Geriatric Rehabilitation

Published on May 2016 | Categories: Documents | Downloads: 37 | Comments: 0 | Views: 351
of 36
Download PDF   Embed   Report

Comments

Content

GERIATRIC REHABILITATION
PREPARED BY: FLORIZA P. DE LEON, PTRP

GERIATRIC REHABILITATION
• 65 years and older • Accounts for 1/3 of total personal health expenditures • Decline in function • Greater utilization of healthcare resources • There is an increase in both the prevalence of chronic conditions and activity limitations • By age 76, 50% of elders were using assistive device

AGE-RELATED FACTORS THAT MAY AFFECT REHABILITATION
•Multiple diseases •deconditioning •contractures •disease-disease interactions •polypharmacy •subclinical organ dysfunction

Biologic

Psychologic

•Cognitive deficits •depression •atypical presentations •motivation

Social

•Societal prejudice •lack of services •inaccessible buildings •reimbursement regulations

DISEASE-RELATED FACTORS THAT MAY AFFECT REHABILITATION
•Muscle Strength •Cardiac Function •Pulmonary Function •Aerobic Capacity •Vital capacity •Minute Volume •Orthostatic Changes •Peripheral Resistance

Biologic

Psychologic

•Slow Learning pace •More repititions •Beliefs about rehab •Beliefs about recovery •Beliefs about self

Social

•Negative views of aging •less frequent referrals •self-ageism •financial barriers

• Geriatric Rehabilitation
• Medical treatment plus prevention, restoration plus accommodation, and education

• • Accommodation – to the irreversible effects of normal and pathological aging and requires an associated education of the patient and his or her family • Prevention of disability and restoration of function • Medical treatment – treatment is needed to cure when possible or at least to stabilize the disease when cure is not possible; many of the impairments of the elderly are chronic and incurable.

BIOLOGY AND PHYSIOLOGY OF AGING

BODY COMPOSITION
• Gradual loss of lean tissue and an increase in fat • Loss of muscle mass: total body muscle mass, limb muscle volume, muscle cross sectional area, and muscle fiber number and area • Bone mineral is lost • Peak bone density across is 30s and 40s and thereafter gradually declines

POSTURAL CHANGES OF AGING
• Progressive anterior thrust of the head and extension of the cervical spine, accentuated thoracic kyphosis, and straightening of the lumbar spine • Increased extension of the arms with scapular protraction at the shoulders is associated with flexion of the elbows, ulnar deviation at the wrists, and finger flexion • In LE: there is an increase hip and knee flexion and a decrease in ankle dorsiflexion • Widening of the bony pelvis with aging • Angle of femoral neck to the shaft increases, resulting in a valgus deformity of the hips • Progressive widening of the standing base with aging is noted • In women, knees can develop varus deformities with narrowing of standing base • COG is shifted behind the hips by flexing the knees and that this may require the use ambulatory aids such as a cane • Increased postural sway • Ability to balance on one leg with eyes either closed or open decreases • Righting reflexes decrease and reaction time increases

NEUROLOGICAL CHANGES OF AGING
Eye Signs Small, irregular pupils Diminished reactions to light and near reflex Diminished range of movement on convergence and upward gaze Slowed pursuit movements with cogwheeling Tendency to tremor Gait: short-stepped or broad-based with diminished associated movements Dysmetria Dysdiadochokinesia Atrophy of interossei Increased muscle tone; legs more than arms, proximal more than distal Diminished muscle strength: legs more than arms, proximal more than distal Diminished vibratory sense distally; legs much more than arms Possible change in proprioception Mildly increased threshold for light touch, pain and temperature Impaired double simultaneous stimulation Diminished or absent ankle jerks Some reduction in knee, biceps, and triceps reflexes Abdominal reflex sometimes lost Babinski signs may not occur Primitive reflexes occur in 20-25% (palmomental, snout, and nuchocephalic –doll’s eyes)

Motor Signs

Sensory Signs

Reflex Signs

SKIN
• Decreases in moisture content, epidermal renewal, elasticity, blood supply, and sensitivity to touch, pain and temperature • More susceptible to injury (pressure sores) or infection

CARDIOPULMONARY CHANGES
• Decreased cardiac reserve, contractile function, and heart rate • Blood pressure tends to rise with aging • Pulmonary function mildly decreases with a decline in vital capacity • Main functional deficits secondary to cardiopulmonary system are due to disease and not aging changes

UROLOGICAL CHANGES
• Urinary frequency, hesitancy, retention and nocturia are common complaints in both sexes and relate to anatomical and physiological aging changes of the urinary system • Bladder capacity is reduced and residual volume increased • Prostatic hypertrophy is almost universal in elderly men

HYDRATION
• Elderly have approximately a 25% decrease in thirst perception as compared to the young • Medications (diuretics or laxatives) might increase their need for H2O to maintain adequate hydration

TEMPERATURE
• More susceptible to hyper and hypothermia • Febrile response to infection and other inflammatory diseases can fail to develop in the elderly and can lead to missed diagnosis

EXERCISE
• “use it or lose it” principle – indicates that the decrease in physiological functioning in the elderly is not solely due to aging process but is also due to inactivity

PHARMACOLOGY
• Because of physiological changes including liver and kidney function, and absorption and body distribution of drugs, have a greater sensitivity to the effects of medication
Guidelines for Medication Use During Rehabilitation of Older Adults Maintain a HIGH index of suspicion for medication toxicities Obtain accurate over-the-counter and prescription medication histories Review that each medication is still indicated Record a clear diagnosis for which each medication, especially psychotropic medication, is prescribed Gradually eliminate unnecessary medications Review that medication dosages are correct Simplify medication schedules as much as possible Clarify with patients that they are willing and able to take medications Educate patient and family about indications for medications and their side effects

FUNCTIONAL ASSESSMENT
• Mini-mental State Examination (MMSE) – assessing tool that can be used to help detect and assess dementia • Geriatric Depression Scale – screen for the common symptoms of depression in the elderly

BALANCE
• Key component of mobility • Adequate muscle strength in the extensors of the hips and knees and normal ankle muscle are necessary for normal balance •

GAIT
• Muscle develop a gait pattern of small steps with a wide base during walking and standing • Women typically develop a waddling style of gait with a narrow walking and standing base • Swing phase decreases and double support increases • Aging person typically compensates for the increased energy demand by using a slower walking speed • Pathological gait patterns in the elderly can be due to neurological or musculoskeletal causes and are often diagnostic of the underlying disease • • Circumduction hemiparesis • Scissoring UMN disease • Ataxia vitamin deficiency • Cervical spondylosis • Cerebellar dysfunction • Apraxia (N) pressure hydrocephalus • Senility arterial degeneration • Waddling muscle weakness

FALLS
• Occur in about 1/3 of the elderly
Visual impairments Presbyopia and decreases in accommodative capacity, visual acuity, night vision, peripheral vision, glare tolerance, impaired blue-green discrimination, and contrast sensitivity Reduced righting reflexes, proprioceptive input, and cerebral function; increased reaction time; lessened awareness of vibration, touch and temperature; increased distractibility Osteopenia; musculoskeletal stiffness; reduced or uncoordinated muscle control Postural hypotension Women: waddling gait, narrow walking and standing base Men: small-stepped gait, wide walking and standing base Reduced speech discrimination Increased high-frequency threshold Wax accumulation

Nervous system impairments

Musculoskeletal impairments Cardiovascular impairments Gait changes

Auditory impairments

COMMON IMPAIRMENTS

PAIN
• Musculoskeletal pain is the most common type reported • Spinal problems are common causes of pain in the elderly
• Spondylitic changes are present in 82% of persons in their 6th decade of life • Cervical disc degeneration presents more commonly at C5C6, followed by C6-C7 and C4-C5 • Cervical spondylitic myelopathy is the most common reason for spinal cord dysfunction in patients over 55 y/o

DYSPHAGIA
• Motor function of the lips, tongue, and masticating muscles slow with aging • Amplitude of esophageal contractions decreases with age.

ARTHRITIS
• Elder persons have smaller muscle fibers and fewer anterior horn cells • Tendons, ligaments, and capsules surrounding joints lose elasticity as evidenced by a decreased ROM & a sense of stiffness

OSTEOPOROSIS AND PAGET’S DISEASE
• Back strengthening exercises contribute to good posture and skeletal support, but flexion exercises of the spine not recommended owing to the possibility of anterior wedge fractures • Paget’s disease can lead to fracture, rare cancerous changes, total joint replacement, and paraplegia

FRACTURES
• Osteoporosis and falls are the reason for the great majority of fracture of radius, hip and shoulder

STROKE
• Older persons are more at risk of being institutionalized after a stroke • Multi-infarct dementia can be a confounding problems •

TBI
• Falling is the most common cause of TBI in those more than 65 y/o and pedestrian accidents yield the most fatalities • Alcohol is involved commonly (in men) • Protection from a 2nd fall is a major goal to prevent further TBI and fractures

MOTOR NEURON DISEASE & PARKINSON DISEASE
• Attention to dysphagia, respiratory problems, self care, balance and mobility, nutrition, and psychotherapy are all important

PNS IMPAIRMENT
• Decreased or lost vibratory sense (82%) and ankle muscle stretch reflexes (70%) • Drug related and toxic neuropathies, postherpetic, diabetic, entrapment, rheumatic, carcinomatous are common in elderly • Neuromuscular junction, changes and muscle atrophy are commonly seen

VISUAL IMPAIRMENTS
• Vision is a major factor contributing to balance and is an important factor in the risk of falling • Poor vision often results in social isolation, impaired morale, and a decreased sense of well being • Cataracts, age-related macular degeneration, glaucoma and diabetic retinopathy are amenable in varying degrees to visual rehabilitative services

HEARING LOSS
• Incidence of significant hearing loss appears to these more than 65 y/o • Often patients refuse to wear hearing aids because of sound distortion, impaired dexterity in their use or adjustment, uncomfortable fit or vanity

PVD & ISCHEMIC SKIN ULCERATION
• Intermittent claudication must be distinguished from similar complaints of discomfort • Proper foot care, including appropriate shoes, is part of the spectrum of care • Chronic venous insufficiency and lymphedema can be helped with compression garments in selected patients • Skin ulceration especially in malnourished older persons, needs careful, aggressive treatment •

FOOT DISORDERS
• Ankle and foot can be likened to a “fatigue trampoline,” which has decreased shocked absorption and spring abilities as a result of problems such as bony disfigurement joint disorders, muscle imbalance, and skin and toenail disorders. • Aging can result in insensitive feet with increased potential for ulceration and decreased ability to heal

SEXUAL FUNCTION
• Sexual activity is affected by age-related changes in female and male hormonal levels; alterations in vision, hearing and smell; negative social attitudes toward sexuality in the elderly; erectile and ejaculatory changes; vaginal dryness and dyspareunia; urinary stress incontinence; decreases in muscle strength and endurance; and limitations in movement from osteoarthritis • Additional problems in sexual functioning can arise from medical illnesses • Drugs can also cause sexual dysfunction

PRINCIPLES OF REHABILITATION MANAGEMENT OF THE ELDERLY PATIENT
• • • • • • • • • • • • • • Ascertain level of function (functional assessment) Ascertain available resources and options Avoid immobilization Be aware of altered physiological reactions Determine patient’s significant goals, motivation Determine family expectations (psychosocial issues) Differentiate between delirium, dementia, depression Emphasize function; management not diagnosis; cure Emphasize task-specific exercise; simplify program Encourage socialization and stimulation Minimize medications Realize that function may not be regained Recognize that patients have multiple interacting impairments Understand that improvement occurs in slow increments

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close