Geriatric Rehabilitation

Elderly

• Early is defined as people aged 65 years old

• Elderly dependency rate is defined as ratio between the elderly population and the working age (15 – 64 years) population

4 Components of Geriatric Rehabilitation

1. Accommodation of Irreversible Changes of Aging.

2. Restoration of Function For Reversible Impairments.

3. Prevention of Disability.

4. Medical Treatment of Existing Conditions.

Factors Affecting Rehabilitation

Activity Recommendation in Older Adults with No Limitations

Physiological Changes: Muscle

• Overall decreased in lean body mass with increased in fat content.

  • Loss of type II with predominance of type I muscle fibers.

  • Type I: slow-twitch, for endurance

  • Type II: fast-twitch, for short powerful movements

• Decreased number of motor units.

Cachexia

• Weakness and muscle wasting due to a disease

• Type 1 Muscle Fiber Loss

Sarcopenia

• Weakness and skeletal muscle loss is due to aging.

• Type 2 Muscle Fiber Loss

Neurologic

• Decreased brain volume, frontal gray matter loss decreased cerebral blood flow.

  • Cognitive deficits

  • Decline in episodic and long-term memory with personal context

  • Stable and is even improved procedural and semantic memory.

• Vision declines due to challenges in all ophthalmic tissues.

  • Retinal aging is associated with muscular degeneration and loss of central vision.

  • Optic nerve damage can result in glaucoma and visual field loss.

  • Lens aging may result in cataracts.

• Age related hearing loss (Presbycusis) is a bilateral and symmetrical process

  • Affected by intrinsic and extrinsic factors

  • Conductive hearing loss with a narrow range of audibility

  • Inability to hear high-frequency sounds.

Cardiovascular

Progressive decline in maximal heart rate at 6–10 beats/min/decade after the age of 25.

Changes in Aging:

• Decreased Arterial Compliance

• Increased Systolic Pressure

• Left Ventricular Hypertrophy with Impaired Filling

• Decreased Beta-Adrenergic Receptor Stimulation Response

• Decreased Sa Node Automaticity

• Decreased Number of Myocytes

Pulmonary

• Lung surface area decreases due to alveolar and duct enlargement.

• Loss of elastic recoil and lung stiffening resulting in increased lung compliance  and decreased thoracic wall mobility.

• Decreased respiratory muscle strength.

Gastrointestinal

• Increased Cholecystokinin and Leptin

• Decreased gastric acid production

Cholecystokinin (CCK)

Stimulates satiety center in the brain and delays gastric emptying time.

Leptin

Inhibits hunger

Decreased Gastric Acid Production

• Impaired absorption of Vitamin B12, calcium, iron, zinc, and folic acid.

• Change in microbial flora within GI tract.

Genitorurinary

• Reduction in bladder capacity and urethra & bladder compliance.

• Inability to postpone voiding

• Postmenopausal changes include increased vaginal wall fragility and decreased vaginal lubrication.

• Benign prostatic hyperplasia develops under hormonal influence and is almost universal in men over 40 years of age.

• Incontinence and erectile dysfunction are not a consequence of aging.

Endocrine

Decreased anabolic hormones such as testosterone, GH, insulin-like growth  factor, estrogen:

• Changes in Body Composition

• Impaired Glucose Tolerance

• Collagen Loss and Thinning of the Skin

• Bone Loss

Skin

Consider changes due to normal aging as well as environmental factors:

• Thinning of the Epidermis

• Decreased Cell Turnover

• Impaired Immune Response and Wound Healing

• Decreased Moisture Content, Elasticity, Blood Supply and Sensory Sensitivity

Medication Metabolism

• Increase in adipose tissue increases the volume of distribution of fat-soluble drugs and prolongs their half-life.

  • Reduce frequency of medication

• Total body water decreases, which decreases the volume of distribution of water-soluble drugs, resulting in higher serum concentration

  • Reduce dose of medication

• Hepatic and renal clearance could also be decreased by 30–50% in elderly.

Gait

Associated with falls and fear of falling.

Characteristic Gait of Elderly

• Decreased Speed

• Increased Double Limb Support

• Shorter Stride Length

• Broader Base of Support

Recommendations for Fall and Injury Prevention in the Elderly

Health Concerns

1. Frailty

2. Falls

3. Osteoporosis

4. Malnutrition

5. Depression

6. Delirium

7. Dementia

Frailty

Age- and disease-related loss of adaptation, such that events of previously minor stress result in disproportionate biomedical and social consequences.

Clinical syndrome in which THREE OR MORE of the following are present:

1. Unintentional weight loss of at least 10 lbs over the past year

2. Self-reported exhaustion

3. Weakness (grip strength)

4. Slow speed walking

5. Low physical activity

Falls

• Falls and near-falls occur in more than 30% of people aged 65 years or older.

• Causes significant injury:

  • 90% of fractures in the hips, pelvis, and forearm result from falls

  • Most common cause of TBI

  • Primary etiology of accidental deaths in those older than 65 years

Risk Factors for Falls in the Elderly

Osteoporosis

• Extremely prevalent

  • Affect ⅓ of postmenopausal women.

  • ½ of the population is older than 75 years.

• An important consequence of osteoporosis is fracture.

Risk Factors: Malnutrition

1. Physiologic Factors of Aging

2. Physical Conditions

3. Consequences

Physiologic Factors of Aging

• Decreased Total Body Protein Level

• Decreased Taste and Smell Sensation

• Increased Levels of Neurotransmitters that Decrease Appetite and Promote Early Satiety 

Physical Conditions

• Reduced Physical Activity 

• Poor Dentition

• Digestive Disorders

Consequences

• Decrease Immunity

• Poor Wound Healing

• Increased Skin Fragility 

• Increased Risk of Complications from Existing Comorbidities 

Depression

• Most common mood disorder in geriatric population

• Risk of suicide is 5x higher than that of any other age group

• Early diagnosis and management can help to decrease further disability, restore function and reduce risk of suicide.

RIsk Factors: Depression

• Poor Self-Rated Health

• Poor Cognitive Function

• Impaired ADLs

• 2 or More Medical Visits in the Past Month

• Frequent Falls

Delirium

• DSM V criteria

  • Disturbance in attention and awareness

  • Usually of acute onset and temporary 

• Frequently due to physical disease or drug effects

• Risk of delirium is higher in severely ill patients with co–morbidities.

• MMSE is helpful in determining delirium

  • MMSE <24 is abnormal, with attention, concentration, and recall subscales being the most sensitive for detecting delirium.

Dementia

• WHO definition:

  • Memory decline, especially in the learning of new information, lasting longer than 6 months.

• It is not a normal part of aging

• Diagnosis is based on the gradual onset of cognitive impairment and continuing decline, when all other causes have been excluded.

• Alzheimer’s Disease is the most common cause of dementia (60–70 % of geriatric patients has dementia)

• Risk Factors:

  • Advanced Age and Family History

  • Down Syndrome

  • Head Trauma

  • Clinical Depression

  • Low Educational Level

  • Small Head Circumference and Brain Size have been Associated with Early Onset of Alzheimer’s Disease

Driver’s Evaluation

• Elderly have the highest accident rate per mile driven.

  • Failure to yield the right-of-way

  • Not abiding by signs or signals

• Account for 13% of all driving fatalities

Factors Affecting Driving Ability

1. Physiological Factors

2. Cognition

3. Psychomotor Functioning

4. Medical Condition

Physiological Factors

• Vision is the most important sensory change in predicting driving impairment.

Cognition

Distraction while driving.

Psychomotor Functioning

Limited cervical range of motion.

Medical Condition

Risk of collision resulting in injury is substantially increased among older diabetic drivers who are taking insulin or oral agents for more than 5 years.

Driver’s Test Step

Driver’s Evaluation

Cessation of Driving

Common factors associated with driving cessation

• Increasing Age

• Female S3x

• Functional Impairments

• Neurologic Disease

• Visual Impairment 

Those who stop driving are at risk for social isolation, depression and functional impairment.