geriatric physical therapy musculoskeletal & coginative disorders
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PRESENTED BY,
SYED SHAHZAD ALIM.S.P.T 3RD SEMESTER
IPM&R,DUHS
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y the branch of medicine concerned with
the illnesses of old age and their care.
y Gerontology: the scientific study of the factorsimpacting the normal aging process and the effects ofaging
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y Progressive with time.
y process of growing old, that describes a
wide array of physiological changes in the body systems.
y
Evidenced by a:(1) Decline in homeostatic efficiency.
(2) Increasing probability that reaction to
injury will not be successful.
y Varies among and within individuals.
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CATEGORIES OF ELDERLY
A. Young elderly: ages 65-74(60% of elderly population).
B. Old elderly: ages 75-84.
C. Old, old elderly or old & frail elderly: ages> 85.
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Leading causes of chronicconditions(morbidity) in personsover 65, in order of frequency.
A. Arthritis, 49%.B. Hypertension, 37%.
C. Hearing impairments,32%
.D. Heart impairments, 30%.E. Cataracts , 17% .F. Orthopedic impairments, 16%.G. Diabetes 9%
Most older persons (60-80%) reporthaving one or more chronic conditions .
Leading causes of Death
(mortality) in persons over 65in order of frequency.
A. CHD 31 % .
B. Cancer, 20%.C. Cerebrovascular disease
D. COPD
E. Pneumonia.
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1. Osteoporosis
2. Fractures
3. Degenerative arthritis
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1. Delirium
2. Dementia
3. Depression
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Physiologic changes:
y Narrowing of joint spaces
y muscle strength
y bone for
m
ation and b
one reabsorption,leading to osteoporosis
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mobility
Joint stiffness& muscle strength
Pain
Disability, fallsloss of independence,
frailty
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mobility
MSK-relatedposture & gaitchanges
Neuro-related gait& proprioception
changes
Environmentalhazards
fall risk Fractures
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Malnutrition
Kneearthritis
Depression
Weakness
Pain
Immobility
Difficulty
walking
Difficulty
ADLS
Social
Isolation
Loss of ability to
live
independently
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Geriatrics 14
y An acute confusional state
y Transient reduction in the clarity of awareness of theenvironment
y Fluctuating level of consciousnessy Asyndrome, usually referable to an underlying disease
process
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Geriatrics 15
y Memory impairment
y Cognitive impairment as evidenced by one of thefollowing: aphasia, apraxia, agnosia, disturbance inexecutive functioning
y The cognitive deficit causes significant impairment insocial or occupational functioning
y Does not occur exclusively during the course ofdelirium
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y Adisorder characterized by depressed
Mood and lack of interest or pleasure in all activities,
And associated symptoms for a period of at
Least two weeks.
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y Comprehensive
y Multidisciplinary
y Long termy Medical evaluation
y Prescribed exercise
y Risk factor modification
y Counseling/Education
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y Bed mobility andtransfer
y Gait and balance
y Ambulatory endurance+/- gait aid and stairclimbing
y Hip and knee extensor
training
y MobilityAids
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y GERIATRICS REHABILITATION( 2ND EDITION BYANDREW A. GUCCIONE)
y NATIONALPHYSICAL THERAPY EXAMINATIONREVIEW & STUDY GUIDE (2008)
y COGINATION REHABILITAION (BY ROBERT D. HILL)
y HTTP://WWW.GOOGLE.COM
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THANK-YOU.
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Losses
y Sedentary people loselarge amounts of muscle
mass (20-40%)y 6% per decade loss of
Lean BodyMass (LBM)
Gains
y Lean body massincreases 1-3 kg
y Resistance trainingimproves strength by arange of 40-150%
y Muscle fiber area 10-30%
Aerobic Activity
ISNOTsufficient
to stop this loss!
BOTTOMLINES:1. MUSCLE STRENGTHENING EXERCISES REQUIRED2. MUST INCLUDE BALANCE+FLEXIBILITY IN OLDERADULTS
3. FEWER FALLS, FRACTURES, DISUSE, FRAILTYANDSARCOPENIA
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y Mode:Aerobic+Strength +Balance+Flexibility
y Duration
y
Frequencyy Intensity:
y Touch > No Touch > Eyes Closed for balance
y 5-6/10 self-perceived exertion
y Timely Follow Upy Therapy (Preventive and/or Therapeutic)
The MD FITT Prescription(for the older adult)
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Moderate Intensity(brisk walk)
30 minutes5 times per week
2007ACSM Guidelines For Older Adults
Vigorous Intensity(jogging)
20 minutes3 times per week
Strength Building Exercise(weight/resistance training)
8-10 exercises2 times per week
FlexibilityActivities(static stretch)
10 minutes10-30 seconds/stretch
3-4 repetitionsAll days of the week
Balance Exercise
(not specified)3 times per week
Intensity
Rating 5-6/10
Intensity is relative to level of fitness
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StaticDynamic
Intensity=sensory or time
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Geriatrics 28
y An acute confusional state
y Transient reduction in the clarity of awareness of theenvironment
y Fluctuating level of consciousnessy Asyndrome, usually referable to an underlying disease
process
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Geriatrics 29
y Four strong predictors of deliriumyAge > 80
yPrior cognitive impairment
y Fracture
y Institutionalization
y Other predictors: Systemic infection,
narcotic or neuroleptic use
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Geriatrics 30
y Organ Failurey Respiratory failurey Congestive heart failurey Hepatocellular failure
y Infectionsy Acute bronchitis/Bronchopneumoniay Bladder infectiony Septicemia
y Metabolicy Dehydrationy
Hypo/hypernatremiay Hypoxia, uremia, hypo/hyperglycemia
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Geriatrics 31
y Drugs: ANY, ANYTHING NEWLYADDEDy Anticholinergics (including anticholinergic
antidepressants, and antihistamines)y Antibioticsy Narcoticsy Neurolepticsy Anticonvulsantsy Digoxin & other antiarrhythmicsy Alcohol/alcohol withdrawal
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Geriatrics 32
y Neurologic causesy Subdural hematomay CVAy Cerebral infectionsy Raised intracranial pressure
y Miscellaneousy Postoperative deliriumy Sensory deprivation
y Recent institutionalizationy Change of living arrangement
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Geriatrics 33
y Historyy Prior functional status: ADLs/IADLsy Alcohol use: they wont tell youy Prior cognitive functiony Time course of changes in consciousnessy Medications used, both RX and OTC
y Physical examinationy Neurologic examination (including mental status)y
Rectal (fecal impaction)
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Geriatrics 34
y Initial labsy Chem profile
y CBC w. diff
y UA
y CXR
y EKG
y Pulse ox or
ABGs
y Serum albumin
y Considery Ammonia levely Blood/urine culturesy CT/MRI of heady Drug levelsy Serum/urine drug
screens (alcohol)
y Thyroid functiony PVR uriney CSF examy Folate/B12 levels
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Geriatrics 35
y Memory impairment
y Cognitive impairment as evidenced by one of thefollowing: aphasia, apraxia, agnosia, disturbance inexecutive functioning
y The cognitive deficit causes significant impairment insocial or occupational functioning
y Does not occur exclusively during the course ofdelirium
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Geriatrics 36
y Alzheimers disease (AD)-- > 60%
y Vascular (multi-infarct) dementia-- 15-20%
y Mixed dementia: AD + vascular features
y All others rare:
AIDS,
Parkinsons, Lewy-bodydementia, Downs syndrome
y Reversible dementias: depression, thyroid disease,vitamin deficiency, infections, normal pressurehydrocephalus
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Geriatrics 38
y Dementia is present
y Two or more of the following are present:y Focal neurological signs on physical examy Onset was abrupt, step-wise or stroke-relatedy Brain imaging shows multiple strokes
y Diagnosis requires presence of cardiovasculardisease, dementia and a definite temporalrelationship between the two
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Geriatrics 39
y Dementia present
y Two of the following core features:y Fluctuating cognition with pronounced variation in
attention and alertnessy Recurrent well-formed visual hallucinationy Spontaneous motor features ofParkinsonism
y Supportive features: repeated falls, syncope, transientLOC, neuroleptic sensitivity, systematized delusions
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Geriatrics 40
y Chronic infections
y Chronic heart failure
y Chronic obstructive pulmonary disease
y Drug-induced cognitive impairment
y Thyroid disease
y Normal pressure hydrocephalus (cognitiveimpairment, gait disturbance and urinaryincontinence)
y Alcohol related dementiay Vitamin B12 deficiency
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Geriatrics 41
y Depression can look like dementia(pseudodementia)
y Duration is weeks to months, not months to years
y
Islands of recent and long term memory lossy Language preserved
y History of depression usually positive
y Responds to questions with I dont know
y Patients impression of disability: exaggeratedy Screen with Yesavage Geriatric Depression Scale
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Geriatrics 42
y Focused medical and family history
y Physical examination and laboratory tests
y Functional status examination
y
Mental status examinationsy Assessment for Depression
y Brain scans (CT or MRI)
y Neuropsychological testing usually not needed
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Geriatrics 43
y CBC
y Comprehensive chemistry profile
y Thyroid function tests
y Vitamin B12 & Folic acidy ESR
y VDRL
y HIV if high risk
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Geriatrics 44
y Mini Mental Status Exam (Folstein)yConsidered the gold standard screen
y
Maximum score of30, cut-off of21-23 fordementia
yRequires verbal and written responses
y No time limit
yReproducible over timey Specificity goes down, sensitivity rises with
higher educational levels
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Geriatrics 45
y CAST: Cognitive Assessment ScreeningTest (AFP54: 1957-62)yWritten, self-administered testy
No time limity Set Test
yCategory fluency: name 10 colors, towns,fruits, animals
y
80% of demented score less than 15/40yConsidered a measure of executive,i.e., frontal
lobe functioning
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Geriatrics 48
yWidespread use and multiple trials confirm thatthese drugs offer a plateau in functional declineand positively influence behavioral
manifestationsy Cognitive decline is postponed, but these drugs
do not influence neuronal decline
y All patients in whom AD is clinically confirmed
and categorized as mild to moderate should beoffered a long term therapeutic trial
y Probably help vascular and Lewy body dementiatoo, though not labeled
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Geriatrics 49
y Donepezil: (Aricept) HS dosing, 5-10 mg., metabolizedbyP-450 system
y Rivastigmine: (Exelon)1.5-6 mg BID with meals;
available in liquid formy Galantamine: (Reminyl)4-12 mg BID with food; avoid
with hepatic impairment
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Geriatrics 50
y Antioxidants (Vitamin E) & Ginkgo Biloba extract:benefit supported by a single clinical trial
y NSAIDs and estrogen replacement therapy: benefit
supported by epidemiologic evidence but notconfirmed by prospective trials
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Geriatrics 51
y Create a predictable schedule: active day, quietnight
y Maintain a familiar, calm environment
y
Foster reminiscence: photos, music, objectsy Keep life simple; reduce choices
y Match activities to capabilities and preferences
y Avoid overwhelming situations (family reunions)
and challenges (shopping)y Learn dementia speak: dont reason or argue with
a demented person
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