Geriatric Rehabilitation Lecture PDF

TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATIO...

TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ○​ Muscle loss with fat loss LINKS AND REFERENCES ​ Biglaang pagpayat LINKS: Hyperlink and label accordingly. E.g. Lec Pt. 1 ​ Sarcopenia: loss of muscle mass & strength, increase ​ Add link to PPT/PDF slides here in fat mass, and abdominal girth ​ Add link to recorded lecture here ○​ Loss of muscle only ​ Add links to other references (books, other transes, etc.) ​ Can be seen in older people ​ does not have fat loss LESSON OUTLINE BONE: I.​ Body Changes in Aging ​ Insufficient load-bearing → demineralization II.​ Conditions and Diseases in the Elderly ○​ Not bearing weight that much, i.e. not walking or III.​ Management Issues carrying that much ​ Nawawala yung stress sa buto ​ Our bones need stress since it stimulates bone GERIATRIC REHABILITATION growth ​ Produces cells that are needed for growth ​ Global average life expectancy at 60 years: 20 years ​ Without stress in bones and joints → ↑ of ○​ Depends on the location; slightly lower in the PH osteoclastic activity (kinakain yung buto) ​ Biology and neurobiology of aging ​ Affected by changes in endocrine system, more ​ 65-75 years: significant in women after menopause ○​ aka “old geriatric population” ○​ Women’s hormones have an effect on activity of ​ >85 years: calcium & phosphorus​ ○​ aka “oldest old” ​ Increased osteoclastic activity possibly d/t Vit. D ​ >90 years: nonagenarian deficiency = osteopenia/osteoporosis ○​ nona: 90 ○​ Vit. D = Cholecalciferol ​ Octogenarian - 80s ​ Helps with absorption of calcium in the ​ Centenarian - 100s intestines ​ Increase in the number of people who are aging ​ Produced by our own body under the sun ○​ more people who are experiencing the symptoms ​ Bedridden pts are given Vitamin D to help with ○​ ↑ population = ↑ people with Sx absorption of nutrients BODY CHANGES IN AGING NEUROLOGIC ​ Musculoskeletal ​ Decreased brain volume, frontal gray matter loss, ​ Neurologic decreased cerebral blood flow ​ Cardiovascular ○​ Frontal gray matter: cognitive functions ​ Pulmonary ​ Cortical thinning ​ Gastrointestinal ○​ Cortex = higher function ​ Genitourinary ​ Cognitive changes i.e. dementia ​ Endocrine ○​ Dementia ​ Medication Metabolism ​ Alzheimer’s: decline in episodic memory ​ Gait ​ Syndrome; there's different types of dementia like Alzheimer’s disease MUSCULOSKELETAL ​ Decline in episodic memory ○​ recalling the events that happened MUSCLE: ○​ “Lolo, what happened this morning? What did you ​ Loss of muscle fibers, decreased fiber size and eat, where did you go?” → doesn’t remember quality resulting to loss of force per unit area ​ Decline in vision due to retinal aging ​ Disproportionate loss of type II fibers (fast twitch) ○​ Aging or paghina of the retina ○​ Decline of type 2 fibers ​ Lens aging may lead to cataracts ​ Loss of motor units ○​ Lumalabo mata ○​ Motor unit - part where the motor neuron meets the ​ Age-related hearing loss (AHL) muscle ○​ Intrinsic: genetics, cochlear aging ○​ Decline in the ability of the muscle to generate force ​ Higher disposition ​ Cachexia: attributable to an underlying disease; loss of ○​ Extrinsic: noise exposure, ototoxic drugs both muscle and fat mass ​ Medications that affect our hearing sensory organs 1 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ​ Factors that we can avoid to reduce the ​ Compressive stockings can be worn by the chances of AHL patient to facilitate in venous return which will ​ Olfaction, light touch sensation, vibration, proprioception lessen the chances of hypotensive episodes ○​ Sense of smell is lost ​ Will also have loss of taste since its associated PULMONARY with sense of smell ​ What would you do ​ Impaired pulmonary gas exchange and V/Q mismatch ​ Loss of elastic recoil and lung stiffening CARDIOVASCULAR ○​ Will relax then come back ​ Increased lung compliance and decreased thoracic wall ​ MHR decreases 6-10 bpm / decade after age 25 years mobility ​ VO2max decreases 5-15% / decade after age 25 years ​ Decreased strength of respiratory muscles ○​ VO2max is the maximum oxygen consumption ○​ Diaphragm, accessory muscles ○​ ↑ VO2max = ↑ endurance ​ Leads to increase in Residual Volume and Functional ○​ ↓ VO2max = ↓ endurance → ↑ fatigue Residual Capacity ​ Decreased arterial compliance ○​ Residual capacity is the air thats left thats not part ○​ Arteries are not complying since they're more stiff of the gas exchange → increase in BP ○​ BP diameter to BP GASTROINTESTINAL ​ Blood vessel has blood flowing inside → increased the blood flow → accommodation of blood vessels → BP is the pressure exerted by ​ Decreased appetite and energy intake → malnutrition the blood to the blood vessel ​ Smell and taste sensation may decrease → loss of ​ Rush of blood into the blood vessel = blood enjoyment from eating vessels dilate to accommodate which avoids ↑ ○​ Doesn't appreciate or enjoy eating since wala nang BP gana ​ If the arteries don't accommodate in older pts, ​ Decreased gastric compliance → early satiety and there's increase in BP prolonged postprandial satiety ​ Increased SBP ○​ Decreased ability of the stomach to expand ○​ d/t loss of patency of arteries resulting in increased ○​ Early satiety: gets full fast pressure in the arteries ○​ Postprandial: fullness after eating ​ Left ventricular hypertrophy with impaired filing ​ Hypochlorhydria - decreased production of stomach ​ Decreased beta-adrenergic receptor stimulation acid response ○​ Can lead to bacterial overgrowth in small intestine ​ Decrease SA node automaticity (SI) ○​ SA node: can produce its own action potential to ​ There is a normal gut microbiome in the mouth, stimulate the heart stomach, and intestines ○​ Predicts 60 beats per minute ​ When there is an imbalance/overgrowth in this ○​ If it's not easy to excite the heart since microbiome, this will result in different kinds of beta-adrenergic is decreased (which is for fight and diseases dt overgrowth flight response) ○​ Impaired absorption of vit. B12, calcium, iron, zinc, ​ Decreased myocytes folic acid ○​ Muscle weakness ​ Increase in cholecystokinin and leptin - suppresses ​ Exercise-induced adaptations are not as available to appetite elderly ○​ Hormones normally secreted in the GI that has an ​ Decreased sensitivity to catecholamines & impaired effect on appetite vasoconstrictive responses ○​ Will be commonly seen GENITOURINARY ○​ Impaired vasoconstrictive responses: seen in the LE ​ Decrease in renal mass ​ LE vessels need to contract continuously for ○​ There is a level of concentration in the tissue that venous return for the blood to circulate back to should be maintained the heart ​ Whether the fluid should be absorbed or ​ When the venous return is impaired & there is retained less blood pumping back to the heart, this results to hypotension 2 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ​ Decrease RBF → decrease in GFR (glomerular filtration ​ The half life is from the time from the point rate) where it goes from 100mg to 50mg ​ Impaired water balance → water loss ​ Decreased total body water → decreased volume of ​ Urinary incontinence distribution of water-soluble ○​ Konting gulat lang, naiihi na ○​ Since the hydration is low, you would expect ○​ Other elderly wear diapers decrease volume of water > more concentrated drugs > more potency and adverse effects of drug ​ Hepatic drug clearance decreased up to 30% ENDOCRINE ○​ Stays in the body longer ​ Renal clearance decreased up to 50% ​ Reduced hormone secretion and tissue responsiveness ○​ Longer duration of drug in the body ​ Decreased testosterone, hGH, insulin-like growth factor ○​ We should be aware of what drugs we give them (anabolic hormones) → impaired muscle fiber protein and the side effects synthesis ○​ Insulin like - all anabolic hormones ​ To produce other cells GAIT ○​ impaired muscle fiber protein synthesis if decreased function of the hormones -> decreased protein ​ Decreased speed, increased double limb support, ○​ Can lead to sarcopenia shorter stride length ​ Decreased glucose tolerance ○​ Increased double limb support - both feet at floor ○​ Cannot reabsorb glucose ​ Affected by vision, cognition, motor control, balance, ​ Decreased estrogen → collagen loss & thinning of skin peripheral sensation, strength, joint health, and ○​ Bone loss → osteopenia & osteoporosis metabolic demands ​ E.g. in menopausal women ○​ Sensation of joints, movement, and position sense ○​ Lead to changes in skin ​ Gait speed: predictor of survival, possibly a biomarker of health status in older adults ○​ If able to walk faster > more chances of survival SKIN ​ If slower than normal > poor prognosis ​ More precautions e.g. fall precautions ​ Caused by normal aging and environmental factors since more likely to have fall incidents ​ Thinning of epidermis​ ​ Indicators of gait speed: 6-minute walk test ​ Decreased cell replacement (6MWT), etc. ​ Impaired immune response and wound healing ​ 1.0 m/sec relatively good function ​ Decreased moisture content, elasticity, blood supply, ​ 0.8m/sec predicting median life expectancy for age & sensory sensitivity sex ○​ More prone to wounds ○​ Median life: middle of their life ​ Increased risk of skin disorders and injury ○​ because of these physiologic changes in geriatric patients CONDITIONS & DISEASES IN THE ELDERLY ○​ more prone to injury FRAILTY MEDICATION METABOLISM ​ Age and disease-related loss of adaptation, such that ​ Reaction to drugs not always the same as in younger events of previously minor stress result in age groups disproportionate biomedical and social consequences ​ Adverse effects more frequent and may be more severe ​ Clinical Syndrome (should have 3 or more of the ff): ​ Increased adipose tissue causes larger volume of ○​ Unintentional weight loss of at least 10 lb over the distribution for fat-soluble drugs → prolonged biologic past year half-life ○​ Self-reported-exhaustion ○​ More diffused in the body → more fat stored in the ○​ Weakness (grip strength) body ○​ Slow walking speed ○​ Half-life of medications: e.g. 100mg drug > ○​ Low physical activity intestines > liver > kidneys > filtered and broken ​ Physical activity diary - one way to assess pt’s down physical activity ​ Lower and lower as they pass through liver and ​ Can be attributable to aging, diseases, and comorbidity kidneys until it becomes half ​ Category of patients at risk for adverse outcomes 3 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ○​ Give pts extra attention to avoid risks of falls & ​ Loss of loading > promote physical activity in hospitalizations these facilities DISUSE AND IMMOBILIZATION ​ Exacerbates decline in body systems ​ Combination of inactivity and lack of mechanical loading lead to negative effects of bed rest ○​ Nasa kama lang > more effects to the body ○​ Encourage them to perform more physical activity and walking ​ Increase their motivation ​ Loss of muscle mass RECOMMENDATION FOR FALL AND INJURY ​ Loss of strength and power PREVENTION IN THE ELDERLY ​ Increased muscle insulin resistance ​ Fall risk assessment by qualified healthcare ​ Increased bone loss professionals or teams ​ Decreased pulmonary function and exercise capacity ​ Individualized, group, and home-based exercise ​ Orthostatic Hypotension (OH) ​ Balance, strength, & gait training exercise (e.g tai chi) ○​ Inability of blood vessels to adapt ○​ Pwede mag tai chi ○​ Low venous return ​ Home safety evaluations and modifications ​ Impaired balance and coordination ○​ ​ Increased risk for pressure ulcers ​ Medication review and reduction program with family ○​ Contributes in physiologic changes to skin, physician & patient involvement incontinence (pt pees in bed, or has diapers) > ○​ To review the medications since higher chances for maceration of skin falls ○​ Low nutrition can contribute to pressure ulcers ○​ What medications are possible to be withdrawn ​ Immobility from bed rest, predictor of decline in ADLs, ​ Careful, medically directed tapering of high-risk institutionalization & death in hospitalized older patients medications ​ The body signals if Ito yung kaya lang natin; but the ○​ E.g. there's drugs that affect the neurology of the pt body has more reserves eg. respiratory and cardiac which affects the balance reserves; as you age, there's lower physiological ​ Changes in BP and other factors which capacity is lower predispose pts to falls ○​ (?) Increase until it reaches the border of the ​ Addressing foot/ankle pain and dysfunction physiologic reserve > more tired ​ Treating vitamin D deficiency (at least 700 international units per day) FALLS ​ Cataract surgery and dual chamber cardiac pacing if indicated. ○​ Visual impairments ​ Major cause of morbidity ○​ Energy management techniques ​ Cause of majority of fractures of the forearm, pelvis, hip, ​ Recommend ADs pelvis ​ Criteria for falls ​ Fx, increase the risk of placement in skilled nursing ○​ Berg-balance scale facility ○​ How to identify high risk for falls ○​ More tendency to have fracture ​ Risk factors for falls in the elderly ○​ Age OSTEOARTHRITIS ○​ Physical impairments ○​ Cognitive impairment, dementia, depression ​ Common among older adults ○​ Previous falls ​ Most common affected: hands and knees ○​ Medications ​ Hips & spine significant source of pain & disability ​ More medications that the pt is taking ​ Disc desiccation can lead to spinal stenosis which can ○​ Comorbid conditions cause nerve root impingement ○​ Chronic pain & arthritis ○​ Loss of fluid (numinipis yung disc) > Narrowing and ○​ Poor functional status stenosis of joint > smaller space between vertebral ​ If you see this in pts, there's high falls body > nerve root impingement precaution 4 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ​ Risk factors: obesity, genetics, inadequate nutritional content, muscle strength TRAUMATIC BRAIN INJURY OSTEOPENIA AND OSTEOPOROSIS ​ >75 y/o, highest incidence of hospitalizations and death d/t TBI ​ Low bone density ​ Attributable to falls > motor vehicle collisions ​ More common in postmenopausal women ​ Poorer outcomes assoc. with increasing age ○​ Doesn’t mean men will not get ○​ Implications: as pt gets older, avoid falls to prevent osteoporosis/osteopenia TBI ​ Increased risk for fractures leading to pain, immobility, ​ Risk factors: physical and cognitive impairments and functional dependence ​ Having multiple medical conditions & medications ​ Osteopenia: bone mineral density score -01.0 and 2.5 ​ Osteoporosis: bone mineral density T score -2.5 or less SPINAL CORD INJURY ○​ Males may still have osteoporosis ​ Risk factors: increasing age, family hx, glucocorticoid therapy, smoking ​ Loss of bone mass and changes in body composition ○​ Familiarize with different glucocorticoid therapy, increase risk for SCI steroids ​ Traumatic SCI likely d/t falls ​ Aside from immunosuppressant, it prevents ​ Nontraumatic SCI attributable to cervical or lumbar from other inflammatory diseases spinal stenosis d/t degenerative joint processes disc ​ E.g. long term steroid use for Duchennes > herniation, or mass effect from hematoma or tumor water retentive, immunosuppressed (doesn't growth easily get fungal suppression), can easily get fx ○​ Spinal stenosis - degenerative dt long term GC use ​ First-year survival is good ​ Mortality rates increase dramatically with age HIP FRACTURES DEMENTIA ​ More common in older adult ​ Associated with increased mobility, mortality, and health ​ Group of symptoms that affect the patient’s daily care use and cost function ​ Result in long-term disability and increased functional ​ Executive cognitive dysfunction, memory impairment, dependence mood, personality, and behavior changes ○​ Not all elderly are recommended for hip arthroplasty ​ Reversible: caused by SDH, NPH, depression, hormonal ○​ They would have to live with that fracture for the imbalances, drug and alcohol abuse, vit Deficiency rest of their life ​ Irreversible: alzheimer’s, parkinson’s, huntington’s ​ Risk factors: falls, associated risks of falls, disease, AIDS, repeated neurovascular insults, severe osteoporosis, skeletal fragility or repetitive TBIs ​ Rehab should emphasize weight-bearing as soon as ○​ repeated neurovascular insults: E.g. repeated possible with goals of pain control & early loading while ischemic stroke or TBI avoiding fracture dislocation & implant failure ​ Early identification, critical ​ Mild cognitive impairment (MCI), clinically identifiable precursor to AD STROKE ​ Isn’t noticed immediately → onset starts years ahead ​ Leading cause of acute neurologic admissions to ○​ Hallmark of Alzheimer’s: plaques are seen in MRI – hospitals and death point of no return ​ Health outcomes are worse among older adults because ○​ Need to start early c increased physical activity (150 of age-related comorbiditiess and frailty mins of moderate physical activity and resistance ​ Rehab begins in the acute setting exercises) ○​ Can still be progressed ○​ early identification is critical ​ Strengthening, ROM, spasticity management, low-vision, cognitive, and urinary incontinence DELIRIUM interventions can be performed ​ Risk factors: previous stroke, transient ischemic attack (TIA), HtN, hyperlipidemia, heart disease, DM ​ Acute neurocognitive disorder 5 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ​ Transient, reversible ​ Premorbid function, more important predictor of ​ Occurs more commonly among elderly successful prosthetic rehab ​ Diagnostic criteria: ○​ If their physical condition is good prior to the ○​ Disturbance in attention and awareness that disease, indicates a more successful rehab develops over a short period of time and waxes and wanes during the course of the day CANCER ○​ Disturbances in cognition ○​ Disturbances in attention and cognition are not better explained by a pre-existing neurocognitive ​ More prevalent among those >65 y/o disorder ​ Prevalence increases with increasing elderly population ○​ Evidence that the disturbance is directly d/t a ​ Cancer treatment considerations: pathophysiologic process such as a medical ○​ Comorbidities and cognitive/functional status, condition or drug-related toxicity cancer type ​ Treatment is pharmacologic & should be referred back ​ Multiple comorbidities increase the likelihood of death d/t to MD non-cancer related causes ○​ One of the problems is the cardiotoxicity of the treatment for cancer NORMAL PRESSURE HYDROCEPHALUS ​ Effects of treatment may compete with the patient’s interest and wishes ​ Idiopathic or related to previous meningitis or ​ Moderate physical activity, 150 mins/week decreases subarachnoid (SA) hemorrhage total mortality risk by 24% among breast CA survivors & ​ Hallmark signs; dementia, gait disturbance, urinary 28% among colorectal CA survivors incontinence along with ventriculomegaly with normal ○​ Can the pt comply to the physical activity required CSF pressures ○​ Sometimes the family prevents pt from exercises ​ Ataxia ​ Skills in convincing and persuading ​ “Magnetic gait” as condition worsens ○​ Difficulty in amb that looks like their feet are being POLYPHARMACY magnetized to the floor ​ Use of multiple drugs PARKINSON DISEASE ○​ Effect is there's multiple reactions ○​ May side effects from various drugs ​ Progressive neurodegenerative disorder ​ Adverse drug reactions from multiple drug regimens ​ Ataxia, bradykinesia, tremor, cog-wheel rigidity ​ Common ADRs include dizziness, insomnia, confusion, ​ May have dementia sedation, nausea, changes in bowel habits, balance ​ Resting tremor increases with stress problems ​ Parkinsonian gait, can be festinating ○​ Hard to differentiate medication side effects from sx ​ Resistance training: positive effects of strength & of the pt’s disease function for mild to moderate PD ​ Medication side effects can be confused as symptoms of a new illness ​ “The prescribing cascade” AMPUTATION ○​ Increasing amount of drugs ​ Increase the risk for falls & delirium ​ Attributable to vascular disease ​ Life expectancy is shorter after amputation ​ Prognosis for successful prosthetic rehabilitation, MANAGEMENT ISSUES influenced by number and type of comorbidities ○​ More comorbidities, poorer prognosis ​ Medication management ​ Increased energy demands result in poor outcomes ○​ Give least amount of medications ​ Comorbid respiratory disease affect gait retraining ○​ Management through non-pharmacologic means as ​ End-Stage Renal Disease (ESRD) miss rehab much as possible schedules d/t dialysis commitments and frequently affect ​ Pain management limb volume ○​ Relieving pain for a specific function ○​ Limb size can change during dialysis ​ Nutrition ○​ Limb needs to be shaped for prosthesis prescription ○​ What would be the effects of malnutrition on → changes in limb size will lead to inaccurate physical activity and health prosthetic fit ​ Physical exercise 6 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML TERM 2 SHIFT 1​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3PTB PT10123: SPECIAL CONDITIONS LEC​ ​ ​ ​ ​ ​ ​ ​ UST CRS BSPT 2025 1.3 GERIATIC REHABILITATION Lecturer: Sir Jon Timothy Rivero, PTRP ○​ Moderate physical activity (150 mins a week) ​ Ambulatory assistive devices ​ Orthoses & footwear ​ Psychosocial support ​ Modifying the environment ○​ E.g. Are their floors slippery, how high or low their bed is ACTIVITY RECOMMENDATIONS IN OLDER ADULTS WITH NO LIMITATIONS ​ Moderate-intensity aerobic activity: enough to result in noticeably increased heart rate and breathing for at least 30 minutes 5 days a week. ​ Resistance training (calisthenics, weight training): at least one set of 10 to 15 reps of an exercise that trains the major muscle groups on 2 or 3 nonconsecutive days each week ​ Flexibility: at least 10 mins of stretching major muscle & tendon groups at least 2 days each week; 10-30 seconds of static stretches and three to four repetitions for each stretch. Ideally performed very day that aerobic & resistance training is performed ​ (Possibly) Balance exercise three times a week (ideal type, frequency, and duration has not been defined.) Reference: Braddom’s Physical Medicine and Rehabilitation, 5th ed. Chap 7 | PT10123 | KAHL, CAV, BM, ALN, AA, JAR, JRM, DML