Behavioral Treatment for Geriatric Syndrome

Geriatric syndrome is a term used to capture complex clinical conditions such as frailty, falls and fractures, urinary incontinence, malnutrition, and declining mental health, which do not fit into discrete disease categories but are serious problems among the elderly population. They are highly prevalent in the elderly, especially in frail adults with low levels of functional capacity. These geriatric syndromes have a large effect on the development of disability, dependence, decrease in quality of life, morbidity, and mortality. Having multiple underlying factors involving impairments in multiple organ systems contribute to the occurrence of geriatric syndromes (Tinetti et al., 1995). Thus, prevention and treatment of geriatric syndromes such as frailty, falls, and urinary incontinence in its early stages are important strategies in maintaining health and independence among the elderly.

and low physical activity (Fried et al., 2001).The prevalence of frailty is greater in women than men, and increases which age.Frailty status, or the presence of frailty can predict disability and adverse outcomes, where those who are frail have a significantly higher risk of further debilitation, specifically in mobility, activities of daily living (ADL) and falls, eventually leading to hospitalization and death (Fried et al., 2004) G. (2004).Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.The Journals of Gerontology.Series A,Biological Sciences and Medical Sciences,Vol.59,No.3,,by permission of the Gerontological Society of America.) Falls are an especially serious problem among the elderly, as approximately 30% of community-dwelling older adults over the age of 65 experience falls every year.Falls are the leading cause of unintentional injury, functional decline, hospitalization, institutionalization, and increased healthcare costs.In order to prevent falls, a thorough understanding of the causes and risk factors for falls among the elderly is required for the development of effective preventative strategies.
Urinary incontinence, particularly in the elderly, is considered to be an important determining factor for admission into long-term care and has been associated with loss of independence, reduced quality of life, restricted social activities, increased anxiety and social isolation.
diseases such as cardiovascular disease, pulmonary disease and diabetes.Hence, treatments for frail older adults usually require specific care needs (Fried et al., 2004) (Fig. 1).With the presence of comorbid conditions, there may be competition between the treatments.The combinations of medications and treatment regiments may limit the desired effects of the treatments, or have adverse effects.Comorbidities lead to the over-use and mixing of prescription medication which is a risk factor for falls.Frailty, coupled with low bone mass is associated with increased risk of hip fractures which are a major threat to survival in the elderly.Research has shown that 17.4% of people who suffered hip fracture over the age of 65 died within 12 months of a fracture (Magaziner et al., 1989).Fig. 1.Comorbidity, disability, and frailty: definitions and major health care implications.(Fried, L.P.;Ferrucci, L.;Darer, J.;Williamson, J.D. & Anderson, G. (2004).Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.The Journals of Gerontology.Series A,Biological Sciences and Medical Sciences,Vol.59,No.3,,by permission of the Gerontological Society of America.) There are numerous factors that contribute to muscle weakness and loss of muscle mass in aging adults such as chronic disease, a sedentary lifestyle, and under-nutrition, where some factors can be reversed with lifestyle changes, and others need specific medications and cannot be reversed.Xue et al. (2008) hypothesized the cycle of frailty, as many of these factors can theoretically be unified into a cycle associated with decreasing energetics and functional reserve (Fig. 2) The core elements of this cycle, including weight loss, sarcopenia, decrease in strength and walking speed, as well as low activity, are commonly identified as clinical signs and symptoms of frailty.

Falls
In the recent decade, several epidemiologic studies have identified risk factors for falls.
While the classifications of these risk factors have not always been consistent, they are generally classified as intrinsic, extrinsic, and environmental.Intrinsic risk factors include muscle weakness, gait and balance deficits, functional and cognitive impairments, and visual deficits, extrinsic such as the use of four or more prescription medications and bifocals, and environmental factors, which include poor lighting, loose carpets, and lack of bathroom safety equipment (American Geriatric Society et al., 2001).Low vitamin D levels are also significantly associated with a high prevalence of falls in elderly women, as well as low physical performance (Suzuki et al., 2008) (Table 2).
The most common risk factors for falls are muscle weakness, history of falls, gait deficit, balance deficit, use of assistive device, visual deficit, arthritis, impaired ADL, depression, cognitive impairment, and older age (over 80 years old) (American Geriatric Society et al., 2001).The risk of falling increases linearly with the number of risk factors, from 8.0% with none to 78.0% with four or more risk factors (Tinetti et al., 1988).Furthermore, those who experience falls once have a greater chance of recurrent falls, which may lead to a fear of falling.Some older adults may then begin restricting activities both indoors and outdoors.Not only does this lead to a further lack of physical activity, but research has shown that older persons who restrict activity for fear of falling are more physically frail and have greater burden of chronic conditions and depressive symptoms compared with those who do not restrict activity despite their fear of falls (Murphy et al., 2002).

Urinary incontinence
There is general agreement on the multifactorial nature of incontinence.Permanent incontinence also is typically the result of neurological damage or, intrinsic bladder or urethral pathology.However, incontinence is associated with several potentially reversible conditions.Lower urinary tract function, environmental factors, physical and cognitive function, psychological distress, mobility, manual dexterity, medical conditions, and medications may all have an effect on urinary incontinence status in the elderly (Landi et al., 2003).The incidence of urinary incontinence is typically higher in women than men, and those who experience incontinence are usually older with lower functional fitness levels for both sexes.Although there is a large amount of information regarding the mechanisms and treatment options for urinary incontinence, little is known about the potentially reversible causes of this condition in community-dwelling elderly people.Several of the known causes that may be reversible include urinary tract infections, as they can cause the urge to void quite frequently, physical restraints and drastic limitations in mobility, and environmental hazards.
Lifestyle and functional fitness are significantly associated with the onset of urinary incontinence in community-dwelling elderly people (Kim et al., 2004) (Table 3).

Treatment for geriatric syndrome
Declines in functional fitness such as walking speed, muscle strength and balance ability in the elderly are strongly associated with the development of geriatric syndromes.Hence, exercise focusing on strength, balance, and mobility improvement, even into advanced age, is usually offered as a strategy for the reduction of frailty, falls, and urinary incontinence in the elderly.

Frailty
Aging is characterized by a gradual decrease in muscle mass and muscle strength, which contributes to declines in physical function, increased disability, frailty, and loss of independence.Out of many factors associated with the development of frailty, muscle disuse and nutritional deficiencies are the factors that are potentially reversible or preventable through interventions and a more active lifestyle (Fiatarone et al., 1994).

Nutritional supplementation
Declines in muscle mass are related to declines in muscle protein synthesis rates in older adults.In order to resist and reverse the effects of muscle protein synthesis declines, protein or more specifically, amino-acids, have been the focus of research.Investigators have found that leucine enriched essential amino-acid mixtures are primarily responsible for aminoacid-induced muscle protein anabolism in the elderly.Amino-acid supplementation can increase muscle mass in this population; however, an increase in muscle mass is not always accompanied by an increase in muscle strength (Dillon et al., 2009).Essential amino-acid supplementation alone is probably insufficient in increasing muscle strength.Carbohydraterich supplements have also been examined for any effects on muscle strength and muscle mass.However, supplements rich in carbohydrates are inadequate for the purpose of increasing muscle mass and strength (Fiatarone et al., 1994).Vitamin D supplementation, which will be discussed further (see section 3.2.1)has also been shown to increase strength.

Exercise
Exercise in elderly individuals may potentially modify risk factors for age-associated reductions in muscle mass (Liu & Latham, 2009).Research has shown that high intensity resistance training is effective in counteracting muscle weakness and physical frailty in elderly people.More specifically, exercise interventions focused on the major muscle groups that are crucial for performing functional activities, are especially important for the reversal of muscle weakness.
Extensive research has confirmed that doing resistance training two to three times a week can improve physical function and functional limitations, and also reduce disability and muscle weakness in older people.Resistance training in elderly people produces increases in strength from 9 to 15% (Borst, 2004), and about 1.1 kg in lean body mass (Peterson et al., 2011).While more improvements are seen with high intensity and volume resistance training, moderate intensity exercises are also beneficial, and are much safer for aging adults.Exercise prescriptions must be of a safe intensity, duration and frequency to avoid further injury and complications (Taaffe, 2006) (Table 4).
Combinations of both exercise and nutritional supplementation have also been studied by researchers.Amino-acid supplementations alone have beneficial effects such as increasing walking speed, and exercise itself also has beneficial effects of improving physical function.
Exercise and amino-acid supplementation together have significant effects in enhancing muscle mass, strength and functional fitness.The combination of high resistance exercise and a high carbohydrate mixture containing small amounts of soy protein is effective in the enhancement of muscle strength.High resistance exercise alone increases both muscle mass and strength, while the carbohydrate supplementation alone does not (Fiatarone et al., 1994).Further research is still needed to investigate which supplementations coupled with exercise, or alone, are most effective.

Resistance training program recommendations
Exercises 8-10 that target the major muscle groups Repetitions 8-12 per set.When able to achieve 12 repetitions, increase resistance so that 8 repetitions are possible

Sets
Minimum of 1, preferable 2-3 per exercise with 1-2 minutes rest between sets Frequency 1-3 days per week with at least 48 hours between sessions Velocity 2-3 seconds concentric and 2-3 seconds eccentric.Some sets of rapid concentric movements can also be included

Breathing
Normal breathing on each repetition (no breath holding)

Duration
Less than 1 hour Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners).

Falls
The development of effective preventative strategies to reduce the fall rate in communitydwelling elderly people who are at risk of falling require a better understanding of the modifiable risk factors for falling.Among the numerous risk factors for falling, those that are considered modifiable include muscle weakness, impairments in balance and gait, and the use of multiple prescription medications.These risk factors can be modifiable through behavioral strategies such as muscle strengthening exercises, balance and gait training, and education about nonpharmacologic treatments to reduce the number of prescription medications used (Tinetti et al., 1994).Furthermore, the occurrence of falling rises with increasing number of risk factors present; therefore, strategies targeted to reduce these modifiable risk factors may be effective in the prevention of falls.

Vitamin D supplementation
In several trials of older individuals at risk for vitamin D deficiencies, vitamin D supplementation improved strength, function, and balance in a dose-related pattern.A high daily vitamin D supplementation dose (about 700-1000 IU) can reduce the risk of falls by approximately 20%; although small doses (less than 400 or 700 IU) may not be sufficient to reduce falls (Bischoff-Ferrari et al., 2009).

Exercise
Falls in older people are not purely random events but can be predicted by assessing a number of risk factors.Some of these risk factors such as decreased muscle strength, impaired balance, and gait deficit can be modified using exercise, whereas poor vision, and psychoactive medications require different strategies.Exercise can be used as a fall prevention intervention on its own or as a component of a multifaceted program.The pooled estimate of the effects of exercise was that it reduced the rate of falling by 17.0% (Sherrington et al., 2008).Home-based and tailored group exercise classes seem to be effective in reducing falls by improving balance and muscular strength.Also, while home hazard management (e.g.removing tripping hazards) and vision screening are not markedly effective in reducing falls when used alone, they add value when combined with an exercise program (Day et al., 2002).

An exercise-based falls prevention program
Exercise programs designed for fall prevention in elderly people should address three major areas -strength, balance and gait.People at high risk of falling due to muscle weakness, balance impairment, and gait deficit should be instructed to perform low or moderate intensity exercise containing safe and simple movements at entry level.

Strength training
A moderate-intensity strength training program aimed to reduce falls should target the major muscles such as the tibialis anterior, soleus, quadriceps femoris, iliopsoas, tensor fasciae latae, and sartorius (Fig. 3).Tripping is a leading cause of falls in communitydwelling elderly people, responsible for up to 53% of falls in this population (Blake et al., 1988).Trips may be associated with weakness of the tibialis anterior muscle, which would cause low toe-clearance or walking in a "shuffling" manner where the toes do not lift off the ground sufficiently to avoid small obstacles that may cause trips.

Target Muscle Exercise Exercise Description
Tibialis Anterior

Seated Toe Raises
Place hands in comfortable position while seated.Lift toes of both feet as high as possible with the heels still on the floor.Hold for 3-5 seconds, breath normally, and slowly lower toes to the floor.Perform 8-10 repetitions.
Remind participants to not rock the body back when raising toes.

Quadriceps Seated Knee Extension
Lift one leg still bent at the knee while inhaling, and extend the leg without "locking" the knee (keep knee slightly bent) while exhaling.Bend the knee again, with the hip still flexed, and place the foot on the floor.Perform 8-12 repetitions, and repeat on the other side.Remind participants to not lean back while lifting the leg, or extending the knee.

Soleus and Gastrocnemius Heel Raises
Stand tall with feet flat, shoulderwidth apart.Hold on to back of a chair for support.Slowly lift both heels off the floor while exhaling.Hold for 5-10 seconds, breath normally, and slowly lower the heels to the floor.Repeat 10 times.

Balance and gait training
Training is crucial for the improvement of balance in the elderly, and static as well as dynamic and lateral balance exercise have been recommended for reducing falls.Balance exercises progress from holding on to a stable supporting structure such as a chair, to performing the exercises independent of support.Not all elderly people will necessarily start at the first level of each exercise or be prescribed all the balance exercise such as one-leg standing, tandem stance, tandem walking, and side step (Fig. 4).
The results of a large scale study, known as the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials, suggest that exercise interventions (flexibility, resistance, balance) and Tai Chi for elderly people reduce the risk of falls (Province et al., 1995).To evaluate the effect of Tai Chi on functional fitness and falls, it is necessary to analyze the characteristic movements of Tai Chi.Tai Chi consists of a series of smooth movements linked together in a continuous sequence of whole body weight-shifting, with a low center of gravity.Also, Tai Chi movements involves shifting the weight forward and standing on one foot while lifting the other foot an inch off the floor, which contributes to the improvement of static balance.Moreover, the safe completion of the steps requires an adequate amount of dynamic balance, postural strength, and lateral stability (Li et al., 2004).Participants in the FICSIT trial were instructed on correct foot placement and posture, standing in a semi-squat position, which requires substantial lower extremity strength.These movements are directly or indirectly related to improvement of functional fitness.

Urinary incontinence
The common treatments for urinary incontinence include surgery, drug therapies, and behavioral treatments.Behavioral treatments such as pelvic floor muscle (PFM) exercises and bladder training are recommended as a first line of treatment in the management of urinary incontinence, because of the potential benefits with few risks and no side effects.Urinary incontinence is usually classified into three different types: stress, urge, and mixed.Stress incontinence is urine leakage associated with increased abdominal pressure such as coughing, sneezing, laughing, heavy lifting, standing, running, or other types of physical activity.Urge incontinence is leakage associated with running water, or an urge to void and not being able to reach the toilet in time.Mixed urinary incontinence is when characteristics of both stress and urge incontinence types are present.

Pelvic floor muscle exercise
PFM exercises (Fig. 5), initiated by Kegal in 1948, is hypothesized to enhance urethral resistance by increasing the strength and endurance of the periurethral and perivaginal muscles and by improving the anatomic support to the bladder neck and proximal urethra (Kegel, 1948).These exercises are the preferred treatment for stress incontinence but have recently been recommended for urge or mixed incontinence because of reflex bladder inhibition associated with pelvic floor muscle contraction.The efficacy of PFM exercises in improving urine leakage has been validated by many investigators, and the improvement rate has been reported to range widely from 17 to 84% (Bo, 1995).The durations of the exercise training periods vary between 3 weeks and 6 months.Bladder training appears to have its greatest efficacy at 6 weeks; PFM exercise appears to be best between 11 to 12 weeks; and combined bladder training and PFM exercise seems to be most effective between 8 to 12 weeks of training (Wyman et al., 1998) (Fig. 6).

Fitness exercise
Several studies have reported that obesity and high body mass index (BMI) are associated with urinary incontinence.Presumably, increases in body weight causes increases in abdominal-wall weight, hence increasing intra-abdominal pressure and intra-vesicular pressure (Bo, 2004).Therefore, reductions in abdominal fat from exercise may contribute to decreasing intra-abdominal pressure, causes improvements in urethral sphincter contraction, and therefore decreased risk of urinary incontinence (Fig. 7; Fig. 8).Weight reduction is desirable for women complaining of urinary incontinence (Subak et al., 2009).Bump et al. (1992) found that surgically induced weight loss in obese women significantly reduces weekly incontinence episodes.
Although a direct cause-effect relationship between obesity and incontinence has not yet been established, there is evidence that weight reduction or decrease in BMI may be beneficial for treatment of incontinence.Kim et al. (2007) investigated the distribution of subjects cured from urinary incontinence according to tertiles of BMI, maximum walking speed, and adductor muscle strength, found that a significantly higher proportion among those who were cured of incontinence episodes, demonstrated improvements in BMI and walking speeds (Kim et al., 2007).Therefore, weight reduction, decrease in BMI, and increase in walking ability are desirable qualities for the treatment of urinary incontinence (Table 5).Lying head raise    (2007).Effectiveness of multidimensional exercises for the treatment of stress urinary incontinence in elderly community-dwelling Japanese women: a randomized, controlled, crossover trial.Journal of the American Geriatrics Society, Vol.55, No.12, pp. 1932-1939, with permission from the American Geriatrics Society.)

Obesity is a risk
While the details of the beneficial effects that exercise may have on the different types of urinary incontinence is not entirely clear, the current literature seems to suggest that PFM and fitness exercises are beneficial for all three types of urinary incontinence after a training period of three months.However, the effects of exercise training are maintained more in those with stress incontinence compared with those urge or mixed incontinence (Kim et al., 2011a) (Table 6).
Recently, other treatment methods including abdominal and lower back heating have been introduced.The heating may have positive effects on renal function such as renal sympathetic nerve activity suppression, promotion of bladder voiding, and increasing frequency of urination.
The heat and steam generating sheet (HSGS) can be any thin, flexible filmed sheet that generates heat and steam immediately after unsealing.When the sheet is placed on the body, the temperature of the skin surface rises to 38 to 40℃and it continues to generate heat  and steam for over 5 hours.Research has suggested that the HSGS in combination with exercise yields the highest cure rates of urinary incontinence compared with exercise or the HSGS alone.The HSGS also has beneficial effects for the different urinary incontinence types.Research reveals higher cure rates in those with stress urinary incontinence with the combination of both exercise and heat; however, there is strong evidence that the HSGS can be used as a supplementary treatment method in order to enhance the effects of exercise on those with urge, mixed, and stress urinary incontinence (Kim et al., 2011b) (Table 7).

Predictor variables
Multiple characteristics that may influence the treatment outcome such as age, gender, urine loss frequency and amount, incontinence type, duration of urinary incontinence, chronic conditions, medications, and functional fitness as well as adherence to the prescribed exercise regimen have been examined.Many previous studies have emphasized that compliance to exercise is the key factor to long-term success (Lagro-Janssen & van Weel., 1998;McDowell et al., 1999), and confirmed that BMI reduction have positive influences on urge, mixed and stress UI treatment (Kim et al., 2011a) (Table 8).

Conclusion
Geriatric syndromes are highly prevalent and associated with substantial morbidity and poor outcomes.Various factors cause frailty, falls, and urinary incontinence in elderly people including chronic disease, lack of physical activity, malnutrition, and aging itself, some of which are unpreventable.Exercise and nutritional supplementation are among the beneficial treatments promoting healthy and independent lifestyles in the elderly.
Evidence reveals that exercise targeted at reducing risk factors is an effective strategy for treating geriatric syndromes in elderly people.Progressive and moderate-intensity exercise should be encouraged among elderly people to minimize the degenerative physical and mental function that occurs with aging.
feet flat, shoulderwidth apart.Lightly hold on to back of a chair for support or place hands on the hips.Slowly lift one foot off the floor while exhaling.Hold position for 10 seconds, breath normally, and slowly lower the foot to the floor.Repeat by lifting the other leg.Perform 2-3 sets per day.Dynamic Balance Tandem Walk Stand tall with feet flat on the floor, near a wall or railing for safety.Place one foot directly in front of the other foot, allowing the heel of the front foot to touch the toes of the back foot.Repeat with the other foot.Continue for 10 steps.Lateral Balance Cross Step Place a piece of tape or draw a line (refrain from anything that may cause trips) on the floor.Begin by standing with both feet together on one side of the tape.Lift the foot farther from the tape, and place it forward (diagonal) on the other side of the tape in a crossfashion.Shift weight to the front foot, cross the other foot and place on the other side of tape.Note: Both feet do not come together.Continue for 10 steps.

Fig. 5 .
Fig. 5. Pelvic floor muscle exercise for the prevention of urinary incontinence.At the beginning of PFM training, it is important to teach the elderly people participating in a training program, the structure of the PFM in order to gain awareness of these muscles.The participants should be taught that straining the abdomen would increase the abdominal pressure and would exert load on the PFM.Training should focus on how to exert force on the PFM without excessively straining the abdomen.Most exercise regimens are designed to strengthen the fast and slow-twitch fibers located at the pelvic floor.PFM exercise programs often incorporate alternations of fast contractions, usually held only for about three seconds, sustained contractions, where the participants would hold the contraction for about six to eight seconds, and ten-second relaxation periods between the contractions.The PFM exercises are usually performed in the seated, lying, and standing positions with the legs apart, and the emphasis placed on training of the PFM and relaxing of the other muscles.
Fig. 7. Strengthening exercises to reduce abdominal fat prevents urinary incontinence

Table 3 .
Multiple logistic regression model of risk factors associated with the onset of urinary incontinence