Hello. Good afternoon, everyone. I'm Dr. Paduri. Welcome to the 2021 Annual Assembly of AAPMNR Geriatric Rehab Community Sessions. I am going to introduce you to four excellent speakers for our session. We have Heart Topics in Geriatric Rehabilitation today. And the objectives of our session are the participants will learn about polypharmacy and pain management in COVID-19 era from Dr. Patel, understand age-friendly health system initiative and post-pandemic opportunities from Dr. Medina Malko. Describe co-management of fractures through interdisciplinary care and issues around transitions of care from Dr. Mendelsohn. Lastly, understand physiology of normal aging. Describe the benefits of participation of various exercises. And finally, recommendations for prescribing exercises for older adults. These are from Dr. Garstang. And as you can see the pictures, I just wanted to give you an introduction of them. And let me briefly introduce you individual speaker here. Dr. Kunj Patel, he is Board of Directors, Young Physicians Director, American Society of Interventional Pain Physicians, Director of Center for Regenerative and Interventional Spine and Sports Pain at St. Louis, Missouri. And he will be speaking to us on managing polypharmacy, pain management and care in the COVID-19 era. Very timely. The next speaker will be Dr. Anna Medina Malko. She is Paul H. Fine Professor of Medicine, Chief of the Geriatrics and Aging Division and Director of the Aging Institute at the University of Rochester in Rochester, New York and President of the Executive Board of the American Geriatric Society. And she was also the immediate past president of the AGS. We are very happy to have her here and she's an excellent speaker. She will be speaking to us on transcending the pandemic, the age-friendly health system initiative and call to action. Now our third speaker is Dr. Daniel Mendelsohn. He is William and Sheila Conner Family Professor of Family Professor of Geriatrics, Palliative Medicine and Person-Centered Care at the University of Rochester Medical School. And he's also Associate Chair of Medicine at Highland Hospital in Rochester, New York. He's the Lead Medical Director of AGS CoCare Orthopedics and President of International Geriatric Fracture Society. We are delighted to have him to speak to us on false and hip fractures, management and true interdisciplinary care and care transitions in the elderly. I'm so sorry, it's the older adults. And our very own Dr. Susan Garstang. She's an Associate Professor in PM&R at the University of Utah Medical School. She is DEO and Associate Chief of Staff of Academic Affiliations at the VA Salt Lake City Healthcare in Salt Lake City, Utah. She's going to be speaking to us on exercise in older adults, physiology, benefits of exercise and recommendations. This is very timely as we see more and more numbers are increasing in the adult population in the geriatric side. And she will be enlightening us as to how to recommend exercise in the older adults. Please join me to welcome our outstanding speakers for the geriatric rehab community at the AAPM&R Annual Assembly. And please post your questions for each speaker in the chat box so they can address to you at the very end at 4 p.m. Eastern time. When all the four lectures are over, we'll address the chat box and address your questions. Thank you very much. And please join me to welcome Dr. Patel, the first speaker. Dr. Patel? Yes. Thank you, Dr. Paduri. Thank you for that introduction. If Dr. Paduri, if you can stop sharing your screen so I can start. All right, so yeah, welcome. So my talk is managing polypharmacy pain management and care in the COVID era, 19 era and geriatrics. You've already heard the introduction. So I got interested in this topic during my training at Emory under the auspices of Dr. Strasser and my other mentors. So I don't have any disclosures that are relevant to this talk. I am an equity shareholder in SafeBeatRx, which is a cardiology software company with no commercially available product on the market. So we're going to talk about managing polypharmacy through the use of lower risk and supplement medications that are compared to alternatives. They are much safer, don't require as much monitoring, et cetera. We can talk about interventions, pain management interventions, some of the newer ones that have come out that can reduce the reliance of patients on medications. And then also we're going to briefly touch on remote care monitoring as it pertains to COVID-19 and beyond, because this will be part of the future. So polypharmacy, as you know, is a somewhat imprecise label that usually describes the accumulation of medications, typically five or more. And this results in drug-related interactions, drug toxicity, predisposes to falls, deliriums, and medication non-adherence. And the way to address this is typically with a team approach with the patient, their caregiver, the medical care team, other providers, and basically avoiding high-risk therapy or trying to use, if it is appropriate, counseling on the monitoring parameters for it, or substituting with less risky medicines. And that's what we're going to be focusing on in the beginning of this talk, is alternative treatments that have evidence for pain, that have, like I said, a much lower risk profile than conventional medicines that we use. So these are divided into two types of pain, non-susceptive neuropathic, the most common types of pain that our patients suffer from. And just quickly, you know, how did I get interested in the alternative therapies? Well, you know, this was actually entirely driven by patient demand. I could spend an entire visit talking to a patient about how gabapentin might help their neuropathic pain, but they go to the pharmacy, get a long list of side effects, and then refuse to take it. Or they're just taking so many medications, they don't want to add another. But if you suggest a supplement, suddenly that gets a, you know, a pass. First of all, they may already be taking supplements, so it's helpful to know about the supplements that they're taking. But also, somehow it just falls into a different category. Although it looks exactly like another pill, you know, I found that I don't meet the same resistance that I do. And you know, it's viewed as more natural. So there are some advantages. We'll also talk about some disadvantages of using supplements as therapy kind of at the end. But and as I mentioned, you know, for non-susceptive pain, for instance, the typical medications like non-selective NSAIDs are listed on the peers list to avoid chronic use or to avoid entirely because of the risk of GI and kidney side effects. And similarly, with some of the neuropathic medicines. So we're only going to focus on a couple supplements, one for non-susceptive pain and one for neuropathic pain. There are many, many other supplements and herbs we could talk about. But my goal is really just to get some useful information that can be, that you can use in your clinical practice and not to be a, this is not a comprehensive talk. So the ones that we'll focus on will be turmeric or curcumin and also alpha lipoic acid. And that's kind of because of the preponderance of use among the patient population. Many patients are already taking this. For instance, turmeric is the number three most used supplement according to some studies for medicinal purposes. And yeah, and then also because of the preponderance of evidence. So historically people have believed that curcumin is the active ingredient in turmeric. And so most of the studies actually in the literature focused on curcumin. But actually the curcuminoids only comprise three to 7% of the turmeric powder, you know, which comes from the root that you can see here on the right, bright yellow powder. That's typical of many cuisines, particularly Asian and Indian cuisines. So it turns out though, that in in vitro studies, many of the actions of turmeric may come from the curcumin-free components and those showing even more potent activities. And here's just a list of the many different curcumin-free components that are present in turmeric compounds that have some anti-inflammatory activities in vitro. Nonetheless, as we review the literature, you'll see a lot of mention of curcumin because that again, as I mentioned, that's the preponderance of evidence in the literature. So here's a study dating back to 2009, where they compared curcumin extracts to ibuprofen 800 milligrams per day. And what they found is that they compared it to level walking, they looked at stairs and time spent on a hundred meter walk going up and down the stairs. And that solid line here is the turmeric extract versus the control, which is ibuprofen. And you can see in each of these case, it achieves the same effect or slightly better. And you'll see that as typical of these studies comparing curcumin versus conventional therapy NSAIDs. In this study, this was on rheumatoid arthritis. It's a small study of 15 patients in each group. And what it showed is that there was decreased comparable effect on joint pain, swelling and disease activity score when compared to a hundred milligrams of diclofenac. In this study, a multi-centric study, there was actually fairly large in 2014, 367 patients of about 180 patients in each arm. What they found again is comparable efficacy between curcumin and ibuprofen. You can see with chronic pain, this is after four weeks. And again, with increased mobility. And usually what I counsel patients is it can take up to four weeks to get the maximum effect, but I'll show you some studies that show that the effect actually works much sooner. Here is another study. This is from this year, actually a multi-center randomized trial on turmeric extract. And again, what it showed is that this was administered daily over three months. And again, it had a quite significant comparable effect. This was placebo controlled. So sorry, this was again, showing that it had a good safety profile. And that's the main reason. It's not just the efficacy that we're talking about this, but also the safety profile, which we'll also discuss briefly. Here's what I wanted to mention about the onset of action. The onset of action can happen as soon as one hour. And this one, in this study in medicine, it showed that perceptible pain relief occurs at roughly two and a half hours. This was compared to acetaminophen. And you can see very, very comparable relief and meaningful pain relief around four to five hours. And there was a review done, just a systematic review done this year in the BMJ. And they reviewed 10 studies that all showed improvement in pain and function from baseline with turmeric therapy. And in the three studies comparing turmeric to NSAIDs, there were equivalent outcomes and there were no significant adverse effects. And that's the point that I really want to hone in on, that it's showing comparable efficacy in these studies, randomized studies, but also no significant adverse effects, which is very unusual when you look at the side effect profile of NSAIDs. And again, just to rehash this, non-selective NSAIDs are on the BEERS list for, you know, to avoid chronic use. And some of the higher risk ones, indomethacin, Shorlac, are listed to avoid entirely. And so the side effect profile, like for one thing, the gastric side effect of NSAIDs, you know, is one of the main reasons to avoid, but with curcumin, it actually increases the prostaglandin that builds up the stomach lining or that is a beneficial effect on the stomach lining. And we'll talk about it later, but curcumin is actually safe for renal patients, including those with hemodialysis. Another study showing that compared to Tylenol, the onset of effect happens within a matter of hours. So the mechanism of action, you know, part of the reason why it's been tough to turn this into a pharmaceutical is because curcumin has so many different effects. It's what's called a false lead in the pharmaceutical industry. And but, you know, among these are, it's a TNF alpha inhibitor in vitro, you know, similar to steroids, but without some of the negative side effects, but it has many, many pleiotropic effects. Has numerous inflammatory targets that are modified, that's been shown by in vitro studies. And there's even some emerging evidence that it can help with opiate tolerance as well, and opiate hyperalgesia. So as far as instructions for patients, so again, many of your patients are already taking this, whether or not prescribed by us or not. So it's simple counseling of how to take the medicine might be helpful. So the bioavailability of curcumin from the gut is actually very, very poor. It's, you know, it can be around 7, 6, 7% only. But there's a very easy way to increase the bioavailability, which is adding black pepper. The active ingredient in black pepper that gives its pungent taste is piperidine. And studies have shown that that increases the bioavailability by 2000% because it inhibits some of the metabolism from the liver. And so it stays in the bloodstream longer. Also, if you take curcumin within its natural form with turmeric, there are some natural oils in turmeric that have been shown to increase the absorption seven times. So the typical dosing recommendation is to start with a 500 milligram capsule. These are available at any pharmacy or even supplement store. So typically you want it with black pepper or piperidine that will be written on the label and it's 500 milligrams twice a day. You can increase safely to a thousand twice a day or, you know, studies have also shown that in cancer patients, patients have taken up to eight grams per day for several months without serious side effects. But generally you don't want to go above one to 2000 milligrams per day. Alternatively, many patients have this in their house just as a cooking material. So you can do a one half teaspoon to a full teaspoon of turmeric powder and just add a tiny pinch of black pepper. And that is basically equivalent to a thousand to 2,500 milligrams per day. And as mentioned, there's no renal dosing that's required. There are a host of supplements that interact. I'm not going to go into all of these, but this relates to, we'll talk about the side effect. One of it is that it can prolong clotting. So generally you should avoid it with other agents that increase the risk of bleeding. So definitely avoid with warfarin and any of the novel anticoagulants. It can also lower blood sugars. So some of the oral hyperglycemics, and these are just some supplements that also lower blood sugar. It's not that these are contraindications, but there should be some extra monitoring. I would consider the bleeding ones to be very cautious with those. So nothing surprising about the most common side effect, nausea, vomiting, diarrhea, similar to most side effects that are listed on medications. It is contraindicated with people with existing biliary tract stones. And the reason why is because if you look at this study where they gave just a half teaspoon of turmeric, it increases the gallbladder contractility, which is actually a very good thing for preventing stones. Just a half teaspoon increased the contractility by four times. However, if they have existing stones, it can be painful. Similarly, turmeric has oxalates in it, which in the body combined with calcium to form calcium oxalate. And so for kidney stone formers, that puts them at risk for forming kidney stones because 75% of kidney stones are due to calcium oxalate. There's also some advice, although there's no firm evidence to avoid in pregnancy because it hasn't been studied. It can be a pro-stimulant for the uterus. As mentioned, that it can prolong the clotting time. So use caution with patients who are also on antiplatelet agents. And generally you should stop one, two weeks before surgery, and you can resume 24 hours after the surgery is done. That's again to prevent the extra bleeding. It can drastically lower the blood sugar. So use cautiously or just have them have a monitoring protocol in place. Very high amounts can interfere with iron absorption. So use cautiously in iron deficiency patients. There's some data that it can worsen reflux. And the last one is there is some association with lead toxicity. And that last one is actually very interesting. There's an article that you've probably seen that turmeric may contain dangerous levels of lead. And you wonder how in the world is this happening because turmeric is a root on the ground. Well, it turns out that in order to increase the vibrant yellow color of turmeric and also the weight, some of the farmers in Asia, in Bangladesh, and some of the countries where this is harvested, they are adding lead powder, which has a bright yellow color to the powder to give it a more aesthetic and also to increase the weight. So unfortunately, that is a risk with turmeric. And as most of our source of turmeric comes from those countries, it has made its way into US patients. So the only thing you can do to kind of guard against your exposure to lead is look for brands or labels that advertise GMP on the label, which means that they follow good manufacturing practices. It's not a perfect system, but theoretically, this means that the maker, the manufacturer, will screen their product for heavy metals. So shifting now to the neuropathic agent that I wanted to discuss. So alpha lipoic acid. So this has actually been around. It's actually currently approved for the treatment of diabetic neuropathy in Germany. It's a natural substance that's found in many plant and animal sources. It's actually made normally in humans, but in very small quantities. So supplements will contain a thousand times more than is available in typical food sources. It's known to be an antioxidant, but beyond that, its exact mechanism for neuropathic pain treatment is somewhat unknown. Here's showing some of the antioxidant activity. So it both acts as a direct antioxidant itself, but also recycles other antioxidants. It's a heavy metal chelator, and also it can inhibit NF-kappa B. So alpha lipoic acid has some history going back. So in a 2010 systematic review of five randomized control trials and one meta-analysis, they looked at oral and intravenous alpha lipoic acid, 600 milligrams per day, and showed that it does indeed have a 50% reduction in the total symptom score. However, with the oral, in these early studies, they were, as you'll see, they were not carried out for a very long period of time, three weeks here in most of these studies. And again, I counsel patients that, you know, it can take up to four weeks to see a maximum effect of the alpha lipoic acid. So in these studies, there was a preponderance of a better effect size from the IV formulations. Obviously, administration of alpha lipoic acid is not common in the U.S., but it's really as a proof of concept, and I'll show the later studies, which have focused on the oral formulation. So again, another systematic review. This is, again, just going back historically, 15 RCTs that focused on the IV formulation. And the reason why I bring this up is because not only has it been studied about the efficacy, but also the nerve conduction effects. In particular, what they're showing is that there is a benefit. So just reviewing these 15 studies, you can see alpha lipoic acid plus some sort of control supplement. In this, this is the funnel plot showing it's fairly evenly distributed for the study. And what they're showing is that not only is it efficacious here in this forest plot showing that it favors treatment, but also if you look at the median and nerve conduction velocities, it actually shows improvement with the intravenous form of the alpha-lipoic acid. So this was actually quite an advance because it's showing an effect on the nerve. Same thing with the peroneal nerve conduction velocities. So I thought that was a really positive development, you know, as a proof of concept that it's having an effect. And so this was taken, carried forward into this study from 2020, from this year. It was a prospective interventional study, but it was carried out for a longer duration, which as mentioned is required to have the full effect of the oral form of the alpha-lipoic acid. So it was only 600 milligrams daily before meals, 90 patients. And this replicated what was seen in the other intravenous study, which showed significant improvements in neuropathic symptoms, nerve conduction velocity, and also autonomic neuropathy, which has historically been quite challenging to treat. There's also some improvement in the baseline cardiac markers. So here's some of the data from that article showing 75% of patients had improvement in symptoms of neuropathy. There was even more, even a higher percentage of patients benefited from their nerve conduction velocity tests improved, almost 90%. And then also a significant percentage, 77% improved in their cardiovascular autonomic neuropathy tests. You can see some of the baseline markers of patients. They improve with weight. The hemoglobin A1c you can see improved. And then some of the LDL, HDL markers, which is quite impressive that it was shown in this study. That does beg one question though, pardon me, is the improvement in the neuropathy symptoms, was it related to the alpha-lipoic acid or was it related to glycemic control? Well, if you look, there's a position statement from the American Diabetes Association showing that no compelling evidence exists for glycemic control as a therapy for neuropathic pain. So it can help with preventing the development of symptoms, particularly in type one diabetics, but as a treatment mechanism, it's not been shown. So that actually does support that. Granted, this needs to be a randomized trial, but at least it's probably not due to glycemic control, the improvement in the symptoms. And again, another study with 600 milligrams daily, 72 patients, and it showed that there was a reduction in neuropathic symptoms at day 40 versus baseline. The reason why I wanted to mention this study is not only did it show symptoms reducing by about half as far as burning, painful, cold, electric shock, tingling, pins and needles, a lot of the neuropathic symptoms we care about, but this study also looked at some of the work disability score improvements, the social life disability score and family disability score. And what they found is at day 40, all of those improved significantly. And then we have a forest plot summarizing a lot of studies, including the oral apoplectic acid studies and showing that there is in fact a cumulative effect towards beneficial for treatment. And lastly, I'd like to, on this topic, I'd like to review a real-world study where they had patients, it was 293 patients who were switched from oral lipoic acid. So they were on this for five years and then they were switched to gabapentin. And what that study showed is that almost half of the patients stopped, once they were switched to gabapentin, they stopped due to treatment side effects. And of the people who were non-responders to gabapentin, they were ultimately changed to another drug and outpatient visits doubled when switched off of the alpha-lipoic acid. So this just goes back to showing that this is a therapy that is very well tolerated compared to two alternatives. And yeah, and many, many patients actually prefer it. Not to mention that many of these agents for neuropathic pain, this is from the 2019 beers list, are listed here. So if you have gabapentin based on the creatinine clearance, it may be listed even to even to loxatine. And of course, you know, the tricyclic and the paroxysin are on there. So the starting dose is 600 milligrams per day. As mentioned, effects can take up to four weeks for maximal effect. You don't have to wait that long to increase dose again, because it's very safe. It can be increased up to 600 milligrams, three times a day. There's no renal dosing that's needed. It's safe for hemodialysis patients. The bioavailability does increase by 30% if taken on an empty stomach. And the safety in pregnancy hasn't been established, although a retrospective study found no effects for people who are started between, that took the medicine between 10 to 37 weeks of gestation. And it is something that children can overdose on. So it's something to keep, like most medicines, to keep safe. So some of the notable adverse effects, it can decrease vitamin B1, thiamine. So it's recommended to supplement with thiamine 100 milligrams daily, or you can just use a daily multivitamin which has thiamine in it. This is especially important in patient populations that are susceptible to already having low vitamin B1, particularly alcoholics. So I, you know, unfortunately I saw a patient in the hospital who, she was started on alpha-lipoic acid and this ended up precipitating a Wernicke. So the effects can be very significant. So this is something important to pay attention to, but easily avoided with a supplement. It can cause hypoglycemia. So use caution, particularly when first starting. There are, and there's a risk of some allergic reactions that are more significant with the IV formulation. Again, as far as interactions with other drugs, just use caution with oral hypoglycemics because it can also lower the blood sugar. And it may interfere with peripheral conversion of T4 to T3. So monitoring their thyroid levels after initiation, you know, a month or two afterwards would probably be beneficial. So, yeah, that summarizes what I wanted to say about the alternative therapies for, you know, managing polypharmacy. I, you know, these two candidates have a lower side effect profile and can, you know, potentially be used as maybe a first step before going to the more aggressive medications, like I said, that are on the beers list that the older patients can tend to be more sensitive to. Also, because I'm a pain management physician, I just wanted to highlight some of the emerging treatments that are coming out that avoid medications entirely. So, you know, interventions is one way to do it. And so I'd like to talk about radiofrequency ablation. There are issues with, you know, with interventions as well in terms of, you know, patient access, requiring transportation, et cetera. But I believe that the side effect profile is very advantageous. Unlike corticosteroid injections, there are little long-term side effects of radiofrequency ablation. It is covered by Medicare and Medicare Advantage plans. And, you know, and the great thing is that patients can actually try it with just a lidocaine test block before deciding whether or not they want the ablation. So the main, I'm not talking about the spine since that's very well known, but there are some new indications that have come out in the past several years for the hip where the femoral and obturator branches to the articulation are ablated. Also in the shoulder, it's the suprascapular and axillary nerves that are ablated. You would worry if this would cause impairment of motor control, but actually these are the terminal branches. So the motor branches have largely already come off before the point of where the ablation is occurring. So these are largely the sensory branches. And then also in the knee, the genicular nerve branches. And, you know, one of the crux of the issues, the reason why you do a test block is to increase the chances of success. Because as you can see, these nerves are actually very tiny and you're using a very tiny RFA probe. So the chance of failure is significant. And the reason is because there's a very variable nerve distribution. The course can be very variable amongst different patients. So if you look here, this is just an example of where they mapped out the variations of the coursing of the genicular nerves for the knee. And so you can imagine that it can be quite tough to wind the radiofrequency probe up parallel with the coursing genicular nerve. So again, generally it's a two-step process. First is a lidocaine nerve block. Generally 1% is fine. If there's 50% relief for the duration of the anesthetic, can proceed to radiofrequency ablation. Unlike with the spine, there's no requirement to do two successive nerve blocks for most insurances. And as mentioned, because of the variable anatomy of the nerve trajectory, there is a risk of a successful nerve block because the medicine can diffuse quite broadly, but an unsuccessful radiofrequency ablation. There are ways to salvage this, which we won't get into, but basically you can then advance them to considering a peripheral nerve stimulator, which those have gotten very minimally invasive and also can provide longer term relief because the lead length is longer. You're more likely to capture the nerves. It also comes with a trial before the permanent implant, or you can add corticosteroid to the nerve blocks to try and lengthen the effect. And because it's outside of the joint, it doesn't have some of the articular consequences that some of the interarticular corticosteroid injections may have that are starting to be reported. So we'll just look at some of the emerging evidence that's coming out for these. So if you look at the knee, here's a comparison study that looked at three different types of radiofrequency. And what they found is that there was significant improvement in pain at the one month, three month, and six month follow-up. Again, this therapy can take up to four weeks to have a benefit, and also the pain can get worse before it gets better. However, so looking at the data, so the three types that were studied were conventional radiofrequency, pulse radiofrequency, which is typically only available in Europe, and lastly, the cooled radiofrequency, which is associated with a larger lesion size because the tip is cooled, and so that's more likely to capture the nerve. So, but as you can see in this study, there was actually no difference in the effect between cooled and conventional radiofrequency. They all worked equivalently in this meta-analysis. Looking at the HIT studies, now that the data is not as substantial for the HITs, here's a case series that was published this year of 11 HITs. And again, they found that the HIT scores improved in terms of pain and stiffness. And most importantly, with all of these, no major complications were encountered. Patients, no patients went out to retreatment, surgery, or other intervention. A lot of patients will use radiofrequency to delay a surgery. And they can also be used after a surgery if they have postoperative pain. And then another meta-analysis that came out recently that published this year by Cohen and colleagues, again, this is for the shoulder, again, because this is all emerging treatments, granted, even though it's currently reimbursed and covered by insurances, that the data is still building. And what they found is that there is a potential for analgesic benefit. But interestingly, in the case series reviewed, almost all the patients did not have any worsening of motor function, but instead showed an improvement in the range of motion following the procedure. Because if your shoulder is not hurting, you're more likely to move it more. And that's what I've seen clinically as well. So let me just talk a little bit about the remote care portion of the talk, since we have a little bit of time. So I think COVID has been really pushing some of the remote care options, has advancing that perhaps by years compared to what would have occurred otherwise. And so we've had to all innovate a little bit. So navigating this, you've had to kind of put some things in place. One of it is, and so I'll just review a couple of those things. So we'll talk about DME therapy and remote monitoring. So first of all, DME, granted core stability is the standard of care and physical therapy, good physical therapy program is paramount. But if you do want to issue a patient a brace, they can be drop shipped to patients. That doesn't require any in-person contact, actually. The patient just needs a tape measure and the ability to measure themselves, either with themselves or with a caregiver. And for instance, a decompressive back brace, it's just abdominal circumference around the level of the navel, or if it's an unloader knee brace, basically it's just six inches, measuring the thigh circumference, six inches above the patella and also the calf circumference, six inches below the patella. And they do need to sign the standard DME forms. So there are all kinds of solutions now that have come out where you can send the forms electronically and they can sign on their phone, as you can see here. So, but yeah, in order to dispense DME, there are a lot of standard forms that are required to be signed. Also, there's a lot of innovation that's happening with virtual physical therapy. The simplest is just a remote telemedicine visit with a physical therapist. There are companies that now are in all states and it's billed to insurance. So, you know, minus the copay. So I think that's the most convenient and easy thing. There are some new technologies that are coming out where patients wear wearable sensors that interact with an app and the app can count their repetitions. So it's kind of, you know, so that allows patients to do it on their own time, which I think is really nice. And then there are a few other things that are coming out that have, I guess they've been out, but this may be more the future because it requires a virtual reality headset, but there is the ability to do virtual reality physical therapy as well, again, within the comfort of the home. And, you know, and I should, just for completeness, you can mention that also home health physical therapy is always an option as well. A host of remote monitoring devices have come out and now there are reimbursement codes for these, you know, typically reimbursed by Medicare and Medicare Advantage plans. Although a lot of the commercial insurance companies are starting to cover. So the standard ones are, you know, weight scales, blood pressure cuffs. You can do an activity tracker to see how they're responding to your pain treatment. If you are using one like a tricyclic antidepressant that prolongs QTC, there are some handheld devices now that actually are FDA approved for measuring the QTC. It's that the patient can do at home. There's even one company will mail a 12-lead stick-on patch that's FDA approved for patient self-administration at home and you can have a 12-lead EKG within the comfort of the patient's home. There's glucose. This device here allows patients to measure their complete blood count. This is for people on Clozapine or, you know, other medicines that have a risk of agranulocytosis. Some chemotherapy medicines need close CBC monitoring. And then, but again, all of these devices will send the data straight to a web portal that the physician can then log in, review the physician or staff, and then communicate if needed to the patient about the results or any actions to take. And this is built on a monthly code. And the nice thing about these codes is actually it allows for the physician staff time to count towards the billing. This last device here, it's not quite to the point where I would say it's commercially viable for most physician practices, but it does allow for remote monitoring of PTI and R, which is actually a nice way of remotely monitoring patients who are on anticoagulant like Coumadin. So yeah, that's, I think I've summarized the main points that I wanted to talk about. So from the alternative and complementary medicines for nociceptive and neuropathic pain, some of the emerging interventional techniques that will create less reliance on medications to manage the pain, and as well as remote care options that can help in conjunction, you know, monitor better patients, sorry, monitor patients better, again, all with the goal of managing their polypharmacy, making the riskier medicines less risky, and also substituting with less risky therapies. So thank you. Good afternoon, my name is Annie Medina-Walpole and I am from the University of Rochester and I'm the next speaker. Just as a reminder, you can put questions in the chat and then we're going to have some time at the end for all of us to answer your questions as a panel. So I'm just delighted and so honored to be here with you today to present to you on the Age-Friendly Health System and I'd like to sincerely thank Dr. Paduri for inviting me to give this talk as we are long-standing friends and colleagues from the University of Rochester. So I just want to confirm that you are hearing me okay. Let me just make sure. Okay, so I have no conflicts of interest. I am on the Board of Directors of the American Geriatric Society and I do have funding from HRSA as part of our Geriatric Workforce Enhancement Program grant. So our objectives today, I'm going to review with you the Age-Friendly Health System initiative. We're going to look at a patient case using the framework and then I'd like to highlight some evidence-based age-friendly models of care that are from Rochester and then illustrate some opportunities for an age-friendly health system post-pandemic because I think all of us as healthcare providers, you know, hats off to everyone. This has been an incredibly difficult couple years and I think there's a lot to learn from the pandemic and much of what we just heard from Dr. Patel. So what do we know? We know that the rapid growth of the elder adult population poses unique challenges for us and for our entire healthcare system. So as our population lives longer, we almost adapt to the needs of this group and identify the best ways to provide high quality and cost-effective care. So we knew this and then the pandemic hit and really changed so many things and just to put this in perspective, Sharon Inouye is a geriatrician who is now, I believe, at Harvard who has devoted her career to studying delirium and she said if you could design a healthcare system that would generate delirium, you would do exactly what we have with COVID-19. Patients are isolated, staff are stressed, they're rushed, they're wearing protective equipment, muffling their voices and their faces, staffing shortages are severe and sometimes only the bare necessities of care are delivered and this is why an age-friendly health system is so important. So the age-friendly health system is an initiative of the John A. Hertford Foundation, the Institute for Healthcare Improvement, the American Hospital Association and the Catholic Health Association of the U.S. I will tell you I've never been more proud to be a geriatrician in the past two years and as I said, there's never been a better time for an age-friendly health system. So the age-friendly health system is honestly the nirvana of older adult care. It provides older adults with the best care possible. It follows the geriatric evidence base that we have created now for almost 40 or 50 years. It aligns with what matters to the older people and caregiver and it optimizes value and this is, if you take one thing out of this talk, it is reframing our patient encounters from what's the matter to what matters to you and if this is the question we started with we would be so much more successful in our care of older adults. So the age-friendly health system follows what we call the 4Ms framework and what this means is these are a package. So every patient encounter an older adult across every care setting we should be addressing. So asking and then also acting on what matters, medications, mentation which could be mine, which could be mood, and also mobility. So as a wise geriatrician and one of my mentors Dr. T. Franklin Williams once told me when you've seen one geriatric patient you've seen one geriatric patient. So care has to be individualized. We have to ask what matters and that is not simply what someone's code status is. When we think about medications we know, you know, we just had a talk on polypharmacy, we know there's so many adverse events and burden with morbidity, hospital admissions, and costs and that impacts what matters and mobility and mentation. So again and again I find less is more and we have to be thinking about deprescribing those medications that are of questionable benefit and potential harm. When we think about mentation certainly it can be cognitive impairment, again it can be mood, but it also could be delirium and I'm going to focus more on delirium during this talk. Delirium associated with longer length of stay, mortality, institutionalization, again impacting what matters and I don't have to tell this crowd about mobility, but you know the importance of function to health and quality of life of older people and the devastating consequences of falls, bed rest, and immobility and even small gains in function, the ability to transfer, move in bed could be the difference for someone being institutionalized at a higher level of care or going home. So when we think about the four M's we have to remember that they are synergistic and they reinforce each other and they're meant to be practiced together. It builds on the IHI triple aim of better health, better care, and better value and really what it is is assessing each of the older adults in your care for these and then acting on them. So it sounds so easy, right? So why would you want to do this? Why would you care about being part of an age-friendly health system? Or if you're in a system that's starting this, why would you want to join in? Well, it supports the system's mission, vision, and values. It aligns critical quality and safety interventions to improve care. It's utilization of cost-effective services. Again, what matters to that older person and from the heart of a geriatrician, it's the right thing we do for the older adults we serve. There is a business case. So if you go to the website of the IHI or you just Google age-friendly health system, you will find so many resources and materials and things that you can take forward to your institution or your healthcare system. So again, shortening length of stay, lowering readmissions and ER visits, optimizing care sites, sharing in cost savings, increasing bed capacity. So there's many, many reasons why this care is cost-effective and you can certainly make the business case. So I wish it were this easy as this slide, but the first step is to be ready. You're learning about it now. You can go to the website, you can inform the IHI of your interest. And what's really important we have found in Rochester is to find champions, not a champion, but champions. We have a champion in each of our care sites. And I think part of this, part of what's difficult and part of it didn't really paralyze us, but it slowed us because Dr. Mendelsohn and I started on this journey together and we really wanted it to be health system-wide. We didn't want it to be just one hospital or one floor in one hospital. And that was a lot of work. And we realized after talking to IHI that it was better to start at each hospital on one unit and in one outpatient clinic and in our perioperative clinic and start to really develop the framework, figure out which 4Ms really work in our system. We shared the description with the IHI and now we're scaling up to count for months and months and months for at least three months and also to scale up to other care sites. So this takes time and if you started it and you're feeling you're a little behind the eight ball like we were, I think it takes persistence and it takes an entire team or village, if you will. So the IHI has now recognized over 1950 healthcare organizations that either have level one recognition as a participant or level two committed to care excellence. We are just about to submit our three months of data to become a level two commitment to care excellence, which we're really excited about. So to illustrate the importance of the 4Ms in the age-friendly health system, I'm going to share a patient's story. So let's meet Mrs. Vaila. So this is Gogeta Vaila. This is her at her 80th birthday and we're going to meet her six years later and she's changed quite a bit. So she's now 86. She has Parkinson's disease. She has osteoporosis, osteoarthritis. Her family notes that she's declining. She's losing some weight. She's a little more confused and she's been having recurrent falls. They've offered to hire Home Healthy, but she wants to remain fiercely independent and she refuses. So they've had to limit their visits to protect her due to the pandemic, but one visit they opened a drawer and lo and behold, this is the geriatrician's nightmare, right? You have this whole drawer of medications and many of them expired medicines. And when the family went through, this is the bag of gabapentin. There's a few other pills, but most of it is expired gabapentin, which her primary care doctor was trying to prescribe to avoid opioids. And obviously she wasn't taking. So this is Mrs. Vaila now. So it looks very different than the woman that we saw six years ago. And I, you know, if I was in a live audience, I'd ask you what you see, but I'm going to have to tell you. So I think what's most striking is you look at her face. So she looks like she's in pain. It looks like she's suffering. She's chair walking or furniture walking. She's kyphotic. She's arthritic. If you look, you can see the wheelchair here in this corner. You can see she's got one shoe on and one shoe off. And I will tell you that this was in the winter and she's wearing summer clothes. So as a geriatrician, you know, the picture again is worth a thousand words and I'd be worried about her cognition a bit. I'd be worried certainly about her functional state and mobility. So if I ask you if she's fit or if she's frail, I think the entire audience would say she's frail. And what does a diagnosis of frailty portend for Mrs. Vaila? So let's view her story from an age-friendly lens. So what matters to her is maintaining independence, staying in her home, seeing her family. She has two little dogs. She walks them every day. She's falling and it's scary. And sometimes she's not able to get up and a neighbor has to help. She thinks nothing is wrong with her mind, but her family has concern. They're seeing some memory loss. They're concerned she may be depressed and she's clearly socially isolated. For medications, she'd like pain control, but as few meds as possible. We see she's not taking them and likely mismanaging her meds. So what can her family expect? What can, and what we're going to do now is we're going to use the concept of frailty to illustrate something we call the fifth M. So when they made the four Ms, as geriatricians, we were all on board, but we recognize that there's things that don't, there's other things that we care for in an older adult, this very holistic view that aren't mobility, what matters, medication and mentation. The fifth M of geriatrics is multi-complexity. It's multi-vomitity. It's all the rest of the syndromes. It's these complex biopsychosocial situations. And I know as PM&R healthcare providers, you are focusing on all of these with us. And this is why we feel we and you are geriatric superheroes. So we're going to use this concept of frailty to illustrate this, the fifth M throughout her case. So frailty is a distinct physiologic syndrome. It's really dysregulation of multiple symptoms. It's manifest when that dysregulation reaches a threshold where you can't maintain homeostasis in the face of stressors. So more simply put, it's vulnerability. So this slide, you have someone who's independent. You have a minor illness. There's a little blip in their function. They recover quickly back to their same functional status. In someone like Mrs. Vela, who's more functionally impaired, she has a larger dip with an incident, slower recovery, and she may not retain her current level of care or function. If we look at frailty, the definition of frailty, and Linda Freed, again, has spent most of her career studying frailty. Three or more indicates frailty. If you look at all of these, I would guess that Mrs. Vela would have all five positive. So again, she is frail. So you know where the case is going. She's found down in her yard after falling. She's transferred to the ER. It's late on a Friday night. She has rhabdome and acute femoral neck fracture. She tests negative for COVID-19 in the ER, thankfully. She's admitted to ortho. She gets IV fluids. A catheter is put in. She's put on bed rest, and oh my goodness, we hear a murmur in the ER, and so a cardiology consult is placed. Her surgery is delayed. It's the weekend after all. We get some preoperative testing. In the meantime, she becomes fluid overloaded. She becomes agitated. On hospital day four, she undergoes surgery. So let's look at the lens again. What matters? Nothing has changed for her, but now we have bed rest. We have tethers. We put in a Foley. We've probably got bed rails, and we've got an IV. We're delaying her surgery. She's becoming delirious. We have continued isolation, pain meds, anesthesia, diuretics that may wreak havoc with her electrolytes. So again, what could be different in an age-friendly health system? Suffice it to say that it's absolutely critical. So these are some of the events in the hospital that could have been averted, and you can see that she's already getting many of them, right? She's not in the ICU yet, but she's going to get some adverse drug events. She's going to get delirious. She may fall again. And so in the hospital, what I wanted to share, these are some of the things that you can get on the IHI website. So really what it is is knowing about the 4Ms for each older adult. So we're assessing and documenting what matters in the chart. We're reviewing medications. We're screening for delirium, perhaps using the cam every 12 hours or every shift. We're screening for mobility, and then we're acting on them. We're aligning the care plan. We're deprescribing high-risk meds, ensuring all of these important things to help prevent delirium, and ensuring safe and early mobility. So I want to move to the building blocks for an age-friendly health system that we have in Rochester, and this is one of my favorite slides. This comes from Linda Fried and Bill Hall, who was with us in Rochester, and it takes an older person from being robust through the course of the end of their life to the very end, and it highlights all the ways and all the areas where a geriatrician might touch their life. And I use this slide for medical students, residents, and fellows because I really, I love what I do as a geriatrician, and my job and my roles have changed as my patients have, and I think this is just a wonderful illustration. So what I'm going to discuss with you is our hospital elder life program, which is a delirium prevention program, Project ECHO, Geriatric Mental Health and COVID-19, and also Dr. Mendelson is going to talk to you about the Geriatric Fracture Center next. So Mrs. Vela, her post-operative course, as we said, she has delirium, she pulls out her IV, she tries to climb out of bed, so she's put in a posy vest and mitts, and she's administered benzodiazepines, and on hospital day nine, she's discharged at the nursing home. So again, nothing has changed with her, she wants to see her family, she wants to go back home, but now we have restraints, she needs skilled therapy, can she really participate in this, in this current state? She's delirious, she's isolated, and honestly, the nursing home may cause more social isolation because it's certainly in New York State, the restrictions were far greater than even the hospital. And medications, we've got pain meds, anesthesia, diuretics, and now we've got benzodiazepines. So let's think again about that fifth M. We know there's many studies showing preoperative frailty is significantly associated with post-operative complications, hospital stays, and higher mortality. And so with this study, this is a study that shows those who have, who are fit versus frail, and their survival. And this was a study that was from 2012, a prospective cohort study in South Wales in a general medical unit. And so we're not surprised by this. We would expect that those who are more frail might be more likely to have a higher mortality. However, when they looked a little bit further, they found in patients who developed delirium, those that were both fit or frail were more likely to die. And those who had the combination of both frailty and delirium conferred the worst prognosis. So really we want to prevent delirium as best we can in the hospital. So I'd like to introduce you to the HELP program. This is called AGS CoCare HELP. And Dr. Mendelson is going to introduce you to AGS CoCare Ortho. So CoCare is co-management, and the AGS has taken some of these programs, obviously with the permission of those that have developed it, to help with the dissemination across the country and across the world. And so this is the website for all the resources if you're interested in, you'd like to have a HELP or ortho co-management program. So HELP is a comprehensive program designed to prevent delirium and functional decline. It was started in 1999 by Sharon Inouye, who I mentioned, who has devoted her entire career to studying delirium. The interventions are fairly simple, right? But they don't often happen without the HELP program. So there's daily visits with structured cognitive orientation. There's an activity program. People get up and move. There's a non-pharmacologic sleep protocol. Hearing, vision, feeding is addressed. And there is nursing education. And I will say bigger than that, there's team education across the entire interdisciplinary team. So what's neat about this model is we have the patient in the center. We have a geriatrician who honestly has a very small role, but we have an army of volunteers that are being coordinated by an elder life specialist. We have an elder life nurse specialist who is in charge and is interacting with all of these consultants and the entire team. So again, disseminating the interventions and the education. But I think the key to this is this is pretty cost-effective because most of the work is done by the volunteers. So when we look at some of the outcomes, Dr. Inouye in 1999 showed 5% delirium incidence reduction. And then as we move up these, we have a reduction in functional decline, reduction in center use, reduction in institutionalization, falls, length of stay in postoperative delirium. This is most recent in 2019. So these health programs are being disseminated and utilized certainly across our country with similar outcomes and very significant outcomes. Again, if you're going to make the business case to bring this to your institution, you need to show that it's cost-effective. So looking at this again, early studies, $831 savings per patient. On average, I think we're quoting about a thousand dollars. The most famous study is Ruben from Pittsburgh Shadyside Hospital estimated 7.3 million per savings in hospital costs per year, about a thousand dollars per patient. And again, the length of stay contributes quite a bit, but it's all the other costs that are associated with longer length of stay as well as the revenue generated from delirium cases prevented and backfilling of beds. So again, extremely cost-effective and a great business plan. So at Highland Hospital, Daniel is going to tell you about Highland Hospital, but it's a small community hospital, which has really become the geriatric Mecca in Rochester. It's a 200, I think, 55 bed hospital. So our numbers are small, but we started a health program in 2019 and I have data through 2012, excuse me. I have data through 2019 because in 2020, things stopped with the pandemic and the program has just come back on in 2021. But at that point, you can see the number we had trained at about 30 active volunteers, which isn't that many people to keep the program going in a small hospital. We enrolled almost 4,000. The average age was 84.3. There was 22,527 interventions. That is a lot of visits. And what I love is that these volunteers would go back off hours on their shift, not on their day or on their day off to do additional visits because they were so committed to this program. We reduced our length of stay from 7.4 to 5.8, and we had a reduction in delirium from 7% to 2.5. I will tell you that our delirium rate was pretty low for our hospital because we've been quote unquote geriatricizing Highland Hospital for a couple decades. But at some of the hospitals that started, the delirium rates were 40%, 30% really high, and they were able to bring them down. So we are very proud of our health program. The one thing we don't have is we don't have the cost factor. And a lot of times we develop programs because it's the right thing to do. It's a quality, maybe a QI program. But in order for me to take this to the other hospitals in our health system, they're going to want to know. I can show them what happened at Shadyside Hospital in Pittsburgh, but they're going to want to know what happened in Highland Hospital. And that is something that I'm hoping to work on in the next year to really show the cost savings. So how can delirium prevention programs contribute to an age-friendly health system? All of these things. I'm not going to read all of them, but can really, really make a difference. And again, the triple aim, prove quality, cost, and patient experience. So back to Mrs. Vaila. She goes to the SNF. She has persistent delirium. She refuses meds. She's shaking her fist. She becomes combative with care, and she is rehospitalized. And unfortunately, she tests positive in the ER for COVID-19. And this is not an uncommon tale. This is not something we want, but I see it again and again. So I'm going to talk to you now about Project ECHO, Geriatric Mental Health in COVID-19. So Project ECHO stands for Extension for Community Healthcare Outcomes. So this is really a guided practice model. It uses video technology way back before it was Zoom. Now it's Zoom technology to treat common yet complex diseases in underserved and rural areas. So it follows a hub and spoke model. The hub is the academic medical center or the institution. The spokes are sites. It could be a nursing home. It could be a prison. It could be a community healthcare center. It could be a primary care office. But what you're doing is you're doing conferences with case presentations, didactics. We call it tele-mentoring because it's really becomes a learning community of practice where you support, you mentor, and you teach each other. And what happens is you're able to develop subspecialty expertise at these outside locations without coming to the academic medical center or the hub. So the story behind this is kind of neat, and I want to share it. Project ECHO was developed in 2004 by Sanjay Arora, who was a gastroenterologist treating hepatitis C in New Mexico. So at that point, there was about 28,000 cases and less than 5% were treated at the academic medical center. So he did a prospective cohort study looking at how we could treat primary care clinicians at 21 ECHO sites in rural areas and prisons across New Mexico. So he enrolled 407 patients with chronic hepatitis C. He proved he could obtain similar outcomes in patients treated at the medical center versus those treated in the underserved and rural communities using the ECHO model. And so Project ECHO was born. And now Project ECHO is worldwide. So the bright red dot is a super hub. That means you're training. The pink dots are hubs. And here we have the U.S., and here's the University of Rochester. So we have many ECHOs. In addition to the two I'm going to describe, we have ECHOs for seizure disorders. We have ECHOs for eating disorders. We have many pediatric ECHOs. So again, this is something that is really taking off and a wonderful way to disseminate teaching and education to rural areas. So Project Geriatric Mental Health started in 2014. And now I want to give you a geography lesson. So this is our state, New York. Here we are in Rochester. And this is our catchment area. Our catchment area with the university goes through the beautiful Finger Lakes region. We're between Buffalo and Syracuse. And when you say you're from New York, everybody assumes we're close to the city, but this is a good five and a half, six hours away. So really this was developed to help older adults and to help primary care practices to care for older adults with dementia or psychiatric illnesses. So this program was started as a Project ECHO project. It started here, and soon it was disseminated pretty much across the entire state. And what they were able to show is they were able to reduce hospitalizations, ED visits, it was tremendously successful. And then at the same time, a year later, we were looking at our Medicaid reform in New York state. And we realized that again, in our catchment area, there was a huge need in the nursing homes for behavioral health and geriatric mental health. And when they did a needs assessment, they found about 30% of patients have mental illness, half have cognitive impairment, threefold increase in hospitalizations, and again, 20% prescribed and antipsychotic. And if I blow this up for you, the red areas have no geriatric mental health services at all. Blue have some, but are lacking. And again, here we are in Monroe County and we have a wonderful geriatric psychiatry program, but again, there's not that many faculty and they cannot serve all the nursing homes in all the areas. So we embarked on Project ECHO, geriatric mental health and long-term care. So this is just a schematic, but we were part of the team, the geriatricians, psychiatrists, psychologists, social worker, pharmacy, nurses. And here we are. It's pretty simple. Again, pretty cost-effective. We have Zoom technology. We've got a poster in the background. This is one of our geriatricians joining from her office. And this is our team. And on the side are learners. And this is a wonderful teaching tool. We always have people of all disciplines who are learning. So we recruited 60 nursing homes. There were weekly clinics, as we call them, and the nursing homes would share cases. And then we would share didactics and it becomes a group think and learn. In 2017, this was so successful that the New York State Office of Mental Health asked us and they paid for it. Can you add another ECHO on another day to hit more of our state? So you can imagine evaluating this is a little hard because you've got nursing home teams. So we did satisfaction surveys, interviews, looked at the CMS quality indicators and nursing home deficiencies. And what we found is 86% of patients who were presented had symptom improvement. These are all the quality indicators. And you can see decreases in many, many significant indicators, in particular, the prescription of antipsychotics. There were no hospitalizations of case patients that follow up. And providers felt valued, supported. They felt less isolated and improved self-efficacy. And I will tell you, one of my favorite stories is I love being on the ECHO. And so I was on the ECHO and they're explaining the case. And I think I'm about to say something geriatric and profound. And all of a sudden, one of the social workers or nurses from an outside nursing home said the exact same thing that I was going to say, because we have been working together and they're teaching and learning and sharing too. And that to me was so gratifying and so rewarding and showed that this really works. So our outcomes with antipsychotics starting at, I'm embarrassed to say 17%, right? In three years or two and a half years, down to 11%. One nursing home success story, they peaked at 34.9% prescription antipsychotics, which is really just mind boggling to me, down to 11%. So I want to move on to the COVID ECHO Action Network. So ECHO has taken off everywhere. And in 2021, really probably late 2020, the AHRQ invested 237 million to launch this partnership. And Rochester was one of 99 sites. We applied to be a hub for COVID-19 and we trained teams at 69 regional nursing homes. So what this was, was a year-long program. We started in September. We just ended. There were weekly 90-minute tele-ECHO clinics. And I will tell you, everybody was on. We were all struggling at that point. All of us had been through one wave of COVID pandemic in the nursing home. We utilize the all teach, all learn model. There were video presentations that they made. Honestly, the video presentations were called as the virus turns and we had, they were quite good, but they were funny. We had a live QI coach to help. We talked about challenges, successes. And what was most exciting is the nursing homes to participate were paid $6,000 of that money. And the hub sites received $6,000 per nursing home. And I tell you in the time of austerity budgets during the pandemic, it was wonderful to actually be able to bring money in to support faculty time to do such a valuable initiative. So these were the goals. I'm not going to read all of them, but you can imagine essentially keeping COVID out, keeping people safe and helping nursing homes establish best practices. And again, these are all the sites. Here we are in Rochester. There were some closer to the city, but nothing else in the rest of the state. So 99 training centers provided training and mentorship to over 9,000 of about 15,000 eligible nursing homes. And this has led to other things. We have another grant from HRSA, an extension of our GWEP grant to continue this training and to also support caregivers of nursing home residents who were also clearly impacted by the pandemic. So how can Project ECHO contribute to an age-friendly health system? Again, increasing access to subspecialty expertise, creating a community of practice, disseminating best practices, education of staff, and then building blocks for future innovative programs. So the final quality, cost, patient experience, it really works. Okay. So to conclude with Mrs. Vela, a sad end to her case. So she eventually returned to the nursing home with prolonged delirium. We knew she couldn't participate in rehab. She was still isolated from her family. She had complications of COVID. She was immobile. She got deep tissue injuries on her heels. She had a DVT and she expired on hospice, thankfully peacefully, three months after her original fall. And this is not what we want to happen with our nursing home residents. So what can we learn? What can we take from this pandemic that has been so difficult? And how can we utilize the age-friendly health system to really move our health system forward to optimize care of the older patients that we all serve? So a few, I'm just going to highlight these very briefly, frailty, social isolation, and mortality. No surprise. This study is from the Netherlands. It was part of the longitudinal aging study in Amsterdam, looked at 1,400 community older adults, age 65 and older, frail older adults were at increased risk of mortality. And if you were frail and lonely or frail and socially isolated, you were more likely to die. So again, even pre-pandemic, we knew that this was not a good situation. We already talked about frailty and post-operative mortality, but again, this is an article showing across multiple non-cardiac surgical specialties that patients who were frail were again, more likely to die. When we look at delirium in COVID-19, this was a Brazilian study of 707 patients admitted to the acute hospital, delirium identified in about a third, which is again, pretty high, independently associated with in-hospital deaths and people over age 50. So from 50 to 80, and then 80 to a hundred, you can imagine the death rates are going up. So again, delirium versus no delirium, significant differences. And then finally, healthcare costs increased directly and significantly with the level of delirium severity in older adults undergoing major elective surgery. So I realized her surgery is not elective, but this is something that we need to do. And there are also programs, there's a geriatric surgery verification program, which we are trying to develop in Rochester. All of this really aligns with the age-friendly health system and why we need to move forward. So one of my favorite quotes, with the new day comes new strength and new thoughts. And I thought about this a lot during the pandemic. So I want to share with you a few of the really exciting things and how I feel that our field really persevered and overcame the pandemic. So this is an article published by the American Geriatric Society from their Healthy Aging Special Interest Group. And it discusses significant difficulties and obstacles faced by the older adult population during the pandemic. And then what I love about it is it provides a framework related to screening for five domains. So health promotion, injury prevention, optimizing cognitive, physical, and mental health, and then facilitating social engagement. So if we did all this during the pandemic in a more organized fashion, again, tying in with the age-friendly health system, I think that we could have made a difference. And we've learned from this and hopefully moving forward. When we look at some of the other things, we transition to telehealth, right? What do older adults need to succeed? So it wasn't just what we needed to do it, but how can we really meet the needs of our older adults and how can we connect with them via telehealth? I love this one, home visits, two-dimensional view of the geriatric 5Ms. We had adoption of video visits during the pandemic by the VA home-based primary care. These were all articles that have come out in the last year in our Journal of the American Geriatric Society, just showcasing the amazing work. Hospital elder life program and long-term care. Here we have Dr. Inouye. It's coming. And again, applying the age-friendly health system framework to long-term care settings. So again, there are pilots going on trying to do this too. And I think that this is something that's coming down the pipeline and really the age-friendly health system should be across every single care setting, inpatient, outpatient. And also we can teach patients themselves to advocate for age-friendly care. So I think there's really no stopping this. And then finally, for those who are in academic centers, the 5Ms and more, a new geriatric medical student virtual curriculum. Love that. We had to switch everything to virtual. GeriaFlow brought together geriatric fellows who were socially isolated to teach and learn together across the country. And again, a community of practice and friendship. And then I love this one too, succeeding in aging research during the pandemic strategies for fellows and junior faculty. So we've made it. We're not out of it yet, but I really do believe we have persevered. And I do also believe that the care of older adults is optimized in an age-friendly health system. And so I really leave you with this charge and a call to action. The time is here for an age-friendly health system. And what can you do individually? Maybe you're not going to be the individual champion, but maybe you can introduce these concepts to your care team, to your institution, go to the IHI website. I really believe we can all make a difference and be a change agent. So that is my talk. I have many acknowledgments. I'm not going to read them all, but I'm going to show my slide. And then I love to leave you with a wish. And this is from my good friend, Susan Friedman, who was one of the authors on the American Geriatric Society, Healthy Aging article I just showed you. So in many cultures, living to a hundred years is considered to be a blessing. So may you live to be a hundred. May you live to be 100 years with one extra year to repent. This is my favorite. May you live to be a hundred. May the last voice you hear be mine. Good luck. Good cheer. May you live a hundred years. And I added, may your care be in an age-friendly health system and from a geriatrics or physical medicine and rehab trained health professional. So I will stop there, stop sharing, and happy to introduce my close friend and colleague, Dr. Daniel Mendelsohn. Thanks, Annie. Almost impossible to follow, Annie. A wonderful story and wonderful presentation. So I'm going to talk to you about falls and hip fractures and really what I'm mostly going to concentrate on is telling you about the Geriatric Fracture Center and the co-management model. I'm a geriatrician and palliative care doctor at the University of Rochester and co-founder of the Geriatric Fracture Center at Highland Hospital and associate chief of medicine at Highland Hospital. I don't have any commercial disclosures. I am lead medical director of AGS CoCare Ortho and then have a number of roles with other not-for-profit organizations. Our learning objectives this afternoon are to describe co-management and true interdisciplinary care, and I hope I'll be able to convince you by the end of this talk that geriatric fractures and hip fractures are not co-management. I hope by the end of this talk that geriatrics with co-management is added value for other programs. I love this quote. It's attributed to Einstein. Insanity is defined as doing the same thing over and over again and expecting a different result. So what I mean by that is if you don't make a change, you can't expect a different outcome, right? Every system is designed to get exactly the outcome it gets. So if you want a different outcome, you've got to do a different design. You have to think differently. Another way to think about that is you really can't expect better for yourself when you're an older adult than what you're willing to do for older adults now. So the changes we make now are really investments for ourselves. So it's in our best interest to pay attention to all those things that Annie taught us about in the last session. So we all know U.S. health care is really expensive. This is from 2018, and you can see our cost of care per patient is almost double any other country. And you would think with all the money we spend, we'd also have the best quality, but that doesn't ring true either. Even within the United States, more dollars spent don't mean better quality. This graph shows you the quality versus the cost, and you can see there's some very poor quality, high cost states and some high quality, low cost states. And our state, New York, is right here in the middle where there's about average cost and average quality. Again, more evidence that we just don't get very much bang for our buck is the United States, in spite of all that we spend, is right in the middle of the pack of the top countries in terms of longevity. So how do we get to value? Well, value is quality divided by the cost. And the reason we focus on hip fractures is it's so easily identifiable and it's very expensive. It's the 18th most expensive Medicare diagnosis in 2011 and actually has been rising. There's also around 300,000 hip fractures every year. For the Rochester area, that's about 1,000. So there's about 1,000 opportunities to make a difference in people's care with hip fracture every year in our community. So I'm going to talk to you about the five principles of the geriatric fracture center, and then I'll talk to you about how this improves care and why we should be paying attention to it. So most patients benefit from having surgical stabilization of their fracture. Most patients benefit from surgery because it improves pain, it improves function and mobility, and it improves blood loss. And if you're going to go ahead and fix the fracture, then you have to think about making sure you have the right surgical technique, the right implants, surgeons that know how to operate on basically what amounts to operating on a light bulb. But in spite of having the best surgeons, the best implants, and the best surgical techniques, you still need to have a system of care around that patient that supports the outcomes both before the surgery and after the surgery. So that brings us to our next principle, that the sooner patients have surgery, the less time they have to develop iatrogenic illness. Sooner patients have surgery, the less likely they are to develop delirium, pneumonia, skin breakdown, malnutrition, urinary tract infections, thromboembolic disease, and deconditioning. While people are waiting for surgery, they end up with other falls with injury. It's very dissatisfying for a patient to sit around uncomfortable, particularly for their family. The time to surgery is one of the biggest predictors in terms of length of stay and with our very busy hospitals, particularly around COVID, decreasing length of stay means that other patients get better care as well as the patient that got to surgery faster. Also, the longer the patient's in the hospital and the longer it takes to get through their course, the higher the cost is going to be and delays also lead to excess mortality. There's really no good that comes from unnecessary delays. Of course, if there's good solid medical reasons to hold off on surgery, that makes sense, but most of the time patients can be optimized fairly quickly and get to the operating room quickly. So the third principle of the Geriatric Fracture Center is co-management with frequent communication avoids iatrogenesis. Now, iatrogenesis is not a real word, but since I snuck it into the literature and it's been repeated many times, it may become a real word. So I ask that everybody try to use that. It also sort of pushes the buttons of my orthopedic colleague that founded the program with me. And there's very few times a geriatrician gets to poke at a orthopedic surgeon. So help me out with that and we'll use the word iatrogenesis. So co-management means shared ownership. In our system, that means the patient is seen daily by orthopedics and daily by medicine. In our case, the medicine service is geriatrics. And it also means daily communication, equal responsibilities, and very importantly, each service writes their own orders. Really the key to co-management is that everybody takes equal responsibility and everybody writes their own orders. A well-run co-management model has a collegial environment. It's a collaborative environment. There's a great deal of mutual respect. There's shared decision-making. There's good coordination of care and there's true interdisciplinary care. I just want to go back to the shared decision-making model. That is something that is getting more and more important when we talk about person-centered care and as we work with our patients and their families. But it's also important when we work with each other that we use this shared decision-making model. As you can imagine in the operating room, the surgeon is really pretty much the captain. And generally, there isn't a lot of shared decision-making. So it's not a comfortable or typical model for surgeons. So as we try to bring surgeons into a co-management model, particularly outside the operating room, working with them to do shared decision-making, making sure that we're using best practices and that we agree on what those best practices are in the context of that particular patient is really important. The other thing I want to say about a collaborative environment and mutual respect is I really enjoy going to work. I love working with my orthopedicology colleagues, my anesthesia colleagues, the nurses, the physical therapists, the social workers, the patient care technicians, and the folks helping us to turn over the rooms. It really needs to be a good environment. People should be comfortable coming to work and happy to be there. It translates into everything we do. So interdisciplinary care versus multidisciplinary care. Multidisciplinary care is what every single hospital in the U.S. has. It means all appropriate services are there and they care for the patient, but it doesn't necessarily mean that they're integrated or cooperative. In a true interdisciplinary care model, not only are all the appropriate services there, but they're there for that patient and they're in an integrated, cooperative, and collaborative fashion. In other words, with true interdisciplinary care, there's a shared vision and that patient is in the center of everything we do. Another way to look at it is every piece of the puzzle is there and everybody has their piece of the puzzle. They're integrated and at the end of the day, the whole is greater than the sum of the parts. One of the things that often comes up when we talk about co-management is who manages what. And I don't want to go through this entire table, but this is an important service agreement that we have with who deals with what at our health system. And this is just one model. There's many variations on this, but it's an explicit way that we communicate with our orthopedic colleagues, our medicine colleagues, and our nursing colleagues as to who's going to address what and really simplify how problems get addressed. The fourth principle of the Geriatric Fracture Center is standardized protocols decrease unwarranted variability. So I love to show this picture. I'm a scuba diver and for those, I'm sure most of you recognize this as a ray. This is actually a manta ray, which is actually enormous. He's about 20 feet from wingtip to wingtip. And I took this picture while diving in outside the Philippines, I'm sorry, Thailand. But the reason I bring this up is you plan your dive and dive your plan and dive your plan so that you stay safe. Well, this is the same thing with surgery. You plan your operation and then you operate your plan. And that can be said for what we do on the medical side too. You have to have a plan and you follow your plan. You deviate from your plan when it makes sense, but you don't deviate from your plan unless there's a good reason to do so. So we use standardized protocols to avoid unwarranted variability. Our protocols are co-developed where there's evidence, they're evidence-based. They're truly interdisciplinary, meaning that every team member that was affected by the various orders and the order sets got to have input and we eventually agreed where we were going to disagree and what model we were going to go forward with. Order sets match up nicely with the nursing care plans to simplify the ease of execution. And we also have a standardized geriatric assessment that allows us to capture most of the comorbidities and make sure that we're addressing the major concerns that most patients have. When you develop standardized protocols and standardized order sets, it's important to compromise to local best practices. An example of that is when we first started the geriatric fracture center more than 15 years ago. If we sent the patient out on low molecular weight heparin for DVT prophylaxis, they were not able to get a rehab bed. And without being able to get a rehab bed, they were stuck in the hospital. So back at that time, morphine was much more commonly used than low molecular weight heparin. But we all thought low molecular weight heparin was better. We kept an eye on that. And as things changed, it became acceptable at the rehab centers and we switched to low molecular weight heparin, which we think was best practices. Order sets and standardized assessments need to be thoughtful. They'll never be perfect, but they should be thoughtful and you should be willing to adjust them as information changes and style of practice changes. So I like to call unwarranted variability as inappropriate creativity. I love how staff thinks quickly on their feet, but I don't want them to take a shotgun approach. I want them to be really thoughtful and deliberate about how they treat the patient. So our fifth principle of the Geriatric Fracture Center is discharge planning begins at admission. 92% of our patients are going to be discharged to a rehabilitation facility. Less than 2% of our patients pass away any given year. Oftentimes we're less than 1%, which is about half what the Medicare average mortality for hip fractures in the hospital is. Every patient gets a good functional assessment and every patient has care coordination between the patient, their family, the social worker or discharge planner, the physiotherapist, the nursing staff, the medical providers, and the rehabilitation center. It's important to remember that all of these team members are important in coordinating care and at different health systems there may be others that need to be included, but this is the core set. It's important that the team is consistent about the discharge plan and the care plan. Patients and families do much better when they're well prepared and it's not fair for patients and families to have surprises that we could have predicted and told them about. They should only get surprised if we get surprised. In order for patients to be able to get to rehab, it's really important to have these few things well done. So they need a standardized summary that tells what happened to the patient and what the plan for care following their stay is. We have a set of standardized discharge instructions which include things like when their next lab test and x-ray should be, what should happen with their sutures or with their staples, and what anticoagulations they should be on. It's very important to make sure they have a clear and reconciled medication list that is geriatric friendly and appropriate to that patient. It's important to have a complete problem list and at Highland we take having advanced directors and goals of care very seriously to make sure the patient is getting care that is person-centered. The most dangerous time for our patients is in the transitions. Transitions in care are something that require extra attention and we could spend an entire hour talking about how to improve that, but these few things, if they're done well every time, will generally protect your patients in the transitions. So those are our five principles. Most patients benefit from surgical stabilization. The sooner patients have surgery, the less time they have to develop iatrogenic illness. Co-management with frequent communication avoids iatrogenesis. Standardized protocols decrease unwarranted variability and discharge planning begins at admission. So what is the program? For us, it's fragility fractures over the age of 60. This means low energy fractures or falls from a standing height. It's long bone and pelvic fractures. The complicated fractures, the high energy fractures, tend to go to a level one trauma center or Sister Hospital Strong Memorial, who also has recently put together a geriatric fracture program as well. The poly traumas and the open fractures really are best dealt with in a level one trauma center. So all of our patients are co-managed meaning that they have a geriatrician and orthopedic surgeon assigned to them right from the very beginning. We use our patient-centered protocol-driven care. It's a total quality management program that uses lean business flow model to enhance the care. Lean business model, I think, is becoming more and more familiar to health care providers, but it's an important concept in business, which means that we do a comprehensive analysis of all the processes. We eliminate waste and non-contributory processes. We pay attention to the quality. We work as a team, and there's regular communication and regular cycles of improving what we're doing. So the typical three business models are mass production. I'm sorry, craft production, which is what existed before 1911. That's when an individual item is made by an individual craftsman one at a time. Mass production, which Henry Ford introduced us to with the Model T, which is a better use of supply chain and a better use of materials. And then lean production, which is what happened after World War II in Japan, led by the American Deming and championed by Toyota and Ono with car manufacturing. So craft production, there's a wide variability in outcomes. Outcomes are specific to the particular professional. This essentially amounts to, I'm going to find the best surgeon because they're the highest quality surgeon. Often, that's the highest cost. There's often worse quality, but perceived better quality. There's poor supply chain management, worse use of space, and lack of systematic approach and variable customer satisfaction. An example to think about is a Rolex watch versus an Apple watch. A Rolex watch is many, many, many more times expensive, can do much less, but on the other hand, the Apple watch keeps time much better, much more precisely, and can update itself. So one is perceived as highly valuable, but one is actually better quality. Mass production is high volume, which moderates costs. It's systematic. It often is an inefficient use of space, inefficient supply chain management, and still moderate quality issues. In fact, Model T is coming off the line. Half of them needed to be re-engineered to start, and half of them did not start at the end of production. You do get enhanced margins, and there is variable customer satisfaction because of this issue of not every model comes off the line in the same quality. Lean production is also high volume, but now it's an efficient supply chain with materials coming just in time, efficient use of limited space. It's the best quality, the best margins, and the best customer satisfaction. So how do you get to lean? Well, all processes have to be studied. Processes that don't add value have to be eliminated or revised. You must measure what you do. Supporting services need to work together, and you have to study what you're doing at frequent intervals and change what you're doing to maximize the outcomes that are important to the patient. So at the Geriatric Fracture Center, we use a quality management database to keep track of our processes and update our processes to improve the outcomes that we want. I'm going to talk to you a little bit about what our patients look like. So the Geriatric Fracture Center, the patients tend to be older than usual care, older than the Medicare average age, and they're not as likely to die as the Medicare average. They run about 85, so about three years older. It's a very female population, about one in five patients are male. It's a very white population, nearly only about 3% are not white. The Fracture Center, only about 40% of the patients come from their own home, compared to usual care Medicare data, where four out of five come from their own home. So we take the Charleston score for our patients is almost a full point higher than usual care patients, and more than half of our patients are affected by dementia compared to just 20% of usual care patients. So we're taking care of an older, sicker, frailer, more comorbid population, more institutional population. In spite of that, compared to other co-managed programs, we have a very good time to OR, less than about a day. More than 93% are operated on in less than two days. The overall complication rate is quite low at around 30%, and delirium is relatively low at 24%, and infection rates are very low. I'm very proud of the fact that we have no restraint use, and that we have a very respectable length of stay in spite of how old and frail our patients are, and a very low in-hospital mortality and readmission rate. Medicare readmission rates essentially double that number for hip fracture patients. Again, another way to look at things, excellent time to surgery, no restraints, good length of stay, reduction in in-hospital mortality, reduction in 30-day readmissions, and then overall reduction in complications. When we first did the fracture center, I knew that we had decreased in-hospital mortality, and I thought we would decrease 30-day mortality, but I was shocked that we actually reduced one year mortality. Even for frail nursing home patients, we were able to keep the mortality rate at about 30%, which is really quite unusual. Most other studies show that mortality rates are around 30% for all comers. Of course, the community dwellers had the best outcomes, and the assisted living patients had outcomes in between the nursing home and community dwellers. When we first started the program, people thought with a fast length of stay, we must be pushing people out, and therefore, we'd have a bunch of readmissions. Well, in this study of over 1,000 patients, we found that that wasn't the case. This patient population pretty much matches the population that I talked about before with about half having dementia and a Charleston score of around three, significant number from nursing home and assisted living. In spite of all of that, the length of stay was 4.6 days with a standard deviation about 2.3, and the overall readmission rate was 11.9, which again is almost half what you would expect from the Medicare population. Comparing with some other centers, again, Highland Hospital, about 11.9. These other models were well over that, and most of these were typical patient populations. Therefore, we're younger, less comorbid, less dementia, less institutional than our patients. Looking at New York State, again, 11.9 versus 15.3 versus all of Medicare, 14.5. You would think that maybe having a Geriatric Fracture Center increases cost because you have the geriatricians involved. Well, the opposite is true. Geriatricians tend to use less ancillary services and less ICU days and have shorter length of stay, so the Geriatric Fracture Center actually has a significantly lower cost. It's about two-thirds the cost of what you would expect for New York State and the United States in this study. A lot of that is driven by length of stay, but some of that is driven by the lower use of other services. So how do you get to a Geriatric Fracture Center? Well, AGS CoCare Ortho from the American Geriatric Society and supported by the John A. Hartford Foundation essentially packages what we're doing at the University of Rochester and what our colleagues at Brown University are doing. This is really a wonderful project for co-management dissemination so that we can improve the care experience of older adults, improve the caregiver experience, improve the person-centered outcomes, improve system outcomes, reduce costs, and of course, this is a major support for age-friendly health systems. The package includes an online educational curriculum, a co-manager certification process, an implementation toolkit, which is essentially turnkey instructions. There's webinars, coaching calls, there's site visits and reverse site visits available, opportunities to network, and there's online forums and frequently asked questions are answered. Case studies are regularly shared. So I hope I've convinced you that the Geriatric Fracture Center is a value-added program. The quality is higher at lower cost. So co-management in the Geriatric Fracture Center leads to lower morbidity, lower mortality, lower cost, lower length of stay, better bed utilization, lower readmission rates, better quality, better cost, better patient experience, and this of course leads to better provider experience as well. Key points, co-management improves patient-specific outcomes and traditionally care is key to co-management. Lean processes get us to co-management and geriatrics co-management is value-added. Thank you and I look forward to being able to answer any questions later in our presentation. I'll turn the screen over to our next colleague. Thank you, Dr. Mendelsohn. Now we invite Dr. Susan Garstang. Can you see that OK, it's coming out a little bit weird on my screen. It does look cut off. Let me unshare and reshare. Yes, that's great. Great, thank you for the feedback. All right, so I am going to talk about exercise in the older adult. I have no conflicts of interest to disclose. So this is the outline of my talk. So I'm gonna talk about the benefits of physical activity and exercise, a little bit about the physiology of normal aging in the older adults, considerations for recommending and prescribing exercise, safe exercise prescription, how we overcome barriers to exercise, which will apply to everybody, not just older adults, and then a summary of the current recommendations that are in the literature. And so just to start with some definitions. So in this body of literature, 65 is the cutoff for an older adult. They do caveat that adults 50 to 64 could be an older adult if they have clinically significant chronic conditions or functional limitations that affect movement, fitness, or physical activity. And I know in my case, I feel like a little bit older. It's like, oh good, I'm in the older adult category. Anyway, physical activity. So a lot of the guidelines that you'll see recommend physical activity instead of exercise. So physical activity is body movement that is produced by the contraction of skeletal muscles that increases energy expenditure. Exercise is planned, structured, repetitive movements to improve or maintain one or more components of physical fitness. Lifestyle modifications are using opportunities in a person's daily routine to increase energy expenditure and substitute activity for leisure time. And then in terms of sort of more specific things, so resistive exercise training is exercise that causes muscles to work or hold against an applied force or weight. And you'll also see the term strength training in the literature. Aerobic exercise training is exercises in which the body's large muscles move in a rhythmic manner for a sustained period, which is an interesting definition, right? It's not as much a cardiovascular definition as you might think. And then a MET we're all familiar with as a physiological measure expressing energy cost of physical activity. This is the ratio of the metabolic rate during a specific activity to a reference metabolic rate, which is set at 3.5 mils oxygen per kilogram per minute. And a MET is our resting metabolic rate. More definitions, so flexibility exercises, which you'll find are more recommended in the older adult population, are activities designed to preserve or extend range of motion around a joint. Balance training refers to a combination of activities designed to increase lower body strength and reduce the likelihood of falling. And then physical fitness, which is a state of wellbeing with energy to participate in a variety of physical activities, which results from the participation in an exercise program and performing physical activity. So physical fitness is really kind of a summary of the cardiorespiratory endurance, the power of the muscle or the power the muscle can generate, flexibility and body composition. So why do we care? This first study is an older study. They looked at adults from 1981 to 1993. They followed a cohort of about 16,000 older adults in this epidemiologic cohort study. And they showed that there's almost a twofold increased likelihood of dying without a disability in those that are the most physically active compared to those who are sedentary. The largest increment of mortality benefit is seen that if you look at sedentary adults to the next highest, so you don't have to be like a super fit older adult, you just need to essentially to be not sedentary. And then a lot of these references, it's interesting, if you look at the literature now, most of the physical activity guidelines came out in like the late 2000s and the early teens. A lot of the literature that's coming out now is focusing on childhood exercise and health, which is sort of an interesting shift in our culture, I think, or maybe a realization that we have an issue with unhealthy children as well, right? So most recent Department of Health and Human Service report, Physical Activity Guidelines 2008 showed a comprehensive summary of the evidence that shows lower levels of physical activity have a higher risk of developing and dying from various conditions. And so what are the protective effects of physical activity and exercise, right? And this is kind of the, why do we care? So first of all, longevity and successful aging are associated with characteristic behaviors, which include exercising regularly, maintaining a social network. And there's some good literature on that, sort of having a community of people. People tend to have longer lives than those who are isolated. And then a positive outlook on life has also been associated with this concept of successful aging. Physiologic characteristics of these healthy older adults are lower blood pressure, lower body mass index, less central adiposity, better glucose tolerance, and then favorable blood lipids. And the only lifestyle behavior that's been identified to affect everything in those sort of categories of broad systems and risk factors is regular physical activity. And so age is really the primary risk factor for developing chronic diseases. So cardiovascular disease, type 2 diabetes, unfortunately obesity, and then a lot of the degenerative musculoskeletal conditions, so osteoporosis, arthritis, and sarcopenia. Basically, if you graph age against any of those things, you'll see that age is a risk factor for the development. So the good news is increased physical activity or exercise can slow the decline that we see with normal aging and improve the health of some of these systems. So studies have shown that there's a significantly, a significant, sorry, decrease in the relative risk of cardiovascular and all-cause mortality among people that are highly fit or active as compared to those of us who are normally fit and active or low fit and sedentary. So this is a graph. It's a little bit similar, but I noticed one of the prior speakers also had kind of a similar concept in their lecture. And so it's this concept of trying to change kind of a natural curve by an intervention. And so they've shown that regular physical activity increases average life expectancy through its influence on chronic disease development. And it's because it reduces some of these secondary aging effects. So high blood pressure, vascular stiffness, bad lipid profiles, those sorts of things. And that there is a graded and inverse relationship between total physical activity and mortality. And that physical activity, even when initiated later in life, can lessen morbidity and improve mortality rates and postpone the onset of disability. So you can see over here in the picture that if you graph age on the X-axis and muscle strength on the Y-axis, that in early life, it's not as important, right? But if you go through adult life and then into older age, that those people who have less strength and strength being a surrogate for fitness are gonna kind of cross over this threshold of not doing good performance and then into disability at a much earlier age than those people who maintain their strength and thus their fitness. So what are the benefits of regular physical activity? So we can minimize the physiologic changes that we see with normal aging. We can contribute to psychological health and wellbeing, increase longevity and decrease the risk of many common chronic diseases. Regular physical activity can actually be a treatment for certain things. So it can help people with improved glucose tolerance, for example, lower blood pressure. So there's a lot of ways that we're actually treating those chronic diseases just by physical activity and then preserving the complications of disability. So there is strong evidence for these conditions based on physical activity. So physical activity can decrease the risk of early death, heart disease, stroke, diabetes, blood pressure, adverse blood lipid profiles, metabolic syndrome, and interestingly, colon and breast cancers. It can prevent weight gain or cause weight loss when combined with healthy diet. And it's a different lecture, but there's a lot of studies that show that diet alone without activity does not necessarily result in weight loss. It can, but it doesn't always. But if you have physical activity and diet, you can get weight loss more easily. You can also get improved cardiorespiratory and muscular fitness with physical activity, decrease in fall, so fall prevention, reduce depression and improve cognitive function. There's some interesting data I'll talk about in a little bit on the role of physical activity and cognitive function. So there's moderate to strong evidence on improved functional health and the reduction of abdominal, so central and visceral obesity with physical activity, and then moderate evidence on weight maintenance after weight loss. And so you have your patient that's done their diet, they're trying to maintain that weight loss. And so physical activity can help with that. And then decreased risk of hip fractures, increasing bone density, again, depending on the type of exercise, decreased risk of lung and endometrial cancers and improved sleep. And so some of the things that we know occur, this is normal aging. So people have a decline in maximal aerobic capacity, maximal heart rate that can be achieved decreases, heart rate and blood pressure response. When you do submaximal exercises, those things can increase with aging. And then tissue elasticity, muscle strength, muscle power and endurance all decrease, again, with normal aging, motor coordination and neural reaction time, gait parameters, including step length, gait cadence, speed and stability decrease, attention span, memory, cognitive processing, and then accuracy of memories decreases, REM and slow wave sleep duration decreases. And so I have a lot of older patients that talk about how they don't sleep as deeply and that's unfortunately a normal part of aging. And then heat and cold intolerance increases and then temperature regulatory capacity decreases. And this becomes important to remember when you're prescribing exercise in the older adults because they're gonna need longer warmup and cool down phases. And then they also need to think about the climate, the temperature that they're exercising in and their ability to regulate that versus needing more external things, warmer clothes or cooling vests or those types of things. Cardiovascular function also decreases including maximal cardiac output, stroke volume, endothelial reactivity, skeletal, blood flow and the capillary density in the muscles. Your lipoprotein lipase activity decreases, total cholesterol and LDL increases, HDL decreases as does insulin-like growth factor one and growth hormone. And then you have decrease in arterial distensibility, vascular sensitivity and your GFR. Baroreflex function becomes more impaired. So you have more issues with postural hypotension and then pulmonary function decreases with aging. And this is depressing, right? As you go through this list of slides, so. The other thing, just looking at metabolic changes. So metabolic rate and energy expenditure decreases and so does appetite, glycogen storage capacity, glycogen synthase, GLUT4 transporter. So that's the transporter that lets us bring glucose into the cells. That's going to decrease. And then your adipose mass increases and the fat-free mass declines. And then you also get more visceral and truncal adiposity and then decrease in muscle mass, so sarcopenia, the type two fast-twitch muscle fibers and then you have more fat inside the muscle and a decline in muscle quality. And then finally decreased bone mass and density and increased bone fragility. So what's the good news? Now that I've just given us this depressing laundry list of all the things that are getting worse. So healthy, sedentary older adults have the same physiologic response to submaximal aerobic exercises do younger adults. Not always necessarily to the same degree, right? So you may not mount as much of a heart rate response for example, but you still have a heart rate response when you exercise. And so you do have those responses and then you also have changes in your control of your blood vessel. Your organs will be perfused appropriately when you exercise. You get oxygen and substrate delivery to the exercising muscles and then dissipation of heat. So the same processes that we know occur in our healthy young athletes occur in our older folks as well. And then in terms of resistive training, healthy older adults again have normal cardiovascular responses and neuromuscular responses. So in terms of like recruiting muscles more efficiently, hypertrophying muscles with exercise, resistive exercise, those sorts of things. The absolute improvements may be a little bit less in older adults versus the younger but you can also have changes in the VO2 max from baseline, metabolic responses and exercise tolerance with aerobic activity, and then increases in limb muscle strength, endurance and muscle size. So you can tell your older adult patients if they wanna go out and do some resistive training, they will actually get that hypertrophy that people like to see. So, and again, older adults may take a little bit longer to achieve these improvements with exercise. They often have reduced exercise tolerance with heat or cold stress. So like we talked about before that kind of warm up and cool down and attention to environment. And unfortunately, when we stop doing aerobic exercise in our older adult patients, they have that same decline in cardiovascular and metabolic fitness as when our younger patients or ourselves stop doing our aerobic exercise. So what are the caveats? So you can see improvement in physiologic parameters that does not always translate to functional gains, right? So a lot of the patients that I think we're all seeing in the geriatric age range have some functional impairments and we're not thinking about having them go out and run a 10K, right? We're thinking about how we're gonna be able to get them up the stairs. And so having some of these things improve isn't always translated into a functional gain. So they've shown that aerobic exercise, if you don't have resistance training or the other training, it'll improve your cardiovascular health. And again, it may increase longevity or may improve blood pressure responses or those sorts of things, may not have as much of an effect on function. However, there is a threshold of strength where a frail adult can have a marked improvement in their function with a very small change in strength. So a healthy older adult may not have as much of a benefit. So I always think about this in terms of our, you know, quite old, quite frail patients. And I think about my mother-in-law lived with us for a while, she was in her eighties, morbidly obese and very frail. And we got a house where she had to go up five stairs to get to the kitchen. And I was worried, like, how are we gonna get her off the stairs? And is she gonna be able to do that? And it actually turned out that just going up five stairs, you know, maybe two or three times a day made her significantly stronger. She stopped falling. She was able to get off the toilet without using her arms. I mean, it made a significant difference and I would not have guessed that five stairs a couple of times a day would have made that big of a difference. So just understanding that like a little bit more makes a big difference. So above the functional threshold, you get your patient up those stairs. She gets a little stronger. The more you have that person keep exercising, the more they have a reserve in strength. And then if they have a stay in the hospital or they get sick with the flu, say, they have a little bit more of a reserve. And again, that keeps them from falling off that kind of that chart, right? So diseases that are positively influenced by exercise. We went through the list before, very similar to the physical activity list. So arthritis, you do have to be careful when you're prescribing higher impact activities. If somebody has osteoarthritis or doubt, they may not be able to tolerate, you know, running for example, but in terms of just a benefit from like biking or swimming or those sorts of things, walking even, right? Arthritis is cancer. There's some good data on cancer being improved by exercise, different types, and then renal disease, coronary artery disease, depression, frailty in the development of disability. Patients who have had strokes can have positive influences in their health from exercise. Impotence, interestingly, there's some literature, mobility impairment, falls, osteoporosis, and then type two diabetes. And so let's switch to talking about different types of exercise. And so there's really four things we're gonna go through. And the first is gonna be aerobic exercise. So what are the benefits in your population of moderate intensity aerobic exercise? So not just physical activity, but you know, getting your heart rate up and getting your patients to exercise at a moderate intensity. So you'll decrease heart rate at rest and with some maximal exercise, they'll have less of an increase in blood pressure during exercise. And then the muscles will start using oxygen more efficiently and vasodilate appropriately. The cardioprotective effects again of aerobic exercise are reductions in the atherogenic risk factors. So triglycerides and increasing in our HDL, reductions in artery stiffness, improved endothelium, Barrett reflex function, and then an increase in vagal tone. What else? So we can reduce total body fat. We can slow age-related accumulations of central, again, that visceral adiposity. And you'll notice that aerobic exercise can result in fat loss from the visceral region by more than 20%, no change in fat-free mass. So when we talk about resistive, you'll learn that you can increase fat-free mass too, but you can decrease that visceral fat just with aerobic exercise. And then like we've talked about a little bit in the lecture, we can improve glycemic control, lipid profiles get better. And the other thing is you can change, and this is true by the way for older adults and for healthy, you know, all adults, you can change the fuel source that you use during submaximal exercise by doing aerobic exercise. So the more you do aerobic exercise, the more preferentially your body will use fat during submaximal exercises. And so all of these things are related to the intensity of the exercise. So the higher intensity exercise changes how you use glucose and changes the whole body insulin action and glycemic control. Fat, use of fat as a substrate is actually more in kind of that middle range, that moderate intensity of exercise. What about resistive exercise? I think everybody's pretty comfortable with recommending aerobic exercise, right? We like to get our patients walking or get them into the pool, you know, everything we can do to have people do a little bit more aerobic things. But what about resistive? And I think sometimes people are afraid to prescribe resistive exercise in older patients, but it's actually been shown to be super helpful. So it can increase the muscle quality, increase muscle strength or power per unit of volume. And the main contributor to this is increased motor unit recruitment. So when people start an exercise program, the first thing you see is this change in the neural recruitment. So the way that the body recruits the motor unit before you have any type of hypertrophy. You can also see decreased activation of antagonists. That's again, thought to be sort of a neural process and then alterations in the muscle architecture, hypertrophy of the type two muscle fibers, those things all improve this muscle, this concept of muscle quality. And so the strength or power that you're able to utilize. If you look at aged matched aerobic exercise athletes, the resistive exercise athletes have more muscle mass, higher bone mineral density, super important, right? For our older folks, and then higher muscle strength and power. And most studies will show an increase in the fat free mass as well. And so that's thought to be due to muscle cross-sectional area. Obviously, if there's not as much hypertrophy, you don't get that improvement in the muscle mass. What about balance? So the third type of exercise that we're gonna recommend for our older adults is balance training. So balance training activities can be all sorts of things. They can be lower body strengthening. There's studies that show that if you're stronger in your lower extremities, your balance is better, which makes sense, but it has been shown. And then even things like walking over difficult terrain, right? So instead of walking on the sidewalk, walking on, you know, we have these sort of rocky courses at the VA that we can have our patients walk on, obviously with, you know, supervision and support so they don't fall. But it's been shown that these types of training activities improve balance and then can help as part of an exercise intervention to prevent falls. Higher levels of physical activity, so walking in particular, has been shown to be associated with a reduction in the risk of osteoporotic fractures, especially the balance component. And there's some debate about how much of that is improved balance alone or if it's the improved fitness. So, you know, sort of as the strength and the balance and all the things going together to prevent fractures. Multimodal programs that show improved balance, strength, flexibility, and walking programs have also been shown to reduce the risk of falls. And it's hard to know kind of which piece, right? It seems like all the pieces together are the best. And there's some good literature that you're probably all aware of in tai chi, which has been shown, again, to reduce risk of falls. What are the other benefits of exercise? So bone health, we've talked about a little bit. So resistive exercise particularly, although aerobic, can also increase bone mineral density in postmenopausal women. And then the more you load the bone, the more likely you are to improve bone health. So stair climbing, brisk walking, there's walking with weighted vests, jogging. Obviously, not all of our patients can jog or tolerate sort of that impact in terms of their, you know, ligament to support and osteoarthritis and that type of thing. But certainly, those things can improve bone mineral density in postmenopausal women. These have been measured more in short-term periods. And then quality of life, this is really important, right? So regular physical activities associated with significant improvements in psychological well-being. And they've shown that physical fitness and exercise training are both associated with decreased risk of depression, anxiety, and then well-being and quality of life. And the more high-intensity tasks you do, the more you have improved depression and quality of life. Other benefits, so a lot of interesting literature coming out on cognition. So showing that participation in regular physical activity shows a reduced risk of dementia and cognitive decline in older adults. There's also an inverse relationship between strength and the prevalence of Alzheimer's disease, even when adjusted for things such as BMI, physical activity, and vascular risk factors. So strength as a surrogate probably for fitness generally, right? And then another study showing muscle strength associated with a reduced risk of mild cognitive impairment, so the development of kind of that pre-dementia state. And then improved working memory. Interestingly, with resistive exercise, heavier loads can help with working memory. And I don't know that we really understand why that is. And then contraindications to participation in exercise. So obviously, unstable angina, severe left main coronary artery disease would be a contraindication. End-stage congestive heart failure, severe valvular heart disease, particularly aortic stenosis we worry about, malignant or unstable arrhythmias, elevated resting blood pressures, so systolic over 200, diastolic over 110, large or expanding abdominal aortic aneurysms, unknown cerebral aneurysm that is unruptured or a recent bleed from an aneurysm or from, you know, any other type of intracranial hemorrhage, uncontrolled or end-stage systemic diseases, retinal hemorrhages or ophthalmologic surgery, any kind of acute or unstable musculoskeletal injury, right, like maybe a recent fracture or recent ankle sprain, a knee injury or something where you're, you know, you don't want to have the person exercising. And then obviously our folks that have severe dementia or behavioral disturbances should not be exercising until you feel like you're, you know, sort of they're going to be safe in their environment. They're not going to be, you know, an issue for anybody else in the exercise environment also. So when we're screening to our patient here in front of us in clinic, and we're trying to figure out if they're safe for an exercise program, what are the things we look at? Well, you want to look obviously their current health status. Are they safe to participate in exercise? Are there medical problems that would require modification? So, you know, is their blood sugar not well controlled? Is their blood pressure maybe high enough that you want to be careful monitoring them while they're starting to exercise? Do they need closer follow-up? Maybe they have arthritis and you're not sure if it's going to be flared up by exercise. So what are the things you need to see them back for? And then specifically, what are the impairments and conditions we're targeting, right? Are we targeting their balance? Are we trying to improve general health overall? Are we looking at their glycemic control? Kind of what are we focusing on? And then what are the patient's goals, right? Does the patient want to exercise? What, you know, what, like a prior speaker said, like what matters to them? You know, sometimes people will exercise because it allows them to leave the house and go see their grandchildren or, you know, be more involved in a church activity, for example. So kind of what is their goal for exercise? And then in the past, if they've exercised, what did they like to do? Some of my patients love getting in warm water therapy pools. Some of them hate water or will not be seen in a bathing suit, right? And so kind of what environment's going to be the best for them? And then what have they succeeded at in the past? So lots of people are good with like, you know, counting their steps, but don't want to be seen in a gym, for example, right? And then what are going to be the challenges? If they can't leave the house, you know, what are the parameters or, or, you know, finding out if they're not able to walk in their neighborhood because they live in the country and it's a rural environment where there may not be, you know, sidewalks or paved roads or something, just sort of thinking of what the, what those things are. And then in terms of history, obviously you want to take a good general history, but you also want to think about some of these things specifically. So is their vision, you know, safe for exercise? Do they have retinal disease from their diabetes? Have they had a stroke and they have diplopia? Do they have cataracts or glaucoma or a field cut where they may not be safe, you know, walking on a crowded road if the cars are coming on the left and they have a hemianopsia, right? Neurologic, if they had a stroke, do they have proximal weakness? Do they have problems with a movement disorder, their cognitive status? Do they have issues with vertigo or dizziness? Super common, right, in our older population. And then have they had falls or do they have impaired balance that you have to worry about? What's their cardiopulmonary and vascular status? Have they had, do they have a history of an aortic aneurysm, say? Do they get orthostatic? Are they on medications that make them orthostatic? How's their blood pressure controlled? Do they have peripheral vascular disease? And then pulmonary status, right? Do they have asthma? Probably for many of us on this call, especially I'm in the Western United States, we had wildfire smoke in the Salt Lake Valley where people couldn't go outside and exercise this summer. And so if you look at the patients that had COPD or asthma, you can't have them go outside and exercise when the sky is full of smoke. So kind of a different world than we'd been in before, I think. And then are they getting dyspnea on exertion or obviously at rest, which would make them maybe an unstable participant in exercise. And then endocrine issues, of course, diabetes, how do they control their diabetes? When people start exercising, they can have improved glycemic control and need to adjust their medication. So just something to think about. And then do they have problems with hypothyroidism and kind of energy reserves? Do they have issues with hernias if they're going to be doing resistive training or hemorrhoids with resistive training, right? And then the musculoskeletal things we've talked about, right? So arthritis, other joint problems, and then insufficiency fractures or osteoporosis. And then from a genitourinary perspective, do they have issues with the neurogenic bladder? Do they have a catheter, right? Some of my spinal cord patients may have issues with having a catheter and thinking about how that, you know, you can't put them in the pool if they have a Foley, for example, right? So just kind of thinking through those barriers. And then a lot of people have stress incontinence, and again, may not want to be in a pool or in an exercise class. And then in terms of physical, obviously a general physical, but then looking specifically at cognition, are they oriented? Can they attend? Are they going to be safe if you send them out to walk? Or are they going to be able to remember the exercises if you give them, you know, something that may be like a printed handout? I may give a printed handout to a 25-year-old and they love it, and you give it to an older adult and they need it, you know, bigger font or, you know, sort of thinking about the role of cognition in following an exercise program. And then obviously memory. In short, your memory impairments are okay as long as they don't impact them to a point where their safety is involved. And then neuromuscular strength coordination, sensory impairments, balance reflexes, those sorts of things, looking at pulses, circulatory status, abdominal exam, and then functional assessments. And in clinic, it's super easy to do a timed up and go or just have them go from sit to stand and see if they can stand up without using their arms. And then you can do things like six-minute walk to track progress. You can do that when they come into clinic, or you can even do that if you're doing video visits. We're doing a lot of those here. And you can have them do things and time them, you know, over the video, and then it gives them something to measure as they continue. What are the things that are going to make us want more assessment? So previously undiagnosed heart murmur, especially if you're worried about aortic stenosis, resting tachycardia or bradycardia that seems like it's a little bit out of place and needs to be worked up, and obviously other arrhythmias. Are they orthostatic? Again, they can exercise. You just need to think about are they going to drop their blood pressure during exercise? Are they going to drop their blood pressure at the end of exercise? Do they need to be wearing compression stockings? You know, are they on medications that may make them a little bit more dizzy when they stand up first thing in the morning, right? Do they have any undiagnosed vascular issues, carotid bruise, abdominal bruise, pericardial rub, aortic aneurysm, and then hernias, just because, again, if you're doing resistive training, you have to worry about that. And then the things that may require modification of the program, so joint laxity, if they have a strength impairment, so proximal weakness maybe, or an asymmetry. And so if they have, say, a hemiparesis, maybe it's mild and they want to exercise and you're not sure if they're, you know, if they're going to need a little bit of help as they fatigue if you send them walking, you know, will they need an assistive device sort of at the end of the exercise session? Is their range of motion impaired where maybe they shouldn't be doing certain kinds of resistive exercise, for example? Is their flexibility impaired, the opposite of the lax patient? And then do they have contractures? And then sensory loss, right? Do they have a neuropathy where you're going to have to have them really look at their feet after they get back from their walk every day, for example, or be careful in, you know, warmer or cool environment because of the sensory loss? And then just to comment on the, how we can set that maximal heart rate, and if we set the aerobic, you know, the aerobic range that you want them exercising, and you can use a, like a Borg perceived rating of exertion and say, hey, I want you to exercise in this kind of moderate category, but you can also use this formula. This has been showed to be better correlating with stress testing results in terms of what their maximal heart rate can be, and so instead of 220 minus age, you do 207 minus 0.7 times their age, and that's going to set it for, again, for your older adults, so people over 65. And then remembering that people on beta blockers, you also have to adjust their maximal heart rate, predicted heart rate equation. So the American College of Sports Medicine and the American Heart Association also recommend a screening exercise tolerance test if you have an older adult, especially somebody that may have some comorbidities, high blood pressure, you know, diabetes, even if it's well-controlled, and they want to go out, you know, they're that, and you've probably seen a few of these, right, that 65-year-old or 70-year-old that's like, I'm going to do a marathon. You're like, yes, that's great. Let's do a screening exercise tolerance test, right? There isn't as clear of guidance in adults over 75, and I think this is more due to a paucity of literature than if we should be doing screening, or maybe a paucity of the adult over 75 that wants to start a vigorous exercise program, right? But just something to think about. And then if you can't do a screening exercise tolerance test, especially in these pandemic times, and certainly certain times of the year in Utah, it's hard for people to come in and do testing when it's icy and there's, you know, blizzards and those sorts of things. It's okay for the person to start monitoring themselves as they start increasing exercise, and they can look for symptoms. Are they getting angina? Are they really short of breath? Sort of, you know, they can track heart rate. There's, like our prior speaker talked about, there's lots of monitors now you can look at, you know, what's going on with their oxygen saturation when they start exercising, so you can do a lot of remote monitoring, which is maybe a good thing that's coming out of the pandemic and our technology advancements. And then obviously, if a person starts exercising and they develop symptoms, then you have to work them up. So if they start to get angina, if they start dropping their systolic blood pressure during an exercise session, or the systolic goes way up, so over 250 millimeters of mercury, their diastolic goes up to more than 120, or if their heart rate is much higher during exercise than you think it should be based on their age predicted maximum, then you want to do further evaluation. In terms of contraindications to resistance training, again, it's an area I think people are a little bit less comfortable with prescribing resistance training. So obviously, if they have unstable angina, you don't want to start them off on a resistive training program, uncontrolled hypertension, so systolic blood pressure greater than 160, diastolic greater than 100, uncontrolled dysrhythmias, recent history of heart failure that's not been evaluated and, you know, cleared by a cardiologist to be doing resistance training. And then again, valvular disease is important, and then hypertrophic cardiomyopathy. So things that are really going to put a lot of stress on the cardiovascular system, you just have to be a little bit more careful in terms of resistance training. Patients with myocardial ischemia and poor left ventricular function may develop wall motion abnormalities, and ventricular arrhythmias during resistance training. And so you really want moderate to good left ventricular function and reasonably good cardiorespiratory fitness without angina. So if they can get to five to six METs, maybe seven or eight without angina and without ischemic ST segment depression, then those people could do resistance, resistive training programs. If they start to increase their METs doing exercises, say mowing the lawn, and they start having a little bit of angina or they do a stress test and you start seeing those ST segment depressions, then maybe resistance, traditional resistance training would not be the ideal thing to start with. And so just looking at some of the guidelines, and I put in the, at the end of the slides, I put all of the guidelines with the current rendition, so you can go and look at them. There's lots of good things out there. So recent update on physical activity guidelines for American Second Edition showed that key things for older adults, like we've talked about, are multi-component activities, so balance, aerobic, and resistive strengthening. And then there are also some guidelines that suggest flexibility training, so kind of those four things, balance, flexibility, aerobic, and resistive training. Older adults really need to look at their level of effort for physical activity related to their level of fitness. So if you have somebody that wants to improve their fitness, but it takes them a lot of effort to walk out to the mailbox or maybe carry their laundry basket up a flight of stairs, that's kind of an indicator of what their level of fitness is, and you want to think about that first. And then older adults with chronic conditions should understand whether or how their conditions are impacting their ability to do regular physical activity. And so again, if they do regular, they walk out to the mailbox, you know, how does that affect their heart rate or their blood pressure, you know, do they get angina from it, kind of that looking at physical activity in the older adults is kind of a gateway to exercise. So you want them to increase physical activity first, and if they're doing well with that, then you can have them start exercising. But really a lot of our patients, certainly I know in my population, aren't even really physically active, right? They're sitting at home and having trouble getting to the mailbox, and so we have to think about that physical activity first. If an older adult cannot do 150 minutes of moderate intensity of aerobic activity a week, which I think most of my patients can't, you want them to be as physically active as their abilities and their medical conditions allow them. And there have been studies that show that even 10 minutes of moderate intensity aerobic activity a week, or even a little bit of increased physical activity can make a difference. And so it shouldn't, you shouldn't think of this in your head as like, oh, if you can't do 150 minutes, then gosh, it's not worth trying, right? Any amount. And so the first thing we do is we try to promote physical activity. And so reduce sedentary behavior and incorporate activity into daily life. And I have patients that like, their goal is walking around the kitchen island 10 times instead of letting their wife go into the kitchen and, you know, get their lunch and bring it back to them, or walking out to the mailbox. That's something that is a pretty common thing that I'll recommend because people want to see the mail. They're kind of bored at home. The mailbox may be a good ways away. And so it's like, just an example, just like in, you know, our younger patients or some of our healthier, older patients, we give them a step goal, right? You get a pedometer and you say, hey, try for 5,000 or 8,000 steps. So increasing moderate activity, less emphasis on the attainment of the high level of activity, again, any activity. And you can do it gradually. So maybe you do 3,000 steps every day for a week, and then 5,000 steps, right? And then 7,000. And then again, muscle strengthening activities. And so I think traditionally we think a lot about aerobic activities or all the things I'm talking about, right? Doing steps, those sorts of things are more aerobic. Muscle strengthening. And you can have patients just doing, you know, holding the back of a chair and doing like mini squats and strengthening their quads, which is great for getting them up out of a chair too, right? You can have them take a can of soup and do, you know, 20 biceps curls with two cans of soup, right? Just anything where they're doing strengthening. It doesn't have to be weights. They don't have to go to a gym, but sort of those lifting and carrying activities are really good for strength. And then, like I've said, any amount of physical activity is preferable to no activity. You want to emphasize individual activity at home and then community-based. So going out with a group, going to, say they go to a book club, maybe having them do some activity, you know, getting that group of people to walk around the library twice before they start, right? So anything where you can get people together doing increased activity is helpful. And then obviously sort of a risk management philosophy, right? So make sure there's nothing for them to trip over at home. If they're going to do a new activity, making sure there's somebody with them so they don't, you know, fall over while they're trying to do their, you know, their single leg squat in the kitchen or whatever. Just, you know, being safe about those things. And so there's a Move Your Way campaign. There's a lot of good handouts, and I put the link at the end. So this is an activity campaign for older adults, and I just clipped a couple of these out of the brochures. And so the recommendation is, again, for moderate intensity aerobic activity is 150 minutes a week. And then you want to do muscle strengthening activity, so two days a week of muscle strengthening. And you have a little picture, I love their little pictures, of the weightlifting person, but then this person is doing lunges and squats, and remembering that those things are muscle strengthening. And that all sorts of activities count. That's the other thing that we teach. So things you have to do anyway, and things that don't feel like exercise, right? Playing catch with your grandson. This person here, I think, is doing Tai Chi. Probably a younger person jumping rope, maybe the older person's holding the rope, right? So different types of activities. And this is a DHHS publication, so the link is down here at the bottom. And there's different fact sheets. There's all sorts of things. There's social media campaigns and, you know, Twitter feeds and, like, all sorts of things. But they're all basically very straightforward things that sort of make moving not as intimidating for the older adult. And so in terms of writing the exercise prescription, so you want to decide on the goals of the exercise program, you know, you with your patient, and you want to figure out what they're interested in and how confident are they that they can actually do something. And so you want to think about the history of things they've done in the past, what are cultural norms for that person, what are their instructional needs, right, can they watch a YouTube video, do they have, I still have a VCR in my house, right, I still have yoga videotapes, so like, you know, what do they have, do they have, you know, do they have YouTube at home, do they, you know, what are their, do they need like a printed brochure, what's their health literacy, right, how well are they going to be able to track their heart rate and use a rating of perceived exertion, and then what do they like to do habitually, do they like to garden, do they like to walk in their neighborhood, are they motivated, what's their self-discipline, and there's a concept that I like that talks about locus of control, so like, do you believe that you can control, like, I can make myself go out and do this versus, like, somebody else needs to tell me, so if a patient that has an external locus of control, maybe as a physician, you write a prescription and you tell them, like, they may not have great self-discipline, but they'll do it if they're told by somebody who's an authority figure, right, and then logistics of exercise, right, so if you have them go to a pool, is there one nearby, is it going to be paid for by, you know, like the silver sneakers program or Medicare or their insurance, do they have somebody that can drive them, can they use Uber if they don't drive, can they use their Uber app on their phone, you know, those sorts of things, they have shown that participants in exercise are more likely to participate, so five to six times more likely to participate in an exercise program if a physician is recommending that they exercise, and so I have written out something on a prescription pad that's like, you know, walk 10,000 steps a day three times a week, and then you hand it to them as sort of a motivating thing, so elements of a successful exercise prescription, you want to have a measurable target, right, so a distance walked or an amount of time doing the exercise or something, or even, like we talked about, even being able to walk, I don't know, walk to the corner to join a friend, you know, be sort of a target that they, that's important to them, like, you know, hanging out with their grandchild, something that's important to them, something that's realistic, and then something that you think they're going to do, will they be compliant, and are you addressing the barriers, and then you also want to give them some guidance on the frequency, the intensity, the type of exercise, the duration, and how to progress it, and so resistive exercise, three days a week, this amount of weight, you know, using whatever, you know, cans or doing squats in your kitchen, and again, it might be a time or it might be an amount, so 10 repetitions, that kind of thing, and then if you can do this well for the first two weeks, then you're going to add this amount of weight or this distance, sort of map it out for them, and then, like we talked about, aerobic and resistive exercise, exercises for flexibility, and balance exercises, and then you want to see what the, what the patients believe, right, so what are, what are their understanding of exercise, what, you know, do they understand what the behaviors are, what are the benefits, do you know, kind of get a sense of, kind of readiness, readiness for behavior change, right, and then what's their current fitness level and their willingness to be in an exercise program, and I put a link in here on, there's a, there's a readiness for activity questionnaire, I looked at this, this is mostly focusing on, on health-related things, do you have problems with breathing when you walk, do you, those sorts of things, kind of not psychological readiness for exercise, but like physical readiness for exercise, and then if they have health risks, they need to be advised, so, you know, if you do this, you need to stop, if you notice chest pain, or if you get unusually short of breath, you'll notice if you exercise, your blood sugar may go down, and you'll need less insulin, so let's have you monitor it, right, so making sure that they understand that, and then also the health risks that they, that they face if they don't exercise, right, so, you know, studies have shown that if you don't get your blood sugar under better control, blah, blah, blah, and the exercise will actually affect that and help it, and if you don't want to take your insulin, you want to keep taking your metformin, you can go out and walk, or do this resistive training, and it'll actually help you not need to start that insulin, so just kind of, kind of tying that exercise prescription in, and then looking at other techniques to improve adherence, and so this is interesting, and I, I highlighted it in yellow, but it had me thinking a little bit too, because of the pandemic, I think we've learned that some people like social, you know, social interactions, and book clubs, and getting out with other people, and they were super sad when they were on quarantine, but we have a whole bunch of people in our society that were happy to be, you know, at home, and like solitude, and that are really introverted, and are dreading going back to work, and so if you're paid, so, so, so I think the traditional teaching is like, oh, you should join a group, right, you like do it in the community, like I said earlier in the lecture, there's a lot of people out there that don't particularly like being in groups, and that that's okay, so like, if you want to do tai chi in front of your tv, or maybe you don't want people to see you doing tai chi, right, like that solitude is actually okay, whatever they like, if they don't want to go to a gym, like don't make them go to a gym, right, say, of course you can do this at home, or do it just with a good friend, and then again, written instructions, so, so especially our older adults can remember, like, what are the guidelines, what are the benefits of exercise, why am I doing this, how do I do that exercise again, I'm a big fan of printed, printed things, be it printed out, or emailed, or, or during the pandemic, I assembled a whole bunch of YouTube videos, I'm sure you guys have things like that too, you know, this is how to do this exercise, this is how to use your TENS unit, here's the video, I'm mailing the TENS unit to you, right, so, so, just kind of ways to reach your patients, and then remembering that compliance is facilitated by a support network, it may be their family, it may be their community, it may be you as their physician, right, and so, yes, you did more of this, that's great, or, oh, you didn't do as much as you wanted, it's okay, you know, keep giving it a try, or what can we do differently, so, really helping support them, and then, as a provider, you want to arrange follow-up, you want to make sure their health is monitored, right, so what's going on with their insulin, and their blood sugar, and their lipids, and their, all those things, they can journal, they can send you weekly records, they can do, you can do video follow-ups, or phone follow-ups, and just make sure you, you encourage them to continue participating. Let's talk a little bit about barriers to exercise, and so, there, I have about 12 of these, I think, and I'll touch base on each one of them, and these are, these are really for everybody, right, this isn't just for the older adults, so, self-efficacy, I think, is, is a barrier, so I think a lot of people feel like, you know, they've always been overweight, they've never been active, they, like, I'm not athletic, right, you know, I was always picked last on the, on the baseball team, which is true, you know, so, like, they may not feel like, oh, go out, be an athlete, that may not resonate with that person, so what are the, you know, how do you help them build that self-efficacy, so exercises that, that are easy to do, they want to go out to the mailbox, have them start by walking around, you know, around the kitchen island, or out around the block, or something, they don't have to go to the gym, right, and then, again, this idea of frequent encouragement, and, and just adding increased activity into everything they, you know, anything they do every day, just do a little bit more activity, and advance gradually, and then they feel like they're succeeding, right, oh, I was able to do that, you know, oh, I feel better about myself, oh, that wasn't that hard, oh, you know, whatever, I didn't have a heart attack while doing it, you know, all those things help with self-efficacy, and then attitude is a barrier to exercise, so a lot of people don't want to exercise, I don't know, because it's hard work, and you get sweaty, and, you know, people see you in your bathing suit, right, like, and so what are the things we can do to kind of convert that perception to positive, this is going to help you see your grandchild, or this is going to help you not need as much insulin, and then what's enjoyable, like, if they like shopping, yeah, go walk in the mall, stop in a store every once in a while, sort of things that make the, the, the patient's gut reaction to exercise be a positive one, and then how do we overcome discomfort, right, a lot of our patients have, I don't know, knee arthritis, or back pain if they try to exercise, how do we, how do we, or they're afraid of discomfort, right, I'm going to get sore after I exercise, or, oh, it's going to flare my joint pain, so we start with varying the intensity and the range of exercises, cross training, so, like, it doesn't always have to be walking or biking, it can be different things on different days, start them off slowly, and then don't have them overdo things, so don't go out, resistive training, lift a bunch of weights, and have delayed muscle soreness, and then be sad, because you're sore, right, if they have a disability, you can adapt the equipment, you can adapt exercises, they can get a trainer or physical therapist, I'm blessed to work in the VA system, where we can get a lot of equipment for our disabled patients, so I can get them standing frames, and recumbent bikes, and those sorts of things, but there are community resources, there are exercise programs for people with disabilities that may help them get out and exercise, and we even, we have people in Utah that are skiing, we have, it's called the TetraSki, it's a modified ski for tetraplegic patients, so lots of ways you can modify exercise to overcome that disability. What about a fixed income? A lot of patients say, well, I can't afford a gym membership, or I can't afford to go to the pool, and so what can they do? Well, they can walk, they can use household items, like we talked about, canned goods, or exercise bands that are super inexpensive, or just that lifestyle, walk to the grocery store, walk back carrying your groceries, right, that's both aerobic and resistive exercise, so just because you're on a fixed income doesn't mean that you can't exercise, and you don't need super fancy running shoes, right, so lots of ways to overcome that, that issue if people have concerns about that. Cognitive decline is another tricky barrier, right, so they may not remember to exercise, or they may not remember the exercises, right, and so, again, you can encourage physical activity, you can have the family help them, you can give them pictures and instructions, lots of things you can do to help them, then, and, and, and reassurance, I think, too, right, so you do 12 reps instead of 10 reps, that's okay, right, so it's okay to not remember exactly what you're doing during the program, as long as you're moving and being active, and then what do you do about environmental factors, like I said, here in Utah, smoke in the summer, or super cold in the winter, what do you do, you get out and you walk in the mall, there's lots of senior centers, depending on where you live, I think, but in, in sort of our urban areas, I think there's a lot more places now where you can get a membership as a senior, where it's not very expensive, so you can be inside, and then, again, that whole concept of active, active lifestyle, instead of, like, going to a gym, right, if the patients have illnesses that make them feel bad some days, or if they have fatigue, again, you can tell them, it's okay, like, if you can't get to that moderate intensity aerobic exercise every time you're out, it's okay to have, like, a, you know, just a gentle exercise twice a week, and then add that higher intensity on a day that you wake up feeling really good, right, any exercise is better than no exercise. What about fear of injury or falls, and, of course, we're afraid they're going to fall, right, so, like, we talked about balance and proximal strength training initially, making sure they're wearing appropriate clothing, right, don't be exercising in your flip-flops or your clogs, make sure they're, that they have equipment, if they have handrails, if they need them for walking, or a walker, or a cane, make sure somebody's with them when they first start, make sure they pick a route where they're not going to trip over a curb, and then just be careful and start slowly. If they have poor balance and ataxia, sort of like the one above, right, assistive devices can be helpful, it can help them walk further, better to walk with your cane further than without it, right, you just want them safe, and then lots of exercises nowadays from a sitting position, there's a lot more videos, I think, out there now that have the graded, I don't know if you guys ever do, like, yoga, where you have, like, the super flexible person, and then you have the moderately flexible person next to her in the picture, and then you have the not at all flexible person, and so you can pick and follow the person in the video that, you know, resonates with you. So, like, we talked about aquatic therapy is great if they have poor balance, or if they have arthritis, or hemiplegia, lots of things, I mean, the nice thing about the pool is you can't really fall, as long as you have, like, something, you know, so you don't drown, right, like a pool noodle, or a kickboard, or something, people can walk back and forth, and it's great for lots of different conditions. Another barrier is habitual inactivity, and so if patients are, you know, used to sitting on the couch, and used to having their spouse bring them their lunch, because they don't want to get up, put activity into their routine, so, like we talked about, exercising in front of the television, walking around the kitchen island, all those things, you can tell by my examples that my patients are fairly sedentary, right, but those things just get people a little bit more up, and then this idea of, like, being with a group, other people that are doing it as well, oh, Joan is walking, you know, like I have a Fitbit, and I follow steps, and we have, like, step competitions at work to see who can get to 10,000, you know, the soonest in the day, for example, so just kind of getting that community. So, in terms of special considerations, we've talked about this already, so we have a very, often a very inactive baseline for our older adults, and so it's okay to start with light intensity activity that's less than 10 minutes, so any number of minutes, 10 is a good start, I think, but even five is okay, and then, again, you progress the intensity, the duration, intensity, the duration, and the number of days of week, and so start them with walking, and then they can walk more, you know, faster, they can walk with, you know, wrist weights, you know, and progressing it. Functional limitations should be considered, obviously, if they have poor balance or limited flexibility, if they get sick, and they're in the hospital, or they have a fracture, and they're down for, you know, whatever, eight weeks or 12 weeks, start back down at a lower level, and then progress the exercise program, and remember, like we talked about, you need a longer warm-up, longer cool-down, and you want to build that in into the exercise program, and so it's part, just that warm-up is, they don't have to, like, stretch before they go for their walk, you sort of have them start walking slowly, and then increase the pace, for example, and then physical, a physically active lifestyle, so this is the, kind of, the summary of the activity recommendations for older adults, and this has not been updated since 2009, so I alluded to this at the beginning, the American College of Sports Medicine has lots of recommendation statements, and this is ACSM and the American Heart Association, most of them, it looks like, recently have looked at, like, activity for obesity, and activity for children, so these are the most current recommendations since 2009, but they're still pretty applicable, right, and so recommendation for moderate intensity aerobic exercise, 30 minutes, five days a week, if they can, or vigorous, 20 minutes, three days a week, and then combination of moderate and vigorous intensity activity for this, to meet the 150 minutes a week, and then, in addition, the light intensity activities, right, your ADLs, and your walking, taking out the trash, that kind of stuff, and this is just an example, so this is for the older adults, things that are, quote-unquote, moderate intensity, are walking briskly at three to four miles an hour, cycling leisurely, so covering less than 10 miles an hour, swimming with moderate effort, doubles tennis, mowing using a power lawnmower, any kind of painting, home repair, you know, carpentry out there with your screwdriver, leisurely canoeing, I don't, I don't know very much about leisurely canoeing, but there you have it, fishing, and then golf using some kind of a pole cart, so maybe not having the caddy carry your stuff, maybe you carrying it, so these are all things, and this is a good table, I think, for, for, for our older adults who are starting exercise, and it doesn't have to be, you know, running a marathon, it can be these sorts of things instead, and again, you'll see at the bottom, moderate intensity is three to six mats, in an older adults, it may be a little bit lower, depending on their, their fitness, and then in addition to the things we talked about on the past couple slides, muscle strengthening activity, right, so you want that 150 minute a week aerobic activity, you also want a muscle strengthening activity, and so this is using major muscles of the body, and really looking at, like, proximal lower extremities, right, so quads, glutes, core, and then, and those things are going to be both strength and endurance, and then major muscle groups in the upper extremities, so things that will help people lift, and push out of the chair, and those sorts of things, so pecs, and lats, and biceps, triceps, those things, so the recommendation for muscle strengthening activity from ACSM is eight to ten exercises, two non-consecutive days per week, using major muscle groups, and so again, this may be, you know, bicep curls, tricep push-ups, a bench press, that would be three, right, squats would be quads, those sorts of things, so eight to ten, and then you want to try to use an amount of weight that lets them get to 10 to 15 reps for each exercise, but not further, so if they can do 10 or 15 curls with their can of soup, you know, that's fine, if they, you know, if they can do 25 of the same can of soup, they need something heavier, and so just kind of titrating up, that's true in the younger population, looking at like the one rep max, and the 10 rep max for prescribing exercise, same concept, but you want to be able to do 10, but not do the 11th rep, and that's how you know that it's a good amount of weight, and then participation in aerobic and muscle strength activities, and again, this is just the summary from this, I apologize, it's a little bit repetitive from different guidelines, if the person has done those minimum amounts, right, that 150 minutes a week, and the two days a week of non-consecutive resistance exercises, they can do more if they want to improve fitness, improve management of an existing disease like their diabetes at a higher level than kind of that, you know, this is like everybody should do this, or further reduce the risk of premature health conditions, and so in addition to aerobic and resistive, older adults need to perform activities that maintain or increase flexibility, this recommendation is two days a week, 10 minutes a day, and then maintaining an improving balance is the fourth thing, like we talked about, so aerobic resistive flexibility balance, and then like we talked about, if they can't do it the way we want them to, any is better than none, and then you help them come up with a plan, and it may be a gradual stepwise approach where they start with aerobic, you add resistive, then you add balance, then you add flexibility, right, and so you have a plan to do this, and I think that's it, so I put some some resources for your patients, there's some really good resources out there, which I didn't know until I started looking at this topic, so the CDC has activity, these guidelines on activity for everybody, go for life is a good website, this international council on aging, silver sneakers tells you about the fitness benefit that that our medicare patients often can have, arthritis foundation specifically for arthritis, the NIH has exercise and physical activity guides, sit and be fit is a nice website, it has all sorts of things you can do sitting, so heart rate things and strength things and those things, and then this is a little bit of a plug for the VA, but the VA actually has some amazing handouts as part of their move program, so lots of very focused and concise things on exercises and strength training and those sorts of things, and then these are the current guidelines, and there's two pages of these, so you can kind of get a sense if you want to look something up, and so American College of Sports Medicine has a few different ones, American Heart also has things on diabetes, we went through some of these and not the other, so the orthopedic society has things on osteoarthritis, we talked about this DHHS guideline, this ACSM guideline we also talked about, there are ones from the surgeon general on bone health and osteoporosis, there's guidelines on hypertension and exercise, let's see what else, there's one on stroke, there's one on cardiovascular disease, so there's lots of different things out there, one on cholesterol, and so if you have a patient that's concerned about something very specific, you can you can go to these, I tried to have this as a comprehensive resource, and so that is the end. My, what a treat we had today. We had great speakers, Dr. Patel, Dr. Medina Walpole, Dr. Mendelsohn, and Dr. Garstang. It was a real treat for the geriatric community. Thank you so much for spending your time with us and giving us excellent talks. And they're all recorded and will be available for those community members who are not able to attend today. And we hope that we will see you again sometime in the coming meetings. And I can't thank you enough for the wonderful, wonderful information that you gave. Every aspect of your talks was very, very useful for the whole rehab community and the academy members. And I also thank Sean and Brian for their excellent technical support for all of us in preparing and doing. And above all, I would like to thank our academy to give us the opportunity for the geriatric rehab community to host this three-hour lectures that are immensely useful for the whole community. Thank you. And now I'll open it up for questions and I would request, ask Dr. Mendelsohn first, because he has, he and even Dr. Medina Walpole have a conflict at four o'clock. Please shoot your questions to them. I think there may be some in the chat box. Let me see what's in the chat box. Yeah, thank you. I learned a lot listening to you guys, my fellow speakers. So thank you. I don't see anything. All of your talks are wonderful. And we're always looking for geriatric round speakers. So don't be surprised if you get an email from me. It's so easy virtually now, isn't it? It is, isn't it? You know, it is so useful to see the managed care for the fractures. I mean, hip fractures are becoming so, you know, so many, 300,000 a year. That's a lot. And so, and they're not going to get any less unless we jump in and intervene to prevent and give them balanced exercises and prevent falls. Actually, it's interesting. There was a dip in fractures due to the use of bisphosphonates, but the numbers are climbing again. So there was, it was, it's almost, it's almost become bimodal because obviously the population's aging. And actually the, because of the bisphosphonate associated fractures, there's been a fall off in compliance with bisphosphonates too, which is sort of interesting. So for every bisphosphonate associated fracture, it prevents like 25 to 30 fragility fractures. So as soon as you, you know, as soon as you start paying more attention to that, you actually end up with more overall fractures. You know, it's a double-edged sword because you want to treat osteoporosis with bisphosphonates and at the same time they're associated with falls. So you got to be an enemy in fractures. So it's a balancing act to no pun intended, but I think it's, it behooves on us how important it is to first screen, be cognizant of, you know, how to recommend the exercise appropriate for each patient. And then maybe I always say it's not, you know, prehab, I call like for instance, yeah. And then rehab and I say mayhem, that means maintenance. We should not forget our role in checking out later on. Are you doing your exercise? Let me see your documentation or what have you been able to do more than what you did in the last visit? I think that mayhem is really critical thing that we should not miss. And Dr. Patel, your idea of even non-expensive alternatives for pain is so important. And you have shown the results from various studies. I think that is something that very useful for all of us. And we deal with pain in every aspect of life, right? I mean, we see children, we see in older adults. So I think it's a good, maybe we should incorporate the curriculum, that yellow powder you showed us, that should be incorporated in the diets maybe, you know. I did have a question for Dr. Patel on the, do you say, is it curcumin? Yeah, curcumin. Yeah, different ways to pronounce it. Yeah. So is the black pepper as helpful for bioavailability as the encapsulated, like the phosphatidylcholine versions? Yeah, yeah. Thanks for your question. I did see it in the chat. So, you know, there are no studies that show a clinical response based on the dose. But what I would say is that, so the lecithin formulation is generally, it's a curcumin combination. And in my talk, you know, I kind of espouse using the whole turmeric plant, which, you know, because the turmeric powder contains, you know, millions of compounds, aside from just the curcumin. So, you know, the black powder increases it by basically 19 times. Or, well, yeah, I mean, it should get you what you need. There's been no study head to head. And in the study that looked at the lecithin formulation, it's, it increased it by 29 times, compared to the other formulations of curcumin that didn't have black pepper in it. So there's not really been a head to head study that compared black pepper formulation to the lecithin formulation. But it is a curcumin only formulation. So I would, you know, recommend the whole turmeric plant. And yeah, the other thing is that, you know, supplements for most patients are not covered by their insurance. And so when I'm treating like a Medicaid population, it becomes a question whether or not they can afford the medicine. So yeah, generally, I don't recommend these formulations, because I try and keep the medicine as inexpensive as possible. And yeah, it gives good results, as you saw the studies show that it's comparable to NSAIDs, prescription strength NSAIDs. So, you know, I feel like that. But yeah, to the relevance of the other talks, I feel like if patients have better pain control, they can do some of these exercises and maintain their function. And, you know, as Dr. Garstin mentioned, less fractures and falls and the rest of you. I have another question for Dr. Mendelsohn. How often do you follow up with their osteoporosis, like dexascan checkups after they have a fracture and go home? Yeah. So in Rochester, the style is mostly to turn them over to the fracture liaison service, which handles most of that. And it's highly, the follow up rates and what you do is highly dependent on the patient's overall prognosis. So the 40% of our patients come from nursing homes. So most of that's going to be left to their institution. And many of those fractures are really, the treatment is really palliative. So the value of bisphosphonates and other interventions for those patients, it's a wide spectrum. Some really should be treated aggressively and some really shouldn't. So there's, that's one of those things where one size doesn't fit all. In terms of the fracture liaison service, they typically do dexascans about every two years. And most fracture liaison services, I think, are very much geared towards medication management. But as everybody's mentioned, there's so much more to fall prevention and injury prevention than just the medications. And I mean, I know you know about this. You can teach older adults how to fall so that they have less risk of injury when they do fall. And of course, gait training and strength training reduce the likelihood of injury. Teaching people to use the right footwear so the energy that they hit the ground with is less energy because their foot doesn't slip at the same speed. And all those things are very subtle, but they make a difference, especially on a population basis. And what is the incidence of periprosthetic fracture on the other side? Yeah, rising, rising quickly. We're doing so many fractures and the repair of periprosthetic fragility fractures is becoming a real art. And Highland is certainly one of the centers for that. Hard to tell. I don't really know the numbers off the top of my head, but we certainly, we take care of about 500 fragility fractures a year, 550 fragility fractures a year. I would say at least, probably at least one in five are periprosthetic, to be honest, because we collect all the periprosthetic fractures from the region. Thank you. Sometimes you need both a trauma surgeon and an arthroplasty surgeon to do the case that you don't have one person that can really do the whole case. Now, Dr. Medina Walpole, your initiative was so good. Is this getting widespread or is it just a, you know, a model that they started and it's just very slowly rising? No, I think it is getting widespread. And I think there's been challenges. I think we all, you know, three years ago, we jumped right in. We said, we're going to do this. And I think part of the challenges were some of the time it took, you can join an action community. We weren't sure what that meant. It was a big commitment. And for Daniel and I, a little bit overwhelming because we wanted to, like I said, do the entire health system. He said, let's just do it at Highland. No, no, no. It says it's a friendly health system. We're going to wait. And in the end, we found champions at each site. So no, this is really, this is something that we are embracing as an institution, but I think also as a country. So for instance, in New York state, our former governor wanted to have at least half of the state age-friendly, I think within the next year or two, and also the health association of New York, which really guides our hospital care. They are all about age-friendly too. So once they came on board, I started to get emails from people that I had been talking to like our CMO and things saying we need to do this. So I think, I think it is a movement that is taking off, but it takes a while and it's, it's pretty easy to get the certification, but we want it to mean something to us. We really want to do it right. And a lot of this has involved an EMR build. So you can extract the right amount of data. So for instance, for what matters, we can pull code status on everyone, but that's not what we want to use right now. That's our placeholder for what matters, but really what we're trying to do now is in the social work admission assessment. And at a frequent basis, we're asking the individual what matters to them, right? And everyone's going to say going home, but there's many other things. And so having an EMR build where we can actually pull that is important. So we're working on all of those things concurrently. Now, do you see any barriers at any distance from participation? I think the barrier is well, I think there's buy-in, but it's just one more thing, right? So, and Daniel may have some comments too. So now we're saying to the nurses, okay, we want you to do the confusion assessment method, every shift and document, and they can do that, but it's only, you know, you can do all these things, but if the care team is not looking at that data, it doesn't matter, right? And that's what's been happening. So it's getting the whole team on board and coming up with doable metrics. When we looked at all the medications, we said, well, we shouldn't be prescribing benzos, antipsychotics, opioids, you know, we did this whole litany of meds. And then our numbers were horrible. We said, that's too hard. We need to pick the worst. Let's pick the top two worst that we don't want prescribed. And we'll start, you know, going, trying to, I don't know, sort of refine or narrow down. Daniel, I'll let you talk too. Yeah. I think, you know, the biggest barrier is actionable data in a timely fashion. And that's why I think working on the build with the electronic record is so important. If you can't pull out reports quickly that you can act on, like, again, he said it, I mean, it's not really that informative, whether somebody has an advanced directive or not, if there's no integrity behind it, it doesn't do any good. If a CAM score is getting recorded, if nobody sees it, nobody acts on it. So, you know, getting the data in a manageable digestible form is really what you have to do. I always say, if you don't measure something, you can't change something. You have to measure it to change it. Have you had any record of patient reported outcomes on this? I mean, patients? Not yet. We're working on that. I think our colleague, Jen Muniak, who's really a wonderful champion, is very close to getting the right elements in place that we'll actually be able to report out. And we have another colleague that's working very hard on getting the CAM instituted into a clinical pathway that will allow us to react in a thoughtful way in collaboration with the nursing staff. Really a brilliant model that I think is going to take off and be the standard. Thank you all once again. I think Sean wants me to wrap up, but I have one question for Dr. Garstang. I think I'm going to sign off to go to my next meeting. Thank you so much for this opportunity. It's been wonderful to meet all of you. Wish you the best. Thank you very much, Dr. Walpole, and thank you, Dr. Mendelsohn. And we'll hope to see you again soon. I know. By now. Dr. Garstang, my question to you, a lot of older adults have anemia and they have difficulty exercising. What do you recommend for them? They have difficulty exercising because of fatigue or being lightheaded. I think, again, anything they can do. I mean, they could certainly do balance and flexibility training. They may not be able to do aerobic exercise if they have, I don't know, more angina or more lightheadedness. But again, I think the principle of having them do whatever they can do, right? They just feel more than any particular symptom. Yeah. Yeah. I mean, that's hard. I mean, there are a lot of conditions, unfortunately, that have people feeling fatigued and I don't know. That's hard. Yeah. Yeah. I'm just trying to think if you had anemia and you exercise more, if that would help your bone marrow, like make more red cells. I don't know. Yeah. Yeah. We know if they only can get, it's like developing endurance, doing repeatedly and doing a little inch by inch up, right? Yeah. I mean, you could have them do sitting activities. Yep. Yeah. Right. Like a, you know, resistance thing, sitting like stretchy bands or yoga things for, or, or even just like sit to stand from a chair without arms 10 to 15 times. Yeah. But it's hard. You're right. Thank you so much, Dr. Patel, Dr. Garstang. Yeah. Nice to see you. Thank you. And thank you, Brian. And thank you, Sean, for your wonderful support. And thank you, Academy. Bye-bye. Bye-bye everybody. Bye.

Project ECHO Geriatric Mental Health in COVID-19 program

older adults

pandemic

16-week curriculum

Zoom

healthcare providers

mental health

case-based learning

peer support

age-friendly health system

resilience

virtual care

social determinants of health

crises

exercise