geriatric rehabilitation. what would be the most appropriate assistive device? 78 y/o f s/p (l) tka...
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What would be the most appropriate assistive device?
78 y/o F S/P (L) TKA w/ severe RA of hands, shoulders, knees
A. Large based quad cane
B. Crutches
C. Two-wheel walker
D. Forearm supports attached to a two-wheel walker
E. Wheelchair
Geriatric RehabilitationGeriatric Rehabilitation
General Aspects
• Identify the correct diagnosis !
• Assess for comorbidities
• Involve the patient (& family)
• Team approach to care
• Prevent complications(A,B,C,…)
Geriatric RehabilitationGeriatric Rehabilitation
MD
Therapists
RN
Other
Patient
SW, Dietary, PT, OT, SpT, RecT
Rehabilitation TechniquesRehabilitation Techniques
Exercise
Assistive Devices
• Mobility aids
• Orthotics
• Adaptive methods/equipment.
Assistive Devices- Mobility AidsAssistive Devices- Mobility Aids
Device Supports• Canes 15-20 % of body weight
• Crutches 100% of body weight • Walker ~ 50 % (not 100) of body weight
Geriatric RehabilitationGeriatric Rehabilitation
Prevent complications A B C s
A. Aspiration, Anorexia, inActivity
B. Bedsores,
C. Constipation, Contractures, Cognition
D. DVTs, Depression, DUs
E. Else: infections (UTI, Pneumonia), pain,
incontinence
Geriatric RehabilitationGeriatric Rehabilitation
Specifics
• Joints– Elective replacements– Fractures
• Stroke
• General Medical Problems
Spinal/Compression FractureSpinal/Compression Fracture
Mortality unclearAge-adjusted mortality 2.15 (FIT) (a)
RR 1.66 F, 2.38 M (b)
Life expectancy (c)
Men: 6.1 y (60-69y) 1.4 y (>80)Women: 1.9 y 0.4 y
(a) Osteoporos Int 2000;111:556-561.
(b) Lancet 1999;353:878-882.(c) Arch Intern Med 1999;159:1215-20
Am J Med 1997; 103:12S-19S & Lancet 1999;353:878-882
Hip FractureHip FractureMortalityMortality
Acute: 3% F 8% M die
1 year: 20% F 30-40 % M (<80 y)
>50 % M (>80y)
2 year: Returns to rate of general population
Hip FracturesHip Fractures Outcome at 1 yearOutcome at 1 year
40% cannot walk independently
60% require assistance with ADL
80% need help with IADL.
Functional Recovery S/P Hip FxFunctional Recovery S/P Hip Fx
Independent Function Before 6 months after
•Dress 86 49
•Transfer 90 32
•Walk across a room 75 15
•Walk half a mile 41 6
Percentage Able toPerfrom
JAGS 1992;40(9):863.
Joints/FracturesJoints/Fractures
Dx: fracture type determines surgical intervention– Pins/Screws/Plates– THA
Go to pictures
Joints / FracturesJoints / Fractures
Comorbidities:
Osteoporosis
Calcium & Vitamin D
Hormone status: Estrogen, Testosterone
Medications: Steroids, thiazides,
“too late” for DEXA ? use for f/u
Other complications . . .
Joints/FracturesJoints/FracturesComplications
AA – Activity (asap), BB – Look at skin! (NURSING!)
CC – Laxatives (see pain below)
D D – DVT prevention, DislocationMultiple regimens—LMWH, Warfarin, Fondaparinax
EE- Else Infections – Make sure foley out ASAP
Pain– Not moving so it doesn’t hurt is NOT good pain control! (Use routine + PRN meds)
AmputationAmputation
Common 50,000/ year
Level of amputation:
BKA- - work by 40-60%
AKA- - work by 90-120%
Stump healing
ContracturesRisk of contralateral amputation - 20% @ 2 years
StrokeStroke Diagnosis:Diagnosis:
Etiology (hemorrhage, thrombotic, embolic)
Developing interventions in acute phase
Location (frontal, posterior, left vs right)
May be factor in deficits and treatments needed
Coordinated care improves outcomes.
Recovery: Proximal to distalRecovery: Proximal to distal
Flaccid to spastic to recoveryFlaccid to spastic to recovery
StrokeStroke
Rehabilitation is complex due to the variety of causes and residual deficits
Recovery and time needed to reach maximal recovery affected by the number of deficits.– Hemiparesis, hemianopsia & sensory deficits
are less likely to ambulate (I) and will require a longer time than those with hemiparesis only
StrokeStroke
Comorbidities are often multiple:
DM,
Alcohol and Tobacco (withdrawal),
Hypertension,
Hyperlipidemia
StrokeStroke
Complications:AA AspirationSpeech, LRI / Activity
BB Watch skin, (NURSING!)
CC Laxatives, prevent contractures,
DD DVT prev, low threshhold for depression, E E Reflex sympathetic dystrophy (pain),
infection, subluxation…