Older Adults (PT) Set

Description ~

Current trends in healthcare and life expectancy have rapidly increased the numbers of older adults requiring physical therapy services, rehabilitative, or preventative. The goals for most people include skills to independently perform ADLs, such as bathing, cooking, and dressing.

Complex activities necessary for community living are called instrumental activities of daily living (IADLs). ADLs and IADLs are skills that allow an older person to be more independent.

Well Elderly:

People 65+ without physical limitations or whose age-related changes do not affect function.

The primary goal of PT to achieve good physical function and prevent conditions that might limit physical ability.

Frail Elderly:

Pegople 65+ years of age with conditions that significantly impair daily function or who require frequent medical intervention.

PTs offer strategies to regain mobility or modify the environment to maximize the individual’s function.

Roles for PTs with Older Adults ~

PTs are effective advocates for older people in developing appropriate activity programs and in ensuring accessibility to all environments. Provides knowledge necessary to acquire adaptive equipment or assistive devices that provide both safety and convenience.

 Adaptive Equipment:

Allows an individual to perform a functional task with increased ease or independence.

Assistive Device:

Provides assistance during periods of mobility

PTs act as consultants to individuals and programs to determine how to incorporate mobility goals.

Aging-Related Changes ~

These are considered when conducting an examination, formulating an evaluation that includes prognosis, designing a program with clinical interventions, and setting goals for the frail elderly. Biological changes occur, however, many changes are now considered to be related to reduced activity and sedentary lifestyle of many older people.

Weight-bearing joints (like hips and knees) degenerate over time as the articular cartilage is destroyed, resulting in pain, inflammation, and deformities. The central nervous system shows a reduction in conduction velocity, which affects the ability of the nerve to transmit impulses.

Several of the sensory systems display changes that significantly affect mobility, such as visual acuity (cataracts which is clouding of the eye lens).

Presbycusis (“old people’s hearing”):

The decreased ability to perceive higher pitches and distinguish between similar sounds.

Age-related changes reduce the amount of tactile information the individual receives regarding the environment. The characteristic cardiovascular diseases of aging complicate age-related changes in the cardiovascular system. Decrease in maximum cardiopulmonary function and work capacity is also observed.

Limitation in balance and an increase in the risk of falling are common problems in older adults over age 85. Fear of falling and loss of confidence may cause the individual to become isolated or sedentary.

Significant cognitive changes that do fall in the category of normal aging are in memory and conceptualization, with difficulty retrieving newer information. Psychological changes may affect people in older population groups.

Disorders like depression, dysthymia (disorder of mood), and anxiety are more common among homebound older people than those who are able to be out in the community. Understanding psychological issues is critical to any successful rehabilitation program.

Physical changes in older adults that affect the musculoskeletal system often result in poor posture, changes in gait pattern, and decreased strength and flexibility. 

Decreased Strength:

Often related to hypokinesis (decreased activity) and sarcopenia (decreased muscle mass). 

Muscle mass decreases due to decreased nerve fibers, ultimately resulting from a loss of motor neurons.

Changes in Flexibility:

Related to both hypokinesis and biological changes in connective tissue. Additionally, bone mass is smaller and thus weaker in older people.

Connective tissue becomes stiffer with age, and with less activity the muscles shorten over time. They tend to assume flexed positions, leading to postural changes.

Common Conditions ~

Osteoarthritis:

Advancing age and/or obesity results in cartilage deterioration, often affecting the hands, spine, knees, and hips. Often complaints of morning stiffness and pain on movement, which may alter gait pattern or make simple tasks very difficult.

PTs and PTAs can teach appropriate exercise routines (like aquatic exercises) to maintain flexibility without excessively stretching joints. For excessively overweight people, programs that address weight loss in addition to joint protection reduce stress on the joints.

Rheumatoid Arthritis:

A disease of the immune system that causes chronic inflammation of the joints. It is characterized by enlarged joints that are reddend and warm to the touch. Affected joints are stiff and painful, especially in the morning or after extended periods of inactivity. 

PT goals are pain relief, increased joint movement, assistive devices, and rehabilitation when joint surgery is required. 

Heat modalities for pain relief (like hot packs and paraffin baths). Total joint replacements of the hip and knees are common surgeries for older adults.

Osteoporosis:

Characterized by decreased mineralization of the bones, which results from decreased production of new bone cells and increased resorption of bone. 

Fractures are an important problem, which affects especially the wrist and hip in the older population. 

PTs primary role for this disease is prevention.

Hip Fracture:

This is considered to be a major public health problem. Hip Fracture in older adults decreases their life expectancy by almost 2 years. PTs are essential in rehabilitation of patients after hip fracture. 

In hospital, they teach transfer skills, ambulation, and use of assistive devices. In addition, they teach the person to regain additional functional skills, within the setting where the individual will be living.

Diabetes Mellitus:

Chronic disorder with effects on many body systems. Insufficient insulin action affects transport of glucose into tissues. Instead, glucose accumulated in the blood. 

Common complications include renal failure, neurological lesions, neuropathic skin ulcerations, atherosclerotic vascular disease, and retinopathies (can lead to blindness). For non-insulin-dependent diabetes, management through diet and exercise is important.

PTs develop exercise programs that consider the problems associated with diabetes.

Principles of Examination and Evaluation ~

Examination and evaluation should be specifically oriented to the skills and capabilities needed for maximum independence, which differ for each individual. When interviewing the older person, the PT seeks information about how they view the current problem.

Interviewing also gives the PT general impressions of cognitive function to determine whether a more formal examination of cognition is necessary. A thorough social history is important for understanding the patient’s/client’s previous function, amount and type of support, and need for goals.

Input from family members and other caregivers may be an important factor in determining the amount of assistance a person may need from other sources. A thorough chart review is also important to obtain objective information. A systems review entails a brief examination of the individual’s systems to provide the PT with information regarding the older adult’s general health.

Tests and Measures ~

 Examination of an older person proceeds much like the PT’s examination of any individual, except that the PT is especially alert to the common problems of this age group. 

The PT may adapt some examination procedures to be more appropriate to the older individual. The PT must keep in mind potential age-related changes when examining the musculoskeletal system of the older person. Activity level may confer some deficits. 

Neurological examination determines if there is reduced cognition and what impact it may have on the person’s quality of life.

Sensory deficits may significantly affect balance, and each involved system must be examined individually to determine which may be contributing to a balance problem. Both static(while standing still) and dynamic (while moving) balance should be examined.

Static - Romperg test, Functional Reach Test (predicts likelihood of falling)

Dynamic - Gait and functional mobility are important aspects of dynamic balance, several tests available.

Standard tests of cardiopulmonary function should be modified for older people who often fatigue easily and have reduced endurance. An important part of the examination of the older person is to determine whether they are experiencing pain related to movement.

It should be noted whether the pain is acute or chronic and whether it increases or decreases from one session to the next. Since pain is perceived differently from one individual to the next, it is important to assess how much discomfort the person is willing to tolerate to maintain independent function.

Information about the environment in which the older person lives is essential. Environmental examination is equally important whether the older person is in a private home or a Long Term Care (LTC) facility.

The PT investigates access to and from the residence based on the individual’s specific abilities and limitations. Psychosocial information must be collected as part of the complete evaluation of the older person. Success in adjusting to the present disability will help determine the individual’s level of motivation and whether special strategies are necessary to increase that level.

Principles of Eval. Diagnosis, and Prognosis ~

Evaluation is a dynamic process that requires the PT to use clinical judgment regarding the data from examination. The PT determines whether the patient/client is likely to benefit from physical therapy, as well as whether a referral to another practitioner is required. 

The PT determines a diagnosis that directs the course of rehabilitation. Older adults frequently have multiple medical diagnoses. Considers these medical conditions, impairments, and functional limitations and evaluates how they affect the individual’s ability to function.

Procedural Interventions ~

The first consideration in establishing goals for intervention with older person is to set meaningful goals that address daily function. Examples of interventions for older adults include but are not limited to:

•  therapeutic exercise

• functional training

• physical agents

• mechanical modalities

• manual therapies

Effective instruction of the older person encompasses both general and specific information. General, factual information about the effects of aging on the various body systems gives the older person a good background and model from which to judge changes they are experiencing.

  A basic understanding of the disablement process, including the relationships among pathology, impairments, function, and disability, may help the older person understand why the PT is selecting particular interventions.

General, factual information about the effects of aging on the various body systems gives the older person a good background and model from which to judge changes they are experiencing. A basic understanding of the disablement process, including the relationship between pathology, impairments, function, and disability may help the older person understand why the PT is selecting particular interventions.

Modifications ~

Intervention for older adults focuses on improving daily function. Programs should incorporate movement patterns that normally occur during the person’s routine. Cardiovascular conditions, arthritis, and diabetes are common in older individuals and may necessitate modifications of accepted approaches. 

Must consider environmental modification and adaptive equipment. Provide the client with information about how to maintain or improve their health to prevent further problems that could limit physical function.