Quiz 4 Geriatrics

Dysphagia

Difficulty swallowing, often secondary

Unaddressed dysphagia may cause

airway obstruction, dehydrating, malnutrition, aspiration pneumonia

conditions associated with dysphagia

CVA, MS, PD, ALS, CP, tumors of head/neck/esophagus

4 stages of swallowing

• oral preparatory phase

• Oral phase

• Pharyngeal stage

• Esophageal stage

Oral preparatory phase

food is recieved

Oral phase

Tongue propels food back into the pharynx (1 second)

Pharyngeal phase

Food is carried through pharynx with laryngeal closure (epiglottis), also 1 second

Esophageal stage

esophageal peristalsis carries the bolus through esophagus into the stomach (5-15 seconds)

What needs to halt during swallowing

respiration

Penetration

entry of material into laryngeal vestibule (above vocal cords)

Aspiration

Entry of material into the airway below the level of vocal cords

Silent aspiration

no cough with aspiration

Signs of aspiration

fever, SOB, elevated WBC

Bedside swallow examination

SLP will bring foods of different consistencies and evaluate what foods are safest to eat

Instrumental examination

done when there is evidence of aspiration, modified barium swallow evaluation, fluoroscopic view of the throat while someone is swallowing

Fiberoptic endoscopic exam

tube with camera down throat to evaluate the structure of the pharynx/larynx

NPO

nothing by mouth

If long term problem with swallowing, will get nutrition by

gastrostomy tube: direct to stomach

Jejunostomy tube: direct to intestines

Short term swallowing problem will be treated me

NG tube

Treatment of dysphagia

• diet modifications

• Postural changes

• Strengthening/ROM

• EMG/biofeedback/NMES

Function of pelvic floor muscles

• close urinary and anal sphincters

• Closing of vaginal opening

• Support abdominal viscera

• Sexual function

Incontinence is more common in

women

These normally prevent fecal incontinence

internal and external anal sphincters and puborectalis muscle

Defacation is initiated by

Rectal filling, PNS response, voluntary relaxation of puborectalis muscle and external sphincter, assisted by valsalva maneuver

What happens to PFM with aging

weakness, loss of elasticity

Most common cause of bowel incontinence

Fecal impaction, associated with constipation and diarrhea

Leakage can be associated with

sensation or muscle tone losses, cognitive decline

Chronic fecal impaction

caused by inadequate fluid intake, chronic laxative abuse, poor bowel habits. These things lead to liquid stool leaking from higher in the colon, draining at the anus

Dx of incontinence

• patient history

• Physical exam

• Neuro exam

• Mobility/hygiene

• Mental function

Tax of incontinence

• medications

• NM reeducation

• Strengthening PFM

Loperamide

treats diarrhea

Normally, urine remains in the bladder for as long as the pressure is

lower than urethral resistance, then the detrusor contracts forcing urine into the urethra

Urge incontinence

person feels the need to urinate, but is unable to get to the toilet before urination occurs. Most commonly triggered by an external stimulus, caused by detrusor instability

Stress incontinence

Cough/strain/sneeze causes urination, most common in middle aged women

Overflow incontinence

bladder is overly distended, causing bladder pressure to exceed urethral pressure, causing small and continuous urine loss

Functional incontinence

difficult mobility/cognitive function causing incontinence

DIAPPERS

Causes of incontinence

• delirium

• Infection

• Atrophic urethritis/vaginitis

• Pharmaceuticals

• Psychological disorders

• Endocrine disorders

• Restriction mobility

• Stool impaction

Pharmaceuticals causing incontinence

• diuretics

• Anticholinergic agents

• Sedatives

• LT alcohol abuse

Iatrogenesis

Injury that is a result of medical treatment that was done improperly

Iatrogenesis risk is increased

By 2x over age of 65

Cascade Iatrogenesis

development of multiple complications initiated by a seemingly innocuous initial event

This alters distribution

decreased total body water and lean body mass

This alters metabolism

decreased liver mass and blood flow

This alters elimination

Decreased renal plasma flow and GFR

Other causes of ADRs

T2DM, CRF, dementia

Antipsychotics can cause

Parkinsonism, tardive dyskinesia (involuntary movement of tongue and lips)

Testosterone replacement can cause

prostate cancer

May increase falls

analgesics and antidepressants

Used to reduce menopausal symptoms

limiting caffeine/alcohol, stress reduction, light colored therapy, SSRIs, estrogen replacement (vaginal ring)

Dizziness increases risk of

Falls

Most common cause of dizziness

medication changes

Nystagmus

Involuntary rhythmic oscillation of the eye

Vertigo

illusion of movement, rotary component (the room is spinning), caused by inner ear dysfunction or cerebellar stroke

Most common cause of dizziness

BPPV, when otoconia within otolith become dislodged and symptoms are caused with a certain change in head position

Treat BPPV

epley and seamount

Can be used to dx peripheral vestibular disorder

Hallpike did, head thrust test or head impulse test

DHI

dizziness handicap inventory, over 60 increases risk of falls

Most common medication used to treat dizziness

meclizine, best to reduce during PT

Do not respond well to conservative treatment

menieres disease, perilymphatic fistula

Three categories of unsteady patients

• dizzy

• Balance disorders

• Both

Frequent falls mean

over 2 within the past 6 months

This indicates exercise was too difficult

dizziness lasts over 20 minutes after exercise

Self reported balance assessment

FES, ASBCS

Balance assessment

Berg, Functional reach test, SLS, tandem

SOT

expensive version of foam and dome

CTSIB

foam and dome

CSTIB and SOT are used to determine

if the problem is visual, somatosensory or vestibular

Bone healing phases

inflammatory phase (24-48 hrs)- bleeding

Reparative phase (4-6 weeks)- collar formation

Remodeling phase- bony trabeculae forms, osteoclasts remove necrotic bone

Can impair bone healing

osteoporosis, DM, decreased vitamin D and Ca, ORIF

2-4 weeks

callus forms

6 weeks

bony bridging

Stress fractures are typically

intramedusllary and non-displaced

Microfractures

often the patient is unaware, silent fracture

Pathological fracture

Occur from metastasis, commonly have night pain/pain with rest

Osteoporosis related fractures are typically caused by

increased osteoclast activity and decreased osteoblast activity, affecting the cancellous (trabecular) bone

Contractures and stiffness are caused by

fibrin buildup in extracellular space, which is then deposited in the tissues, impacting functional grasp and use of the hand. Could also be after a trauma/surgery

Myofibroblasts

damage to tissue causes cell multiplication and increased cellular secretions (hyperplasia) that creates excessive productive of actomyosin. This results in 30% strength loss

Changes to collagen with aging

collagen loses its elasticity and there is a loss of ground substance volume (extracellular matrix) causing difficulty of fiber movement over one another. Fibers are in closer contact with one another.

Newly developed contractures are

fibrous adhesions

Chronic contractures are

collagenous, requiring heat and progressive low load stretching

Hyaluronic acid

functions to lubricate the joint, this decreases with age and can contribute to stiffness

Cartilage needs — in order to move nutrients in and out of the chondrocytes

loading and unloading, this decreases with age

What changes occur to cartilage with aging

hyaline to fibrocartilage d/t decreased compressive forces

Hypokinesis

slowed movement placing joints in a lengthened/shortened state for prolonged periods causing collagenous adhesions

Elasticity

tissue will stretch and then recoil to original length

viscous component

permanent deformation to connective tissue

avoid compression to vertebral artery by

avoid hyperextension of cervical spine, esp with rotation

peripheral fatigue

reduction in maximum muscle force or motor output, d/t physical activity

central fatigue

general tiredness, weakness, languor or sleepiness

normal fatigue goes away with

rest

fatigue is caused by

chronic conditions

increased fatigue is correlated with

higher mortality

Strategies that may be used for fatigue

• antidepressive tx

• nutrition

• exercise

• limit functional decline

Changes to skin at the hand

• loss of dermis/epidermis on dorsum of hand

• collagen breakdown, making skin fragile

• skin more vulnerable to injury, slowed healing

clubbing of nails

inadequate oxygen

spoon shaped nails

anemia

Colles fx

dorsal displacement

Smith fx

palmar displacement

commonly missed fx with FOOSH

scaphoid

Changes to cartilage with aging

loss of glycosaminoglycans, causing increased breakdown of cartilage