[SPECON] Principles of Geriatric Rehabilitation

This age group is expected to have the greatest increase in population.

Follow Up Question: Because of this, what is the population pyramid expected to look like in the future?

Oldest-old bracket (85+ y/o)

An inverted pyramid

Currently, how many percent of the elderly live in the community and not in nursing homes?

70-80%

This term refers to the bias against elderly based solely on chronological age.

Follow Up Question: Who coined this term?

Ageism

Robert Butler

What is the age of forceful retirement in the Philippines due to declining capacity to perform?

65 y/o

This theory of aging implies that aging is regulated by biological clocks operating throughout the life span. This regulation would depend on changes in gene expression that affect the systems responsible for maintenance, repair and defense responses.

Programmed theory

Based on the Programmed Theory of Aging, these extensions of genetic material get shorter as we age, leading to the actual genes being affected and being unable to do their function.
Follow Up Question: What is the main implication of this theory?

Telomeres

There is nothing we can do to stop aging.

This theory of aging states that aging is a consequence of unrepaired DNA damage accumulation (i.e. finances, psychological, environmental, metabolic). It states that although there are normally parts that repair the damage, their abilities begin to decline as we age.

Stress theory

This theory of aging states that aging is a nonadaptive trait because natural selection is negligent of events that occur in a few long-lived animals that provide little additional contribution to offspring numbers.

Mutation theory

This theory of aging states that organisms age because cells accumulate free radical damage over time.

Free radical theory

This is any atom or molecule that has a single unpaired electron in an outer shell. They are highly reactive cells that accumulate as we age, leading to damage.

Follow Up Question: What should we use to combat this?

Free radical

Anti-oxidants

What are the psychological issues in aging?

• Limited and fragile support system

• Socially isolated

• Multiple sources of stress

• “Devalued” by themselves and others (due to the loss or shift of roles that occurs with aging [i.e. family not letting her help around the house due to her age])

What are the physiologic characteristics of aging?

• Decreased reserve capacity of organ system

• Decreased internal homeostatic control

• Decreased ability to adapt in response to different environments

• Decreased capacity to respond to stress

[Body Composition] Determine if the following will increase or decrease with age.

1. Lean tissue

2. Muscle Mass

3. Fat

4. Muscle fiber number and area

5. Bone density

Increase:

• Fat (up to 30% of BW by 80 y/o)

Decrease:

• Gradual loss lean tissue

• Muscle Mass

• Limb muscle volume

• Muscle fiber number and area

• Bone Density

[Respiratory System] Determine if the following will increase or decrease with age.

1. Residual volume

2. Lung dead space

3. VO2 max

4. Functional residual capacity

5. Vital capacity

6. Maximal breathing capacity

7. Force and volume air flow

8. Minute volume with exercise

9. Sleep related disorders

Increase:

• Residual volume

• Functional residual capacity

• Lung dead space

• Sleep related disorder

• Minute volume with exercise

Decrease:

• VO2 Max

• Vital capacity

• Maximal breathing capacity

• Force and volume air flow

This is an indicator of a longer lifespan due to more oxygen used during an activity, leading to a higher cardiovascular endurance.

High VO2 max

[Cardiovascular System] Determine if the following will increase or decrease with age.

1. Cardiac Output

2. Orthostatic Hypotension

3. Maximal exercise HR

4. Serum Lipid

5. Contractile function

6. Cardiac Reserve

Increase:

• Orthostatic Hypotension (inability of our body to adjust to positional changes)

• Serum Lipid

Decrease:

• Cardiac Output

• Maximal exercise HR

• Contractile function

• Cardiac Reserve

[Cardiovascular System] Determine if the following will increase or decrease with age.

1. Orthostatic tolerance

2. Thrombosis

3. Arterial elasticity

4. Systolic and diastolic BP

5. Capacity to work

6. HD lipoproteins

7. Maximal O2 consumption

Increase:

• Systolic and diastolic BP

• Thrombosis

• HD lipoproteins

Decrease:

• Orthostatic tolerance

• Maximal O2 consumption

• Capacity to work

• Arterial elasticity

[Musculoskeletal System] Determine if the following will increase or decrease with age.

1. Osteoporosis

2. Degenerative diseases

3. Muscle strength

4. Calcium

5. Poor posture

6. Work rate or power output

Increase:

• Osteoporosis

• Degenerative Diseases

• Poor Posture

Decreases:

• Muscle strength (20-30%)

• Work rate or power output

• Calcium

What is the role of calcium in the elderly?

Calcium is important for the sliding filaments and hypokalemic patient can develop low heart rate. Its role is considerably more important than sodium and potassium.

[Neurological System] Determine if the following will increase or decrease with age.

1. Fluid intelligence

2. Ability for new learning

3. Coordination and balance

4. Choice of reaction time

5. Nerve conduction velocity

Increase:

• Choice of reaction time

Decrease:

• Fluid intelligence (ability to feel that he is thirsty)

• Ability for new learning

• Nerve conduction velocity

• Coordination and balance (coordination — knowing the timing of contraction of certain muscles to do fluid movement like walking)

[Sensory System] Determine if the following will increase or decrease with age.

1. Vision

2. Hearing

3. Vibratory perception

4. Touch and pain sensitivity

All of these will decrease.

[Skin] Determine if the following will increase or decrease with age.

1. Moisture content

2. Elasticity

3. Susceptibility to pressure sores and infection

4. Epidermal renewal

5. Blood supply

Increase:

• Susceptibility to pressure sores and infections

Decrease:

• Moisture content

• Epidermal renewal (slower healing)

• Elasticity

• Blood supply

[Others] Determine if the following will increase or decrease with age.

1. Risk of dehydration

2. Thirst perception

3. Febrile response to infection

4. Susceptibility to hyper or hypothermia

5. Lean body mass

6. Glucose tolerance

7. Body water

Increase:

• Risk of dehydration

• Susceptibility to hyper or hypothermia

Decrease:

• Thirst perception

• Febrile response to infection

• Lean body mass

• Body water

• Glucose tolerance

Enumerate the postural changes seen in the elderly:

• Head

• Shoulder

• Scapula

• Elbow

• Wrist

• Finger

• Thorax

• Lumbar spine

• Hip and knee

• Ankle

Follow Up Question: Upon seeing these postural deviations, what should we determine?

• Forward headed

• Shoulder extended

• Scapula protracted

• Elbow flexion

• Wrist ulnar deviation

• Finger flexion

• Increased thoracic kyphosis

• Lumbar spine straightening

• Hip and knee flexion

• Ankle decreased dorsiflexion

Determine if they are due to habit or a condition.

Aside from aging, what else contributes to a decline in physiological function?

Inactivity (lack of exercise)

What are the minimal ROM values for the following:

• Shoulder

• Forearm

• Wrist

• Finger

• Hip

• Knee

• Shoulder: 90° shoulder abduction with sufficient ER/IR

• Forearm: 45° pronation and supination

• Wrist: 45° wrist flexion, 30° wrist extension

• Finger: finger flexion within 1 in of palm

• Hip: normal hip extension, 90° hip flexion

• Knee: normal knee extension, 110° knee flexion

The geriatric population are more sensitive to medicine effects. How much medication do the elderly drink on average?

Follow Up Question: What is the relationship between the dosage of medication and the incidence of adverse reactions?

An average of 5 Meds. per day.

↑ dosage of meds ↑ incidence of adverse reactions

This medication slows down heart rate.

Follow Up Question: Because of this, patients who are taking this medication do not show an substantial increase in heart rate. To ensure accuracy in the monitoring of the patient, what other monitors for exercise intensity can be used?

Beta-blockers

Borg’s RPE, Talk Test, etc.

How often do falls or near-falls occur in the elderly?

~1/3 of the elderly

What percentage of falls result to a fracture?

Follow Up Question: 90% of falls occur as fractures to which areas of the bodies?

3-5%

Hip, pelvis, and forearm

What are the environmental and psychological factors of falls in the elderly?

Follow Up Question: What is the main social risk factor for falls in the elderly?

• Environmental Factors: inclement weather, unfamiliar surroundings

• Psychological Factors: inattention, depression, cognitive impairment

Living alone

Upon learning that the patient has history of falls, what should be done?

Follow Up Question: Upon learning that the patient will be discharged by his doctor and you see that the patient in not fit to return home yet, what should you do?

• Check the patient’s fall risk (BBS, Romberg, TUG, etc.)

• Explain the interpretation of the OMTs, their fall risk, the necessary precautions, and the interventions to be done

• Can also recommend the patient for home visit and assessment to assess the home environment

You can argue with the doctor.

How much percent of nursing home patients have pain?

Follow Up Question: Why are physical measures an important part of the rehabilitation management of the elderly?

~75%

Elderly are more sensitive to meds and are at a higher risk for polypharmacy

When do spondylitic changes present?

Present after the 6th decade in 82%

At what level is surgical disc degeneration common?

Common in C5-C6, followed by C6-C7 and C4-C5

This impairment affects the motor function of the lips and tongue and masticatory muscles, which slow down with aging. It also leads to a decreased amplitude of esophageal contractions.

Follow Up Question: Due to the inability to eat and swallow that occurs due to this condition, what does this lead to for the patient?

Dysphagia

Improper nutrition; can affect motility, other body systems, and immunity

Read: other causes include meds side effects, feeding dependency, neurologic disorder, inflammatory muscle disease, scleroderma, cervical spine disorder, cancer, and tracheostomy

What are the precautions to take in a patient who has undergone a hemiarthroplasty?

Avoid >90° hip flexion, adduction beyond neutral, and internal rotation

Do we need to restore full range of motion at all times for the elderly (especially those with arthritis)?

No, just know the functional ranges and the specific ranges that he needs for his BADLs and IADLs.

What is the most common cause of TBI in the elderly population?

Falls

What are the motor neuron conditions common in the elderly?

Parkinson’s Disease and Multiple Sclerosis

What are the peripheral nervous system impairments seen in the elderly?

• ↓ or lost vibratory sense (up to 82%)

• ↓ ankle stretch reflexes

This visual impairment leads to social isolation, decreased morale, and decreased sense of well-being. This can stem from cataracts, age-related macular degeneration, glaucoma, and diabetic neuropathy.

Poor vision

What is the incidence of hearing loss in the elderly?

25-50% in >65 y/o

What is the proper preventive measure for ischemic foot ulceration?

Proper foot care and wearing proper shoes

What is the intervention for chronic venous insufficiency and lymphedema?

Use compressive garments

What affects sexual function in the elderly?

Age-related hormonal changes

Other Factor: vision, hearing & smell alterations, (-) social attitudes in elderly sexuality, erectile & ejaculatory changes, vaginal dryness, dyspareunia, urinary stress incontinence, ↓ mm strength, endurance & LOM

30-40 years after an acute episode of this condition, 50% of the elderly report having excessive fatigue, progressive weakness, pain, loss of function & atrophy.

Follow Up Question: Specifically what condition is this referring to?

Poliomyelitis

Post-polio syndrome

For patients with an SCI, what is the primary limiting factor?

Motor function (rather than age)

This condition in the elderly presents with hyperthermia, decreased skin sensation and special senses, impaired genitourinary and gastrointestinal systems, and cognitive and affective disorders.

Multiple Sclerosis