GERI ATRI C

REHABI LI TATI ON
GERIATRIC
REHABILITATION
General Medical
Background
General Medical Background -
Definition
Geriatrics
The branch of medicine that focuses on health
promotion and the prevention and treatment of
disease and disability in later life.
The term comes from the Greek "geron"
meaning "old man" and "iatros" meaning
"healer."
Older adult group: 65 y/o and above
General Medical Background -
Classification
No current classification exists
Can be classified as to conditions that occur
amongst this population
Injuries
Chronic diseases
Other conditions
Communicable
Maternal
Perinatal
Nutritional
General Medical Background -
Epidemiology
2002, UN
worldwide number of persons aged 60 years or
older is estimated to be 605 million.
projected to grow to almost 2 billion by 2050
population of older persons will be larger than the
population of children (0-14 years) for the first time
in human history.
54%, Asia
24%, Europe
General Medical Background -
Epidemiology
2002, Population Reference Bureau
In developing countries:
Injuries (12%)
Chronic diseases (44%)
Other Conditions (44%)
In highly developed countries:
Injuries (9%)
Chronic diseases (6%)
Other Conditions (85%)
General Medical Background -
Epidemiology
2007, US Center for Disease Control
At least 80% of the American older population
had at least 1 chronic condition.
It is projected that by 2030, 20% of the US
population will be of the older adults.
Health care spending will increase to 25% due to
this demographic shift.
General Medical Background -
Epidemiology
2006, Population Reference Bureau
Philippines at 3.45 million elderly (4% of the
total population)
General Medical Background -
Etiology
Different etiologic factors predispose the
older population to become susceptible to
the conditions affecting them which are
usually due to age-related factors, such as:
Biologic factors
Physiologic factors
Social factors
General Medical Background
Physiology of Aging
Aging is not a disease
Many physiologic changes occur in aging
Body composition
Posture
Skin/Integumentary
Cardiopulmonary
Urologic
General Medical Background
Physiology of Aging
Aging is not a disease
Many physiologic changes occur in aging
Hydration
Body temperature
Blood
Gastrointestinal system
Hepatic system
General Medical Background
Physiology of Aging
Aging is not a disease
Many physiologic changes occur in aging
Renal system
Immunologic system
Endocrine-metabolic system
General Medical Background
Physiology of Aging
Aging is not a disease
Many physiologic changes occur in aging
Neurologic
Sight
Motor
Sensory
Reflexes
CNS
General Medical Background
Clinical Manifestations
Again, aging is not a disease
More or less, the physiologic changes in
aging are the clinical manifestations of the
aging process
General Medical Background
Complications
The area of most concern in health
professions
Due to increased susceptibility
General Medical Background
Complications
5 Is of Geriatrics (Geriatric Quintet)
Intellectual impairment
Impaired mobility
Incontinence
Impaired homeostasis
Iatrogenic drug reaction
General Medical Background
Complications
Other common complications
Amputation
Arthritis
Burns
Cancer
Cardiovascular disorders
Chronic pain
General Medical Background
Complications
Other common complications
Chronic pulmonary disease
Contractures
Deconditioning
Disc disorders
Fracture
Head injury
General Medical Background
Complications
Other common complications
Trauma
Joint replacement
Lymphedema
Neuropathy
Osteoporosis
Pain syndromes
General Medical Background
Complications
Other common complications
Parkinsons disease
Postural disorders
Pressure sores
Spinal cord injury
Spinal stenosis
Stroke
General Medical Background
Diagnosis
From the medical history:
Drug history
Dietary history
Incontinence history
General Medical Background
Diagnosis
From the physical examination:
Pelvic and breast examinations in women
Rectal examination in both male and female
Check urinary incontinence, distended
bladder, perineal sensation and
bulbocavernososus reflexes in male
General Medical Background
Diagnosis
From laboratory examinations:
Erythrocyte sedimentation rate
Fasting glucose test
Serum creatinine
General Medical Background
Differential Diagnosis
Performed more often in geriatric patients
due to their susceptibility to many
conditions and the possible occurrence of
having multiple conditions
General Medical Background
Differential Diagnosis
Some common errors (either from the
patients or health care practitioners side)
that compromise the development of a
proper database for an ill elderly patient
Symptoms may be attributed to normal aging
New symptoms may be attributed to a chronic
problem
Drug toxicity may not be considered
General Medical Background
Differential Diagnosis
Some common errors (either from the
patients or health care practitioners side)
that compromise the development of a
proper database for an ill elderly patient
Fear that a symptom, if revealed, might result in
hospitalization
Stoicism due to the concern for cost or
discomfort of evaluation
General Medical Background
Differential Diagnosis
Some common errors (either from the
patients or health care practitioners side)
that compromise the development of a
proper database for an ill elderly patient
Considering a patient as too old to undergo
evaluation
Classical or typical manifestation of illness may
not be present
General Medical Background
Differential Diagnosis
Some common errors (either from the
patients or health care practitioners side)
that compromise the development of a
proper database for an ill elderly patient
Longer time requirement for evaluation may
not be considered
General Medical Background
Prognosis
Framing the definition of the outcome is
very important for the success and
professional rewards of the geriatric
rehabilitation.
Their quality of life can be maintained or
improved through appropriate rehabilitation
methodologies and social support from family
and community.
General Medical Background
Prognosis
Most elderly patients live in the community
with ages 85 and above, only 15% of men
and 25% of women live in a nursing home.
Discharge data reveal that over 85% of these
patients are discharged to a non-institutional
setting.
GERIATRIC
REHABILITATION
Medical Management
Medical Management -
Pharmacologic
Largely specific to each condition
Medical Management
Medical/Surgical
General Principles of Geriatric Medicine
Individuals become more dissimilar as they
age, belying any stereotype of aging
An abrupt decline in any system or function is
always due to disease and not to normal
aging
Normal aging can be attenuated to some extent
by modification of risk factors
Medical Management
Medical/Surgical
General Principles of Geriatric Medicine
Healthy old age is not an oxymoron
The onset of new disease in the elderly
generally affects the most vulnerable organ
system
Disease in older patients often presents at an
early stage because of their impaired
compensatory mechanism
Medical Management
Medical/Surgical
General Principles of Geriatric Medicine
Homeostatic mechanisms are often
compromised, multiple abnormalities are
amenable to treatment, and small improvements
in each may yield dramatic effects
Many findings that are abnormal in younger
patients are relatively common in older people
and may not be responsible for a particular
symptom
Medical Management
Medical/Surgical
General Principles of Geriatric Medicine
The diagnostic law of parsimony often does
not apply because symptoms in older people are
due to multiple cases
Treatment and prevention are more effective in
an older patient who is more likely than a
younger one to suffer the adverse consequences
of the disease
Medical Management
Medical/Surgical
General Principles in Geriatric Prescription
Ascertain level of function (functional
assessment)
Ascertain available resources and options
Avoid immobilization
Be aware of altered physiological reactions
Determine patients goals, motivation
Medical Management
Medical/Surgical
General Principles in Geriatric Prescription
Determine familys expectations (psychosocial
issues)
Differentiate between delirium, dementia, and
depression
Emphasize function; management not
diagnosis; cure
Emphasize task-specific exercise; simplify
program
Medical Management
Medical/Surgical
General Principles in Geriatric Prescription
Encourage socialization and stimulation
Minimize medications
Realize that function may not be regained
Recognize that patients have multiple
interacting impairments
Understand that improvement occurs in slow
increments
Medical Management
Medical/Surgical
Surgical intervention
Usually reserved only for specific conditions
GERIATRIC
REHABILITATION
Physical Therapy
Examination, Evaluation,
and Diagnosis
Points of Emphasis
in Examination
Because normal aging produces changes in
all physiologic systems, all components of
the physical therapy examination are
usually included.
Depending on the presence of a condition,
there will be more emphasis on examination
components that are specific to these
conditions.
Points of Emphasis
in Examination
Additional emphasis on the following
aspects due to the impact that these have on
the daily lives of geriatric patients
ADL
Cognitive Status
Depression
Gait and Balance (including Vestibular
Function)
Other
Problem List
Impaired mobility due to:
Weakness
Stiffness
Pain
Poor balance
Psychological
Mixed
Problem List
Incontinence
Urinary
Fecal
Impaired homeostasis
Attributed to normal physiologic aging
Attributed to other presenting conditions
Problem List
Risk of loss of balance and falls
One of the 1 problems addressed by PT
Causes:
Intrinsic deficits
Environmental challenges / obstacles
Rarely are falls due to only 1 of these
Usually a combination of these causes
PT Diagnosis
May fall into any of the diagnostic labels
depending on the condition present in the
individual patient
Most often, multiple diagnostic labels
Due to their susceptibility to conditions and the
possibility of acquiring multiple conditions
PT Diagnosis
If uncomplicated, fall into primary
prevention / risk reduction for:
Skeletal demineralization
Loss of balance and falling
Cardiovascular/Pulmonary disorders
Integumentary disorders
GERIATRIC
REHABILITATION
Physical Therapy
Prognosis (including Plan of Care)
and Intervention
Plan of Care
If with medical conditions:
PT goals will be specific to the condition
present
Total number of sessions:
Condition specific episode of care
Plan of Care
If without medical conditions:
PT goals will be:
Improve mobility
Goals addressed toward specific cause
Improve continence
Improve homeostasis
Reduce risk for loss of balance and falls
Plan of Care
If without medical conditions:
Total number of sessions:
Lasts until the end of the patients lifetime
Considered as an episode of prevention or
maintenance
Intervention
For impaired mobility
Specific interventions as to cause:
Weakness muscle strengthening exercises
Stiffness neuromuscular inhibition, then
facilitation techniques
Pain pain management
Poor balance balance training exercises, vestibular
rehabilitation
Intervention
For impaired mobility
Prevention:
Prescription, application, and, as appropriate,
fabrication of devices and equipment (assistive,
adaptive, orthotic, protective, supportive, and
prosthetic)
Patient education on the effects of immobilization
Intervention
For incontinence
If due to sphincter muscle weakness:
Muscle reeducation techniques
Kaegels exercises
Electrical stimulation
Intervention
For incontinence
If due to detrusor muscle underactivity:
Patient training / education on augmented voiding
techniques
Applying suprapubic pressure
Intervention
For impaired homeostasis
Although normal in aging, may be improved
through regular exercise
General endurance and conditioning exercise
program
Intervention
For risk of loss of balance and falls
Balance training exercises
Vestibular rehabilitation
Gait training to alleviate fear of falling
Environmental assessment and modification, if
necessary
Patient education on compensatory techniques,
including training on proper falling techniques