Geriatrics Exam II

Define sarcopenia.

age related loss of muscle mass and strength

Loss of power has a stronger correlation with ___________ ___________ than loss of strength.

functional decline

What average weight is needed for functional requirements for community-living older adults?

6.7 lbs

What HR values would contraindicate exercise?

RHR <50 bpm or >100 bpm

What BP values would contraindicate exercise?

-resting systolic <90 mmHg or >200 mmHg

-resting diastolic >110 mmHg

What O2 values would contraindicate exercise?

<90%

What general symptoms would contraindicate exercise?

SOB, angina, DVT, cyanosis, increased edema, headache, abnormal heart or breath sounds

What are the parameters for resistance training in older adults with frailty?

-2-3 times per week

-1 set progressing to more, 3x8-12

-intensity starts at 20-30% 1RM progressing towards 80%

-power moderate 30-60% 1RM

-gradual increase in volume, intensity, and complexity

What are the exercise guidelines for intensity in resistance training in older adults?

-begin with light intensity 30-50% of 1RM

-progress intensity to 60-80% (mod-vigorous)

-modified Borg 5-6 mod, 7-8 intense vigorous

What intensity percentage is used to build strength?

80-90%

What are the exercise guidelines for frequency in resistance training in older adults?

>2+ days/week on non-consecutive days;; 48 hrs rest between muscle groups

What are the exercise guidelines for types, reps, and sets in resistance training in older adults?

-8-10 exercises involving major muscle groups

-1-3 sets

-8-12 reps

Once the patient can perform ___ _____ with good form and no pain, add exercises to increase power.

2 sets

After they can easily lift a load ___ _______, increase the load 2-10% and decrease reps to 8-10.

12 times

What are the big three orthopedic conditions in older adults?

osteoporosis, OA, and fractures

Osteoporosis risk factors.

female, aging, thyroid disease, DM, medications

Explain Wolff's law.

bone responds to loads placed on it by remodeling to meet the demands; increase in load equals increase in bone

Evidence supports the use of ___________ ____________ in postmenopausal women to decrease risk of vertebral frctures.

extension exercises

Precautions to exercise in osteoporosis patients.

flexion exercises and machies, combining flexion and rotation, and increase resistance gradually

What are the three major functions of the pelvic floor?

1. Sphincteric (closing and opening)

2. Supportive

3. Sexual function

When does functional incontinence occur?

when a person has normal bladder control but cannot reach the toilet in time due to physical limitations, cognitive impairments, or environmental barriers

What type of incontinence has a high correlation with an increased risk of falls?

Urge incontinence

List the potential effects of aging on incontinence.

-muscle changes (decreased strength, power, endurance, mass)

-decreased speed and safety when getting to bathroom

-decreased bladder capacity

-decreased sensation of filling

-increased urinary frequency

-increased PVR volume

-outflow tract obstruction (men)

-increased constipation

What most often causes outflow tract obstruction in men?

Enlarged prostate pressing on the urethra and bladder

Common mediations that can cause or worsen incontinence symptoms are...

-ACE inhibitors

-antihistamines

-anticonvulsants

-diuretics

-beta receptor agonist

-estrogen

-angiotensin II receptor blockers (ARBs)

What is a normal PVR volume?

0-50 mL

Risk factors of pelvic organ prolapse.

vaginal delivery, parity (higher with more), age, BMI

Cystocele

prolapse of the bladder

Rectocele

prolapse of the rectum

Enterocele

Prolapse of the small bowel into the vagina.

Vault prolapse

vault (cuff) descends into vagina after hysterectomy

What is common treatment of pelvic organ prolapse?

-strengthening/coordination of pelvic floor muscles

-breathing and effort on exhale; no valsalva

-activity modification

-start in gravity eliminated and progress to functional movements

-lunge instead of squat to add support

What are symptoms of benign prostatic hyperplasia?

-difficulty initiating stream and weak stream

-slow/blocked urine flow

-feeling of a need to urinate

-nocturia

-terminal dribbling

-urge/overflow incontinence

What areas of prostate cancer management can physical therapy services be beneficial with?

improving continence and quality of life

Define elder neglect.

refusal or failure to fulfill any part of a person's obligations to an older adult (food/water, clothing, shelter, meds, comfort, etc. )

What are some manifestation's of elder neglect?

dehydration/malnutrition, poor hygiene, pressure ulcers, med misuse, hazardous or unsanitary living conditions

What are the different types of elder abuse?

physical abuse, emotional or psychological abuse, financial exploitation, sexual abuse, neglect, and abandonment

Common characteristics of elder abuse victims.

↑ age, female, dependent, cognitively impaired, depression, low income

Common characteristics of elder abuse perpetrators.

Male, ↓ 60, victim's child > spouse > relative, financially dependent on the victim

Risk factors for perpetrators and victims.

Mental illness, alchohol/drug abuse, social isolation, hx of abusive relationships, financial dependency, inadequate housing, caregiver stress

What behaviors are common in victims of elder abuse?

Change in activity level or lack of interest, fear, agitation, denial or hesitation to talk, other implausible explanations

What behaviors are common in perpetrators of elder abuse?

• Attempts to conceal injuries

• "Provider hopping"

• Frequent ER visits

• Inconsistent or implausible explanations

• Speaks for the patient/won't let patient be interviewed alone

• Becomes defensive

• Unreasonable critiques of past providers

What are the four types of isolation?

geographic, presentation, behavioral, attitudinal

Describe geographic isolation.

- result of widowhood, urban crowding, rural lifestyle,

institutionalization; person feels alienated

- treatment: build social support

Describe presentation isolation.

- changes in appearance

- treatment: surround with positive people, compliment on strengths

Describe behavioral isolation.

- displays behaviors that are unacceptable (eccentricity, confusion, incontinence, deviant)

- treatment: help pt identify behaviors and seek

appropriate treatment

Describe attitudinal isolation.

- society's response, ageism

- treatment: explore prejudices

What are the three main types of delirium?

hyperactive, hypoactive, mixed

Describe hyperactive delirium.

restlessness, agitation, hallucinations, and rapid mood changes

Describe hypoactive delirium.

inactivity or ↓ motor activity, sluggishness, abnormal drowsiness, dazed

Risk factors for delirium.

- hospitalized older adult

- triggered by a stress like surgery (especially hip

fracture or vascular surgery) or anesthesia

- modifiable: benzo use and blood transfusions

- nonmodifiable: ↑ age, dementia, prior coma, pre-ICU emergency surgery or trauma

Preventative measures against delirium.

- adequate fluid intake and nutrition

- adequate mobilization and physical exercise

- adequate medication

- avoid withdrawal phenomena due to rapid cessation of meds

- monitor closely in perioperative period

- avoid excessive sensory stimulation

CPG recommendations to reduce or shorten delirium.

- reorientation, cognitive stimulation, use of clocks

- improve sleep; minimize light and noise

- improve wakefulness; reduce sedation

- reduce immobility; early mobilization

- reduce hearing and vision impairment; encourage use of hearing aids and glasses

What are the different types of dementia?

- Multi-infarct (Vascular)

- Lewy Body

- Parkinson's Disease Dementia

- Frontotemporal

- Alzheimer's Disease

Describe multi-infarct (vascular dementia.

Abrupt onset with step-by-step deterioration; fluctuating course and emotional liability; essential feature of CV disease

What are some associated problems with multi-infarct (vascular dementia?

Memory, abstract thinking, judgement, impulse control, personality, apathy, lack of motivation, catastrophic reactions

Second most common neurodegenerative dementia after Alzheimer's is...

Lewy Body Dementia

What are the two types of Lewy Body Dementia?

Dementia with Lewy bodies and Parkinson's Disease Dementia

Describe Lewy Body Dementia

Sx of Alzheimer's and PD; pronounced fluctuations in alertness and attention; early appearance of visual hallucinations; visuospatial, language, and short-term memory deficits

Describe Frontotemporal Dementia.

-rare and progresses more quickly than Alzheimer's

-occurs between 35-75

-2 clinics patterns depending on hemisphere

What is the difference in clinical patterns between hemispheres in Frontotemporal Dementia?

Left: progressive aphasia

Right: personality and social behavior disorders (inappropriate, compulsive, no concerns, binge eating)

Alzheimer's is classified by what 3 pathological changes in the brain?

1. Amyloid plaques

2. Neurofibrillary tangles

3. Loss of connections between neurons responsible for learning and memory

What is the prognosis for a patient with Alzheimer's?

-average of 8 years lived after diagnosis

-age is the greatest risk factor

-development of infections frequently

-pneumonia is most often the cause of death

What reasons would a patient with Alzheimer's have an increased risk for falls?

-lack of understanding of fall potential or poor judgement

-lack of judgement and unable to recognize danger

-overestimate abilities

-poor communication

-forgetting to use AD

What types of visual disturbances are associated with Alzheimer's disease?

Restricted visual fields, visuospatial function, depth perception, contrast sensitivity, and agnosia

What are different ways that you can prevent challenging behaviors of a memory care patient as a physical therapist?

-supportive language: don't correct, keep it simple, learn the pts vocab

-repetitive behaviors: reassure the pt instead of answering the same question, try distraction

-limit choices and don't argue or convince

-motor organization deficits: physical cue instead of verbal, change the environment

With dementia and Alzheimer's patients, what 6 categories of functioning should be evaluated?

1. Cognition

2. Affect, personality, and behavior

3. Neuro signs: reflexes, tone, gait, tremors, seizures

4. Functional mobility and ADLs

5. Caregiver roles and abilities

6. Psychosocial components

When designing a rehab program for a dementia or Alzheimer's patient, use the acronym FUNCTIONAL.

Familiarity

Understanding

No distractions

Cues and eye contact

Touch

Intact abilities

One step at a time

Never rush

Automatic activities

Limit choices

What types of patients would be appropriate for palliative care?

-chronic disease state

-multiple hospital readmissions

-multiple comorbidities

-declining function

-life-limiting incurable disease

-needing end of life planning

What are the biggest differences between palliative and hospice care?

palliative: in conjunction with other therapies to prolong life, early in course of illness

hospice: focus on caring not curing and provided when curative treatment is d/c, when life expectancy is measured in months or less

Hospice Levels of Care: individual has elected to receive hospice care at their residence

Routine Hospice Care

Hospice Levels of Care: for pain control or other acute symptom management that cannot feasibly be provided in any other setting

General Inpatient Care

Hospice Levels of Care: care provided 8-24 hours a day intended to maintain terminally ill pts at home during pain or symptom crisis

Continuous Home Care

Hospice Levels of Care: available to provide temporary relief to the patient's primary caregiver

Inpatient Respite Care

A majority (75%) of hospice patients are enrolled in hospice for ___ days or less.

87 days.

Define terminal restlessness.

form of delirium and agitation that occurs in the final days, weeks, or hours of life

What type of services does Medicare Part A cover?

hospital services; inpatient and skilled care with palliative care such as hospitalization, SNF, home health, or acute care

What type of services does Medicare Part B cover?

outpatient services such as doctor's appointments, medical equipment, couseling, and rehab therapy

In order to get Medicare Hospice Benefits, what must a patient do?

certify that they are no longer seeking curative measures

Roles of Physical Therapy in hospice care.

-reduce pain and physiological/psychological stress

-optimize remaining function and QOL

-improve sleep quality

-maintain safety

-energy-efficient mobility and conservation

-improve respiratory function

What are the five steps of Briggs Management Model?

- Rehab Light

- Rehab in Reverse

- Case Management

- Skilled Maintenance

- Supportive Care

Describe the Rehab Light Step of the Briggs Management Model.

-pt has ups an downs as disease progresses

-regain small strength

-limited and targeted exercise

-low frequency for short duration

Describe the Rehab in Reverse Step of the Briggs Management Model.

-pt training and caregiver instruction as pt moves through transitions from independent to more dependent

-may require more equipment or assitance over time

-eventually need positioning and pressure relief

Describe the Case Management Step of the Briggs Management Model.

-monitor changing needs of pt

-monthly or PRN assessment

-may follow rehab "light" intervention

-may be initial eval

Describe the Skilled Maitenence Step of the Briggs Management Model.

-activities too complex or unsafe for caregivers

-medically necessary to maintain current level of function or prevent/minimize decline or progression of impairments, etc.

-will need proper justification to insurance in order for coverage

Describe the Supportive Care Step of the Briggs Management Model.

-education to family

-gentle PROM

-edema mangement for comfort

-ease discomfort of inactivity

-reduce contractures