Geriatrics - Final Exam Study Guide - Modules 7-13 - With Exercise Guidelines

How frequently should older adults exercise for muscle performance?

2-3 days per week with day of rest between exercise days

Further parameters depend on goal

-i.e. strength, endurance, power

What are the recommended exercise parameters for strength?

2 x per week

Moderate to High intensity: 60-80% 1 RM,

-60% threshold (RPE 12-13/20),

-80% threshold (RPE 15-17/20)

1 set of 7-9 reps to failure, progressing to 2-3 sets

What are the recommended exercise parameters for endurance?

30-50% 1 RM,

12-20+ repetitions,

short recovery (~1min)

What are the recommended exercise parameters for power?

1-3x/week

Low-mod intensity, 30-60% 1 RM,

15-30 reps, 1-6 sets with longer rest period between sets,

What are exercise recommendations for those with frailty, low self-efficacy, and/or minimal to no history of participation in structured exercise?

3 days per week

1 set of 8 reps,

You may need to begin at 20% of 1RM, progress towards 40-80% 1RM

What are the exercise recommendations for bone health?

High impact progressive resistance training for 2 sets of 8-12 repetitions at 70-80% 1 RM, 2 times per week

-At least 50 impact activities daily

What are the ASCM guidelines for aerobic exercise in community dwelling older adults?

150-300 mins of moderate intensity aerobic activity

-at least 30 mins 5 days/week

Or Vigorous Activity, 75 minutes per week for 3-5 days per week

Either way - At least 10-minute bouts is recommended

What is the recommendation for aerobic HIIT training for healthy yet sedentary community dwelling older adults?

3-4 days a week for 30 weeks

40-50 minute sessions

Shooting for 66-73% HRR

What are the recommendations for flexibility exercises?

Frequency: Daily is preferred yet also recommended to be performed specifically on aerobic and strength days.

Should include: shoulders, hips. back, wrist, hamstrings, and ankles.

Dosage: Hold 30-60 seconds, 2-3 sets

Intensity: Slow movements into sustained positions feeling a slight tightness and stretch discomfort

What are the balance exercise recommendations?

Duration: 25-30 minutes/day or 2-3 hrs/week

Intensity: Moderate-High Challenge using Rate of Perceived Stability

Multicomponent Individualized program

What are the 6 neurocognitive domains?

-Executive function

-Complex attention

-Learning and memory

-Perceptual motor function

-language

-social cognition

What is involved in the executive function neurocognitive domain? (6)

•Planning

•Decision making

•Working memory

•Responding to feedback

•Inhibition

•Flexibility

What is involved in the complex attention neurocognitive domain? (4)

•Sustained attention

•Divided attention

•Selective attention

•Processing speed

What is involved in the learning and memory neurocognitive domain? (6)

•Free recall

•Cued recall

•Recognition memory

•Semantic & autobio-graphical

•Long term memory

•Implicit memory

What is involved in the perceptual motor function neurocognitive domain? (3)

•Visual Perception

•Visuo-constructional reasoning

•Perceptual Motor Coordination

What is involved in the language neurocognitive domain? (5)

•Object naming

•Word finding

•Fluency

•Grammar and Syntax

•Receptive language

What is involved in the social cognition neurocognitive domain? (3)

•Recognition of Emotions

•ability to understand that others have different thoughts, feelings, and intentions than you do

•Insight

What kind of questions could you ask a patient to investigate the executive function neurocognitive domain? (1)

Do you have trouble working household appliances?

What kind of questions could you ask a patient to investigate the complex attention neurocognitive domain? (1)

Do you have trouble following TV programs or a book?

What kind of questions could you ask a patient to investigate the learning and memory neurocognitive domain? (5)

-Do you have difficulty remembering things that have happened recently?

-Do you lose objects more often than you did previously?

-Do you have trouble remembering the time/date?

-Do you think that your memory is poorer than that of other people your age?

-Do you have trouble remembering how to turn off the stove or lights?

What kind of questions could you ask a patient to investigate the perceptual motor function neurocognitive domain? (1)

Do you have trouble finding your way around familiar streets?

What kind of questions could you ask a patient to investigate the language neurocognitive domain? (1)

Do you have trouble finding the right word to describe something you know well?

What are 5 different cognitive screens?

1) St. Louis University Mental Status Exam (SLUMS)

2) Brief Cognitive Rating Scale (BCRS)

3) Montreal Cognitive Assessment (MoCA)

4) Mini Mental Status Exam (MMSE)

5) MiniCog

How does the scoring work for the miniCog?

Word List (up to 3 points)

–1 point for each word recalled after the clock drawing

Clock Draw (Scored all or nothing, 2 or 0 points)

–2 points =

•All numbers, #s1-12 in correct location (none missing)

•2 hands present, 1 pointing to 11 and other to the 2

•Length of hands doesn’t matter

Refusal or can’t draw clock = 0

What is the scoring interpretation for the miniCog?

5/5 = Pass but doesn't rule out cognitive impairment

4/5 = Pass but may indicate a need for further evaluation of cognitive status

<4/5 = Fail; refer patient to medical provider for further screening for dementia

What is dementia?

Dementia is a syndrome of impaired function and cognition that has a range of symptoms.

-Interference with their functioning & representing a decline

-Objective impairments on cognitive functioning tests

-Not delirium

What is needed for a diagnosis of dementia?

The individual has to have a cognitive impairment of memory loss and 1 other cognitive domain impairment, that causes an inability to complete ADLs and IADLs

What does advanced dementia involve?

Advanced dementia involves brain stem and autonomic functions that includes:

-vocalization,

-self-expression,

-walking reflexes,

-posture control reflexes for sitting,

-swallowing,

-breathing.

What are 5 types of irreversible dementias / types of neurocognitive impairment?

1) Alzheimer's Disease

2) Vascular Dementia

3) Lewy Body Dementia

4) Behavioral Variant Frontotemporal Dementia

5) Mixed Dementia

What is characteristic of Alzheimer's disease?

Memory impairment & functional loss in at least 1: aphasia, apraxia, agnosia, or executive dysfunction.

What is characteristic of vascular dementia?

Step-wise cognitive decline, most obvious after stroke & TIA or cardiovascular disease/MI

What is characteristic of Lewy Body Dementia? (3)

Cognitive impairment at least 1 year prior to Parkinsonism presentation (Rigidity, bradykinesia, shuffled gait, tremor)

Cognitive fluctuations (may be delirium-like)

Visual Hallucinations (early stage)

What is characteristic of behavioral variant frontotemporal dementia?

Affected Social cognition domain: Patient has socially inappropriate behavioral deficits

What is mixed dementia?

Mixed dementias involve a combination of pathologies from different forms of dementia (e.g., Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia).

The hallmark is the coexistence of these pathologies. This coexistence of multiple underlying causes of dementia can make diagnosis and treatment more complex.

What type of types of neurocognitive impairment is represented in this case?

"Age 73, Known MCI, difficulty recalling recent events, getting lost when driving, misplacing wallet and keys, Difficulty using TV Remote, getting caught up trying to find the right words"

Alzheimer's Disease

Rationale:

-Memory impairment & functional loss in at least 1: aphasia, apraxia, agnosia, or executive dysfunction.

What type of types of neurocognitive impairment is represented in this case?

"Age 79, started having difficulty remembering conversations throughout the day but then would be fine, at times seem to be "out of it", starting shuffling when walking, and sometimes says he sees a snake at the end of his bed."

Lewy Body Dementia

Rationale:

-Cognitive impairment at least 1 year prior to Parkinsonism presentation (Rigidity, bradykinesia, shuffled gait, tremor)

-Cognitive fluctuations (may be delirium-like)

-Visual Hallucinations (early stage)

What are some red flag symptoms for cognitive decline/dementia?

1.Rapid Decline

2.Young age of onset (younger than 60)

3.Prominent alterations in attention

4."high risk" exposures

5.Unusual physical exam findings

What are some potentially reversible causes of DEMENTIAS? (10)

Drugs

Eyes and ears

Metabolic

Emotion

NPH (normal pressure hydrocephalus)

Tumor

Infection

Atrial fibrillation and Alcoholism

Sleep apnea

What are 2 types of mild cognitive impairments? and what are they risks for?

Mild Cognitive Impairment (MCI) can be:

-amnestic

-non-amnestic

Both types are markers for different risks of dementia.

What is Amnestic Mild cognitive Impairment?

Prominent memory impairment

What is non-amnestic mild cognitive impairment?

Prominent cognitive domain deficits other than memory

(visuospatial, executive function, complex attention)

What is cognitive frailty?

Subjective Cognitive Complaints (though no dementia present), with physical frailty using the FRAIL Scale

-Fatigue: self-report exhaustion

-Resistance: Can't do 1 flight steps;

-Aerobic: Can't walk 1 block;

-Illness: More than 5 illness

-Loss of weight: more than 5% body weight in past 6 months

Also:

-Grip strength < 20th percentile

-Gait Speed <0.8m/s

-Low physical activity: <45-60 min of mod intensity perweek

-unintentional 10lbs loss in 1 year

What is motoric cognitive risk syndrome (MCRS)? and what is the significance of it?

Motoric Cognitive Risk Syndrome is a combination of slowed preferred walking speed (1 SD below) and subjective cognitive complaints.

It is considered a preclinical risk factor for cognitive decline and dementia

What are the 4 major elements of the PT care framework for older adults with dementia (Ries 2022)?

Relationship: emphasis on relationship over task with person centered care, rapport & therapeutic alliance, respect the person's reality, bring positivity

Communication: short simple phrases, yes/no options, avoid elderspeak, confident & friendly tone, genuine smile & relaxed body language, remember that a patient's behavior is non-verbal communication, be flexible!

Motor Learning: incorporating procedural memory and implicit memory with an emphasis on: Repetitive, Constant blocked practice, specificity of training, errorless learning, intensity and challenge, functional goals, learning by doing

Environment: safety, emotional security, minimize distractions, relevant music, environmental cues, atmosphere of joy!

What are the implicit memory techniques by White et al. (2014) to help individuals with dementia? (5)

-Spaced Retrieval

-Feedforward Instruction

-Modeling

-Physical Assistance

-Modify Task Variables

What are the principles of the Strength-Based Approach (Dawson & Judge 2019) for treating dementia? (5)

-Keep it short and simple

-External memory aids

-Learning by modeling

-Allow individuals with dementia to choose

-Use familiar activities or hobbies

What is the FAST?

A dementia staging tool (Functional Assessment Staging Tool)

Used for Staging the Severity of the patient's functional challenges.

There are 7 total stages.

What is the difference between the Global Deterioration Scale (GDS) and the FAST?

The GDS categorizes cognitive decline (memory challenges), while the FAST categorizes functional decline.

What is FAST level 1?

Normal - No cognitive decline.

What is FAST level 2?

Dementia stage: Subjective very mild

Patient has subjective work difficulties.

What is the FAST 3?

Dementia Stage: Mild

Patient has decreased function in demanding situations and difficulty traveling to new places.

What is FAST 4?

Dementia Stage: Moderate

Patient has decreased ability to perform complex tasks

What is FAST 5?

Dementia stage: moderate to severe.

Patient requires assistance selecting attire and coaxing to bathe.

What is FAST 6?

Dementia Stage: Severe

Severe cognitive impairment while requiring extensive assistance with ADLs

What is FAST 7?

Dementia Stage: Very Severe

Inability to speak or communicate; Inability to walk; Require assistance with nearly all ADLs

What FAST scores typically live in independent community living?

FAST 1, 2 and 3

What FAST scores typically live in assisted community living?

FAST 4

What FAST scores typically live in SNF or assisted living facility with memory specializations?

FAST 5 and 6

What FAST scores typically live in Skilled nursing facility community with specialty memory care?

FAST 7

What cognitive screen is used to assist with identification of staging?

Brief Cognitive Rating Scale (BCRS)

What is the Brief Cognitive Rating Scale (BCRS)?

A screening tool designed to assess an individual's cognitive and functional abilities related to dementia.

It includes 5 key axes, each evaluating different aspects of cognitive function:

-Concentration: Ability to focus and perform tasks (e.g., serial subtraction)

-Recent Memory: Recall of recent events (e.g., breakfast, current events).

-Past Memory: Recall of personal history (e.g., childhood memories, past occupations).

-Orientation: Awareness of time, place, identity, and self.

-Functioning and Self-Care: Ability to perform daily activities (ADLs/IADLs) and need for assistance.

Each axes is scored 1 (no difficulty) to 7 (marked difficulty or inability)

How is dementia staging performed?

Clinician would perform the Brief Cognitive Rating Scale (5 questions within subjective exam). Divide total score by 5 = Staging level.

What are some valid and reliable functional outcome measures to use with individuals with dementia?

-Tug/Tug manual/Tug cognitive and 10 meter walk test for mobility

-6 MWT for aerobic capacity

-Berg and miniBEST for balance / fall risk

-5x sit to stand or 30 second chair rise for muscle strength and power

What is the best LE strength alternative if the patient is not able to cognitively understand MMT?

5x sit to stand and modified 30 second chair rise

What are tips for successful functional outcome measure administration? (11)

-Refer to your patient by their name

-Use the rapport & therapeutic alliance & kindness to your advantage

-Use non-verbal cues: eye contact and smile

-Have patience for processing

-Minimize distractions

-May need to have them repeat instructions back "in their own words"

-Clear Speech-No more than 3 step command or less

-Monitor fatigue and anxiety -> Allow for short rest breaks

-Reliability may be compromised

-Utilize equipment to facilitate best performance

-Understand there are "good days and bad days"

What functional measures may be appropriate to perform with individuals with Moderate to Severe Dementia? (4)

-Short Physical Performance Battery

-FIST

-30 second arm curl test

-Timing functional transfers based on the specific needs and abilities of the individual.

What would be included in the short physical performance battery if working with an older adult who has a moderate to severe cognitive impairment?

Short Physical Performance Battery Includes:

-4mWT

-5x Sit to Stand (or can do Modified 30 Second Sit to Stand)

-Narrowed BOS, Semi-tandem, & Tandem (Cannot hold tandem for 10 seconds = Increased fall risk)

What are the Pain in Advanced Dementia (PAINAD) Rules?

-Observe for 5 behaviors

-score what you see for 5 minutes

-During and after active movement.

-A score of 0-1 = likelihood no pain behavior is presenting

-A score of 2-4 = likelihood of pain behavior presenting

-Remember that severity of pain does not correlate with PAINAD score

What are the 5 behaviors looked for on the PAINAD?

-Breathing independent of vocalization

-Negative vocalization

-Facial expression

-Body language

-consolability

Each item is scored 0-2 based on the patients behavior.

What is the ABC approach to managing expression?

•A = Antecedents (Why)

•B = Behavior (What)

•C = Connections (How to help)

What is Antecedents, in the ABC approach to managing expression?

Antecedents involves considering what occurs before the “expression” & what may have triggered it? For example:

-Things that other people did or said

-Emotional state (depressed, tired, anxious)

-The environment (hot, noisy, cramped, bright lights)

-Mismatched expectations with ADL performance

These can be viewed as predictors of the expression and if you know when the “expression” will occur, then we can prevent it from even happening

The overall take away is to find the root cause of the expression!

What does the "B = Behavior" in the ABC approach mean?

Determining the "behavior" that needs to be assessed, answers the “what?”

It helps to describe the expression:

-What does it look like? Provide details so that others would be able to recognize the reaction.

-How long does it last? (Duration)

-How often does it happen? (Frequency)

-How severe is this behavior? (Intensity)

What does the "C = Connections" in the ABC approach mean?

Using connections through Coping Strategies or communication & cues to respond to the expression

-Look for situations that increase or decrease its occurrence

-Use patience & perseverance

What are some strategies for managing triggers? (3)

-Build & maintain good rapport

-Avoid or minimize known triggers, including environment if possible

-Sometimes a distraction or redirection away from the trigger may be all that is necessary

What are some strategies that caregivers can use during the occurrence of the behavioral expression?

-Visually look interested, follow their lead, go slow

-Stay calm, make eye contact, and speak in an even tone

-Give simple directions, slowly, 1 step/question at a time

-Listen thoroughly and Patiently wait for responses and gestures

-Use non-threatening hand gestures, and in some cases a gentle touch

-Use "it sounds/looks like" empathetic phrases & Provide reassurance and promote a sense of safety

-Recognize when it's time to disengage for personal safety and remember the strategies to manage triggers

What are some other communication techniques that are helpful with dementia patients? (3)

Reflective listening, validation, and redirection.

What are the most common behavioral expressions that occur with Alzheimer Disease? (5)

-Agitation / Aggression

-Depression / Dysphoria

-Apathy

-Irritability

-Sleep Disorder

What are the most common behavioral expressions that occur with Frontotemporal Dementia? (6)

-Agitation / Aggression

-Apathy

-Irritability

-Aberrant Motor

-Sleep Disorder

-Appetite and Eating Disorder

What are the most common behavioral expressions that occur with Vascular Dementia? (4)

-Depression / dysphoria

-Anxiety

-Apathy

-Irritability

What are the most common behavioral expressions that occur with Mixed Dementia? (5)

-Agitation / Aggression

-Depression / Dysphoria

-Apathy

-Irritability

-Sleep Disorder

What are the most common behavioral expressions that occur with Lewy Body Dementia? (8)

-Hallucinations and Delusions

-Agitation / Aggression

-Depression / Dysphoria

-Anxiety

-Apathy

-Irritability

-Sleep Disorder

-Appetite and Eating Disorder

What is behavioral and psychological symptoms of dementia (BPSD)?

Symptoms of disturbed perception, thought, content, mood, or behavior that frequent occur in patients with dementia. These problems are usually associated with unmet personal needs and exhibited as non-verbal expression (such as needing to use the bathroom, physically uncomfortable, etc.).

They are a major source of burden for care partners and are a frequent reason for admission to long term care. This tends to worsen over time with progression of the disease, requiring more support and increasing cost of care

Aside from the disease specific expressions, what are other general behavioral and psychological symptoms of dementia (BPSD)? (8)

•Sundowning

•Wandering/Walking About

•Abnormal motor movements

•Repetitive questioning

•Psychosis

•Resistance to care

•Eating disorder

•Disinhibition

What is behavioral and psychological symptoms of dementia (BPSD) associated with? (3)

-Poor prognosis

-More rapid cognitive decline

-More rapid illness progression

Also commonly results in decreasing QOL, rising cost of care, etc.

What is the first line clinical practice for treating behavioral and psychological symptoms of dementia (BPSD)?

Non-pharmacological interventions are the first line clinical practice.

Note: Except for emergency situations, referring mostly to situations in which that patient's reaction/expression is harmful to them or other persons"

What is delirium?

Delirium is an acute and fluctuating neurological syndrome.

It is characterized by cardinal features of inattention and disorganized thinking.

There are multiple causes most common include: medications, infections, surgery, sleep deprivation.

It is a medical emergency!

What is the Dr. Dre mnemonic for delirium?

DR = Disease remediation of the underlying medical issues - UTI, sepsis;

DR = Drug removal = like any anticholinergics or benzodiazepines.

E = Environment = meaning the environment is cognitively stimulating, familiar people are around, there's adequate lighting, want to encourage exercise, normalize the sleep-wake cycle, ensure they have their hearing aids/glasses.

What is characteristic of depression?

Patients can present with sadness, apathy, poor attention/focus, social withdraw (which can look a lot like Alzheimer's disease), and neglect of basic self care.

Onset is weeks to months.

What does the mnemonic SIGECAPS mean for depression?

Used to help recall the most frequent symptoms of depression

Sleep disorder,

Interest deficit,

Guilt,

decline in Energy and Concentration,

Appetite disorder,

Psychomotor slowing/agitation,

Suicidality

How does the speed of onset differ between delirium, depression, and dementia?

Delirium is acute - hours to days

Depression is weeks to months

Dementia is months to years

How does the presentation of dementia differ from that of depression and delirium?

Onset is months to years.

Dementia is a chronic condition that progressively deteriorates over time and can present differently depending on the specific type.

Patients are likely unaware of their cognitive decline.

What is the confusion Assessment Method (CAM)?

A tool used to identify the presence of delirium.

The measure looks at 4 primary features:

-Feature 1: Acute onset or fluctuating course

-Feature 2: Inattention

-Feature 3: Disorganized thinking

-Feature 4: Altered level of consciousness.

When using the confusion assessment method, what is needed for diagnosis of delirium?

The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4

-Feature 1: Acute onset or fluctuating course

AND

-Feature 2: Inattention

AND

-Feature 3: Disorganized thinking

OR

-Feature 4: Altered level of consciousness.

What must a patient be in order to receive home care coverage under the Medicare benefits?

They must be homebound or confined to the home.

Therefore, it is important to document on every home visit their homebound status/reason. For example:

-Leaving home could worsen condition or incapacitate patient for rest of day

-Dependent on assistive device, loss of balance, impaired gait

-Requires moderate assist of 1 to negotiate stairs (or ambulate)

What qualifies as "home" in home health?

Private homes

Assisted living facilities

Over-55 communities

Memory care units

SNFs (Skilled)

What is OASIS (Outcome and Assessment Information Set)?

A collection of data at start of care, or on transfer, that covers socio-demographics, environment, support system, health status, functional status, etc.

Relates to reimbursement, outcomes, and quality measures

What is identified through OASIS?

•Support system, Socio-demographics, PLOF and Prior AD use, CLOF, Co-morbidities, patient goals

•Risk for re-hospitalization, diagnoses, pain frequency, dyspnea, fall risk

•Cognitive, Sensory, and Communication concerns

•Emergency preparedness plan

Who cis responsible for opening home health cases as part of coordinating care with Nursing, OT, PT, SLP?

Nursing, PT, SLP - responsible for opening cases

OT CAN'T open the case; BUT can remain if necessary when all others have discharged.

What are important time points for documentation of OASIS?

-Start of care

-Transfer to hospital, whether or not d/c'd from agency

-Recertification after 60 days (if continued care is justified)

-Discharge or death

What is the Insurance payment coverage for Home Health?

Traditional home care is covered by Medicare A which pays 100%