Geriatric

Rehabilitation
DR . KOBA L SA N GA JI , S P K F R
DE PA RTEMENT R E HA BIL ITASI M E DI K
AWALBROS P E KA NBARU
• According to data from World Population Prospects: the
2015 Revision, the number of older persons—those aged
60 years or over—has increased substantially in recent
years in most countries and regions, and that growth is
projected to accelerate in the coming decades.

• As per census 2011 reports, 103.54 million( 50.91 million

males and 52.62 million females) of Indian Population is

aged 60 years or above.

With increasing
population of ageing
the prevalence of
diseases, injuries
and degenerative
condition increases
and so is the
demand for planned
geriatric
rehabilitation.
 AGING: Denham Harman postulates that aging is
the result of progressive accumulation of changes in
the body which occur with passing time and which
cause the increase in the probability of the disease
and death of the individual.

 GERIATRICS: The care of aged is called geriatrics

or clinical gerontology.

 GERIATRIC REHABILITATION can be defined as

medical treatment plus prevention, restoration plus
accommodation and education
•At what age old age begins cannot be universally defined.
•Most developed-world countries have accepted
the
chronological age of 65 years as a
definition of 'elderly' or older person.

•The United Nations has agreed that 60+ years may be usually
denoted as old age
•Sub-grouping is
•young-old (65 to 74),
•middle-old (75–84),
•and oldest-old (85+).
•IS IT GENETICS?

•ENVIRONMENTAL
DAMAGE?
• Physical changes related to ―Normal‖ aging ARE
NOT diseases.
• People who live an active lifestyle lose less
muscle mass and flexibility as they age.
• Problems in elderly are multi-faceted and
often a single problem may be the result of a
complex chain of decompensation of body
functions.
Death by underlying or multiple cause, expressed in rates per
100,000 people, as a function of age for the 2001 US population
aged 85 and older. Source: CDC/NCHS, National Vital Statistics
 H
E
A VISION
R
I
N
G

TOUCH AND PAIN

TASTE AND SMELL
CHANGES IN NERVOUS SYSTEM
CHANGES IN RESPIRATORY
MUSCULOSKELETAL
CHANGES IN AGING
 Physiology of normal aging
Body composition
•Gradual loss of lean tissue
(loss of muscle mass)
•Increase in fat
•Bone mineral is lost
 Postural changes of aging
• Progressive anterior thrust of the head
• Extension of cervical spine
• Accentuated thoracic kyphosis
• Straightening of lumbar spine
• Scapular protraction, ulnar deviation of
wrist
• Increase hip and knee flexion and
decrease in ankle dorsiflexion
• Functional effect---------- shift of COG
 Gait
• Men  small steps with a wide base
• Women  waddling style of gait
with a narrow walking and
standing base
• Decrease in swing phase
• Increase in period of double
support
increase energy cost slower
walking speed
 Normal neurological changes
• Tendency to tremer
• Atrophy of interossei
• Diminished muscle strength
(LL>UL)
• Increased muscle tone( LL>UL)
• Diminished vibratory sense distally
• Increased threshold for light touch,
pain, temp
• Diminished or absent ankle jerks
 Skin changes
• Decrease moisture content
• Decrease Epidermal renewal
• Decrease Elasticity
• Decrease sensitivity to touch,
pain and temp
 more susceptible to
injury
 Cardiopulmonary changes
• Decreased cardiac reserve
• Decrease contractile function and
heart rate
• Decrease response to exercise
• Decrease in pulmonary function
and vital capacity
 Urological changes
• Decrease in bladder
capacity
• Increase in residual vol
• Prostatic hypertrophy in
men
Geriatric Rehabilitation

Involves
•Prevention along with
treatment.
•Accommodation along
with Restoration
 Components of geriatric rehab
• Accommodation
-to the irreversible effects of aging
-requires education of patient and family
• Prevention of disability & the
restoration of function
-exercise
-―use it or loss it‖ concept (Bortz)
• Medical treatment of impairment
-cure when possible or stabilize
FALSAFAH & TUJUAN
REHABILITASI MEDIK

Falsafah rehabilitasi medik ialah meningkatkan

kemampuan fungsional seseorang sesuai dengan
potensi yang dimiliki untuk mempertahankan dan
atau meningkatkan Kualitas hidup dengan cara
mencegah atau mengurangi Impairment, Disability
dan handicap semaksimal mungkin
3 STADIUM FUNGSIONAL PERJALANAN PENYAKIT /
CEDERA YANG DIDERITA SESEORANG :

―IMPAIRMENT‖ (tingkat organ) :

Stadium dimana penderita masih memerlukan / tergantung pada perawatan dan

terapi secara aktif, sehingga tidak mampu melaksanakan kegiatan sehari-hari (ADL),
―temporary disability‖

―DISABILITY‖ (tingkat manusia) :

Stadium disebut juga ―recovery period‖ dimana penderita mulai dapat melaksanakan
pekerjaan sesuai keadaan kesembuhan penyakitnya

―HANDICAP‖ (tingkat sosial) :

Stadium cacat menetap, keterbatasan kemampuan dan melaksanakan tugas

pekerjaan
Prof. Soelarto Reksoprodjo
Unit Rehabilitasi Medis
Jakarta - Indonesia
Konsep Upaya Pencegahan
dari Sudut Rehabilitasi Medis

I. Pencegahan Primer
Sehat  cegah jangan sakit (impairment)
II. Pencegahan Sekunder
Sakit (impairment)  cegah jangan cacat
(disable)
III. Pencegahan Tertier
Cacat (disable)  cegah jangan handicap
 THE ESSENTIAL COMPONENTS
OF A COMPREHENSIVE
REHABILITATION PROGRAM

PREVENTION PREVENTION PREVENTION

PATIENT PSYCHOSOCIAL
PATIENT ASSESMENT TRAINING EXERCISE FOLLOW UP
INTERVENTION

PREVENTION PREVENTION

Prevention Strategies
 EVALUASI REHABILITASI
DIAGNOSIS GOAL JANGKA GOAL JANGKA PROGRAM
REHAB/
EVALUASI FUNGSIONAL PENDEK PANJANG
TERAPI

REEVALUASI
REPROGRAM
Rehabilitation
Rehabilitation efforts for frail elders may be directed to
avoid loss of function, to help promote return or lost
function, or both.
Rehabilitation of older adults can take place in an acute
hospital medical or rehabilitation unit, the nursing
home, an outpatient area, or at patient’s home
An important preventing measure in primary care is to
encourage physical activity to help patients achieve a
higher level of baseline function, so that they will have
more functional reserve during an illness.

Nusbaum NJ
primary geriatric care
a cased based approach 2007
 Functional Status
Examinations of function divided into three
levels:
◦ Basic Activities of Daily Living (BADL or ADLs)
◦ Instrumental Activities of Daily Living (IADL)
◦ Advanced Activities of Daily Living (AADL).
 Barthel Index

The Barthel Index was used to document

improvement.
Patients who did not improve their score during rehabilitation
were believed to have poor potential for recovery.
 INDEKS ADL BARTHEL (BAI)

NO FUNGSI SKOR KETERANGAN

1 Mengendalikan rangsang pembuangan 0 Tak terkendali/tak terukur (perlu pencahar)
tinja 1 Kadang-kadang tak terkendali (1x seminggu)
2 Tak terkendali

2 Mengendalikan rangsang berkemih 0 Tak terkendali atau pakai kateter

1 Kadang-kadang tak terkendali (hanya 1x/24 jam)
2 Mandiri

3 Membersihkan diri (seka muka, sisir 0 Butuh pertolongan orang lain

rambut, sikat gigi) 1 Mandiri

4 Penggunaan jamban, masuk dan keluar 0 Tergantung pertolongan orang lain

(melepaskan, memakai celana, 1 Perlu pertolongan pada beberapa kegiatan tetapi dapat
membersihkan, menyiram) mengerjakan sendiri beberapa kegiatan yang lain
2 Mandiri

5 Makan 0 Tidak mampu

1 Perlu pertolongan memotong makanan
2 Mandiri

6 Berubah sikap dari berbaring ke duduk 0 Tidak mampu

1 Perlu banyak bantuan untuk bisa duduk (2 orang)
2 Bantuan minimal 1 orang
3 Mandiri
INDEKS ADL BARTHEL (BAI) (lanjutan)
NO FUNGSI SKOR KETERANGAN

7 Berpindah/berjalan 0 Tidak mampu

1 Bisa (pindah) dengan kursi roda
2 Berjalan dengan bantuan 1 orang
3 Mandiri

8 Memakai baju 0 Tergantung orang lain

1 Sebagian dibantu (mis mengancing baju)
2 Mandiri

9 Naik turun tangga 0 Tidak mampu

1 Butuh pertolongan
2 Mandiri

10 Mandi 0 Tergantung orang lain

1 Mandiri

TOTAL SKOR 19

Skor BAI
20 : Mandiri 5-8 : Ketergantungan berat
12-19 : Ketergantungan ringan
0-4 : Ketergantungan total
9-11 : Ketergantungan sedang
Lawton IADL Scale

No
1 Dapatkah menggunakan telephone
2 Mampukah pergi kesuatu tempat
3 Dapatkah berbelanja
4 Dapatkah menyiapkan makanan
5 Dapatkah melakukan pekerjaan rumah tangga
6 Dapatkah melakukan pekerjaan tangan
7 Dapatkah mencuci pakaian
8 Dapatkah mengatur obat-obatan
9 Dapatkah mengatur keuangan
Keterangan :
1 = mandiri
2 = butuh bantuan
3 = ketergantungan
Nilai maksimal = 27
 Hierarchy of physical function

Integration level III Role function

Task or
Integration level II goal-oriented
function
(e.g., ADL, IADL)

Specific physical
Integration level I Movements
(e.g., 8-foot walk)
Basic component

Coordination
Balance Strength Flexibility Endurance
Line motor
 Hierarchy of Physical Function and Disability

ADL = activities of
Physically daily living
elite
• Sports competition,
BADL = basic ADL
Physically
Physical function

Senior Olympics
fit Physically
• High-risk and power independent
• Moderate physical
sports (e.g., hang-
work
gliding, weight • Very light physical Physically
lifting
• All endurance work frail
sports and games Physically
• Hobbies (e.g., • Ligtht
• Most hobbies walking, housekeeping dependent
and games
• Food preparation • Cannot pass
• Low physical some
demand • Grocery shopping or all BADLs :
activities (e.g., golf, • waling
social dance, hand • Can pass some • bathing
crafts, traveling, IADLs, all BADLs • dressing
auto- • eating
mobile driving) • May be • transferring
homebound
• Can pass all IADLs • Needs home or
institutional care

Disability

Adapted from Spicduso WW. Physical Dimensions of Aging. Champaign, IL; Human Kinetics; 1995
Basic Consideration
If we are to rehabilitate our elderly patient successfully we
need:

1. Timing of treatment
2. The team
3. Techniques
Age-related factors that may
affect rehabilitation

Biologic
Muscle strength Psychologic
Cardiac function Slow learning pace
Pulmonary function More repetitions
Aerobic capacity Belief about rehab
Vital capacity Belief about recovery
Minute volume Belief about self
Orthostatic changes
Peripheral resistance

Social
Negative views of aging
Less frequent referrals
Self-ageism
Financial barriers
Disease-related factors that
may affect rehabilitation

Biologic
Multiple diseases
Deconditioning Psychologic
Contractures Cognitive deficits
Disease-disease Depression
interactions Atypical presentations
Polypharmacy motivation
Subclinical organ
dyfunction

Social
Societal prejudice
(―Disabilityism‖)
Lack of services
Inaccessible buildings
Reimbursement regulations
• 3 main principles:

1.VARIABILITY of aged

2.ACTIVITY v/s inactivity

3.OPTIMAL HEALTH
 The aged are more variable in their level of
functional capabilities. The differences that
can be identified cognitively are just as
remarkable.
 Chronological age is a poor indicator of
physical or cognitive function.
 The impact of this variability is an important
consideration when defining rehabilitation
principles and the practices of the aged
 EXAMPLES OF
VARIABILITY
1. Reaction time

2. Visual capabilities

3. Strength

4. Cognition
•Common reason for loss of function is inactivity/
immobility
•IMMOBILITY divided as-
ACUTE immobility
CHRONIC immobility

•DECONDITIONG results from immobility . It

involves multiple organ system including the
neurological, cardiovascular and musculoskeletal
system to varying degrees.
• Thermoregulation is altered by bed rest.
• Decline in motor performance and balance
decrements are significant after 2-3 weeks
of bed rest.
• Orthostatic hypotension occurs within the
first week of inactivity.
• Bed rest imposes inactivity in a non uniform
way in muscle groups.
• Overall immobilization accelerates the
process of aging.
• B- Bladder and bowel incontinence and
retention; bed sores
• E- Emotional trauma; electrolyte imbalance
• D- Deconditioning of
muscles and nerves, depression,
demineralization of bones.
• R- ROM loss and contractures, restlessness
• E- Energy depletion
• S- Sensory deprivation, sleep disorders
• T- Trouble
 FALLS
• Falls /near-falls occur in more
than 30% of people aged 65 years
or older
• Injuries occur in 10-20% of falls
• 3-5% of injuries result in fractures
• Approximately 90% of fractures
in the hips, pelvis, and
forearms result from fall
• Fear of another fall>> immobility
 Risk factors…………..
• Musculoskeletal impairments
• Cardiovascular impairment-
postural hypotension
• Gait changes
• Auditory impairments
• Reduced speech discrimination
• Increased high-frequency threshold
• Wax accumulation
 Proprioceptive dysfunction
• Screening for Vit. B12 def.
• R/o cervical spondylosis
• Balance exercise
• Appropriate walking aid
• Correctly sized footwear with
firm soles
• Home safety assessment
 Dementia

• Detection of reversible
causes
• Avoidance of sedative or
centrally acting drugs
• Supervised exercise & gait
training
• Home safety assessment
 MUSCULOSKELETAL DISORDERS

• Appropriate diagnostic evaluation

• Balance & gait training
• Muscle strengthening exercises
• Appropriate walking aids
• Home safety assessment
 Foot disorders

• Shaving of calluses
• Bunionectomy
• Trimming of nails
• Appropriate foot
wear
 Postural hypotension
• A common cause for falls
• Aging is associated with
impairment of the baroreflex.
• Changes in baroreceptor
sensitivity, heart rate response,
vascular compliance, vasopressin,
renin, angiotensin, and renal
concentrating abilities
 Common impairments
• Fractures • Amputations
• Head injury • Arthritis
• Immobility • Burns
• Joint • Cancer
replacement • Chronic pulmonary
• Lymphedema disease
• Neuropathy • Contracture
•• Osteoporosis • Deconditioning
Pain syndrome( acute • Disk
disorders
• Parkinson’s disease
 Pain

Proper pain history

•Special care regarding
secondary gain or hidden
agenda
•hearing loss, dementia, pseudo
dementia & underreporting of
symptoms can influence the
accuracy of information
• Musculoskeletal pain- m.c. Type
• Spinal problems are common causes
• Spondylitic changes- up to 82%
• Cervical spondylitic myelopathy-
(m.c.c. of spinal cord dysfunction in
patients over of 55)
• Shoulder pain -25%( soft tissue)
• Elbow , wrist & hand pain, medial or
lateral epicondylitis, median or ulnar
nerve entrapment
 Pain management
• Physical therapy
• Pharmacological
management
• NSAIDs
• Paracetamol
• Nonopioid analgesics
• Adjuvant drugs
 Arthritis
• OA is more common (knee>hip)
• In older people
–Smaller muscle fiber & fewer
horn cells
–Tendons , ligaments & capsule
lose elasticity-
• Resulting in decrease
joint ROM
• Sense of stiffness
 Fractures
• Osteoporosis & falls –imp causes for
fractures esp hip and wrist
• Wt bearing and ROM are important
issues
• Subcapital Hip fracture
Repair by pinning
Restricted wt bearing for 6 weeks
• There is substantial evidence that regular physical
activity has a number of health benefits.

• Each type of exercise appears to have unique

benefits. Exercise can be classified in five
categories: resistance, aerobic (endurance),
balance, flexibility, and functionally based.
• Resistive exercise has been generated
because, not only are there age-related
changes in muscle strength, but resistive
exercise has been shown to improve a
number of physiologic parameters of great
importance to the older person, including
insulin sensitivity, bone mineral density,
aerobic capacity, and muscle strength.
• Most studies show that aerobic exercise can
improve aerobic capacity.
• Keysor and Jette report that 70% of studies of
aerobic conditioning exercise in older adults
showed improvements in aerobic capacity, but
that the effect of aerobic exercise on body
composition is less consistent.
• Physiologic benefit of aerobic exercise is the
prevention of or reduction in the severity of
diseases whose end-organ effects cause
disability (eg, stroke in uncontrolled
hypertension), so older people who already
suffer disability may experience less benefit.
 E
• Various types of exercise interventions, including
Tai Chi, have been used to treat persons at risk for
falls, with apparent benefit.
• A review of randomized trials of falls prevention
interventions identified 23 studies that included
exercise, 9 studies of home assessment and
surveillance, 1 study of hip protectors, and no
studies of footwear.The authors concluded that the
majority of exercise studies suggest a decrease in
falling, with balance training appearing to be the
most effective exercise intervention, and they
concluded that the majority of home assessment
studies showed benefit as well.
• Despite the fact that many disease processes
common among elderly people can adversely
affect flexibility (eg, stroke, arthritis), there are few
studies in the older population of the effect on
outcomes of a loss of range of motion or of the
efficacy of exercise interventions to restore
flexibility.
•Most of the studies are done on single type of
exercise . More research is required to study and
compare various forms of flexibility exercise.
• Task-specific resistive exercise has been used successfully to improve
the endurance during and rapidity of rising from sitting to standing
by persons with mobility disability who live in congregate housing
facilities.
• Massed activity (repetitive exercise activities for up to 8 hours per
day), often used in conjunction with constraint therapy for stroke
patients that may have substantial efficacy for both acute and
chronic stroke. There is some evidence that this

therapeutic approach may be effective for motor

deficits.
Quality of Life Paradigm has
meaning for both patient and
physician