PRINCIPLES OF REHABILITATION IN ELDERLY

PRINCIPLES OF REHABILITATION IN ELDERLYOleh :Dr. Dedi Silakarma Sp.KFRREHABILITATIONOne of the most basic component of comprehensive care for the elderly.

A philosophical approach : to help achieve the highest possible level of function, independence and quality of life.

Definition : Restoration of the ill or injured to an optimal function level in the home or community in relation to physical, psychosocial, vocational and recreational activity.American Geriatric Society, defines :Rehabilitation as the maintenance and restoration of physical and psychological health - Independent living- Functional independence

Rehabilitation is concerned with :Lessening the impact of disabling condition on individuals and their family members. Especially important in the elderly who often have multiple comorbid condition that may impact on the outcomes of rehabilitation.WHO ( 1980 ) to characterize the disablement process :International Classification of Impairments, Disabilities and Handicaps ( ICIDH ) :

* disease : the underlying diagnosis or pathological process, noticeable at a microscopic level.

* An impairment : A disease that progress to a point at which an organ system is unable to function normally.

* A disability : an impairment of an organ system that causes a restriction or lack of ability to perform ADLs.

* A handycap : a disability with unable to fulfill social rules.

May 2001 WHO released a revision of ICIDH International Classification of Functioning, Disability and Health (ICF) : The function as the consequence of a dynamic interaction between various health condition and contextual factors.

Various health condition : diseases, disorders, injuries or agingContextual factors : environmental factors and personal factors

The model : three domains of human function ( body function and structures, activities and participation ).

Body function and structures : the physiologic functions and the anatomical parts of the body

The execution of a task or action by a person is an activity

Participation is the application to a real life activityRehabilitation Site Started as soon as patient is able to tolerate the exercise to prevent secondary functional loss and promote early restoration of function.

Each setting has its own advantage & disadvantages.Acute Inpatient RehabilitationUsually provided for the patient who needs at least 2 different therapies (PT, OT, ST).Able to tolerate therapy at least 3h/day 6 days/week & is likely to show significant improvement.Monitored by interdiciplinary team, include physician who is experienced in rehabilitationWeekly team meetings allow for review, discussion, and planning of the rehabilitation process.The duration of inpatient rehabilitation varies from days to months depending on many factors.Subacute Rehabilitation .Patient who are not appropriate for acute inpatient .

Home RehabilitationHome is often the best site for the rehabilitation process

Out patient RehabilitationFor some patient, out patient rehabilitation is the best option. Process of RehabilitationA comprehensive geriatric assessment is often helpfullThe assessment should include measures at a person ability to perform task to ADL, leisure activities and social interaction.Two people with the same impairment and resulting disability may have different goals.It is important to select the functional assessment instrument that are valid and reliable for this purpose ( Barthel Index, FIM )Geriatric Rehabilitation TeamPhysician especially in physical medicine and rehabilitation)NursePhysiotherapistOccupational TherapistSpeech & language pathologistPsychologistSocial WorkerDietitianRecreational therapist

PHYSICAL MODALITIESHeat agents : Superficial : Hot pack, Infra RedDeep : SWD, MWD, USD

Cold agents : - Icing : cold pack- Cryotherapy

Electrotherapy : ES, TENS

Equipment

The best benefits and safetyGait problem (+) : canes, crutches, walker or wheelchairEnvironmental adaptations : modification bathrooms and entryways.Common geriatric problems Stroke Osteoarthritis Hip fracture Deconditioning Falls & Instability AmputationRehabilitation for common Geriatric problemsSTROKEGeneral consideration The third leading cause of death in US leading cause of serious, long term disability.Treatment Acute care Intensive rehabilitationLong term careRehabilitation approach should be continuing process, started as soon as life threatening problem are under control during acute hospitalization.Candidates for intensive rehabilitation :Medically stable but have residual disabilitiesNeed help with at least 2 ADLs :are able to sit (with or without support) for 1 hour and are able to learn and participate in active rehabilitation treatments.

Intense inpatient program Home or outpatient programAble tolerate 3 hours of* Only supervision or minimaltherapy each day assistance in mobility or ADLsIncreasing age worse functional out come at hospital discharge and follow up.

An elderly person may have more disabilities after stroke than younger person but will have the same degree of functional improvement after the stroke.

Rehabilitation intervention strongly associated with improve functional outcome are early initiation of rehabilitation services ( 72 hours post stoke) & rehabilitation provided in an interdiciplinary in patient setting.

Most of the functional recovery in the first 6 month after stroke

Some patient continue to gain functional abilities with physical therapy and exercise after 6 month.

In patient who are initially aphasic, 50% recovery of speech occur in the first month and then recovery continue at slower pace for 6 month.

Complication :a. DepressionInterfering with the ability to perform ADLs Unrecognized but treatable condition that improves with medication or psychotherapy or a combination.b. FallingStroke patient are susceptible to fallingFall incidence can be reduced significantly with appropriate evaluation and intervention.c. Spasticity & contractures.

Common after strokeTreatment :- Aggressive and consistent ROM exercise- Proper positioning- SplintingOral medication unsuccessfull

Selective local intra muscular injection low dose of Botulinum Toxin A has been effective in reducing local muscle true for 3-6 month, resulting in improved function in selected patients.

d. Poor Caregiver HealthSupport services for families have been shown to increase social activities significantly and improve quality of life for caregivers. OSTEOARTHRITISGeneral ConsiderationOA is the most common disabling condition in older people.

The first step in evaluating the rehabilitation potential of a.person with OA is Physical Examination with special attention paid to ROM/ Range of Motion (active & passive) condition of joint (inflamed, deformed, swollen, unstable) , MMT/ muscle strength, postural or gait instability, CV fitness and subclinical conditions that could be exacerbates by exercise.

TreatmentSuperficial heat commonly used than deep heat (MWD, SWD, USD) for OA joint Many patient prefer cold to heat for symptom relief.Superficial heat (+) , before exercising and early in the morning to help relieve morning stiffness.Topical ointment : capsaicin and trolamine salicylate (+) in OA joint but are often poorly tolerated by elderly patient.TENS helpfull for hand, wrist & knee pain

The best program for patient functional problem are most important to the patient help prioritize them work with the patient to set spesific short and long term goals.Flexibility exercise stiffnes , joint mobility , prevent soft tissue contracturesStrength training essential part of rehabilitation for people with OA.Isometric training better option if the joint inflamed or unstable can improve muscle strength & static endurance.

Isotonic trainingIsotonic muscle contraction(+) perform ADLs

Has positive effects on energy metabolism, insulin action, bone density and functional status .

Joint damage is severe contracture (+) more aggressive treatment may be beneficial including:- Arthroplasty Indication : Pain relief !!- Serial casting- Serial casting combined with traction- Manipulation under anesthesia.HIP FRACTURE- Major cause of disability in older adult- Rehabilitation (+) reduce the disability of hip fracture.TreatmentThe typical post op course of hip fracture is as follows:ROM exc , WB locomotion as tolerated, pivot transfer :, isotonic ankle exc and isotonic gluteal exc.4-6 weeks post surgery (endosteal and bridging calluses (+)Active ROM exc around hip and knee,Active resistive exercise as tolerated

8-12 weeks post surgeryWB transfers & ambulationWeaning from assistive devices

DeconditioningResult of prolonged limited mobility

The reason for the limitation of mobility can be physical (eg. pain, imbalance, reduced ROM), psychological (fear of falls, depression), environmental (restraint neglect) or a result of lifestyle choices.Significant deconditioning (+) 3 days of ImmobilizationThe primary manifestation of deconditioning are :- Muscle strength (espc in the antigravity and large muscle ) - Joint flexibility- Contracture- Fatique- Resting tachycardia or abnormal high HR with sub max exc.- Orthostatic intolerance.

Treatment .

Providing adequate sensory and intelectual stimulation.Regaining an upright postureImproving joint ROM (active or passive exc)Increasing strength and coordination with combination of isometric, isotonic and functional activities.4-8 weeks of resistance excercise strength and improve functional activity.To prevent deconditioning bed rest is generally avoidedFalls & Instability

Each year 30% of community dwelling people older than 65 and 50% those older than 80 fall.Falls leading cause of accidental death in the elderly.Besides physical injury, falls also cause psychological and social consequences such as fear of falling, anxiety and admission to long term care institution.Risk factor of falls are :- Muscle weakness- History of falls- Gait deficit- Use of assistive deficit- Visual deficit- Arthritis- Depression- Cognitif impairment- Age > 80- External factors : environment etcBecause of fall is usually the result of many interacting factors intervention (+)Intervention are usually :A combination of gait training and appropriate of assistive devicesTreatment of postural hypotensionModification of environmental hazardsTreatment of CV disorder (incl. arrythmias)Taichi helpfullHome assesment to ensure elimination of environmental risk factor !. AMPUTATION> 100.000 new amputatee yearly in US.Elderly with PVDBecause of advances in vascular surgery and technology decrease the number of AK amputation BK amputation >>Important (+) BK amputation : Reduce- Energy cost for ambulation

- Psychological morbidity

Successful RehabilitationTreatmentEvaluated preoperatively rehabilitation planStart measure to improve muscle strength (espc. Hip extensors and the upper body) and prevent contracture.Emotional effect of limb loss is significant patient and families need supportive environment.

Bed excercise first post op dayGet out of bed & begin balance training within 3-4 daysTemporary prosthesis usually fitted 6-8 weeks after surgery when the limb stump has resolved and healed.Take care the stump with massage and wrapping edema , Prevent infection and pressure.Phantom sensation >>Phantom pain