Elderly Midterm

Y r u gey

Be able to compare and contrast the theories of aging

For each of the following, state the core concept of the theory and the reasoning behind each

• Mitochondrial aging theory (Role of energy production and associations with aging)

• Developmental genetic theories (Core concept and aging as a continuum)

• Stochastic theories (Core concept and mechanism)

• Newer theories: evolving ideals in aging research (Sleep and aging, telomere theory)

1. Mitochondrial Aging Theory

 a. Role of Energy Production (ATP): As mitochondria become damaged over time, ATP production decreases.

 b. Associations with Aging: Mitochondrial decline results in less energy for cell maintenance and repair, accelerating aging.

2. Developmental Genetic Theories

 a. Core Concept: Aging is a genetically programmed process. Genes that regulate growth and development may also control lifespan.

 b. Aging as a Continuum: Aging is not separate from development; it's part of a continuous, genetically regulated timeline, much like puberty or menopause.

3. Stochastic Theories

 a. Core Concept: Aging results from random environmental damage (pollution, food quality, pesticides) to cells and molecules (DNA, proteins, lipids) over time.

 b. Mechanism: Environmental stressors like radiation, toxins, and ROS cause damage that accumulates and impairs cellular function.

4. Newer Theories: Evolving Ideas in Aging Research

 a. Sleep and Aging: Poor sleep quality is associated with accelerated aging and neurodegeneration.

 b. Telomere Theory: Telomeres (chromosome end caps) shorten with each cell division. When critically short, they trigger cell senescence or death.

Be able to describe the normal physiological changes associated with aging

• What can be seen visually (appearance) ?

• In terms of thermoregulation?

• Musculoskeletal changes?

• Skin changes?

• Cardiovascular changes?

• Pulmonary changes?

• Neurological changes?

• Gait changes in older adults?

• Immune function?

• Intersystem homeostasis?

• Hormonal changes?

• Gastrointestinal changes?

• Renal and urinary changes?

• Sensory changes (For hearing, vestibular and proprioception, taste and smell, and vision)?

Appearance

• Gray hair, skins changes, tooth color, posture, movement, body composition

Thermoregulation

• Hypothermia Risks: slower metabolism, decreased body fat, poor nutrition, impaired ability to perceive the cold (dementia)

• Hyperthermia Risks: decreased sweating, chronic illness, meds, dehydration

  • Prevention is key!

Musculoskeletal Changes

• Cartilage: decreased hydration & elasticity, reduced elasticity

• Muscle: less type II fibers, sarcopenia, decreased strength and muscle mass

• Bone: decrease in calcium, vitamin D, bone strength, increased fracture risk

  • Organ shrinkage is one of the main reasons why mortality increases in MVA involving older adults. Think of a smaller brain moving within the skull, causing a terrible whiplash

Skin Changes

• Slower healing, less able to resist injury and infection

• Sweat and sebum glands as well as sensors and hair follicles atrophy

  • Think of the fat pads that cover the veins and tendons of our hands and feet. Older adults lose this fat pad, so they are essentially walking on “skin and bones”

Cardiovascular Changes

• Increased BP, decreased HR max, decreased VO₂ max, stiffer vessels

• Decreased response to stress, decreased ventricular compliance

• Loss of cells from the SA node (pace maker needed)

  • A pulse pressure over 60 is indicative of a future cardiac event!

Pulmonary Changes

• Decreased chest wall compliance & elastic recoil

• Decreased intercostal/diaphragm/abdominal strength

• Decreased vital capacity, increased residual volume (lungs are overinflated)

Neurological Changes

• Decrease in neurons, decreased conduction velocity, decreased blood flow

• Decrease in sensory neurons, slower response time

• Decreased encoding and retrieval with age (learning issues)

• Plaques and tangles noted in neurons

• Memory loss that does not impair social or personal functioning

Gait Changes in Older Adults

• Decreased speed, decreased step length, increased stance time

• Increased gait variability, decreased joint excursion

• Decreased ankle power, more stooped posture

Immune Function

• Decreased infection defense, more prone to autoimmune disorders

• Increased systemic inflammation (what helps: anti-inflammatory drugs, antioxidants, caloric restriction, exercise)

Intersystem Homeostasis

• Decreased thermoregulation, decreased basal metabolic rate, decreased hormonal regulation, ANS dysfunction, decreased BP to the brain

Hormonal Changes

• Decreased insulin, testosterone, estrogen

• Considerations for hormone replacement

Gastrointestinal & Hepatic Changes

• Decreased motility, decreased nutrient absorption

• B12 deficiency: Lack of intrinsic factor reduces absorption in the stomach, so sublingual pills tend to be used often to bypass the stomach

• Gallbladder: increased gallstones

• Liver: decreased function, increased fat accumulation

Renal & Urinary Changes

• Decreased kidney mass, decrease in nephrons, decreased blood flow

• Increased nocturia, residual urine, UTI risk, incontinence

Sensory Changes: Hearing

• Presbycusis: decreased high-frequency hearing

• Decreased auditory receptors, TM changes

Sensory Changes: Vestibular & Proprioception

• Decreased otolith function, decreased proprioceptive input

Sensory Changes: Taste & Smell

• Decrease in taste buds, decreased saliva, decreased olfactory bulb cells

Sensory Changes: Vision

• Decreased tear production, decreased lens flexibility (presbyopia)

What are the keys to successful aging? (3)

1. Avoiding Disease: chronic illnesses and their complications

2. Maintaining High Cognitive and Physical Function: the ability to think clearly and move independently

3. Engagement with Life: staying socially and productively involved

How does sleep architecture change with aging?

Sleep Latency

• Increased time to fall asleep

Deep Sleep Decline (Slow-Wave Sleep)

• Decreased time spent in deep sleep (Stages 3 & 4)

• Less restorative sleep contributes to feeling unrefreshed

REM Sleep Decline

• May affect memory consolidation and emotional regulation

Increased Sleep Fragmentation

• Nighttime awakenings and lighter sleep

Breathing-Related Disruptions

• Snoring and sleep apnea cause arousals

Increased Sleep Disorders

• Insomnia, obstructive sleep apnea, restless legs syndrome, and gastroesophageal reflux disease

Decreased Sleep Satisfaction

• More daytime fatigue

Medical and Medication Effects

• Physical and psychiatric conditions (pain, depression) and medications (beta-blockers, diuretics, antidepressants)

Circadian Rhythm Changes

• Shift toward earlier sleep and wake times ("advanced sleep phase")

Phase Advance Syndrome

• Rhythm is shifted so that the older adult falls asleep early in the evening but then wakes up very early in the morning while still obtaining the same 7 or 8 hours of sleep

  • Light exposure may be a helpful treatment

How can we promote improved sleep hygiene with our older patients, while maintaining safety?

• Establish a consistent?

• Create what type of environment?

• Limit what two things?

• Monitor intake of what?

• Establish a Consistent Sleep Schedule

• Create a Sleep-Conducive Environment: Quiet, cool, dark bedroom; remove noise or light distractions. Use nightlights to prevent falls

• Limit Naps: If needed, nap early in the day and keep it under 30 minutes.

• Limit Screen Time Before Bed: Blue light suppresses melatonin production.

• Monitor Caffeine, Alcohol, and Fluids: Reduce fluid intake 1 to 2 hours before bed to avoid bathroom-related falls.

How do nutritional components and exercise relate to brain health and the prevention of Alzheimer’s?

• What type of diet is ideal for Alzheimer prevention? What diet combines two (and what diets does it combine)?

• What supports neuronal membrane integrity and reduces brain inflammation?

• What do antioxidants do?

• B vitamins lower ______ levels. Higher ______ levels are associated with?

• Low levels of vitamin ___ are associated with cognitive decline

• Exercise and brain health promotes/improves what things?

  • Increases what factor? This factor helps with?

• Mediterranean Diets → Leafy greens, berries, whole grains, nuts, fish, olive oil

  • MIND Diet: Combination of Mediterranean and DASH (diuretic)

• Omega-3 Fatty Acids → Fatty fish (salmon, sardines), flaxseed

  • Supports neuronal membrane integrity and reduces brain inflammation.

• Antioxidants → Berries, dark chocolate, green tea, leafy greens

  • Counteract oxidative stress that damages brain cells.

• B Vitamins (B6, B12, folate) → Whole grains, legumes, leafy greens, eggs

  • Lower homocysteine levels (high levels are linked to brain atrophy)

• Vitamin D → Low levels are associated with cognitive decline

• Exercise & Brain Health → promotes neuroplasticity, improves sleep and mood, enhances blood flow to the brain

  • Increases Brain-derived Neurotrophic Factor (BDNF): supports the survival of neurons and the growth of new brain cells, particularly in the hippocampus (key for memory)

  • Reduces Risk Factors: diabetes, obesity, hypertension, and depression

How can patients keep their cognitive abilities sharp?

• Stay Mentally Active: Learn a new skill or hobby, do puzzles, crosswords, Sudoku, or brain training apps, read books or listen to informative podcasts

• Stay Physically Active: Improves blood flow to the brain and supports memory

• Stay Socially Engaged: Join clubs, volunteer, or attend classes

• Neurobic Activities (brain-stimulating activities designed to build new neural pathways by breaking your everyday routines and engaging multiple senses simultaneously)

What would be considered neurobic activities?

• What are neurobic activites? How does it work? Examples?

• Neurobic activities are non-routine tasks that engage the brain in novel, multisensory, and emotionally engaging ways.

• Stimulate different neural pathways, enhancing brain flexibility and memory.

  • Brush your teeth with your non-dominant hand

  • Listen to music you don’t normally hear

  • Eat with chopsticks if you usually don’t

Describe nutritional issues related to older adults.

What is the connection of various nutrients related to conditions associated with aging?

• What two vitamins are good for older adults and why? Deficency risks?

Vitamin D

• Enhances calcium absorption in the gut and regulates bone turnover

  • Older adults often have lower sun exposure and decreased skin synthesis, leading to vitamin D deficiency

  • Deficiency Risks: Increased bone loss, fractures, falls, and muscle weakness

Calcium

• A key mineral for bone structure and strength

  • Intestinal absorption decreases with age

  • Deficiency Risks: Accelerated bone loss and osteoporosis

How does protein relate to sarcopenia?

• What sort of resistance do older adults have? How does protein intake relate to this?

Anabolic Resistance

• Older adults have anabolic resistance, meaning their muscles are less responsive to protein intake

• Higher protein intake is needed to stimulate muscle maintenance

  • Sarcopenia

    • Age-related loss of skeletal muscle mass and function

  • Protein

    • Provides the amino acids necessary for muscle protein synthesis

What are the Blue Zones’ 9 Lessons for Living Longer?

What are the areas of the “blue zone”?

Blue Zone Principles

1. Move Naturally: Be active without having to think about it

2. Hara Hachi Bu: Stop eating when you are 80 percent full

3. Plant Slant: Avoid meat and processed foods

4. Grapes of Life: Drink red wine in moderation

5. Purpose Now: Take time to see the big picture

6. Downshift: Take time to relieve stress

7. Belong: Participate in a spiritual community

8. Loved Ones First: Make family a priority

9. Right Tribe: Be surrounded by those who share Blue Zone values

Moving Hara Plants Grapes Purposefully Down Below Love Tribe

Areas of the “Blue Zone”

• Loma Linda, California

• Sardinia, Italy

• Icaria, Greece

• Okinawa, Japan

• Nicoya, Costa Rica

Lomo Saltado Is Outstanding Naturally.

How can the physical therapist use the Mini-Nutritional Assessment to evaluate a patient?

• What age is this usually done for?

• What are the normative values?

Nutritional Risk Assessment

• Evaluate nutritional risk in older adults (usually age 65+). It helps identify malnutrition or risk of malnutrition

• Malnutrition impacts muscle mass, bone health, wound healing, and immune function

• Addressing nutrition can enhance therapy outcomes, promote independence, and reduce hospital readmissions

Scoring

• Normal = 12-14 points

• At risk = 8-11 points

• Malnourished = 0-7 points

Be able to design an appropriate exercise prescription for an older adult.

• Aerobic, including HIIT

  • 150 min / aerobic a week

  • Prolonged warm up & cool down to prevent arrhythmias

• Balance (for fall prevention)

• Range of Motion and Flexibility (Static and Dynamic Stretching)

  • For fall prevention

  • Static stretching for 30s: optimal to increase ROM and minimize the negative effects on the neural function of involved nerve roots

• Strength, Muscle Endurance, Power, Key Muscle Groups, Plyometrics

  • 2-3x per week

  • 1 set of 8-12 reps major muscle groups

• Posture

• Aquatics

  • Should not wear paddles or webbed gloves

  • Fins are okay on LE as long as they have no severe weakness or pain

  • Snorkel is good for cervical ROM

How does the exercise prescription relate to functional activities?

Exercise targets specific deficits to improve daily function

• Sit-to-stand → squat strength for transfers

• OH press → reaching activities

How can the exercise program be advanced? Modified based on a case scenario?

• Progress by increasing intensity, complexity, or duration.

• Modify based on pain, fatigue, or impairments

Be able to apply the FITTE formula, including all elements of an exercise prescription.

• F - How many days a week?

• I - Min, mod, or max intensity?

• T - How many minutes a week of aerobic activity?

• T - What types of exercise are ideal?

• E - What would boost adherence?

• Frequency (3 to 5x/week)

• Intensity (moderate)

• Time (≥150 min/week aerobic)

• Type (aerobic, strength, flexibility)

• Enjoyment (individual preference boosts adherence)

Be able to apply the CDC Older Adult Physical Activity guidelines to a patient case scenario

• How many minutes a week and what intensity for aerobic activity?

• How many days a week of strength training and how many reps per activity?

• What type of training for fall prevention? Give some examples. What muscle groups can be strengthened to also improve fall prevention?

150 min/week moderate aerobic activity

• 2+ days/week of strength training

  • 8 to 12 repetitions per activity

• Balance training for fall prevention

  • Walking backward, standing on one leg, or using a wobble board are examples of balance activities

  • Strengthening back, abdomen, and leg muscles also improves balance

Calculate exercise heart rates, including the Karvonen formula

• What is the Karvonen formula? What is the formula for HRmax? What intensity range is ideal?

 • THR = [(HRmax − HRrest) × %Intensity] + HRrest

 • HRmax = 220 – age

 • Use 50–85% intensity range

Prescribe appropriate resistance training parameters

• How many sets, how many reps, and how many times per week?

2 to 3 sets, 8 to 12 reps, 2 times per week

What is aquatic heart rate reduction? How is it found? Target heart rate for land and aquatic?

• How does hydrostatic pressure help?

• How does buoyancy help?

• How does thermal conductivity help?

physiological phenomenon where your heart rate is typically 10 to 17 beats per minute lower in water than during land-based exercise

Subtract 10 to 17 bpm from land-based target HR due to hydrostatic pressure and cooling effect

• Land Target HR = 130 bpm

• Aquatic Target HR = 115–120 bpm

Hydrostatic Pressure

• Water pressure helps circulate blood more efficiently

• The heart doesn't have to work as hard to return blood to the heart

Buoyancy

• Reduces gravitational stress → less effort from muscles and heart

Thermal Conductivity

• Water removes heat from the body faster, keeping the cardiovascular system cooler and reducing HR

Prescribe a stretching program for an older adult. How long to hold a static stretch?

• Hold static stretches 30 seconds

How are the different types of muscle contractions related to function and exercise prescription?

(Not on Ashleys, general chat GBT answer here)

• Concentric (muscle shortens) – helps with movements like standing up from a chair or climbing stairs.

• Eccentric (muscle lengthens) – helps control movement, such as sitting down slowly or walking downhill; important for balance and fall prevention.

• Isometric (muscle contracts without movement) – helps improve stability and maintain strength when joint movement is limited.

How do specific types of contractions and motor learning relate to an exercise program?

• Concentric and eccentric: Which one is shortening which one is lengthening? What does concentric improve vs eccentric?

  • The gait cycle is about __% eccentric or concentric contractions?

• What is Isometric? What does it help improve?

  • Use for what muscles?

• What is the cognitive stage, associative stage, and autonomous stage when it comes to learning a movement?

Concentric

• Shortening → Strength building

Eccentric

• Lengthening → Improves control, reduces injury risk, helps with balance and shock absorption

  • Gait cycle is about 60% eccentric contractions!

Isometric

• No movement → Builds joint stability, useful when joint movement is painful or restricted

  • Use for trunk muscles!

Cognitive Stage: Patient is learning the "what and how", needs more verbal/visual feedback

Associative Stage: Patient refines movements, fewer errors, improved coordination

Autonomous Stage: Movements become automatic, less conscious thought, functional carryover

How does The Physical Stress Theory relate to strength training?

Body adapts to the level of stress

• More load = more strength

• Too little = atrophy

• Too much = injury

Be able to prescribe power exercises.

• Use ____, ____ movements with what level of load (light moderate or heavy)

• Give some example exercises.

• Use fast, controlled movements with light or moderate loads

• Sit-to-stand with speed, step-ups

How are the concepts of Fun, Function, Frail, and Failure related to the slippery slope of aging?

• Aging is a continuum, what can prevent decline?

• Explain each of the “F”s.

• Aging is a continuum. Exercise prevents decline.

  • Fun (unrestricted participation)

  • Function (some limits): may need to modify performance

  • Frail (assistance needed)

  • Failure (dependent): may be bedridden

Design an exercise program related to functional movements and key muscle groups.

Nothing on ashleys. Self explanatory really.

How can a physical therapist maximize patient education activities?

• Use simple language, visuals, hands-on demos, and repeat key info.

• Make it relevant and goal-focused.

Describe how ageism and bias might influence physical therapy care.

• One mistake is to assume?

• Treat based on what?

• What method can be used to bolster positive age beliefs?

• Assuming limitations due to age may lead to under-dosing or ignoring goals

• Treat based on ability, not age

ABC Method to Bolster Positive Age Beliefs

• Awareness: Identifying where negative and positive images of aging are found in society

• Blame: Understanding that health and memory problems can be the result, at least in part, of the negative age beliefs we acquire from society

• Challenge: Taking action against ageism so that it is no longer harmful

Describe the physiology of aging and normal changes associated with aging

Discussed in previous cards

How do these (age) changes impact functional status?

• Decline in?

• Decrease ability to preform what activities?

• Loss of?

Decline in mobility, balance, and endurance

• Increased fall risk and fatigue

• Decreased ability to perform ADLs (dressing, bathing, walking)

• Loss of independence!

How could these age-related changes influence a patient’s motivation?

• Can cause what emotions? This can decrease what and lead to what sort of issues?

Cause frustration, fear, or a sense of dependence

• Decrease motivation: “I’m too old to get better”

• Lead to depression or apathy, especially with multiple comorbidities

How can a physical therapist strengthen a patient’s motivation?

• Set meaningful, achievable goals

• Use motivational interviewing and positive reinforcement

• Include them! Encourage patient choice and shared decision-making

• Celebrate small wins and functional gains

• Incorporate social support (family, groups)

How does lifestyle relate to the physiology of aging?

• What type of lifestyle slows decline and improves cognition?

• A sedentary lifestyle accelerates what? This can lead to?

  • What are some things that are ideal to know for patient history?

• Active lifestyle slows physical decline and promotes cognitive health

• Sedentary behavior accelerates loss of function and leads to depression

  • History of exercise? Exposure to sunlight?

Describe how aging interacts with the various systems of the body (Age related change and functional impact)

• Muscular

• skeletal

• Cardiopulmonary

• Pulmonary

• Nervous

• Sensory

• G/Renal

System	Age-Related Change	Functional Impact
Muscular	↓ Mass & strength	Weakness, ↓ mobility
Skeletal	↓ Bone density	↑ Fracture risk
Cardiovascular	↓ Reserve, ↑ BP	↓ Endurance, ↑ cardiac stress
Pulmonary	↓ Elasticity, ↑ RV	↓ Exercise tolerance
Nervous	↓ Reaction time, balance	↑ Fall risk, ↓ coordination
Sensory	↓ Vision, hearing	Difficulty with ADLs, ↑ fall risk
GI/Renal	↓ Absorption, ↓ excretion	↑ Medication sensitivity, constipation

How would a physical therapist accommodate these age-related changes into treatment?

• Should have a thorough screening of what?

• Tailor _____. Start low and progress based on?

• Use of what devices and why?

• Address _____ loss. How?

• What training is critical to do due to increased fall risk?

Thorough Screening

• Fall risk, strength, endurance, vision/hearing, cognition

Tailor Intensity

• Start low, progress based on tolerance (FITTE model)

Use Assistive Devices

• For safety and independence

Address Sensory Loss

• Speak clearly, use large print, ensure good lighting

Balance Training

• Critical due to increased fall risk

What modifications to physical therapy interventions would be necessary?

• Longer warm-ups and cool downs

• Frequent rest breaks

• Simplified instructions, demonstrations

• Use of functional tasks (sit-to-stand, step-ups)

• Incorporate dual-task or cognitive-motor activities

• Hydration and nutrition education when appropriate

What accommodations can be made for an older adult with sensory impairments?

• What can be done for the environment?

• What assistive technology can help?

• Demonstrate exercises and use what method?

Environmental Modifications

• Lighting, noise reduction, contrasting colors, clear pathways, adaptive equipment

Assistive Technology

• Hearing aids, voice-activated & text-to-speech software

Demonstrate Exercises

• Teach back method

Design a marketing brochure or written home exercise program to accommodate older eyes.

Bruh she asking for too much fr (Not on ashley’s)

Distinguish between macular degeneration, cataracts, diabetic retinopathy, and glaucoma.

macular degeneration: Blurriness of central vision.

cataracts: Opacity of the lens reduces visual acuity. Complaints of “glare” from bright lights.

glaucoma: Increased intraocular pressure to the optic nerve that causes a slow loss of visual field

diabetic retinopathy: Damages the blood vessels in the retina, usually complains of floaters or dark spots.

What are eye floaters?

• How should the PT respond if the patient described an increase of floaters or a flash of light with the onset of floaters?

Eye floaters: are tiny spots that appear to move within your field of vision.

• The PT should refer out → advise the patient to seek prompt medical attention from an ophthalmologist or retina specialist.

How would you assist your patient with vision or hearing loss?

• How do these sensory deficits relate to overall patient safety?

• What accommodations would be necessary to promote patient function and safety?

Vision Loss

• Speak before touching the patient

• Use high-contrast colors

• Use large-print instructions or verbal explanations

• Recommend magnifiers, bright lighting, night lights

• Make sure they are wearing their glasses

Hearing Loss

• Face the patient so they can read lips or see facial expressions

• Speak clearly, not loudly, and at a moderate pace

• Use written instructions or visual cues

• Reduce background noise

• Encourage use of hearing aids and verify if they are working properly

Accommodations to Promote Function and Safety

• Visual cues

• Assistive technology

• Grab bars

• Non-slip flooring

• Adaptive lighting

• Personal emergency response systems

• Regular caregiver or family education

What safety considerations would need to be made for a patient with diminished smell or touch?

Diminished Smell (Hyposmia/Anosmia)

• Cannot detect smoke, gas leaks, spoiled food

  • Install visual fire/smoke alarms

  • Encourage use of electric stoves over gas

  • Regular food checks for freshness

Diminished Touch (Neuropathy)

• Higher risk of burns, pressure injuries, and injuries from falls

  • Use thermometers for bath water and food

  • Encourage protective footwear

  • Perform regular skin checks for injury or breakdown

  • Pressure-relieving cushions and mattresses

What considerations would be necessary when designing residential facilities or a PT clinic?

• Wide, clear hallways and doorways

• Non-slip, low-glare flooring

• Bright, even lighting without harsh glare

• Large-font, easy-to-read signage

• Visual and auditory emergency systems

• Inclusive design for mobility and sensory impairments

What intrinsic or extrinsic factors would place a patient at risk for falls?

Musculoskeletal

• Weakness, decreased range of motion, pain

Cardiopulmonary

• Blood pressure issues, decreased oxygenation, heart arrhythmias, limited endurance

Vision

• Acuity, depth perception, glare recovery

Balance

• Visual, vestibular and somatosensory systems

Medications

• Side effects (postural control, cerebral perfusion, and/or cognition) and multiple medications (polypharmacy/ +5)

Environmental Factors

• Obstacles, Poor design of home, Inappropriate use of assistive devices, Lack of safety equipment

Diseases

• Neurological disorders, Cardiovascular disorders, MSK disorders, Psychological disorders (depression), Visual disorders (glaucoma, cataracts, macular degeneration, diabetic retinopathy), Incontinence

Based upon a patient’s risk factors, design strategies to minimize functional loss

• What questions should you be asking?

• History of Falls: Have you fallen in the past year

• Balance Issues: Do you feel unsteady when standing or walking?

• Fear & Trauma: Do you worry about falling?

Be familiar with the ICF model, especially as related to fall prevention and mobility restrictions.

For each part of ICF, give examples.

Assessment and treatment should consider all ICF domains, not just physical impairments

• How they affect activities, participation, and how environment/personal factors contribute

Health Condition

• Parkinson’s disease

• Osteoporosis

• Post-stroke

Body Functions and Structures

• Decreased strength

• Poor balance

• Visual deficits

• Vestibular dysfunction

• Joint limitations or pain

Activity Limitations

• Walking on uneven surfaces

• Rising from a chair

• Climbing stairs

• Maintaining balance during turns

Participation Restrictions

• Avoiding community outings due to fear of falling

• Unable to work

• Attend social gatherings

• Exercise with others

Environmental Factors

• Poor lighting, loose rugs (barriers)

• Use of grab bars, walker, handrails (facilitators)

Personal Factors

• Fear of falling

• Motivation and confidence

• Age

• Previous fall history

• Cognitive status

What examination procedures can be utilized to assess fall risk? For each of the following state what they are and the scoring for increased fall risk

• Berg Balance Scale

• Tinetti performance oriented mobility fall risk

• Functional Reach Test

• Four Square Step Test (FSST)

• Timed Up and Go (TUG)

• Walking While Talking Test

• Dynamic Gait Index (DGI) or Modified DGI

Berg Balance Scale (BSS): 4-item test assessing static and dynamic balance (standing, reaching, turning)

• Score <45/56 = increased fall risk

Tinetti Performance-Oriented Mobility Assessment (POMA): Evaluates gait and balance components

• Score <19/28 = high fall risk

Functional Reach Test: Measures limits of stability (how far a person can reach forward without losing balance)

• Reach <6 inches = high fall risk

Four Square Step Test (FSST): Assesses ability to step over objects in multiple directions quickly

• Time >15 seconds = higher risk of falls in older adults

Timed Up and Go (TUG): Measures mobility, balance, and fall risk. Can add dual-task component

• Time >13.5 seconds = increased fall risk

Walking While Talking Test: Assesses dual-task performance

• Delays or stops while talking suggest increased fall risk

Dynamic Gait Index (DGI) or Modified DGI: Assesses gait under varied conditions (head turns, obstacles)

• Score <19/24 = predictive of falls

Explain each of the following:

• Independent

• Supervision

• Close guarding

• Contact guarding

• Minimum assistance

• Moderate assistance

• Maximum assistance

 1. Independent: Patient is able consistently to perform skill safely with no one present.

 2. Supervision: Patient requires someone within arm’s reach as a precaution; low probability of patient having a problem requiring assistance.

 3. Close Guarding: Person assisting is positioned as if to assist, with hands raised but not touching patient; full attention on patient; fair probability of patient requiring assistance.

 4. Contact Guarding: Therapist is positioned as with close guarding, with hands on patient but not giving any assistance; high probability of patient requiring assistance.

 5. Minimum Assistance: Patient is able to complete majority of the activity without assistance.

 6. Moderate Assistance: Patient is able to complete part of the activity without assistance.

 7. Maximum Assistance: Patient is unable to assist in any part of the activity.

How do functional balance tests relate to determining fall risk?

Functional balance grades? (5)

Identify Fall Risk Level

• Low, moderate, or high risk for falling

Guide Intervention Planning

• Balance, strength, dual-task training

• Results reveal specific balance, strength, or coordination deficits

Track Progress Over Time

• Repeat testing shows objective changes, helping assess the effectiveness of treatment and adjust goals

  • MDC and MCID

Support Referrals or Justify Needs

• Assistive devices

• Home modifications

Functional Balance Grades:

1. Normal: Patient able to maintain steady balance without support (static). Accepts maximal challenge and can shift weight easily and within full range in all directions (dynamic)

 2. Good: Patient able to maintain balance without support, limited postural sway (static). Accepts moderate challenge; able to maintain balance while picking object off floor (dynamic)

 3. Fair: Patient able to maintain balance with handhold support; may require occasional minimal assistance (static). Accepts minimal challenge; able to maintain balance while turning head/trunk (dynamic)

 4. Poor: Patient requires handhold and moderate to maximal assistance to maintain posture (static). Unable to accept challenge or move without loss of balance (dynamic)

 5. No balance

Shorter version:

• Normal:

  • Static: No support

  • Dynamic: maximal challenge

• Good:

  • Static: No support

  • Dynamic: moderate challenge (maintain balance picking up object from floor)

• Fair:

  • Static: Handhold support, occasional min assistance

  • Dynamic: minimal challenge (maintain balance with head/trunk turning)

• Poor:

  • Static: Handhold support and mod to max assistance

  • Dynamic: No challenge

• None:

  • No balance

Based upon a case scenario, select the most appropriate balance tests and measures. For each of the following state the population and when to use:

• Berg balance scale

• Tinetti performance oriented mobility assessment

• Functional reach test

• Four square step test

• Timed up and go

• Walking While Talking Test

• Dynamic Gait Index (DGI) or Modified DGI

Berg Balance Scale (BBS): Older adults, stroke patients, patients with static and dynamic balance deficits

• Use when: You need a comprehensive balance profile (14 tasks). The patient can stand and follow directions safely

Tinetti Performance-Oriented Mobility Assessment (POMA): Older adults at risk for falls, patients with gait deviations and poor postural control

• Use when: You want to assess both gait and standing balance, You have moderate time available, and Patient ambulatory

Functional Reach Test: Frail older adults, patients with limited time, space, or endurance

• Use when: You want a quick snapshot of limits of stability and patient is able to stand unsupported

Four Square Step Test (FSST): Community-dwelling older adults, patients who report tripping, poor coordination, or difficulty changing directions

• Use when: You want to assess dynamic balance and stepping in multiple directions

Timed Up and Go (TUG): General fall risk screening in older adults, patients who are ambulatory

• Use when: You want a fast, functional measure of mobility and you can add TUG-cognitive to assess dual-task ability

Walking While Talking Test: Older adults with cognitive decline or distraction-related falls

• Use when: You want to evaluate dual-tasking and attention while walking

Dynamic Gait Index (DGI) or Modified DGI: Community-dwelling adults, especially those with vestibular, neurological, or sensory issues

• Use when: You need to assess walking under varied conditions (head turns, obstacles)

How can we help patients prevent falls?

• Treatment of acute or chronic conditions

• Consult with MD regarding medications

• Exercise programs

  • Gait training

  • Balance training

  • Strength training

• Proper fit and use of assistive devices

• Proper footwear

• Daily Activity

  • Repetition and practicing functional movements

• Referrals

  • PT

  • OT

  • Orientation and Mobility Specialist (low vision)

Given a case scenario, design physical therapy interventions related to fall prevention.

• What exercise programs?

• What gait and balance activities?

• What type of tech?

Exercise Programs: Strength training, Endurance, Flexibility, Posture, Attention to precautions, Safety, Aerobic training

Gait and Balance: Specificity (home and community), Dual tasking, Directional changes, Obstacle course, Response strategies to perturbations

High Tech: Virtual reality, Computerized balance training, Gaming systems

Perform an environmental assessment and be able to recommend adaptive equipment.

• Safety training

• Environmental Modifications: Recommend lighting upgrades like bright, non-glare lights in hallways and bathrooms

• Remove trip hazards like Rugs or Cords. Suggest grab bars in the bathroom, non-slip mats, and clearly marked steps

• Assistive Device Prescription: Assess need for a cane or walker based on balance testing. Train in safe use of the device on different surfaces and with dual-tasking

• Dressing assistance

  • Elastic shoe laces

  • Reacher

• Home Safety Assessment: Recommend changes like handrails, bathroom aids, nightlights, decluttering

Be able to determine the best fall recovery strategies for a given patient

• What systems can be use?

• Encouraging the patients to keep what within reach?

• Teach patients how to do what safely?

• Educate patients and caregivers on?

• Emergency Alert Systems: Devices (worn or installed) that let the patient quickly call for help after a fall, especially useful for those living alone.

• Portable or Cell Phone: Encouraging the patient to keep a phone within reach at all times so they can call for help if needed.

• Floor Transfer Training: Teaching patients how to safely get up from the floor or reach a stable position after a fall to prevent long periods on the ground.

• Education: Informing patients and caregivers about fall risks, safe movement techniques, and what to do after a fall to reduce fear and improve response.

How does fear of falling impact behavior and fall risk?

• Causes what and leads to what?

• Increased risk of failing that leads to a vicious cycle, what is the cycle?

• Patient education?

• Behavioral modification?

• Causes social isolation, limited mobility, and weakness → activity avoidance, physical deconditioning, loneliness and depression.

• Increased risk of falling that leads to a vicious cycle: Fear → inactivity → weakness → instability → higher risk → more fear

• Patient Education: Teach about safe movement strategies, fall prevention, and how activity builds strength and confidence.

• Behavioral Modification: Gradually increase challenging activities to rebuild trust in mobility. Incorporate positive reinforcement and goal-setting

When would vibrating insoles or hip protectors be appropriate to prescribe for a patient? How do they work?

When to Prescribe Vibrating Insoles

• For older adults with balance impairments but who are still ambulatory. Especially useful for peripheral neuropathy and age-related sensory decline

• Vibrating insoles deliver subsensory vibratory noise to enhance sensory input, which can improve gait stability, postural control, reduced sway

When to Prescribe Hip Protectors

• Do not prevent falls, they might be helpful in preventing fractures. Appropriate if the patient has low bone density, a history of hip fractures, is frail or in a long-term care setting

• Help protect the greater trochanter from impact during a fall. May include hard plastic shields or soft foam pads

Be familiar with the evidence-based approaches to fall prevention.

• Matter of balance

• STEADI (What is it? Consists of? Three questions to screen for fall risk)

Matter of Balance: Program that emphasizes practical strategies to reduce fear of falling and increase activity levels.

• Participants learn to view falls and fear as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance.

STEADI: “Stopping Elderly Accidents, Deaths and Injuries”

• Tool Kit for Health Care Providers: offers educational brochures and resources for patients and caregivers

  • Look for OH (BP irregularities such as hypertensive crisis)

  • Falls, screening options, medications linked to falls, standardized gait and balance assessment tests, online trainings that offer continuing education

• Three Questions to Screen for Fall Risk

  • Have you fallen in the past year?

  • Do you feel unsteady when standing or walking?

  • Do you worry about falling?

Compare and contrast the normal gait pattern with typical gait changes in older adults.

• What would you see decrease and increase?

• Decreased gait speed

• Decreased step or stride length

• Increased stance time and double limb support time

• Increased variability of gait

• Decreased excursion of movement at the hip, knee, and ankle

• Decreased reliance on ankle kinetics and power

• Less upright posture

Be familiar with the phases of normal gait. What are the three primary tasks of gait?

Three primary tasks of gait: weight acceptance, single limb support, limb advancement

What sensory systems are related to postural control and balance? How does the CNS relate to these systems?

• Visual System: Provides information about the environment, orientation, and movement relative to surroundings

• Somatosensory System (Proprioception): Detects body position, movement, and surface contact

• Vestibular System: Detects head position and motion relative to gravity

  • The central nervous system integrates input from all three systems to maintain balance. If one system is compromised, the others must compensate.

Describe recovery strategies related to balance perturbations.

• Ankle strategy

  • Muscle sequence?

• Hip strategy

  • Muscle sequence?

• Stepping strategy

• Reaching/Grasping strategy

  • Important for fall prevent in what population?

• Suspensory strategy

Ankle Strategy: Small, slow perturbations on a firm surface

• Distal to proximal muscle sequence

Hip Strategy: Larger, faster perturbations or when the ankle strategy is insufficient. Rapid hip flexion or extension moves the center of mass over the base of support

• Proximal to distal muscle sequence

Stepping Strategy: Very large or fast perturbations when balance cannot be regained with ankle or hip movements. A step is taken in the direction of the instability to widen the base of support

Reaching/Grasping Strategy: Stabilize by grabbing an object

• Important for fall prevention in older adults

Suspensory Strategy: Lowering the center of mass to be closer to the base of support. Bending the knees during standing or ambulation

What skills would be necessary for community ambulation?

• Starts and stops

• Acceleration and deceleration

• Sideways stepping

• Backward stepping

• Changing directions

• Obstacle clearance and avoidance

• Picking up, carrying, or putting down objects

• Turning around

• Pushing and pulling doors

• Managing displacement forces

• Terrain changes

• Lighting changes

• Weather changes

• Stepping up and down curbs, stairs, and ramps of different heights and grades

What activities would be included when training patients to resume community ambulation?

• Varying Terrain Practice: Grass, gravel, ramps, curbs, uneven surfaces

• Crossing Streets: Timed walking (simulate traffic signals), increased gait speed

• Car Transfers: Practice entering/exiting vehicles safely

• Stair Navigation: With and without handrails, practice ascent and descent

• Dual Tasking: Walking while talking, holding objects, or counting

• Carrying Items: Practice with shopping bags or small loads

• Endurance Training: Extended walking sessions to simulate real distances

• Navigating Obstacles: Walking around cones, stepping over objects, changing directions

Be able to prescribe an appropriate assistive device for a patient, based on a case scenario.

• Single point cane

• Quad cane

• Standard walker

• Front wheel walker (2WW)

• Four wheel walker (Rollator)

• Hemi walker or Narrow base quad cane

• Single-Point Cane: Mild balance loss, needs occasional support. Increases base of support, minimal assistance

• Quad Cane: Moderate balance deficits, slower gait speed. More stable than a single-point cane

• Standard Walker: Prescribed when a patient needs maximum stability and support for walking but still has enough upper body strength and balance to lift the walker safely

• Front-Wheeled Walker (2WW): Bilateral lower extremity weakness, needs moderate support. Provides continuous support without needing to lift the walker

• Four-Wheeled Walker (Rollator): Poor balance, history of falls, needs maximal support. Offers high stability, includes a seat and storage for independence

• Hemi-Walker or Narrow-Base Quad Cane: Significant one-sided weakness or asymmetry (post-stroke). More support than a cane but still unilateral

How do concentric and eccentric contractions relate to stair climbing?

• Stair ascent and descent. What muscles fire for each?

Stair Ascent (Going Upstairs) → Concentric Contractions Dominate

• Quads, glutes, calves contract concentrically to lift the body upward.

• Muscles shorten as they generate force to extend the knee, hip, and ankle.

Stair Descent (Going Downstairs) → Eccentric Contractions Dominate

• Quads and glutes contract eccentrically to control the lowering of the body.

• Muscles lengthen under tension to prevent a rapid or uncontrolled descent.

Why would gait speed be considered a functional vital sign?

• What gait speed is considered “dead”?

serves as a highly reliable, objective summary of an individual's overall physiological health and functional capacity. It is clinically useful and flexible

• <2 MPH = dead. A commonly used threshold that delineates older adult community ambulators from those who are more limited is 1 m/s

Be able to prescribe a gait training program based on the patient’s functional impairments.

• Consider how to progress the patient during gait training and how to use a task specific approach during physical therapy treatment sessions.

Nothing on ashleys

How does dual tasking relate to gait training activities?

• Dual Tasking: Walking while talking, holding objects, or counting

• Gait and Balance: Specificity (home and community) dual tasking, directional changes, obstacle course, response strategies to perturbations

Be able to perform an examination/evaluation on an older patient/client.

• What is crucial to understand?

  • Environmental assessment include what modifications?

  • For adaptive equipment, what is important to remind them about?

  • Assess support includes? Take into consideration what 2 things?

• Cognitive and psychological functioning

  • What are three assessments that can be used to assess mental status?

• Grip strength test

  • Lower grips strength is associated with?

CRUCIAL to understand their home or environmental situation

• Environmental Assessment: home modifications

• Adaptive Equipment Needs: Remind them this will not make them dependent on something, but rather help them stay INDEPENDENT!

• Assess Support: family, friend, financial resources

   ▪ Take into consideration patient AND family goals

Cognitive and Psychological Functioning

• Depression, dementia, how many command can they follow at once

• Take into consideration: mental status, orientation, learning style, ability to follow directions, psychosocial functioning

  • Geriatric Depression Scale

  • Montreal Cognitive Assessment (MoCa)

  • Short Blessed Cognitive Test: Sensitive to early cognitive changes associated with Alzheimer’s disease

Grip Strength Testing

• Lower grip strength is associated with a higher risk of mortality

What is the purpose of the Senior Fitness Test?

• Assess the physical abilities in relation to everyday functional tasks of older adults (typically 60+ years) in comparison to others in their age category

How would you perform the various components of the Senior Fitness Test?

• Chair stand test

  • Risk Zone?

• Arm curl test (how weight for men and for women)

  • Risk Zone?

• 6 minute walk test

  • Risk Zone?

• 2 minute step test

  • Risk Zone?

• Chair Sit-and-Reach test

  • Risk Zone (for men and for women)?

• Back stretch test

  • Risk Zone (for men and for women)?

• 8 foot up and go test

  • Risk Zone?

• Height and weight

  • Normal BMI range for older adults?

1. Chair Stand Test (Lower Body Strength): Sit in a chair with arms crossed over chest. Stand up and sit down as many times as possible in 30 seconds.
    a. Risk Zone: < 8

2. Arm Curl Test (Upper Body Strength): Seated, curl a dumbbell (5 lbs women / 8 lbs men) as many times as possible in 30 seconds.
    a. Risk Zone: < 11

3. 6-Minute Walk Test (Aerobic Endurance): Walk as far as possible in 6 minutes
    a. Risk Zone: < 350 yards

4. 2-minute Step Test (Alternate for Aerobic Endurance): March in place for 2 minutes, raising knees
    a. Risk Zone: <65 steps

5. Chair Sit-and-Reach test (lower body flexibility): sit on edge of chair, extend one leg forward with heel on floor. Reach toward toes with both hands for 2 seconds
    a. Risk Zone: Men = 4 inches; Women = 2 inches

6. Back scratch test (upper body flexibility): one hand over shoulder, other up the back; try to touch fingertips (+ if overlap, - if gap)
    a. Risk Zone: Men = 4 inches, Women = 2 inches

7. 8-foot up-and-go test (agility/dynamic balance): from seated position, stand up, walk 8 feet, turn around, and sit back down
    a. Risk Zone: > 9 seconds

8. Height and Weight (Body Composition): BMI = weight (kg) / height² (m²)
    a. Normal BMI range for older adults = 18.5-24.9

Case Study: When performing the Senior Fitness Test, your patient did only 5 unassisted stands during the 30 - second chair stand component which puts him in the risk zone. Why is this score significant and what impact does this information have on your physical therapy intervention?

• Falls into the “risk zone” (<8): This indicates marked lower body weakness, especially in the hip and knee extensors

• Therapy: Focus on quadriceps, glutes, hamstrings, and core stabilization. Begin with assisted sit to-stands, mini-squats, step-ups, and resistance band work. Practice tasks like transfers, toilet/bed mobility, and stairs in therapy

Be familiar with patient examination procedures. Have an understanding about the mentioned tests and measures and how the scores impact your physical therapy intervention.

• Vital Signs → At rest and following an activity

• Strength → Functional strength, grip strength, MMT might not be the best

• Circulatory Status → Capillary refill, rubor of dependency, venous filling time

• Sensation → Monofilament testing, protective sensation, diabetes

Be able to select the appropriate tests and measures based upon a case scenario.

• Timed up and go

• Functional reach

• Berg balance scale

• Tinetti assessment tool

• Dynamic gait index

• Toe tap test

• Walking while talking test

• Rhomberg test

• Occiput to wall test

• Timed Get Up and Go: Quick measure of basic mobility and balance

  • Most adults walk 10 ft (3 m) in 10 seconds → More than 30 seconds indicates dependency with mobility and ADLs

  • If an assistive device is required, the type is recorded

  • TUG cognitive and TUG manual can also be utilized to assess the ability to perform dual tasking. Slower time with these is expected because of dual tasking.

• Functional Reach: Examines limits of stability for individuals with balance disorders at high risk of falls

  • Greater than 10 inches = not likely to fall

  • 6 to 10 inches = 2 times more likely to fall

  • 1 to 6 inches = 4 times more likely to fall

  • Unwilling to reach = 28x more likely to fall

• Berg Balance Scale: Status and dynamic balance with functional tasks

  • Maximum score: 56 points

  • Less than 45 points is associated with a high risk of falls

• Tinnettii Assessment Tool: Also called Performance-Oriented Mobility Assessment (POMA), assesses a person's perception of balance and stability during activities of daily living and their fear of falling

  • Scores less than 19 = a high risk for falls

  • Scores between 19 and 24 = moderate risk for falls

• Dynamic Gait Index: Ability to perform variations in walking on command

  • Maximal possible score = 24

  • Score below 19 = increased fall risk

• Toe Tap Test: Assess motor speed and coordination of the dorsiflexors, may also reflect basal ganglia or cerebellar dysfunction if impaired

  • Young (av. 32 yr): 47 taps per 10 seconds

  • Older adults (av. 72 yr): 34 taps per 10 seconds

• Walking While Talking Test: Walk at self-selected comfortable speed 20 feet and then return, for a total of 40 feet

  • Simple (recite the alphabet): ⩾ 20 seconds = high fall risk

  • Complex (recite every other letter): ⩾ 33 seconds = high fall risk.

• Rhomberg Test: Assess balance, particularly the role of proprioception

  • Feet Together: Eyes Open, Eyes Closed

  • Sharpened Rhomberg with Feet in Tandem: Eyes Open, Eyes Closed

• Occiput to Wall Test: Postural Assessment

  • Standing with buttocks and midback against the wall, eyes focused straight ahead. Inability to touch the wall with the back of the head (occiput) is a positive finding for flexed posture

Given specific components of a test, be able to prescribe a physical therapy intervention.

• TUG

• Functional reach test

• Berg balance scale

• Tinetti assessment tool

• Dynamic gait index

• Toe tap test

• Walking while talking test

• Rhomberg or sharpened Rhomberg

• The balance outcome measure for elder rehabilitation (BOOMER)

• Timed Up and Go (TUG): Gait training with/without assistive device (AD), sit-to-stand and turn practice, strengthening of LE (quads, glutes)

• Functional Reach Test: Static & dynamic balance training (reaching outside BOS), core and trunk stability exercises, standing weight shifts, reaching tasks

• Berg Balance Scale (BBS): Stepping over obstacles, reaching

• Tinetti Assessment Tool: Gait training, practice safe transfers, use mirrors or visual feedback for posture correction

• Dynamic Gait Index (DGI): Walking while turning head, changing speed, stepping over obstacles, dual-task gait training (counting, carrying objects)

• Toe Tap Test: Ankle dorsiflexion strengthening, fast alternating foot movements (marching, quick steps), rhythmic coordination drills (metronome-based)

• Walking While Talking Test: Cognitive-motor training, community simulation (crossing street, navigating while talking)

• Rhomberg or sharpened Rhomberg: balance exercises with reduced vision (eyes closed, foam surface), tendem stance or narrow BOS activities

• The Balance Outcome Measure for Elder Rehabilitation (BOOMER): Assesses standing balance and functional mobility in the elderly population

Your patient scored a 20 on the Mini-Mental State exam. How would you modify your treatment?

• Maximum points is? A score below ___ indicated cognitive impairment?

• What condition may affect the score of the MMSE?

• The MMSE is _______ and must be _______ for clinical use

Simplify instructions ➔ Use visual and verbal cues ➔ Increase repetition ➔ Create a structured routine ➔ Tie exercises to functional tasks to improve relevance and engagement ➔ Monitor safety closely

• Maximum points is 30: A score below 24 indicates cognitive impairment, not considered normal for an older adult

  • Depression may be reflected on the MMSE. As the depression improves, the MMSE score will also increase.

  • The MMSE is copyrighted and MUST be purchased for clinical use

What are the components of the MoCA and Mini-Cog?

• MoCA: Assesses what? What does it consist of? You must be what to use MoCa? Time to administer is? Total score is? A score of __ or above is consider normal.

• Mini-Cog: Quick screening for what and the results help determine what? What three things does it consist of? Total score of? Cut point of ___ has been validated for dementia screening.

Montreal Cognitive Assessment (MoCA): Assesses cognitive domains

• Attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation.

• You must be certified to use the MoCa

  • Time to administer: 10 minutes.

  • The total possible score is 30 points

  • A score of 26 or above is considered normal.

Mini-Cog: quick screening for early dementia detention → identify possible cognitive impairment in older people, results help determine when it might be time for more in-depth testing.

• Three Word Registration, Clock Drawing, Three Word Recall

  • Cut point of <3 has been validated for dementia screening

  • Total possible score is 5

Your patient scored a 380 on the Holmes and Rahe Life Events Scale. Why is this significant? Scoring?

Indicates your patient is experiencing significant stress, which may impact healing, motivation, immune function, and treatment adherence

• Score greater than or equal to 300 → High risk of illness or health breakdown due to stressful life events

• Score of 150 to 299 → Moderate to high chance of a serious illness

• Score below 150 → Indicates mild stress of a lot to moderate risk of serious illness in the near future

Your patient scored a 17 on the Tinetti Gait and Balance test. What does this score indicate? Scoring?

• HIGH fall risk

• Indicates your patient is at a significantly increased fall risk and suggests balance and gait impairments that require immediate intervention

  • Maximum score = 28

  • Score < 19 = High risk for falls

Your patient scored a 48/56 on the Berg Balance test. How does this information relate to fall risk?

• 48 = Borderline fall risk → patient may be functionally independent but still at moderate fall risk, especially with more complex or dynamic tasks

  • Score ≤ 45 = Increased fall risk

Your patient scored a 33 on the Fullerton Advanced Balance Scale. What does this mean? Scoring?

Indicates your patient is not at high risk for falling but may have some difficulty with advanced balance tasks (turning, stepping over obstacles, tandem walking)

• Test of both static and dynamic balance under varying sensory conditions.

• Designed to measure balance in higher-functioning active older adults.

  • Score of 33: Below the optimal cutoff for high-functioning balance

  • Cutoff for fall risk: Typically ≤25 suggests high fall risk in older adults

  • Max score of 40 (google)

Your patient was able to complete the Four Square Step Test in 19 seconds. What does this mean? Scoring?

Increased risk of falls and likely has reduced dynamic balance and coordination

• >15 seconds = Increased fall risk

• ≤15 seconds = Lower fall risk (normal mobility)

When does the timing begin and end with the Four Square Step Test? The Timed Up and Go?

The Four Square Step Test:

• As soon as the first foot touches the floor in square 2. It’s not when the command is given or when they start moving in square 1, it starts when they step into square 2.

  • Timing ends: both feet return to square 1 after completing the full sequence

The Timed Up and Go:

• On the command “Go,” when the patient’s back leaves the chair. Do not start the timer on the verbal cue alone; it's triggered by movement initiation.

  • Timing ends: patient sits back down and their back touches the chair again.

How does grip strength relate to predicted functional decline?

• It is a simple yet powerful indicator of overall muscle strength, physical function, and even mortality risk.

• Low grip strength is associated with weakness in other major muscle groups, making it a quick screen for global sarcopenia (age-related muscle loss)

What are the components of the AFIT? What is it used to identify?

Components: General health history, vital signs, posture, flexibility, balance, endurance, and strength

• “Adult Functional Independence Test”: This performance-based functional assessment tool identifies potential problems early so they can be addressed using an individualized exercise program prescribed by a PT

What are the components of the BOOMER? Scoring?

• Components: Step Test, Timed Up and Go, Functional Reach, Timed Static Stance

  • “Balance Outcome Measure for Elder Rehabilitation”: For older adults with deficiencies in standing balance

  • Maximum score is 16. Each item (4 items) can score between 0 (unable to perform the test) to 4 (excellent). A minimum clinically significant change in the BOOMER is 3 points over its 16-point scale range

How is the Walking While Talking test administered? What do the scores indicate?

Walk at a comfortable speed 20 feet and then return, for a total of 40 feet

1. Simple (recite the alphabet): 20 seconds or longer = high fall risk

2. Complex (recite every other letter): 33 seconds or longer = high fall risk.

What is polypharmacy? Increases risk of? What is a critical element in comprehensive care?

The use of FIVE or more medications at once

• It increases the risk of drug interactions, side effects, confusion, falls, and medication non adherence

• Optimization of the medication regimen is one of the critical elements in comprehensive geriatric care.

How does aging impact drug absorption, distribution, metabolism, and excretion?

• Calcium is a ____ _____ vitamin and can become what?

• Absorption: Slower gastric emptying and reduced blood flow may delay absorption onset

• Distribution: Increased body fat leads to increased storage of fat-soluble drugs (diazepam) which leads to prolonged action. Decreased lean body mass and total body water leads to increased plasma concentration of water-soluble drugs.

  • Calcium is a fat soluble vitamin and can become toxic!

• Metabolism (Liver): Reduced hepatic blood flow and enzyme activity leads to slower metabolism of certain drugs which leads to longer half-lives and risk of drug accumulation

• Excretion (Kidneys): Decreased glomerular filtration rate (GFR) leads to reduced clearance of renally-excreted drugs. This slower excretion raises the risk of overdose and toxicity

What are some of the common adverse drug reactions in older adults?

• Cognitive & Central Nervous System (CNS) Effects

• Balance, Falls, and Mobility

• Gastrointestinal (GI) and Urinary Issues

• Metabolic/Electrolyte Imbalances

Cognitive & Central Nervous System (CNS) Effects

• Confusion, delirium (from anticholinergics, opioids, benzodiazepines)

• Sedation (opioids, benzodiazepines, antipsychotics)

• Depression (beta-blockers, corticosteroids, sedatives)

• Fatigue & weakness (CNS depressants, antihypertensives, diuretics)

  • Extrapyramidal symptoms → movement disorders, tremors, rigidity, bradykinesia (antipsychotics, metoclopramide)

• CNS effects → hallucinations, cognitive decline (anticholinergics, corticosteroids)

Balance, Falls, and Mobility

• Falls & dizziness (sedatives, benzodiazepines, antihypertensives)

• Orthostatic hypotension (antihypertensives, diuretics, nitrates)

• Fatigue & general weakness (diuretics, statins, beta-blockers)

• Peripheral effects → numbness, tingling (chemotherapy agents, antidiabetics)

Gastrointestinal (GI) and Urinary Issues

• GI bleeding (NSAIDs, corticosteroids, anticoagulants)

• Nausea and vomiting (opioids, antibiotics, digoxin)

• Constipation (opioids, calcium channel blockers, anticholinergics)

• Urinary retention (anticholinergics, antihistamines, tricyclic antidepressants)

Metabolic/Electrolyte Imbalances

• Electrolyte disturbances → hyponatremia, hypokalemia (diuretics, laxatives)

• Dehydration (diuretics, laxatives, poor intake due to cognitive decline)

How would you recognize depression in an elderly patient?

• Hopelessness and helplessness

• Anxiety and worry

• Memory problems

• Weight loss

• Loss of feeling pleasure

• Slowed movement

• Irritability

• Lack of interest in personal care

• Tiredness, listless

• Unexplained aches or pain

How is depression treated?

• Pharmacotherapy: mostly biochemical, sometimes situational

• Psychotherapy: maybe talking is not for them, but maybe it is!

• Exercise and Physical Activity: endorphins

  • Sidenote: emotional support animals

How would depression or social isolation impact your physical therapy intervention?

• Patient may lack?

• What is the suicide and crisis lifeline number?

• Reduced adherence to?

Loneliness is a public health threat!

• Patients may lack the energy, interest, or hope to attend sessions or complete exercises

  • 988: Suicide and crisis lifeline

• Reduced adherence to home programs or follow-through on care plans.

How would you recognize caregiver stress? What coping strategies could you suggest?

Signs: Denial, anger, social withdrawal, anxiety, depression, exhaustion, sleeplessness, irritability, lack of concentration, health problems

A few simple steps can help prevent exhaustion:

• Plan ahead to be sure you have the supplies and resources you need.

• Take one day at a time.

• Develop contingency plans for emergencies and obstacles.

• Accept help, don’t take on more than you can handle.

• Make YOUR health a priority. Get enough rest and eat properly.

• Make time for leisure.

• Be good to yourself!

• Share your feelings with others, it’s okay to be tired and frustrated

What would be considered normal cognitive aging?

• Abilities That Remain Stable or Decline Minimally

  • Implicit memory?

  • Emotional regulation often?

  • Long term autobiographical memory is?

• Cognitive Functions That Typically Decline Gradually

  • Processing speed?

  • Word finding and name recall?

  • Executive function?

  • Cognitive flexibility?

  • Working memory (short-term retention and manipulation of information)?

  • Encoding information?

Abilities That Remain Stable or Decline Minimally

• Implicit (procedural) memory remains stable → riding a bike, brushing teeth, social/emotional responses

• Emotional regulation often improves or remains intact

• Long-term autobiographical memory (recall of meaningful past events) is generally preserved

Cognitive Functions That Typically Decline Gradually

• Processing speed slows (tasks take longer)

• Word-finding and name recall may become slower or more difficult

• Executive functions decline → includes planning, multitasking, switching tasks, and problem solving.

  • Cognitive flexibility is reduced → may struggle to adapt if routines or familiar strategies fail

• Working memory (short-term retention and manipulation of information) becomes less efficient.

  • Encoding new information becomes harder, especially under distraction

In general, how do personality traits relate to aging?

• What two personality traits tend to increase with age? What three decrease?

• These changes are often seen as part of the _____ principle.

• Agreeableness and Conscientiousness tend to increase with age

• Extraversion, Neuroticism, and Openness to experience tend to decrease

  • These changes are often seen as part of the "maturity principle" → people become more emotionally stable and less open to new experiences

Describe the continuum of cognitive change as we age.

The continuum spans from normal aging to severe cognitive impairment, and reflects a gradual spectrum (not an all-or-nothing process)

What is cognitive reserve?

• The brain's ability to withstand the negative effects of aging or brain damage, and maintain cognitive function despite such challenges.

• It's a measure of the brain's flexibility and efficiency in adapting to changing circumstances, essentially acting as a buffer against cognitive decline.

  • Helps individuals maintain function and live longer with minimal cognitive decline

Describe the four types of memory.

• Working

• Episodic

• Semantic

• Remote

Working memory: Remembering bits of information

Episodic memory: Memory of an event or episode

Semantic memory: Language based, memory for facts and words

Remote memory: Past events