Stanbridge - T4 - Peds - W8 - Geriatrics

Psychosocial Theories of Aging

• Aging is another developmental stage in the circle of life
• In the US, "old age" is considered age 65 and older
• The mean life expectancy is 84 years old, compared to 47 years old in 1900
• Aging involves adjustments to changes such as:
  • Social roles
  • Employment status
  • Financial stability
  • Loss of family and friends
  • Perception of aging and death

Erikson's Developmental Theory

• It is a profile of development extending into old age
• The developmental process is a series of 8 stages throughout life
• The full development of one's ego is central to it
• Each stage represents a positive and a negative choice
• The last 2 stages involve the older adult
• The concerns during the previous stages involved developing a career and family up until 40-50 +/-
• Then possibly becoming "empty nesters"
• The developmental task is contributing to society and helping to guide and monitor future generations

Erikson's Crisis of Generativity vs Stagnation

• Adults begin to consider spiritual needs and giving back to society in more general terms once previous needs are established

Erikson's Crisis of Generativity vs Stagnation

• Involves developing a sense of productivity and accomplishment
• Individuals who have not met the challenges of relationships and career may become resentful
• Stagnation involves self-absorption and a lack of care for others
• Ex: Jean Valjean in Les Misérables redeems himself when he starts to care about others

Erikson's Crisis of Integrity vs Despair

• Involves looking back at their life and evaluating accomplishments
• Positively resolved when an individual feels a sense of fulfillment from a life well lived (integrity)
• The individual learns to experience his or her own wisdom
• A sense of regret and despair follows if they feel that their life was misspent or did not accomplish what they wanted to
• This includes feelings of self-disgust and fear of death

Maslow's Developmental Theory

• In 1962, theories were published establishing a theory of quality of life
• It is based on the development toward happiness, not age
• The lowest level includes biological and physiological integrity (ex: the person is trying to feed themselves, stay warm, and clothed)
• The second level includes safety and security, where the person protects themselves from the elements and other people
• The next levels are belonging, self-esteem, and finally self-actualization

Intelligence and Learning

• Intelligence is broken into fluid and crystallized
• Fluid intelligence means the ability to use short-term memory, create concepts, perceive complex relationships, and undertake abstract reasoning
• Crystallized intelligence means lifelong learning patterns that are influenced by sociocultural and educational components
• It involves the ability to perceive relations, engage in formal reasoning, and understand principles such as opinions and others' perspectives
• Infancy through early adulthood: fluid and crystallized intelligence improve the same Middle and late adulthood: fluid intelligence declines. Crystallized keeps improving

Clinical Perspective of Intelligence

• There are several clinical implications of these 2 types of intelligences
• The PTA can expect different intellectual ranges in older patients
• Poor performance may not mean poor learning; it may be the result of:
  • Disinterest
  • Depression
  • Medications
  • Nutrition
  • Sleep patterns
  • Sensory changes
  • Cultural and educational variations
  • Patient motivation
  • Health

Intelligence and learning in Rehabilitation

• Learning new activities or ways of functioning with a disability can lead to frustration for the older adult if they do not see the value of the task or ADL
• Better to tap into an activity that is of interest to them
• It is important to focus on one task at a time
• Both cognitive and motor practice of each component of the task needs to be step by step
• Important to reduce distractions such as noise and environmental stimulation

Retirement

• Retirement is a lifestyle adaptation that can be bad or good
• Work/career fulfills many social needs and gives status
• The retiree often misses the association with work-related relationships
• May get a part-time job or volunteer somewhere
• The retiree loses structure of daily activities
• Many older adults see retirement as a new chapter in their lives with pre-retirement planning
• This period may open many opportunities that were not available to them with the restrictive schedule of employment
  • Ex: Travel, new hobbies, and spending time with grandchildren

Death, Dying and Grief

• The frequency of loss increases as we age and has a cumulative effect
• Common losses include:
  • Loss of mobility, productiveness, usefulness, and body image
  • Loss of time left to live, health, income, and social status
  • Loss of loved ones (spouse, friends, neighbors, family)

Kubler-Ross Five Stages of Dying

• Death is a part of the lifecycle
• Kubler-Ross is most known for work on the process of dying
• The stages of dying are:
  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
• Not everyone goes through each stage
• A PTA's role:
  • Be aware of the stages
  • Support one's ability to die with dignity or be cared for with dignity
  • Focus on immediate future and present opportunities such as treatment modification
  • Reduce energy expenditure
  • Decrease pain and increase comfort
  • Boost their self-esteem
  • Be a good listener with a caring attitude and a non-biased manner

Ageism

• Ageism denotes a prejudice against a person or group of persons due to their age
• Perception of aging has changed throughout history
• During colonial times in the US, old age was honored and leaders were esteemed
• The problems inherent in ageism are pronounced in healthcare
• Services are sometimes denied due to age alone

Elder Abuse

• National Center of Elder Abuse website can be found at: https://ncea.acl.gov/ The Elder Justice Act (EJA):
• Enacted as part of the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010. It was the first piece of federal legislation passed to authorize a specific source of federal funds to address elder abuse, neglect, and exploitation.
• Establishes national leadership in the Office of the Secretary of Health and Human Services in the form of an Elder Justice Coordinating Counsel and an Advisory Board.
• Authorizes grants to support improvements to Adult Protective Services and Long-Term Care Ombudsman programs and state survey agencies for Medicare- and Medicaid-certified long-term care facilities.

Elder Abuse: APS definition

• Adult Protective Services (APS) programs promote the safety, independence, and quality-of-life for vulnerable adults who are, or are in danger of, being abused, neglected by self or others, or financially exploited, and who are unable to protect themselves.
• APS is a social service program authorized by law in every state to receive and investigate reports of elder or vulnerable adult maltreatment and to intervene to protect the victims to the extent possible.
• APS FactSheet: https://ncea.acl.gov/resources/docs/archive/APS-FactSheet.pdf Reporting Elder Abuse
• In nearly every state, there are certain professions that are required by law to report concerns of maltreatment --mandatory reporting
• Healthcare professionals including students are mandated to report it (SPTAs must know the institutions policies and follow them)

Elder Abuse reporting

• Some states require all citizens to report concerns
• All states: -accept voluntary reports -allow for anonymous reports -provide good-faith reporters with legal protections
• Reports to APS are often made by phone
• Some states have web-based methods of accepting reports
• Visit www.napsa-now.org/report for a list of state reporting information

Adult Protective Services in California

• Each California County has an Adult Protective Services (APS) agency to help:
  • Elder adults (65 years and older)
  • Dependent adults (18-64 who are disabled)
• County APS agencies investigate reports of abuse of elders and dependent adults who live in private homes, apartments, hotels or hospitals
• Contact your local county APS office to report elder abuse or dependent adult abuse
• https://www.cdss.ca.gov/Adult-Protective-Services

Introduction to Geriatric Rehabilitation: Geriatrics Defined

• Geriatrics is the branch of medicine that focuses on specialized care of aging populations, healthy living, and the prevention and treatment of disease and disability in later life.
• A geriatric PT treats older patients to prevent/manage multiple disease symptoms
  • Develops comprehensive care plans addressing their specific health care needs.
• Shift in clinical focus includes preventative interventions, treatment of sports and leisure related injuries, more attention to health and fitness, & more home/community based care.
• Basis of geriatric rehab: assist disabled aged in recovering lost physical, psychological, or social skills so that they: -become more independent -live in satisfying environments/maintain- meaningful social interactions
• In many cases, complexity of interventions requires an interdisciplinary team approach
• PT on the team often serves as point person for functional and physical aspects of care
• Team should always include patients and their families

Role of the PTA

• Integral part of the team: -Assists the PT in implementing treatment programs according to the POC -Training pt's in exercise and ADL's -Conducting treatments using special equipment -Administering modalities and other treatment procedures
  • Reporting to the pt on the pt's response
• Plays a critical role by interacting and observing the pt's progress and collaborating with the pt

Functional Capacity- ADLs

• Functional capacity is defined by 3 levels of ADL (activities of daily living)

• 1. Basic ADL- (BADL) – self care activities -bathing, dressing, feeding, using toilet/continence
• 2. Instrumental ADL (IADL) -using telephone, driving, shopping, housekeeping, cooking, laundry, money management, taking medications.
• 3. Mobility- combination of BADL and IADL -leaving ones residence and moving to different locations (public transportation) -ability to cope with environment

  Assessment of pt functional capabilities ◦Primary tool for geriatric rehabilitation

• Ability to walk, transfer, and independently manage BADL's -Determines if pt will be discharged to home or extended care facility

Acute vs Chronic Rehab Directions

• Acute settings -Stabilizing primary problems -Preventing secondary complications (bedsores, pneumonia, contractures.) -Restoring lost function
• Chronic settings -Restoring lost function -Help pt adapt to new environment/disability

Activity vs Sedentary Lifestyle and Bed Rest- Immobilization

• 3 Main Types
  1. Acute - accompanies acute illness (hip fracture, pneumonia, stroke) activity decreased- until pt medically stabilized- and heals
  2. Chronic - results from: amputations, arthritis, pulmonary disease, cardiac disease, Parkinson's, low back pain, depression, diabetes, or severe strokes
  3. Accidental - due to environmental barrier in acute and chronic settings such as: -bed rails, height of bed, physical restraints, inappropriate chairs, fall precautions
• Inactivity and sedentary lifestyle (deconditioning) includes: Changes in multiple organ systems (cardiopulmonary) -"Use it or lose it” has tremendous ramifications in the elderly
• Relationships exist betwiin physiologic decline and functional loss -85 yr old unable to climb stairs (CV deconditioning, muscle weakness, impairment in balance due to sensory loss or sedetary lifestyle)
• Consequences of inactivity on all systems may be extreme and occur in elderly

Complications of Bed Rest- mnemonic!

• Bladder and bowel incontinence + Bedsores Emotional Trauma, Electrolyte Imbalances
• Deconditioning of muscles and nerves, Decubiti, Depression, Demineralization of Bones
• Range of motion loss with Contractures, Restlessness, Renal Dysfunction
• Energy depletion, EEG activities decrease

-Sensory deprivation, sleep disorders, skin problems Trouble in All Systems!

• Additional information on the complications of bed rest include -Osteoporosis -Risk of DVT -Decreased endurance -Predisposition of falls -Impaired mobility 3% per day loss in strength -Decreased muscles-tendon flexibility -Systemic complication of bed rest-elderly are more susceptible

Optimal Health of Geriatric Pt- World Health Organization Definition

-Principle for Geriatric Rehab: -"Health is in a state of complete physical, mental/social wellbeing, not merely the absence of disease

• Goal for Geriatric Rehabilitation: striving for relative optimal health

• Maximal functional and physical capabilities of the ages individual(considering his/her current health status

  -Leads to improvement in overall quality of life -is Cost effective preventative ( ex fracture , disease )

Encouraging Healthy Behaviors

-decreased stress

-decreased obesity -stop smoking -increasing activity levels Important Preventative Measures and* Good Screenings skills* -early detect problems (developing problem into major issue.

Benefits of Elderly Exercise

-Improves physical fitness, agility, speed of response

• Improves balance: decreases fall risk -Provides social and psychological benefits -Positively affects sense of wellbeing and quality of life Creates higher level of independence! -Successful in motivating eldery!

• Alterations in instructions (telling pt to do an exercise till comfortable then rest.

• This can take ominous tasks by omitting points of potential failure -avoids ridgity

Communicaions

• RULE of Excersis -monitir levels base of ease with speaking Mild- Ability to carry conversations w o breathing Moderate- (sub maximal aerobic range) short pauses to catch breaths. Maximal- Inability to speak. Exercise should not be cookie cutter dep on cognition, flexibility , and fatigue. -Pt. should have normal muscular, cardio, and cardiovascular systems -Normal again affects functioning capacity during Tollerance session. Any exercise does help above of rests

Therepeur Exercise Principles and Progressives

• No cookie cuter treatmets -Paralled to younger pt but have and may need modifications to frail or medicine complex! (pt with osteoporosis, less agressive strengthening would be appropriate and safe
• Gait training importance -is one of most techniques -safety when doing this

Fears with falling can be defined as : - Sudden unintentional changes in position Causung an individual to land lower Elderly, those with falls (or those with risk) have fear of falling causing activity to decrease -Guarding is unsafe.

Causes and Risks with FALLING

Balance issues Underlines physical dysfunction Medication/enviroment hazards ( poor lighting ) -Impaired (vision/ or other body parts) -Nutrition conditions ( osteoprosis) -gait divinations ( Falls are not a Aging Process)

Fall Prevntion

• Administer fall risk (nursing,pt.0t) Ex: tug, bergs, ( specific balance )

• Enivoromental modifications to to reduce hazards -(grab rails, and furniture adjustment and proper rugs .

• Can use Phyiscal strains need Dr. Orders! With family and STATE LAW!! - use ( belts ,beds , and wrist) Therapy/Physical Therapy (PTA and PT) -gaits , strateries and corrections , rom! , mobiltys!

  • Use walking( adaptives) aids, and shires to improve stability!

• Declinatimg of Muscles can c=be from what? . risk factor and/ or what issues? Is it? -from Gaits

  • From unballanced

• and Hazrds -Or the "All OF THEM!!!!!!!!"

Age-Related Changes vs Disease

• Important to recognize normal changes due to aging vs. effects from disease or inactivity Untreated disease can result in excess disability and reduced quality of life
• Much of the illness and disability associated with aging is related to inactivity and other modifiable lifestyle factors Healthy aging is an issue of increasing importance as the size of the older population continues to grow

Homeostasis and Aging

Homeostasis- the body's ability to maintain an internal balance especially the physiological processes Enables humans to survive in many environments and to withstand many biological and physiological challenges

• Homeostasis is our body's response to physical or emotional stress or an illness, then returning to pre-stress levels
• This ability: declines with : -Age -DeclinesWith Deconditioning + Illness
• Example: contracting the flu, may be experienced more intensely by an elderly person leading to: -Dehydration -Electrolyte Imbalances -inability to resume Adl's -With all the pt will decline

Basic Cellular Changes with Age

• Basic changes are seen in each cell of the body as we age There are also changes in each cell due to dehydration, lower levels of activity, and poorer nutrition, results in decreased physiological efficiency Aging causes functional changes in cells

• Example: the rate at which cells multiply (mitosis) slows down Immune function cells- T-cell lymphocytes, decrease with age Cells can be classified as mitotic( division) and as postmitotic (not capable of cell division(nerve and muscle))

• With cells -apoptosis- (program cell the tissue would clear

• With disease (Apoptosis can be off -Cancer continues to divide and is program to not die. -Alzheimer will build amyloid and could Brain

Body Composition Changes With Age

Most notable to aging fat, water, content. :decreased water content (leading por homeostasis Decreased Lean, with redistribution -pt's do have Fat doublings (btwn the age of 25 and 65)

• Shifted to deeper to the body shifts and changes

body shifts And changes

Women: body increase till 60 then declines. slowly Men: body weight increase until age 50 and then decrease faster Connective Tissue Changes with Age

• Age related is function of our body's collagen and elesatic -Young pt are have strong and flexible (with in active the waste builds with de hydration. resulting in dense cell)
• Cell, can have thick and less porus walls this causing nutrients cell damage.

Building Blocks and Functions

• Collagen: bones ,tends joints.,lig, and cartilage

With CROSSLINKIING: Pt. with inactive body. Have poor nutrition can lead to Contractures. Older pt. With hip Can leads with hip and knee contractures (with people getting "STUCK “)

• Elastic
  • join in end - 2 - branch form, latticework
  • Give elastic properties after stretched. decrease elastin skin -Inelasticity, tearing or scaring. Glycoproteins -are out side Cell with nutrients fluids and tissue -Rest and Non Bearing helps these.
  • Decreases with age! -If pt. does it nourish them they don't have nutrients .

The Importance of Hyaluronic Acid

• Helps to regulate the viscosity of tissues Helps Lubricated. In CELL (like OIL -tin man and engine) -helps decrease fraction.
• Produced during weight bearing with active - Reductions, is as act with inactivity and aging and reducing ease Move " With Poor Cell Lubricaion, Degradation Occurs during Wear and tear. Contractible Proteins -provie waste removal within ti sues enhances mobility. -The Amount (increases with inactivity) or (immobilization) with (Parkinson and strokes In activity results in soft tissue restriction
• MUST STRESS MOVENMET TO PT. ENOUH"**
• ANTYhing ABOVe REST IS ENOUGH"*
• • PREVENT COntractikle Protien. -decrease hydration
    • not much for ( blood supply )

If POOR Cartilage( cracks and freys

• Cartilaginous , eroding the bone for cells.
• Muscle
  • muscle, endurance, speeds to contraction- Decreases to most of the cell " Loss conercstion in specific enzymes, muscle.

Sarcopenia

    -Age, lost with strength  and mass: that increases
    -Decrease woth wegiht an endurance

"80"

Phase II fibers - These contact Greats lost : -inpact the body to work safely , to increase ability

LE: Flexior muscle the LE show With muscles -water,Na,Chior

-blood flow decreases leading to less muscle

Skeletion

-Bones is the normal aging process which Is characterize Decree is to bone Bio is abinormalies in plasma the system -Enlarger medullary cavity -in the 30% womn have osteoporesis

REABORTOION: As we grow elder, we are are off ballance -As osteoclast grows a lot stranger. Vit D: DECREASES CA(Less)

Posture in a older person would look (Kphosis) Lower cartilage spinal cords

• Feet in a are flat with kness ( flexed) and forward head

Cardiovascular Changes with Age

• There is much to to Variation (hereditary+ Environment +disease,
• Hearth*:
  • Increase in muscle wall thicness
  • decrease muscle. In contractions and can lead of SA node lost with fiber -Can use reasult in slower HR! Baro are less sensitive with Bp control.
• *-Physiciol resounds - Heart rate decrease
• *Takes long for BP and ****Hr=normal rest levels later. -quick change causr hypotension BP increase. (conduction system
• *Damage can load -abnomal thrym - can b blocked - extra or preautmte beats -can increase .with loss can leads

Vesses! Blood flow

• Aorta and other arterial b become s thicker Vas less responses for normal Thickening of membranels Increased Calcium + risk atherorserosis.

• carina ( superiol) and the Infernal with Trance -Lung are Stiffer

• Respitotry muscle strength and endurance (weaker) with dia,hragm to Inter Costal Total lungs decrease -Residual , Max for inspiration. (IN crease lung capacity. decrease : lung

• Pulmonary Aging

• Increase work by standing .alverora decrease( with oxygen) "" Alvenlor Can Clapp's ( Sooner Increase in Mucus Cells Cilla decline

Nervios systems

Brains decaes Gray matter has less cells and less. Cells in cerbeoum Blood flow decreases with narrowing( increases schemia)

Vascular will cause ( stroke) ( TIAs)

• NERVES

  • conduction is s slowly
    • less syrpased + Nero transfers , denidite, branched Transmit and increase with fibers all decrease with impluses/

• Cognicive d decline of (stimulus) can be for reasons, Abstract can be more ( Time) But Hard , can be With less calling , deacrese and loss can be FUNCTIONAL" , the reason can : deceases time Decrease in reflects. Balance

With Gait: there are sevral things that -Rigidly , with not as much speed arm - Fewer accuracy -Narrow steps- Wider

• With Swinging in Stance- decreases , - hesl And slow Ca- decrease -
• Periphial , (Nerusl change :

Sensories

Nervous , with responses can be sensory that is -To what is - touch:Skin ( -sensory is off

( Sensory ( the Neuro

Less hear and and has bad hearing with in actions that causes: Responses are confusion, anger, sosxal disrtonaitons,sosical isolates, or even social -Ptas can eductre and help self. Documented chsnge can limit Monitor

• Feedback
• Tranmisons.

5th sense skin touch

Touch and to pain. Are at the same. Amount is less in layers Messiner- texture declien Pasinian - vibrations Decline. Results is " Hight Threshold!

Worry (all sensitivity goes)

• Temprute -( heat heat they don"t notice) Worse bum and can steps on glass More over Skin

Thinners in dermis's all decresse

• Cell sized decrease lack of water Skin also will have reduced more Sub fats

• thins, vascularity that increases -skin that will brea. -The Bairer goes and that includes

  • less # hair and sweat

• leads to:

  • less sweat production

Skin Increase risk of Sking Caner

• Shingles***** Causes dormant Virus is will (lead 2 Pain) Can inhibits

####### Hearing Decline 10 With each