(left to right) Anna Maria Dunn, MD, clinical assistant professor, Lisa Luciano, DO, clinical assistant professor, Jonathan Quevedo, MD, clinical assistant professor, and Keith Cicerone, PhD, professor, all from the RWJMS Department of Physical Medicine and Rehabilitation. Not pictured is Iqbal Jafri, MD, associate clinical professor.

Improving function and quality of life in the aging population by Keith Cicerone, Jonathan Quevedo, Lisa Luciano, Anna Maria Dunn, Iqbal Jafri

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he Department of Physical Medicine and Rehabilitation at RWJMS—in partnership with the JFK-Johnson Rehabilitation Institute and the Center for Traumatic Brain Injury—has made a commitment to the aging population by providing ongoing research and services to this group, primarily in the areas of cardiac rehabilitation, pain management and traumatic brain injury.

People older than age 65 have a higher incidence of traumatic brain injury (TBI) than any other demographic group and are at risk for increased severity of injury and functional loss. Unlike in other age groups, the most common cause of TBI in the elder population is falls, which may indicate the greater prevalence of co-morbid vascular or neurologic illness. The factors that contribute to the higher risk for falls also predispose the elderly to motor vehicle, pedestrian, and recreational accidents that may result in TBI. Traumatic brain injuries due to motor vehicle accidents are common in the elderly, as they are in other age groups. But unlike accidents involving younger adults, the majority of motor vehicle accidents involving those 65 and older are low-speed, low-impact collisions.

Despite the lowered velocity at impact of these motor vehicle collisions, they often produce significant mortality and morbidity. In people older than 70, the likelihood of intracerebral lesions is estimated to be six times greater than the risk of chest, abdominal, or pelvic injury in collision survivors younger than 40. Recent research conducted through the Traumatic Brain Injury Model System (TBIMS) national database, supported by the National Institute on Disability and Rehabilitation Research, has examined patterns of rehabilitation utilization and effectiveness for the elderly population. Criteria for inclusion in the database are: age 16 or older, presentation to a designated TBIMS hospital emergency department within 24 hours after sustaining a TBI, and receipt of acute medical care and inpatient rehabilitation within the TBIMS.

The analysis of functional gains during acute rehabilitation suggested that older adults are capable of improvements in cognitive and neurologic function and can successfully return home after rehabilitation. However, after controlling for initial injury severity, those older than age 65 required twice the rehabilitation length of stay, made half the rehabilitation gains, and had twice the nursing home placement rate as compared with patients who were age 50 and younger. At one year post injury, those 65 and older had a two- to-three-fold increased risk for persistent physical and
cognitive limitations compared to younger age groups. These findings suggest the need for research into additional preventative and rehabilitation strategies for the elderly. Current research efforts are being directed at the possible cognition-enhancing and neuroprotective benefits of cholinergic agents in the elderly, as well as community-based interventions to optimize functioning and quality of life.

Thomas Strax, MD, clinical professor and chair, RWJMS Department of Physical Medicine and Rehabilitation

Older patients being treated for cardiac problems and those who have undergone surgery for coronary bypasses, valve replacements and heart transplants require specialized rehabilitation treatment with close medical and cardiac monitoring. Particular attention is placed on regaining function within the community. Ongoing retrospective studies revealed that in 2006, despite being admitted at a lower level of functioning, patients had a decreased length of stay by two days as compared to 2005. Evolving therapy and medical studies have enabled patients to achieve their individual goals in a shorter period of time. Over the last five years, the Cardiac Rehabilitation Department has treated more than 10 patients with hearts transplants. Retrospective studies of these patients and those with critically diminished cardiac capacity are fostering the development of focused therapeutic strategies and monitoring, which will improve functional performance, quality of life, and, we hope, overall survival.

Pain management in the older population is problematic largely because of the potential side effects of opiates and other oral medications. A research pain management team is focusing on treating this population of patients with sphenopalatine blocks on a monthly basis. The sphenopalatine block puts a local anesthetic such as lidocaine or tetracaine on the sphenopalatine ganglion. The numbing agents block the transmission of pain signals, providing up to 50 percent reduction in pain. Ongoing research is exploring applications for this procedure in the treatment of facial pain from trigeminal neuralgia, headache, fibromyalgia, and RSD/complex regional pain syndrome.

Stroke is one of the functional scourges of an aging population. The treatment of patients affected by a stroke has shown remarkable success in improving quality of life. Only a few of the new technology strategies have been shown to improve the rate of achieving positive outcomes or reduce the cost of care. We are evaluating and comparing functional electrical stimulation of the hand and robotics with traditional care in effecting a positive outcome.

The Johnson Rehabilitation Institute-TBI model system recognizes the need for a continuum of care, ongoing research, community reintegration and addressing the ever-changing, long-term needs of this population.

Thomas Strax is professor and chair, Department of Physical Medicine and Rehabilitation, RWJMS, and medical director and vice president of JFK Johnson Rehabilitation Institute. He received his medical degree from NYU School of Medicine; and completed his PM&R residency there. He has served as president of the American Academy of Physical Medicine and Rehabilitation and president of the American Congress of Rehabilitation Medicine. Dr. Strax spearheaded the Access to Assistive Technologies Summit held in 2003, sponsored by AAPM&R and the Foundation for Physical Medicine and Rehabilitation. He has received numerous awards including the AAPM&R’s Distinguished Clinician Award, the Governor’s Pride Award, the Clara Barton Medical Science Award, the Gold Key Award from ACRM, the Solomon A. Berson Medical Alumni Achievement Award in Health Sciences from NYU Medical Center, the Spencer Lectureship Award from Baylor College of Medicine, the Frank H. Krusen Award from the American Academy of Physical Medicine and Rehabilitation, and the 2005 INDE award from the American Medical Rehabilitation Providers Associations (AMRPA). Since 1979, Dr. Strax has been a reviewer for Archives of PM&R, and he has authored or co-authored more than 60 publications.

Keith D. Cicerone, PhD, is the director of neuropsychology, rehabilitation psychology and cognitive rehabilitation at JFK-Johnson Rehabilitation Institute. He is a diplomat in clinical neuropsychology of the American Board of Professional Psychology, and a fellow of the National Academy of Neuropsychology, the Division of Rehabilitation Psychology of the American Psychological Association, and the American Congress of Rehabilitation Medicine. He has more than 50 publications to his name in the area of neuropsychological rehabilitation.