Stanbridge - T4 - Peds - W9 - Care of the Geriatric Patient

• This PowerPoint discusses the care of the geriatric patient.

Settings of Care in Geriatrics

• Chapter 8 of "The Role of the PTA- Bottomley" covers settings of care of patients with Geriatrics.
• The objectives are to distinguish different geriatric practice settings, explain the home care setting and PTA's role, and differentiate hospice and palliative care, and what physical therapy offers.

Practicing in Geriatric Rehabilitation Settings

• Older adults are treated in various settings or rehab-based programs:
  • Acute and subacute care hospitals
  • In-patient and outpatient rehab facilities
  • Long-term care skilled nursing facilities
  • Assisted living environments and group housing
  • Home health care
  • Community-based care
  • Hospice

Models of Care in the US Health Care System

• Emphasis is on decreasing the length of stay to reduce costs.
• Rehab spans a continuum of care, from acute hospital to rehab unit or freestanding facility, then home with home health care and home care settings.
• Home care settings include the patient's own home, a senior center, an assisted living community, or a retirement home.
• Physical therapy services in the home setting need to be provided safely and effectively.
• Medicare and third-party payers restrict the number of treatments or cap payment (limit reimbursement).

Home Care Settings and PTA's

• The Centers for Medicare and Medicaid Services (CMS) provides general supervision of the PTA.
• CMS requires an initial direction and periodic reassessment by a PT.
• Supervision of a PTA in the home setting does not need direct, on-site supervision by the PT.
• A PTA may perform interventions specifically prescribed by the PT.
• Treatment protocol changes can occur as prescribed by the PT following communications between PTA and PT or on-site reinspection by the PT.
• The PTA is responsible for the documentation of each treatment session.

Hospice and Palliative Care

• Hospice care provides support and care in the last phase of an incurable disease to live as fully and comfortably as possible.
• Palliative care improves the quality of life for patients who have a serious or life-threatening disease.
• PTAs are often involved in palliative care of elders near the end of their lives.
• Care may be provided in a hospice center or in the home.
• The PT’s and PTA’s role is to maintain patient function and provide relief of pain.
• Hospice care means NOT working towards improving functional status, but allowing patients dignity and control at the end of life.
• Physical therapy offers services in pain management, relief, positioning to prevent pressure sores, therapeutic exercise, edema management, equipment training, home modifications, and family/caregiver education.

Treatment Rationale and Design in Geriatrics

• Chapter 9 of "Bottomley" covers the treatment rationale.
• Learning objectives include explaining elders' fundamental treatment principles, identifying common assessment tools, discussing the PTA’s role in clinical decision-making, discovering how long and short-term goals are established, and determining the PTA’s role in treatment intervention.

Fundamental Principles of Treatment Prescription in the Elderly

• A PTA will use acquired skills in academia.
• Competency is needed in every area of PT to ensure a comprehensive, holistic, patient-centered approach.
• The PTA will provide therapeutic care for a frail, medically complex older adult with age-related changes:
  • Inactivity.
  • Poor nutrition and hydration.
  • Multisystem involvement due to chronic conditions.
  • Polypharmacy.
  • Psychological influences.
  • Environmental barriers.
• The tenets of geriatric care include consideration of the older patient’s:
  • Autonomy.
  • Thorough examination and assessment.
  • Realistic goal setting.
  • Comprehensive interventions.
  • Team-based treatment approaches working in concert with other disciplines and caregivers (interdisciplinary).
  • Ensuring quality of services through ongoing review and case management & patient and caregiver/family education.

Assessment Tools Commonly Used in Geriatrics

• The choice of assessment tool depends on the evaluation purpose and desired outcome.
• Tools must account for individual differences due to aging.
• Appropriate care and time allotted may be necessary for accurate data.
• Some assessment tools are diagnosis-specific.
• A Brunnstrom evaluation would be specific to a CVA.
• The Parkinson's Disability Rating Scale establishes the patient’s phase and helps direct treatment.
• Diagnosis-specific tools should be used to give accurate disease status.
• Some tools are global, looking at functional status or specific outcome measures (typically interdisciplinary).
• Many tools look at one element of function such as balance, gait, fall risk, or cardiovascular status. Examples:
  • Functional Reach Test.
  • MMT (manual muscle training).
  • Mcgill Pain Questionnaire.
  • Fugl-Meyer Assessment.
  • Dementia Rating Scale.
  • Geriatric Depression Scale.

Evidence-Based Practice

• The PTA must work closely with the supervising PT and frequently re-evaluate the progression of a geriatric patient's POC (plan of care).
• The term "evidence-based practice" is rooted in research and the effectiveness or ineffectiveness of treatment interventions being used therapeutically.
• Interventions should be backed by investigation and research.

Clinical Decision Making

• Clinical decision making involves discovering the patient’s functional and physical problems and finding solutions.
• PTA participates in clinical problem-solving activities related to the patient’s status during treatment.
• PTA notifies the PT if there's a need to alter or redirect treatment.
• PTA is responsible for recognizing and recommending modifying treatment within the PTs set plan of care.
• See Figure 9-1 pg. 261 Clinical Decision Making and Problem Solving for the PTA in geriatric care.

Establishing Short Term and Long Term Goals

• The PT needs to identify the patient’s rehab potential and decide what needs to take place for healing.
• Potential includes determining presentation and features due to deconditioning, pathology-specific issues, or aging.
• Determine what is reversible or permanent and what is manageable.
• The PTA needs to know the difference between therapy vs patient-centered goals. Goals need to be centered towards safety and maximum function.
• Discharge goals need to be established early:
  • Does the patient plan/expect to return home or will need to go to a long-term care facility?
• When working toward goals with geriatric patients, the PTA must consider the following:
  • Does the patient/caregiver understand the illness?
  • How important is the illness vs other circumstances such as social, psychological, or physical?
  • What is the elder's style of coping?
  • Mood?
  • Cognitive status?
  • Will the treatment cause pain?
  • Energy expenditure?
  • Is progress visible?
  • Are there financial obligations?
  • How much time will rehab efforts take each day?

Drugs and Function in the Elderly

• Chapter 7 of "Bottomley" covers drugs and their functions.
• Learning objectives include:
  • To explain effects of medication on a aging body
  • Agree that commonly prescribed medications can misused by the elderly
  • Using tables that list drugs, side effects and purposes

Aging and Drug Effects in the Elderly

• Over 65s use more drugs than any other age group.
• Pharmacodynamics: How drugs affect the body and individual response.
  • Age-related changes alter pharmacodynamics.
• Pharmacokinetics: How the body handles absorption, distribution, metabolism, and excretion.
  • May affect the choice, dosage, and frequency of drugs prescribed. Drug therapy is complicated by cost and accessibility.
• Advanced age brings changes that may alter how an older adult reacts to medicine.
• Changes in the digestive system may interfere with drug absorption.
• The decline in kidney and liver function makes it harder for the body to breakdown (metabolize) and eliminate certain drugs.
  • Can lead to toxic drug levels.
  • Reduction in renal clearance can cause nephrotoxicity.
• Elder adults are more sensitive to drugs (reaction stronger or more adverse).
• Changes in mental function may impact the ability for an older person to comply with taking their medications properly.
• Monitoring drug dosages and side effects are important.
• Diuretics (water pills) cause an increase in the flow of urine.
  • Results in a loss of potassium and minerals.
  • Potassium deficiency symptoms: Listlessnesss, loss of appetite, weakness, and irregular heartbeat.
• Opioid analgesics, anti-psychotics, and anti-Parkinsonian drugs need caution due to adverse effects and worsening side effects.
• Anti-hypertensive medications may cause depression, drowsiness, dizziness, and orthostatic hypotension.
• Sedatives, tranquilizers, and barbiturates might cause confusion, psychosis, and shakiness
• Digitalis, prescribed to strengthen the heart, may develop toxicity with symptoms like fatigue, vision problems, and loss of appetite.
• Difficulties with taking medications can occur as age changes ability to swallow a pill, a tablet needs to be crushed, requiring more water, and an inability to open bottles.

Misuse of Drugs in the Elderly

• Mixing drugs & alcohol.
• High use of tranquilizers.
• The most common misuse is multiple drug use (polypharmacy).
  • Taking too many drugs.
  • Inappropriately taking drugs that interact.
• Not following instructions as prescribed.
  • Not taking with food/taking an hour before eating when instructed
• Forgetting to take medications or taking two doses together.
• Not finishing prescribed medicine.
• Taking leftover pills from an old prescription.
• Polypharmacy is a big problem in elderly, seeing several doctors and being prescribed multiple medications for the same issue.
• Self-medicating w/ OTC medications or from relatives/friends.
• Table 7-1 classes of prescribed medications on pages 155-171
• Table 7-3 classes and definitions of prescription drugs use by elderly on page 173
• Table 7-4 Risks drugs with side effects in elderly on page 174-175
• Tables for commonly used drugs for certain disorders like heart disease, wound care, and RA (Tables 7-5 through 7-30, pgs. 176-208)
• Drugs that may cause hypotension, dehydration, confusion, depression, and dizziness for elderly (table 7-31 to 7-37 pgs 208-214)

Nutritional Considerations With Aging

• Chapter 6 of Bottomley covers nutrition.
• Learning objectives:
  • Perceiving elderly people's nutrition
  • Distinguishing physiological changes that affect nutrition
  • Recognizing the relationship between chronic conditions and nutritional problems
  • Identifying feeding disabilities as related to certain diagnoses and discussing appropriate interventions and rehabilitation.
• Nutrition and aging go hand in hand.
• How the body is nourished will affects the way one ages.
• The right nutrition pattern plays a role in health promotion, wellness, disease prevention and rehabilitation.
• Nutrition is vital in all phases of the lifecycle growth, development), maintenance, and recuperation.
• Nutrients sustain metabolism of cells, tissues, and systems to maintain equilibrium:
  • There are 50 nutritional compounds/elements that are proper for cellular functioning
  • If even one is deficient/excessive, these sequences are disrupted, can lead to disease/death.
• Calories need to decreased as you age for elderly but still needing nutrients in body:
  • It’s a challenge to have nutrients for a healthy diet and not over eat to cause excessive weight gain.
• Several age-related changes can affect the digestive tract/taste/smell senses.
  • Decline in taste and smell, decreased saliva, atrophy of taste buds, decreased motility of esophagus and intestines.

Causes of Poor Appetite in the Elderly

• Poor dental health affecting ability to chew or difficulty with dentures
• Loneliness- lack of desire to prepare food and eat by oneself
• Change in taste- Food taste bland.
• Drug interaction or side effects- feeling nauseous, bloated, full.
• Decreased saliva, causing chewing and swallowing difficulty.
• Diseases of digestion i.e., indigestion, GERD, IBS- may cause discomfort.
• Mental confusion.
• Decreased sense of sense.
• Nutritional frailty, a disability that occurs in old age with loss of body and muscle, and low BMR
• Reduced levels of activity means fewer nutrients absorbed

Nutritional Needs in the Elderly

• A balanced diet including protein, carb, fat, vitamin and minerals is important to maintain health.
• Proteins contain abt 4 calories per gram.
  • Adequate intake of protein crucial for maintaining muscle and organ mass, and promote healing and fighting infections.
• Glycogen is a carbohydrate that is important in cell functions:
  • Protection from stress fractures, regulation of cell growth and division, abt. 4 calories per gram, crucial carbohydrate.
• Fats have about 9 calories per gram.
  • It ensures the body has essential fatty acid and fat-soluble vitamins and metabolism.
• Water needs should be 1.5-2.0 liters.
  • lack of this intake will increase the risk of dehydration.
• conditions like Alzheimer's disease, CVA and diabetes may have diff. conditions that can cause the pt to have difficulties.
• Tables to consider:
  • Table 6-1 for changes and nutritional considerations in the systems.
  • Refer to table 6-2 for chronic conditions.
  • Refer to table 6-3 physical manifestation of malnutrition on (pg. 126)
  • Refer to table 6-4 for review of malnutrition signs (pg. 133)

Nutritional Intervention and Programs

• The PTA is a part of the feeding team in home care, hospitals, and clinics.
• To monitor pt. in this team along with dietitian, nurse, pharmacist, ot, social worker, pt, etc..
• This team will evaluate for:
  • feeding issues (oral-motor, positioning, if they don’t feed themselves)
  • nutrition assessment (BMI, clinical malnutrition)
• Occupational therapist and PT check swallowing with team:
  • May consult each other.

Rehabilitation Management of Specific Feeding Problems

• Occupational therapist and PT check swallowing with feeding assessment with team (Refer to Table 6-6)
• Assessment to consider:
  • Oral motor dysfunction.
  • UE use
  • Eye-hand coordination/apraxia
  • Adaptive environment
  • Positioning
  • Dietary considerations
  • Perceptual and cognitive impairment
• PT will be involved in evaluating trunk and head Control and sitting ability
• Oral motor exercise tests facial muscle
• Ability to test if handling excretions
• Look if doing breathing exercises.
• Will work on wheelchair to bed positions
• -If Pt is well positioned PT will help gravity keep food in mouth for Pt when swallowing.
• Patients will need to use adaptive feeding equipment and will be trained on it if one handed and etc. (refer to Box 6-1, pg. 138).
• Management of Swallowing disorders (refer to Box 6-2, pg. 139)
• PTA NEED TO KNOW IF Pt has swallowing/ feeding issues like NPO.

Common Pathologies in the Elderly

• Bottomley's Chapter 4 is adapted for pathologies.
• Learning Objectives:
  • To identify common pathologies, symptoms of depression, differences of confusion, delirium and dementia and how to manage these conditions

Common Elder Pathologies

• Musculoskeletal:
  • Arthritis
  • Degenerative Disc Disease
  • Osteoporosis
  • Myopathy Cardiovascular:
  • HTN
  • CHF
  • Atherosclerosis and CAD
  • Arythmia or conduction system
  • Valve disease and PVD
• CAD
  • Aspirin to prevent aggregation of platelets
  • Beta and channel blockers to lower heart muscle/function
  • Nitroglycerin to dilate arterial function
• CAD intervention:
  • Exercising the muscles to build oxygen take and blood flow
  • Use of respiratory muscles
  • Surgical obstruction removal
• Pulmonary diseases*:
  • such as bacterial disease more cause for elder like confusion.
• Neurological disease*
  • CVA with aneurism and parkinson's disease
  • Alzheimer's disease or
  • General dementias and depression
• Endocrine disease*
  • With either hypo Or hyperthyroidism
  • And diabetes diseases such Cataracts disease
• Elder has vision disease*
  • Glaucoma

Depression in the Aged

• Depression "common cold" of elderly. Not caused by aging but circumstantial because of life variables like lost loved ones, retirement and incontinence and just chronic disease and disabilities. Often goes undiagnosed. Patients may say "I don't feel anything".
• PTA's role will daily interact with a Pt to check for anything.
• PTA SHOULD KEEP PT MOTIVATED! and report to lead therapy so they can evaluate.
• Symptoms* are but not limited:
  • low self esteem and just poor concentration with stress.
  • The somatic systems will have fatigue to weight gain or loss
  • Affective systems will have sadness and fear.

Confusion and Delirium in the Elderly

• Complex for PTA because they're similar disorders like dementia, and confusion.
• 2/3 Cognitive disorders can make up a huge reason people go to a nursing home!
• Manifestation include:*
  • Confusion restless and agitation and will not be able to have an attention span
  • they can reverse sleep cycle and be delusional or halluncatinate.

General Confusion and Delirium

• is pathological brain problems from toxin or metabolic imbalances. can get correction with a good prognosis
• It needs identified to stop cognitive issues due to chronic forms such Alzheimer's
• To avoid toxic and harmful chemicals with medications. (see list)

Dementias

• characterized by a slow onset loss of intelligence
• loss including*:
  • memory
  • disorientation
  • social skills and behavior -depression is often associated. behavior can be aggressive.
• It could be reversible*. Can affect the patient a lot: high blood pressure, or Huntington with tremors.
• • Alzheimer's Disease: **
• The early stages of Alzheimer's disease usually begin with a loss of short-term or recent memory. Loss of short-term or recent memory, cannot remember turn of stove, pick up kids from school,
• *Progresses to: **
• Getting lost, forgetting simple tasks,
• Alzheimer's Disease has* is a common dementia with brain damage for dementia disorders.
• *Vascular dementia **is a bleeding to brain (can be corrected to fix) Vitamin B12 and can treat these forms too. Intervention and Management:
  • Will alter environment but augment ADL will need emotional support.

To manage dementias:

• Stop the person from anxiety fear and disorientation
• Managing with* stay away of reach and if can't follow direction can be harmful they them to be in safe environment
• Alzheimer's- PT with Med*
• USE THEM*. Techniques:
• sensory integration
• and gait and transfer training
• or use modification but also balance (for tone)
• Alzheimer's- PT with Med*:
  • to increase cognitive function
• Use cholinesterase inhibitors( slows functioning ex donzepizil) Or tranquiler and to control agitation
• Supplements-
• ginkgo biloba- helps with cognitive function and memory
• Music and vitamins B12 can slow function to help.

Sundowner's Syndrome:

- Will be tired with fatigue and not want to be productive.
- Modify therapy for comfort!
- A renal disease high mortality in older Pt and from injury too.

• Acute cessation with high BP
• dialysis treatment if needed
• Monitor their heart!

Theories of Aging

• Chapter 2 in Bottomley covers Aging. Learning objectives:
  • To discover theories of aging and universal theory can accepted and to classify schools thought on theories
• Development genetic theories " wear and tear"
• Every cell in body is due to abuse or other issues tissue or decrease with environmental change.
• Sell age is in cell and deteriation is independent of enviro with other factors.
• Stochastic - random aging with environmental insults or toxins