88, is gleeful to be back on the Hebrew Rehabilitation Center’s recumbent exercise bike after a hiatus of five weeks for back spasms. He is displeased that the interruption in his regimen has left him with tightness in his thighs and irritating balance issues. “I feel like I’ve definitely lost some ground.”
That Bergman is here at all is nothing short of miraculous and a tribute to both his own indomitable spirit and new exercise technology. Following a fall in October 2003, he spent 22 months in several Boston-area hospitals and convalescent centers, enduring spinal surgery, drug reactions, hallucinations and an infection that nearly ended his life.
Bergmann’s medical sojourn began in much the same way that many elderly begin their downhill slide—with a fall. A recent widower, living alone in his Newton, MA home, Bergman “tried to be smart,” climbing the stairs with both hands full, failing to hold on to the railing. He fell backwards down the steps, landing on his spine. Shaken, but with nothing apparently broken, he did not seek medical treatment but went on with his daily tasks. Six weeks after the fall, Bergmann began experiencing “twinges” in his lower back, usually in the evenings. His daughter, Nancy Bergman Temkin, stopped by one evening and found him struggling to get out of his chair. He was hospitalized and the pain increased, requiring morphine. While in the hospital, he fell several times. Bergman’s geriatrician suggested an MRI, a magnetic resonance imaging or picture of the spine. The news was not good. The doctor diagnosed a fracture of the third lumbar vertebrae, dictating surgery or life in a wheelchair. The orthopedic surgeon was frank, telling Bergmann’s daughter ‘This will not be a home run. I can alleviate his pain, but I cannot promise that he will ever walk again."
Temkin, still reeling from the recent death of her mother, didn’t want her father to undergo surgery. “I said I’d rather have a father in a wheelchair than no father at all.” Friends urged him to seek a second opinion, from a neurologist, but Bergman was resolute.
“I was in my late eighties and I was in pain all the time. I decided I was not going to live like that. I was going to do something about it.” And so, in May 2004, Bergman underwent surgery to fuse the second and damaged third vertebrae.
While Bergman has been released from the Hebrew Rehab Center and now lives with Temkin and her family, the road back has been riddled with potholes. A medication, meant to ease depression, gave him hallucinations. A daily exerciser since undergoing a cardiac quadruple bypass surgery in his 70s, Bergman had hoped to begin physical therapy immediately following surgery. Instead, he developed a life-threatening staph infection which required a second surgery to drain the wound. For more than three months, Bergman received daily three-hour intravenous infusions of antibiotics and antifungal agents. The pain was huge, requiring the stiffest of narcotics--Oxycotin, Oxycodine--and much of that period is now a blur. In three weeks, Bergman shed 15 of his normal 190 pounds and much of his muscle strength. Not surprisingly, when he ended up at Hebrew Rehab his doctors thought he was too frail for the “Circle of Fitness” training regimen, but again, Bergman was determined.
“I was in the fitness room working on one of the machines when I was asked to step aside for a scheduled “Circle of Fitness” patient. I told them I felt I was being treated like a second-class citizen and stormed out of the room. The next day my doctor approved me to join the program.”
Bergman’s progress seems to vindicate the findings of University of Toronto researcher Dr. Roy Shepard who has written extensively about the effectiveness of exercise among the elderly. Dr. Shepard believes that muscle strength can be greatly improved by as little as eight weeks of resisted weight training, even in subjects in their 90s. His research comparing active and inactive older people suggests that much of the wasting of lean tissue can be avoided by regular, resisted exercise, and that strengthened muscles will stabilize arthritic bones, reducing the risk of falls.
So, if your parent or family member is sedentary, or frail because of a medical condition, how much exercise is necessary to improve her health? What type of regimen is best? Such decisions are very individual, depending on your relative’s overall health, spirits, and environment. In general, for all of us, the greatest gains in heart-fitness and health are achieved by a workout that raises a sweat and elevates our heart rates. Because initial fitness is low in the inactive old, heart rates rarely exceed 85 beats a minute, but U/Toronto’s Shepard believes regular training on a machine that encourages aerobic fitness, such as a treadmill, stationary bike or rowing machine, can gradually bring this heart rate up to beneficial levels.
Dr. Shepard also believes that regular, load-bearing exercise can halt, or even reverse, bone mineral loss through the eighth decade of a person’s life. Such a regimen is particularly effective when accompanied by a high calcium diet or about 1500 mg of calcium per day.
Current research suggests that exercise needs to be spread over three modalities: weight training (free weights and weighted resistance machines) to strengthen bones and the muscles that hold them in place; aerobic exercise (walking, rowing, or cycling, outdoors or on stationary machines) to maximize heart and vascular fitness; and some form of balance and flexibility training, such as yoga, dance, and stretching.
If our parents are literally falling apart, why is this? Aging negatively impacts the vascular, skeletal and muscle systems, as well as the body’s metabolism, leading to a progressive decrease in strength and flexibility. Capacity for muscle strength peaks when people are about 25 years old, plateaus at age 35 or 40, and then begins an accelerating decline, so that the average non-exercising 65-year-old has lost about ¼ of the strength he had forty years earlier. Loss of muscle strength can progressively impede everyday living. It becomes difficult to carry a ten pound bag of groceries, to open a vial of medicine, and even to lift the body from a toilet seat.
The elasticity of tendons, ligaments and joint capsules also decreases over the natural process of aging if there is not some type of exercise intervention. Over the span of a working life, adults who don’t exercise regularly lose lower back and hip flexibility, and restricted range of movement at the major joints becomes more pronounced during the retirement years. Eventually, independence can be threatened because the older person can not climb into a car or a bath tub, ascend the steps to his front door or bedroom, or complete the movements required for washing, dressing and combing his hair.
Changes are usually greater in the legs than in the arms, possibly because there is a decrease in the use of the legs as people age. But we know this need not always be true: In Germany and the Netherlands, where the elderly actually increase the time spent walking and cycling after retirement, men live an average of three years longer than Americans and their quality of life is better.
Researchers and physical therapists maintain that flexibility can be conserved or even improved in an elderly person by gently taking the main joints through their full range of motion each day. Even bed-ridden patients can benefit from range-of-motion exercises. If muscle weakness and arthritis are advanced, they suggest that range-of motion exercises be done in the warm water of a bath tub or a heated swimming pool where buoyancy supports body weight and warmth increases the immediate flexibility of the joints.
At the University of Pittsburgh Medical Center’s Sports Medicine Center, Kathleen Brandfass, director of neurological and geriatric outpatient services, is like a mother duck, overseeing a pool full of gently exercising human ducklings. Her clients represent a whole gamut of adult-onset physical limitations—Parkinson’s disease, arthritis, hip replacement surgery, diabetes, multiple sclerosis—who come to the center as out-patients for weekly, or even daily, therapy. The pool with its 100 degree temperature and hovering steam is the starting point for all these patients before they move into the adjacent room for their individualized physical therapy regimens—stretching with a therapist, time on the machines, or negotiating an obstacle course while passing a basketball, a drill that improves balance.
You may be thinking, my 89 year old mother can’t afford a physical therapist or trainer and would never, ever exercise on her own. You are right. Senior citizens, like most Americans, resist exercising. The motivated Merton Bergmans of this world are few and far between. But the scene at the UPMC Sports Medicine Center pool provides a clue to a way to set your recalcitrant parent in motion. Exercise is a social activity and, when performed regularly, promotes more than physical gain. Many of our elders are alone—widowed, never married, having suffered the loss of family and friends. Organized exercise, led by professional trainers in inexpensive venues such as YMCAs and community centers, promotes both physical and emotional health by re-connecting the elderly person to a community with similar goals. Engaged in the task at hand, seniors can find new friendships, and a new sense of empowerment, in the local Y, swimming pool, or fitness club.
Following a traumatic injury or illness, Medicare will pay for a limited number of physical therapy visits to return the elderly person to "base line" or pre-trauma form. Paying privately for physical therapy or a personal trainer is a more expensive matter, but not all exercise needs to break the bank. Indoor pools in large cities such as Boston offer year-round swimming passes for as little as $15, and many communities open their high school pools to residents for a small fee. YMCAs, community centers and similar organizations offer sliding-scale memberships for senior citizens and anyone on limited incomes.
Some health maintenance organizations and insurance companies, acknowledging the role of prevention in health, offer discounts on fitness memberships to their clients. Walking in an indoor mall, with even floors, lots of seating and controlled temperatures, is absolutely free and can be done in icy or humid weather. Merton Bergman remembers making a number of new friends when he walked at a mall near his home while recovering from his bypass surgery. As in so many things, residents of poor and dangerous inner city neighborhoods have fewer choices. A walk around the neighborhood or to the local fitness center may be simply too dangerous for many older people to consider.
If you live near your parent, consider exercising with Mom to set her in motion. It can be something as simple as a walk around the mall or around her block, a swim in the town pool, or following along with stretching exercises on a DVD. For a birthday or holiday gift, you and your siblings could give your mother a membership to the local YMCA or a session with a personal trainer who can outline some exercises she can perform at home. Hiring a trainer for your folks and a couple of elderly friends would make the expense more affordable for the adult offspring and more fun for your parents.
Is it risky to encourage your elderly parent to exercise? Thirty years ago, those who had suffered heart attacks or strokes, like my father, were told to pack in their golf clubs and take a chair. Today, exercise physiologists, like those at Hebrew Rehab routinely work with recovering heart and stroke patients like Hilda Bunn. Bunn, 84, came to Hebrew Rehab in August, 2004 after sustaining two bad falls. The first fall occurred in her driveway, causing a severe break to her left elbow which took a long time and therapy to recover; the second occurred in the shower, where she banged herself up pretty badly but didn’t break any bones.
“I thought I had slipped but it turned out that I had suffered a mild stroke.” Bunn confides. When she lived independently, Bunn worked out at a private gym three days a week and she is convinced that that fitness regimen is the reason she didn’t break her hip in that shower tumble.
Merton Bergman is both realistic and optimistic about his physical future. Since moving in with his daughter's family after release from the Hebrew Rehabilitation Center, he has returned to the Circle of Fitness work-outs with renewed commitment. .He says he realizes that he may never be able to walk without a walker, but is “just glad to be able to get out and about.” The $100, out-of-pocket fee entitles him to two supervised workouts each week for 16 weeks. ‘After that,” he declares, “the good Lord willing, I will renew for another 16 weeks.”
Following a patient health crisis, physicians will seek either a clinical evaluation or a stress electrocardiogram, an electronic monitoring of the heart during exercise, before giving their recovering charges the green light to resume exercise. But, in the absence of a recent health crisis, Roy Shepard doesn’t feel such extensive and expensive testing is necessary. In fact, he says, it may be counter-productive for the older person who isn’t looking to embark on very strenuous competitive training but simply wants to increase slightly his level of daily activity.
“It is usually difficult to motivate older people to exercise regularly. Insistence on extensive screening suggests that physical activity is dangerous, and creates additional barriers of cost and time which reduce the likelihood that an intention to exercise will result in active exercise behavior....,” Shepard has written. “Moreover, the person who begins an exercise program is at a lower overall risk of sudden death than a sedentary peer…. Finally, if a well-loved form of exercise does provoke sudden death in an 80-year-old, this is a more pleasant end than many alternative ways of dying.”
Common-sense precautions apply whether it is you or your elderly parent resuming exercise after a sedentary spell. The dose of exercise should do no more than leave the participant pleasantly tired on the following day. Weight-supported activities such as swimming and aquatic exercises, offered at many community centers, are helpful for the elderly who have joint problems. Very frail elders can exercise from a sitting position or, with assistance, even lying in bed. My mother, whose Parkinson's disease seriously restricted her mobility, climbed two flights of stairs (with assistance) into her 94th year and performed chair and bed exercises daily.
Researchers and physicians are recently putting more emphasis on exercises which focus on balance and agility such as yoga and Tai Chi, a Chinese martial art exercise which looks a lot like slow-motion kung fu to the Western observer.
Hebrew Rehab exercise physiologist Evelyn O’Neill runs a drop-in exercise program called “Get Up and Go” for about thirty men and women from the community who work out entirely with small free weights, ankle weights, straight-backed chairs, and a wall of mirrors. On a recent December day, the four women look like an aging ballet class in their sweats and sneakers, all lined up beside O’Neill, facing the mirrors. They are working on balance. They raise their right feet in unison, weighted by eight pound ankle straps, holding the right leg bent behind them at a 45 degree angle, balancing all their weight on their left legs. O’Neill calls the shots. 1..2..3..4…12 No hands. Heads up. Straight backs.
The women on that day range in age from 58 to 77. The youngest has been seriously ill and is working to build up her strength after a long period of recuperation. The other three are focused on prevention.
Betty Connerty, who is 70 and looks more like 50, says it best: “My mother lived to be 96 so I’m pretty sure I’ve got good genes. If I live as long as Mom did, I want to be sure I’m fit enough to enjoy life.”
END
Footnote: Central to a discussion of bone breaks caused by falls is the whole issue of bone density and erosion of calcium in the elderly. There is a progressive decrease in the calcium content of bones as people age. Scientists aren’t sure to what extent the decrease of habitual physical activity contributes to the age-related calcium loss. Another factor is the presence in the body of vitamin D, since Vitamin D, naturally available in sunlight, helps the body absorb calcium. People of all ages living in dark northern climates and the elderly confined to apartments or nursing homes may need Vitamin D and calcium supplements to preserve bone density.
Structural bone changes are more pronounced in women than in men, due in part to hormonal differences and in part to a lower intake of calcium and good quality protein in women. Frighteningly, calcium loss in women can begin as early as age 30 and accelerates for some 5 years around the menopause. In later old age, the bones may become so weak that a mild fall, a bout of coughing, or even a vigorous muscle spasm can cause a break. As we’ve seen, the fracture of a hip quite commonly leads to irreversible bed rest and death.
Your parent’s individual bone density can be determined by a simple, non-invasive test ordered by her internist. If her bone density is found to be poor, you should be also be aware that a number of commercially available foods—milk, juices, cereals—are now fortified with Vitamin D and calcium. As calcium pills can be constipating, your parent may also need to step up her water and fruit consumption.
1. Framingham Heart Study, Archives of Internal Medicine, November 14, 2005
