Embracing Life: Balancing Risk and Reward

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave shares shares how by being too quick to limit risk for our patients we can expedite deconditioning, worsen social isolation and mortality of our patients.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

JEFF MUSGRAVEWelcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Jeff Musgrave, doctor of physical therapy. Super excited to be talking to you about everyone dies, not everyone lives. So I am fresh off an epic motorcycle adventure with the CEO Jeff Moore and Matt in the bike fit division of our company. And it was an epic trip. And a great way to summarize this trip is a quote from a motorcycle brand that I've started following recently. We don't promote this brand in any way, I just thought the quote was great, which is, everyone dies, not everyone lives. So just to kind of set the stage a little bit, I'm new to motorcycling, brand new thing, it's something just recently I decided was Important to me a risk that I wanted to take Lots of people in my life very well-meaning that care about me deeply Wanted to just share all the worst case scenarios. They wanted to instill enough fear in me To maybe prevent me from going or to make sure that I'm super safe and and I get that right there is some inherent risk Taking a motorcycle up a cliff face lots of things can happen Some injuries occurred, there were some wrecks, but most importantly, there was the opportunity to really live life. in a very deep, meaningful way to accept some risk, to have a lot of fun, to have some fun stories, to make some fun memories that are gonna last me, I hope, the rest of my life. And I think this is very relevant whether we're talking about older adults or even younger adults. But I think we come in contact with this type of problem with older adults most common. So commonly with older adults, In that same vein, we're trying to help our patients be safe. We want them to make decisions that are going to prevent injuries, prevent falls, and for a lot of our older adults, a fall can be a very serious thing. I'm not making light of that in any way. We know that lots of our older adults are living with low reserve. and low physical resiliency and reserve, so they have very little margin. So if they fall and they have decades of deconditioning, their bones are weak, their body systems are not prepared to help them recover quickly, and this can have a huge impact on their life. So I want to say I recognize that, and we preach this fitness forward approach to try to help build that reserve and build that resiliency, but still what I tend to see when I interact with clinicians, working with older adults, is we treat older adults with kid gloves and we don't want them to be put at any level of risk. But I think the thing that we forget is what they're missing out on. What are the things that they want to do that are risky and how meaningful may they be to their life? So I'd like to give you a few tips just from my clinical experience to help patients live until they die. We want them to live their life as fully as possible, and I think sometimes we don't think about, when we limit our patients, what the downstream effect is for their life. So I've got a few tips here that I think will be helpful, and then we'll go through an example of what this could look like. So, you know, many of our patients, they're maybe not trying to take a motorcycle adventure into the Rocky Mountains. Maybe it's something like walking without an assisted device, or maybe they really need a walker but they're only willing to use a cane. So I think the first thing that we have to do is we have to have an objective assessment here. We can't just make assumptions. We don't want to look at their past medical history, their diagnoses, and decide for them, or heaven forbid, just their age. We know that people age at different rates and have different functional levels. Their age doesn't dictate their treatment. There are clinical findings should, very accurate clinical findings that meet them where they're at. So the first thing I would advocate for is to get an objective assessment of the risk. So how risky is this activity? Say it's some type of walking or balance activity and we're worried that their balance isn't good enough. Well, first thing we should do is say, hold the phone. We need to do a good assessment here, so we need to match up the patient's physical ability to the objective measure and make sure that the activity is represented in our objective measure. One that we really like to use, it's pretty comprehensive, is a mini best test. The mini best test is a great way to look at dynamic balance, looking at reactive components, as well as anticipatory. as well as a vestibular system, and reactive, like how are they gonna react if they do catch their toe? Do they have the ability to react? So if it's a balance activity, we'll wanna make sure that that activity is represented in our assessment. So we can have a very clear picture of how much risk is this. Maybe it sounds really risky, and we have them do the assessment, and it's like, meh, it's maybe not the best, but it doesn't look like it's that serious, On the other hand, it could be that it is very risky. They can't even do the task at all safely in the assessment. So either way, we need to know objectively what's their physical ability to do this task, whether we're doing the task directly or we're trying to replicate it. We need to get an idea of what's required and get an objective measure for that. The second thing we need to know is how meaningful would this activity be to our patients? How risky is this? But how much reward is there for our patient as well? So there's two sides to this. So if we're thinking about, we've got our assessment, then we've got a good idea how much risk is this based on say like their fall risk. It looks like they're having trouble walking and carrying something. So them wanting to carry in their own groceries without their hands would be a pretty risky task. But maybe that task allows them to be independent in their home. Or maybe they don't have the financial resources to pay someone to bring their groceries to them or for some type of grocery delivery service. So that could change their living arrangement. So we don't want to just make these big blanket statements based on risk. So we've got to figure out how much risk is there based on an objective assessment. We also need to know how much reward is there for our patient on the other end of that. Or what are the downstream effects of them not doing that task anymore. Will there be more deconditioning? Will there be lack of social connection? Social isolation, especially if someone is pre-frail, increases their mortality risk by over 25%. So if we, our choices for safety, take away the social reward, and we reduce the value of their life, we may also hasten their death. which is kind of a wild thing to think about, but our trying to play it safe could actually lead to them dying sooner, which is pretty awful, and I know that's not anyone, what anyone wants to happen that's listening to this. And then the final thing is you have to come to some type of agreement that you can work with, that they can work with, that you can work with, right? So that this therapeutic relationship can continue. So I'll give you an example, I'll kind of work through this, and I think this will help make this a little more clear, So an objective assessment of someone's risk. Say we've got a patient who's an independent community-dwelling older adult who has had some deconditioning, they've got some balance deficits on board. They say, I've got a cat, I'm widowed, I live alone, I need to be able to take care of Fluffy, but my balance, I'm really struggling to be able to get the cat food in from my car up the steps into the house, and I've actually had some falls recently, and I'm at the end of the bag of cat food, now what do I do? So the first thing we're gonna do is based on that task, pick an objective measure that's gonna be helpful. So for a community dwelling older adult, we'll probably do some type of quick screen to get an idea of strength and balance, so something like the short physical performance battery. And then based on that, if it looks like there's some serious balance deficits, we may wanna do a deep dive with a mini best test to get an idea of her dynamic balance, her ability to recover if she catches her toe, while she is carrying, it'll also take away her visual field during parts of the test to get an idea of what's her proprioception like, how well is her vestibular system functioning, and then from there, we can get an idea of what is the objective level of risk. So say we run the mini BEST test, and it looks like she is at risk for having a fall. And then the third thing is, we know, based on this patient, maybe she doesn't have a whole lot of social outlets, and this is one of the only times she gets out of the house for a medical appointment. So we need to really go through this filter of, yes, she could fall. If she continues to do this task, she could fall. But if we take away this trip out of the house, we take away a lot of activity from her daily life. So if she's not able to, if she's not lifting, carrying, working on her dynamic balance through this task, even if it's once every couple weeks, that is still a huge reduction in her overall physical outlet in her physical health. I mean it's built into her life so taking that away from her will actually probably expedite her lack of reserve, resiliency, expedite her deconditioning, as well as potentially isolate her from her pets. So if she's trying to take care of Fluffy, she doesn't have a whole lot of social outlets, that may reduce her willingness or desire to even live moving forward if she doesn't have that outlet with her pet. the lack of reward or the loss that that would represent to just say, no, not safe for you to do that. Let's have someone else bring the food, which she loses the physical attributes or the physical activity that is keeping her strong, at least at some level. But then the second piece is, maybe if we went to the extremes like, you know what, you're just gonna continue to get older and more deconditioned, you should probably just give the cat away. which is probably the worst thing we could say if there's any hope of her getting her strength back. She'll have the social isolation, probably some depression, as well as not being able to have that at least low level of physical activity. A way that I would come at this, if this was my patient, is I would describe the risk. Hey Betty, you know what? You are at risk for falling. You do have some deficits on your balance, but I realize this connection with Fluffy is really important for you, and I think we can work together to find some solutions. So some things I would be thinking about is if she needs some upper extremity support, maybe she's not using an assistive device, or she's not using the right one, which also happens pretty often, Maybe we can meet in the middle. Maybe we can say, you know what? I think if you get a smaller bag of cat food, you can put it in a backpack. And if you can get it, if I can teach you how to put this in a backpack and put it on your back, you're gonna have your hands free. And maybe until we get you stronger, just till then, we can use a walker to get you from your car to the steps, and then if you've got enough support or you've got your cane you usually use in the house, maybe we can get you to use the cane for a very short distance. Or maybe even let her set the backpack down and drag the thing into the kitchen. There's so many ways we could get the job done, but we may have to change what it looks like for a short time. And I would almost guarantee you, if that example was your patient, that they would 100% be okay with buying a smaller bag of cat food, which may get them out more often, which may help us reduce their sedentary behavior, improve their activity frequency, how often they're doing that, could be really good, as well as keep the cat, which I think is the ultimate goal. If they get to keep the cat, keep doing the task, maintain their independence, and we can limit their fall risk by giving them some extra support, but the task gets done and it's temporary, I bet they're gonna be on board. So I hope that helps. So I would really advocate before we just give blanket statements for safety for any patient, but especially for older adults. We want to make sure that they have the opportunity to live their life. We need to consider the risk, absolutely. We need to get an objective measure on that, but we need to consider what we're taking away or what their life will look like and the downstream effects of telling them no. With the heart of safety, we may expedite someone's death or reducing the quality of their life. The final phase, after you figure that out, is we've gotta come to an agreement. We've gotta continue that relationship, do what we can to reduce the risk for them, but maybe we have to meet in the middle. And maybe we can make some agreement that it's like, hey, until we get you to this point, would you agree to use this extra support? Or do this task a little bit differently? And almost 99% of the time that I've come at this type of conversation with a client this way, it has always gone well. Team, I hope that you go out there and you help your patients live. I hope that you're careful assessing risk. I would love, if anyone has any examples or stories they'd love to share, please drop it in the comments. If there's a cool story where you've been able to meet in the middle, help someone continue to do something like that, or just have some thoughts. I would love to hear your thoughts on that. If you're interested in learning more from the older adult crew, We've got our level one is kicking off in less than a week. It's crazy. It's time to sharpen those mental muscles, get back into L1. So if you just came off live and you're wanting to get your specialty in older adult, we would love for you to hop in there. If you've already had L1, I'd recommend you hop into L2. The last cohort sold out. The next one of those is gonna be October 17th. As far as live courses, myself and Ellen Sepe, The woman, the myth, the legend is going to be with me in Anchorage, Alaska. We're going to have a great time. That's going to be August 17th and 18th. Great opportunity for some awesome continuing education. Meet us live, work on your skills, and also take in a beautiful state at a great time of the year. We also have live courses on September 7th and 8th in Minnesota and Alabama. Team, that's what I've got for you for today. Go help those patients live. Have a great day. Catch you next time.

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