Geriatric Physical Therapy Musculoskeletal & Coginative Disorders

8/8/2019 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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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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Geriatric Physical Therapy Musculoskeletal & Coginative Disorders