Unit 3C - Geriatric Rehabilitation

Definition & Classification of the Geriatric Patient

  • Medicare eligibility benchmark: >= 65 years

  • Sub-categories-

    • “Young-Old”: 65–74 yrs

    • “Mid-Old”: 75–84 yrs

    • “Old-Old”: >= 85 yrs

Components of “Successful Aging”

  • Absence of disease/disability

  • High cognitive & physical function

  • Meaningful social engagement & relationships

Age-Related Physiological Changes

Global & Cellular

  • Annual loss of tissue/organ reserve ~ 3%

  • Immunosenescence → ↑ risk of cancer, infection

  • Common cellular patterns- Atrophy: skeletal muscle, brain

    • Hypertrophy: myocardium, kidneys (often coexist with co-morbidities)

    • Hyperplasia: prostate (BPH)

    • Dysplasia: cervical epithelium

    • Neoplasia: e.g., squamous cell carcinoma

Organ Reserve Decline

  • Greatest in heart, lungs, kidneys → ↓ ability to meet physiologic stress

Musculoskeletal System

  • ROM loss: 6° / decade at hip & shoulder

  • Sarcopenia trajectory (Table 24.2)- 0.5% strength loss/yr> 40 yrs

    • 1–2% strength loss/yr> 50 yrs

    • 3% strength loss/yr> 60 yrs

    • Power declines > strength declines; Type II fibers most affected

    • Lower-limb muscle ↓ ~ 2x upper limb

  • Immobility overlay- Measurable atrophy after 72 hours of bed rest

    • 10–15% strength loss/wk; 50% in 3–5 wks

    • Plantar-flexor strength ↓ 26% after 5 wks complete bed rest

Neuromuscular

  • ↓ peripheral nerve conduction velocity

  • Slower reaction times → Functional & driving implications

Cardiopulmonary

  • Valve calcification / fibrosis, ↑ vascular tone → ↑ systolic BP

  • ↓ arterial elasticity

  • Inspiratory muscle weakness; ↓ vital capacity

Sensory

  • Vision: ↓ acuity, depth perception, contrast → ↑ fall risk, driving hazards

Epidemiology of Chronic Disease & Disability

  • 70% of Medicare beneficiaries = >= 2 chronic conditions

  • Leading causes of death: heart disease, cancer, CVA, Alzheimer’s, CLRD, DM

  • Arthritis prevalence: ~ 80% age >= 55

  • Falls: 1/4 of older adults fall annually; gait & stair negotiation are the most cited limitations

  • 29% report >=1 ADL limitation

Consequences of Sedentary Behavior / Hypokinesis

  • Definition: sitting/recumbent, < 1.5 METs

  • Physical inactivity shortens life expectancy by 2–4 years

  • Bedrest physiology- Strength ↓ 10–15% per week

    • Bone mineral density & multi-system impairment within the first week

    • Recovery rate ~ 10% / wk (much slower than loss)

  • Psychosocial: belief of being “too weak” to exercise reinforces inactivity

Evidence-Based Benefits of Physical Activity (Table 24.3)

Whole-Body Health

  • ↓ all-cause & CVD mortality, HTN, T2DM, dyslipidemia, >= 9 cancer sites

  • ↑ sleep quality, bone density, physical function, QOL

Brain Health

  • ↓ risk dementia, depression, anxiety; ↑ executive function, memory, processing speed (strong evidence for adults > 50)

Chronic Conditions

  • Cancer survivors: ↑ HR-QOL, ↓ disease-specific mortality (breast, prostate, colorectal)

  • MS: ↑ gait speed & endurance

  • Osteoarthritis: ↓ pain, ↑ function

  • SCI: ↑ UE strength, ambulation capacity

Key Interview / Screening Questions

  • Physical activity dose & type

  • Falls: “Have you fallen in the last year? How many? Injury?”

  • FRAX for fracture risk (osteoporosis context)

  • Polypharmacy: >= 3 meds ↑ fall risk; diuretics, antiarrhythmics, psychotropics highest risk

  • Other domains: functional mobility, diet, swallowing, continence, weight change, fatigue, dizziness, cognition, enjoyment of activities

Frailty, Sarcopenia & Geriatric Syndrome (Table 24.4)

Definitions

  • Frailty: systemic vulnerability due to diminished reserve across multiple systems

  • Sarcopenia: muscle disease → ↓ strength, mass, quality; often antecedent to frailty

  • Geriatric Syndromes: multifactorial conditions (delirium, incontinence, dizziness, falls, frailty) that transcend single-disease categories

Frailty Screening (FRAIL or Frailty Phenotype)

  • Weight loss (>5% in 6 mo)

  • Exhaustion/fatigue

  • Weakness (grip strength)

  • Slowed gait

  • Low physical activity

  • >= 3 criteria = frail; 1–2 = pre-frail

SARC-F for Sarcopenia

  • Strength (lift 10 lb)

  • Assistance walking

  • Rising from chair/bed

  • Climb 10 stairs

  • Falls last year

Functional Tests for Older Adults

  • Stair-climbing velocity

  • Self-selected & fast gait speed (<0.8 m/s predictive of adverse events)

  • 30-second Sit-to-Stand

  • Timed Up & Go (TUG)

  • Five-Times Sit-to-Stand (FTSTS)

  • Short Physical Performance Battery (SPPB)

  • Floor Transfer Test

  • Grip dynamometry

  • 6-Minute Walk Test (6MWT)

Exercise Prescription Principles

Aerobic

  • Age-adjusted HRmax ↓; use Talk Test or Borg RPE (target 11–13 for moderate, 14–17 for vigorous)

  • Aerobic capacity ↓ 10% per decade in sedentary men; similar trend in women

  • Monitor for ↑ BP due to peripheral vascular resistance

Flexibility

  • Low-load, long-duration safer because of ↓ tissue adaptability

  • Integrate new ROM into ADL (task-specific carryover)

Balance Training

  • Progression hierarchy: sitting → standing → dynamic → perturbations → gait challenges

  • Manipulate BOS, support surface, vision, cognitive dual tasks

  • Functional integration: sit-to-stand without arms, heel/toe walking, obstacle negotiation, laundry retrieval, golf/tennis simulation

Resistance Training

  • Associated with ↓ all-cause mortality; effective up to >= 96 yrs

  • Intensity: load allowing 8–14 reps with good form = appropriate (~ 60–80% 1RM)

  • Sets: 3 sets > 1 set for strength in older women

  • Frequency: 24–48 h rest for given muscle group

  • Power: introduce only when 3 strength sets tolerated; concentric “as fast as possible,” eccentric 2–3 s

  • Safety- Screen co-morbidities; avoid full-range trunk flexion with osteoporosis

    • Wheelchair adaptations; monitor glucose, cognition, pain

  • Key muscle groups & modalities (Table 24.6)- Hip/knee extensors, abductors, PFs via machines, squats, lunges, monster walks, heel rises

    • Core stabilization vs. flexion for osteoporotic spines

    • Scapular retractors, rotator cuff with bands/cables/Y-T raises

Common Geriatric Disorders & Exercise Considerations

Falls

  • 1 in 4 older adults falls yearly;t he leading cause of injury death

  • STEADI algorithm: strength, balance, gait training + environment & footwear modification

Osteoporosis

  • Fragility fractures (vertebrae, hip, forearm) from “low-energy trauma”

  • Program: strength 2–3x/wk, daily posture & balance, WB aerobic >150 min/wk

Dementia / Alzheimer’s

  • Communication “pearls”: calm voice, simple cues, routine, sundowning awareness

  • Interventions: familiar, low-stress tasks; walking, balance, multisensory stimulation; caregiver education

Osteoarthritis (OA)

  • Highest prevalence knees > hips; comorbidities: obesity, cognitive decline, pain

  • Exercise dosage: 130–150 min/wk moderate, low-impact aerobics; aquatic therapy useful

  • Contra/precautions: avoid vigorous loading on unstable joints, acute flare = ROM only, monitor grip pain

Urinary Incontinence

  • Prevalence 26–46%; stress UI during coughing, sneezing, jumping

  • Pelvic floor muscle training key: integrate with functional cough-sneeze drills

Type 2 Diabetes Mellitus (IDDM on pumps)

  • Monitor BG pre/ intra / post exercise (new exerciser or new pump)

  • ADA: 30 min moderate-vigorous aerobic 3–7 days/wk, target 65–90% HR_max

  • Hypoglycemia window up to 48 h post; foot inspection mandatory (neuropathy/ulcers)

  • BG guidelines- <70 mg/dL: give sugar, defer exercise

    • 70–100: snack first

    • 100–300: safe to proceed

    • >300 (oral meds): trial 10–15 min, re-check

    • >300 (insulin) + ketones: contraindicated

  • Target BG during activity: 5.5–15 mmol/L

Thyroid Disorders

  • Hypothyroidism

    • Presentation: fatigue, bradycardia, cold intolerance, myalgia-

    • Intervention: walking/cycling, ~ 50% HR_max, short bouts 5–7 d/wk; frequent vitals

  • Hyperthyroidism

    • Presentation: heat intolerance, tachycardia, ↑ BP, weakness-

    • Intervention: walking, RROM @ 60–80% HR_max, 15–30 min 2–3 d/wk; monitor for heat stress

Geriatric Fractures & Orthopedic Surgeries

  • Hip fracture: adhere to WB orders; gait, transfers, DVT / orthostatic hypotension monitoring

  • Vertebral compression: acute bedrest + muscle setting → chronic extension & postural training

  • THA/TKA/TSA: respect surgical precautions (dislocation, ROM limits, WB status)

Postural Control & Balance Strategies

Types of Control

  • Steady-state, Reactive, Anticipatory, Adaptive

  • Closed-loop (feedback) for precision; Open-loop (feed-forward) for rapid tasks

Contextual Factors

  • Environment (closed vs. open)

  • Support surface properties, footwear

  • Lighting, gravity, inertia, task specifics

Biomechanical Strategies

  • Ankle strategy: small, slow perturbations on a firm surface (gastrocs → hamstrings → paraspinal for fwd sway)

  • Hip strategy: large/rapid perturbations or near-limit COM excursions (abs → quads for fwd sway)

  • Weight-shift (mediolateral) via hip ABD/ADD & ankle invert/eversion

  • Stepping strategy when COM exceeds BOS limits

Promoting Physical Activity (“Walk the Talk”)

  • Clinician role-modeling & visible advocacy

  • Motivational interviewing & health coaching for adherence, relapse support

  • Create social environments & community linkages; flyers, programs, onsite wellness options

  • Primary–tertiary prevention integrated into PT practice

  • Educate via multimodal materials; use Teach-Back

  • Maintain professional involvement & lifelong learning

Ethical & Practical Implications

  • Match exercise dose to nutritional intake in frail/sarcopenic adults to avoid catabolism

  • Functional mobility training must reflect patient-specific goals & context (home, community)

  • Vigilant monitoring of vitals, glucose, pain, and ognition ensures patient safety & autonomy.