Geriatric PT - Lecture Notes PDF

Geriatric PT  OBJECTIVES Upon completion of this lecture , the student will be able to understand about : Aging Gerontology Geriatrics Life span Life expectancy Senescence Categories of elderly Ageism Implications of an aging population for rehabilitation...

Geriatric PT  OBJECTIVES Upon completion of this lecture , the student will be able to understand about : Aging Gerontology Geriatrics Life span Life expectancy Senescence Categories of elderly Ageism Implications of an aging population for rehabilitation Demography in the elderly Mortality in the elderly Morbidity in the elderly  Aging The process of growing old Describes a wide array of physiological changes in the body systems: Complex and variable. a. Common to all members of a given species. b. Progressive with time. c. Evidenced by: (1) Decline in homeostatic efficiency. (2) Increasing probability that reaction to injury will not be successful. ( increase probability of injury) d. Varies among and within individuals  Gerontology The scientific study of the factors impacting the normal aging process and the effects of aging. Geriatrics The branch of medicine concerned with the illnesses of old age and their care.  Life span Maximum survival potential, the inherent natural life of the species; in humans 110-120 years. Life expectancy The number of years of life expectation from year of birth, 75.8 years in U.S.women live 6.6 years longer than men.  Senescence Last stages of adulthood through death. Categories of elderly a. Young elderly: ages 65-74 (60% of elderly population). b. Old elderly: ages 75-84. c. Old, old elderly or old & frail elderly: ages> 85.  Ageism The discrimination and prejudice leveled against individuals on the basis of their age.  Causes of Death The most common leading causes of death (mortality) in persons over 65, in order of frequency.  Coronary heart disease (CHD), accounts for 31% of deaths. Cancer, accounts for 20% of deaths. Cerebrovascular disease (stroke).  Chronic obstructive pulmonary disease (COPD). Pneumonia/flu. CAUSES OF DISABILITY/CHRONIC CONDITIONS Leading causes of disability/chronic conditions (morbidity) in persons over 65, in order of frequency a. Arthritis, 49%. b. Hypertension, 37%. c. Hearing impairments, 32%. d. Heart impairments, 30%. e. Cataracts and chronic sinusitis, 17% each. f. Orthopedic impairments, 16%. g. Diabetes and visual impairments, 9% each. Most older persons (60-80%) report having one or more chronic conditions. AGING THEORIES  Aging change a- Cellular changes. (1) Increase in size; old cell two or three times larger than young cells. there is an increase in pigments and fatty substances inside the cell (lipids). (2) Fragmentation of Golgi apparatus and mitochondria. (3) Decrease in cell capacity to divide and reproduce. (4) Arrest of DNA synthesis and cell division  Group of similar cells→ form the tissue. The tissues→ form organ. The organs→ form system. The systems →form human body. Golgi apparatus major function is the modifying, sorting,D‫ فرز‬and packaging of protein and fat are synthesized by the cell for secretion (like as post office). Mitochondria is which generate large quantities of energy in form of ATP. DNA Deoxyribonucleic acid‫الحمض النووي‬  b-Tissue changes (1) Accumulation of pigmented materials. (2) Accumulation of lipids and fats. (3) Connective tissue changes: Decreased elastic content Degradation of collagen Presence of pseudoelastins  Connective tissue changes, becoming more stiff. This makes the organs, blood vessels, and airways more rigid. Pigmented granules (lipofucin) is yellow- brown composed of lipid containing residues of lysosomal ( lysosome digest materials taken into the cell within an active hydrolytic enzyme). It is considered one of the aging or "wear-and-tear“. Pigments, found in the liver, kidney, heart muscle, and ganglion cell. C- Organ changes (I) Decrease in functional capacity. (2) Decrease in homeostatic efficiency  Biological theories Genetic Aging is intrinsic to the organism Genes are programmed to modulate aging changes overall rate of progression. Genetic Theory of Aging. The genetic theory of aging states that lifespan is largely determined by the genes we inherit. According to the theory, our longevity is primarily determined at the moment of conception and is largely reliant on our parents and their gene. (1) Individuals vary in the expression of aging changes, e.g., graying of hair, wrinkles, etc. (2) Polygenic controls exist (multiple genes are involved): no one gene can modulate rate of development in all aspects of aging.  Your life could be under the influence of your genes, new research says. Genes play a greater role in traits as self-control, decision making, or sociability than previously thought. (3)Premature aging syndromes (progeria) provide evidence of defective genetic programming individuals exhibit premature aging changes, i.e. Atrophy Thinning of tissues Graying of hair Arteriosclerosis (a) Hutchinson-Gilford syndrome: progeria of childhood. (b) Werner's syndrome: progeria of young adults  Apoptosis is a form of programmed cell death, or “cellular suicide.” It is different from necrosis, in which cells die due to injury. Apoptosis plays a important role in developing and maintaining the health of the body by eliminating old cells, unnecessary cells, and unhealthy cells” by immune cells.”  Biological theories Free radical theory: (oxidative stress theory) Free radicals are highly reactive and toxic forms of oxygen produced by cell mitochondria, as superoxide anion (O2-) and hydroxyl radical (OH) Free radical is an atom or molecule that has a single unpaired electron in an atomic orbital, unstable and highly reactive. caused damage to cell proteins, lipid and DNA, RNA. Cigarette smoking and pollution increase the generation of free radicals in the body.  Antioxidants Antioxidants are substances that can prevent or slow damage to cells caused by free radicals, unstable molecules that the body produces as a reaction to environmental and other pressures. They are sometimes called “free-radical scavengers.” The sources of antioxidants can be natural or artificial. ( medications)  Biological theories Hormonal theory Functional decrements (decrease) in neurons and their associated hormones lead to aging changes. Hypothalamus, pituitary gland, thyroid, adrenal gland are the primary regulators, timekeepers of aging. Thyroxine is the master hormone of the body. controls rate of protein synthesis and metabolism  Hypothalamus linked between nervous and endocrine system located between pituitary gland and thalamus. Keep body homeostasis (temperature, thirst, appetite, weight control, emotions, sleep, blood pressure, heart rate, fluid balance) ex: anti diuretic hormone. Hypothalamus control pituitary gland, and pituitary is a master gland.  The main function of the thalamus is to relay motor and sensory signals to the cerebral cortex Pituitary gland → (growth hormone, thyroid stimulated hormones TSH). Thyroid gland → T4 (Thyroxin), T3 (triiodothyronine). Adrenal gland, → adrenaline, and aldosterone. Hormonal Changes (1) Secretion of regulatory pituitary hormones (TSH) influence thyroid. (2) Decreases in protective hormones: estrogen, growth hormone. Estrogen and progesterone protect from osteoporosis and Alzheimer …. (3) Increases in stress hormones (cortisol): can Damage brain's memory center,( limbic system) and the hippocampus leading to alzheimer. Destroy immune cells Stress hormones (cortisol) secreted from pituitary gland in response to stress.  During stress situation hypothalamus give alarm to adrenal and pituitary gland increasing adrenaline and cortisol which increase blood sugar and (HR, BP).  Repeated stress leading to increase insulin resistance (DM, and hypertension). REGULAR PHYSICAL EXERCISE decrease cortisol level, increase self confidence.  Relaxation techniques stimulate vagus nerve to decrease (HR, BP).  Biological theories Immunity theory 1. Thymus gland is the main organ of lymphatic system located in the upper chest promote the development of cells of the immune system T- Cells and B-cells. 2. Bone marrow that makes blood forming (blood stem cell). These cells turn into blood cells→ White blood cells to fight infection.  Red blood cells to carry oxygen.  Platelets control bleeding. N.B → Bone marrow transplantation for treating leukemia. N.B →PRP (platelet rich plasma) for treatment of OA, intra-articular injection strain, sprain, sport injury. Immunity theory Thymus size decreases Becomes less functional Bone marrow cell efficiency decreases Results in steady decrease in immune responses during adulthood (1)Immune cells T-cells, become less able to fight foreign organisms B-cells become less able to make antibodies. (2) Autoimmune diseases increased with age  Environmental theories Aging is caused by an accumulation of insults from the environment. b. Environmental toxins include: Ultraviolet, Crosslinking agents (unsaturated fats) Chemicals (metal ions, Mg, Zn) Radiation Viruses c. Can result in errors in protein synthesis and in DNA synthesis/genetic sequences (error theory), cross-linkage of molecules, mutations‫ طفرة‬.  Cross-linkage disorders increase possibility of binding glucose and protein under presence of oxygen (senile cataract, appearance of tough (hard) yellow skin). D Diabetic persons Alteration of chemical and biological properties of the cell (loss of elasticity of skin and muscle tissue, stiffening of blood vessel, change of lens of eye, delayed wound healing, and reduce joint mobility.  Sociological theories Life experience/lifestyles influence aging process Activity theory: Older persons who are socially active exhibit improved adjustment to the aging process Allows continued role essential for positive self- image and improved life satisfaction. Healthy life style ( healthy diet, regular physical activities )→→ ↓↓ aging  An integrated model of aging assumes aging is A complex, multifactorial phenomenon Some or all of the above processes may contribute to the overall aging of an individual Which one of aging theories is adequately explained aging? Aging is not adequately explained by any single theory received_715081468961504.mp4 Age related changes on muscular and skeletal system  OBJECTIVES Upon completion of this lecture , the student will be able to the know about the Age related changes on muscular and skeletal system Clinical implications Interventions to slow or reverse the changes Why changes in typeII fibres are more ?  Muscular Changes Age-related changes. a. Changes may be due more to decreased activity levels mobility (hypokinesis) and disuse than from aging process. b. Loss of muscle strength: peaks muscle strength at age 30, remains fairly constant until age 50. After which there is an accelerating loss, 20-40% loss by age 65 in the non-exercising adult. c. Loss of power (force/unit time): significant declines, due to losses in speed of contraction, changes in nerve conduction and synaptic transmission.  Power = force (Newton) /unit time (Second) (N.S) -----------{ one Newton is the force needed to accelerate one kilogram of mass at one meter per second in the direction of applied force}. Strength is ability to overcome resistance Power is ability to overcome resistance in he shortest period of time (speed). d. Loss of skeletal muscle mass (atrophy): both size and number of muscle fibers decrease,. By age 70 lose 33% of skeletal muscle mass. e. Changes in muscle fiber composition: selective loss of Type II, fast twitch fibers, with increase in proportion of Type I fibers. f. Changes in muscular endurance: muscles fatigue more readily. (1) Decreased muscle tissue oxidative capacity. (2) Decreased peripheral blood flow, oxygen delivery to muscles. (3) Altered chemical composition of muscle: decreased myosin ATPase activity, glycoproteins and contractile protein. (4) Collagen changes: denser, irregular due to cross-linkages, loss of water content and elasticity →→ affects tendons, bone, cartilage. binding glucose and protein under presence of oxygen  Type1 slow twitch muscle fiber help enable long endurance such as distance running contain many ↑↑capillaries, ↑↑mitochondria and ↑↑myoglobine, less ↓↓glycogen. Type2 fast twitch muscle fiber fatigue faster but are used in powerful bursts of movement like sprinting.  TypeIIA fast oxidative contain many ↑↑capillaries, ↑↑mitochondria and ↑↑ myoglobine, less ↓↓glycogen movement like sprinting. TypeIIB fast glycolytic contain less ↓↓capillaries, ↓↓mitochondria and ↓↓myoglobine, many ↑↑glycogen (storage of glucose in the liver, and the muscles). Glycogenisis the formation of glycogen, the primary carbohydrate stored in the liver and muscle cells of animals, from glucose.  Glycogenolysis is the breakdown of glycogen occurring in the liver when blood glucose levels drop. Carbohydrate sources by glucagon hormone gluconeogenesis is the synthesis of glucose from non-carbohydrate sources like lactic acid, glycerol, amino acids and occurs in liver and kidneys. During periods of fasting, overnight when sleeping. Glycolysis is a catabolic process of glucose hydrolysis needed for energy and biosynthetic intermediate. 2. Clinical implications. a. Movements become slower. b. Movements fatigue easier; increased complaints of fatigue. c. Connective tissue becomes denser and stiffer. (1) Increased risk of muscle strains, sprains ligaments, tendon tears. (2) Loss of range of motion: highly variable by joint and individual; activity level. (3) Increased tendency for fibrinous adhesions, contractures. Collagen changes d. Decreased functional mobility, limitations to movement. e. Gait changes. (1) Stiffer, fewer automatic movements. (2) Decreased amplitude and speed, slower Cadence‫ ايقاع‬. (3) Shorter steps, wider stride to increased double support to ensure safety, compensate for decreased balance. (4) Decreased trunk rotation, arm swing. (5) Gait may become unsteady due to changes in balance, strength; increased need for assistive devices. f. Clinical : increasing risk of falls. 3. Interventions to low or reverse changes. a. Improve health:- (1) Correction of medical problems that may cause weakness: hyperthyroidism, excess adrenocortical steroids (e.g., Cushing's disease, steroids); It causes physical problems like weight gain, high blood pressure, and diabetes. (2) Hyponatremia (low sodium in blood).  Hyperthyroidism ( weight loss, increase heart rate, and increase rate of bone loss by direct action thyroxin on ↑↑osteoclast and ↓↓osteoblast). The same as over treatment of hypothyroidism. Thyroid hormones play an important role in bone mineral homeostasis and bone density. Both hyperthyroidism and, to some extent, hypothyroidism are associated with reduced BMD leading to increased fracture risk. 2- Correction of hyponatremia. Causes of hyponatremia: chronic diarrhea, (heart failure, renal failure, liver failure)→…… increase water content. (b) Improve nutrition. Calcium and Vitamin D. Older adults need more calcium and vitamin D to help maintain bone health. Vitamin B12. Many people older than 50 do not get enough vitamin B12.... Fiber. Eat more fiber-rich foods. Potassium ( c) Increase levels of physical activity, stress functional activities and activity programs. (1) Gradual increase in intensity of activity to avoid injury. (2) Adequate warm ups and cool downs; appropriate pacing and rest periods. c. Provide strength training. (2) Significant increases in strength noted in older adults with isometric and progressive resistive exercise regimes. (2) High-intensity training programs (70-80% of one- repetition maximum) produce quicker and more predictable results than moderate intensity programs; both have been successfully used with the elderly. (3) Age not a limiting factor: significant improvements noted in frail, institutionalized 80 and 90 year-olds  One-repetition maximum is maximum amount of weight that person can lift for one repetition. Or maximum amount of force that can be generated in one maximal contraction. Ten repetition maximum is maximum amount of weight that person can lift for ten repetition High weight low rep (power). Low weight high rep (endurance).  Difference between delorme and oxford Delorme oxford 1st set of 50% of 10RM 1st set of 100% 10RM 2nd set of 75% of 10RM 2nd set of 75% 10RM 3rd set of 100% of 10RM 3rd set of 50% 10RM 3) Improvements in strength correlate to improved functional abilities. d) Provide flexibility, range of motion exercises. (1)Utilize slow, prolonged stretching, maintained for 20-30 seconds. (2) Tissues heated prior to stretching are more distensible, e.g., warm pool. (3) Maintain newly gained range: incorporate into functional activities  Skeletal System 1. Age-related changes. a. Cartilage changes: decreased water content, becomes stiffer, fragments and erodes; by age 60 more than 60% of adults have degenerative joint changes, cartilage abnormalities.(arthritic change) b. Loss of bone mass and density: peak bone mass at age 40; between 45 and 70 bone mass decreases (women by about 25%; men 15%); decreases another 5% by age 90. (1) Loss of calcium, bone strength: especially trabecular bone. (2) Formed of outer layers cortical bone and inner layers trabecular bone → honey comb like appearance. (3) Decreased bone marrow red blood cell production. c. Intervertebral discs: flatten, less resilient ‫اقل‬ ‫مرونة‬due to loss of water content (30% loss by age 65) and loss of collagen elasticity; trunk length, overall height decreases. d. Senile postural changes. (1) Forward head. (2) Kyphosis of thoracic spine. (3) Flattening of lumbar spine. (4) With prolonged sitting, tendency to develop hip and knee flexion contractures. 2. Clinical implications. a. Maintenance of weight-bearing is important for cartilaginous/joint health. b. Clinical risk of fractures. 3. Interventions to slow or reverse changes. a. Postural exercises: stress components of good posture. b. Weight bearing (gravity-loading) exercise can decrease bone loss in older adults. Clinical implications. a. Maintenance of weight-bearing is important for cartilaginous/joint e.g., walking and weight bearing exercise can increase load. c. Nutritional, hormonal and medical therapies: see discussion of osteoporosis  Walking, jogging, climbing stairs, playing tennis Resistance exercise as weigh lifting, elastic bands exercise and weigh machines. Posture exercise isomeric pulls work shoulders, arms, and back muscles giving the strength to maintain good posture. Exercise against the wall, press exercise.  Geriatrics Physical Therapy Neurological and cognitive changes OBJECTIVES Upon completion of this lecture , the student will be able to the know about the Age related changes on neurological and cognitive system Clinical implications Interventions to slow or reverse the changes a. Atrophy of nerve cells in cerebral cortex Brain weight 20 % from age (45-85). Normal weigh of he brain 3 pound (1,300 – 1.400 g) b. Changes in brain morphology. (1) Gyral atrophy: narrowing of gyri (folds or bumps), with widening of sulci.(the grooves on the surface of the brain) (2) Ventricular dilation due to loss of cells surrounding the ventricle. (the space in the brain that contain cerebrospinal fluid ) ↓  The ventricles of the brain are a communicating network of cavities filled with cerebrospinal fluid (CSF) and located within the brain parenchyma. The ventricular system is composed of 2 lateral ventricles, the third ventricle, the cerebral aqueduct, and the fourth ventricle. (3) Generalized cell loss in cerebral cortex:( frontal and temporal lobes) (4) Presence of lipofuscins, significant accumulations associated with pathology, e.g., Alzheimer's dementia. (lipofucin) is yellow-brown composed of lipid containing residues of lysosomal It is considered one of the aging or "wear-and-tear“. Pigments, found in the liver, kidney, heart muscle, and ganglion cell. (5) Selective cell loss in basalganglia, cerebellum, hippocampus. (6) Increases in stress hormones (cortisol): can Damage brain's memory center,( limbic system) and the hippocampus leading to alzheimer. During stress situation hypothalamus give alarm to adrenal and pituitary gland increasing adrenaline and cortisol which increase blood sugar and (HR, BP). c. Decreased cerebral blood flow and energy metabolism.(diabetes, hypertension, atherosclerosis) d. Changes in synaptic transmission. (1) Dec. synthesis and metabolism of major neurotransmitters, e.g., acetylcholine ,dopamine. (2) Slowing of many neural processes. E. Changes in spinal cord/peripheral nerves. (1) Neuronal loss and atrophy: 30-50% loss of AHC, 30% loss of posterior roots (sensory fibers) by age 90. (2) Loss of motor neurons results in increase in size of remaining motor units (development of macro motor units). (3) Slowed nerve conduction velocity: sensory >motor. (4) Loss of sympathetic fibers. A motor unit consists of a motor neuron and the.muscle fibers that it innervates Upper Motor Neuron. Which is the main source of voluntary movement. they are found in the brain and carry motor information down the spinal cord to activate the lower motor neurons which in turn.directly signal muscles to contract F. Age-related tremors (essential tremor). (1) Isolated symptom, particularly in hands, head and voice. (2) Characterized as postural or kinetic, rarely resting. (3) Benign, slowly progressive; in late stages may limit function. (4) Exaggerated by movement and emotion.  Tremor can be classified into: Resting tremor: (parkinsonism), Psychogenic {increase in stress in case of depression}, Dystonic {rhythmic involuntary movement}, Cerebellar {purposeful movement as trying to press a buttom}, }, fine movement  Aging Effects on movement INCREASED DECREASED 1-Reaction and movement 1- Speed and coordination time 2-Accuracy of fast 2-Errors in movement movements 3- Reliance (dependant) on 3- Recruitment of motor visual feedback for neurons movement 4-Change in movement. 4- cautionary (protective) 5-Movement capacity behaviors 5-Preparation for complicated movement e. Memory. (1) Decline in short term memory; long-term memory retained. (2) Impairments are task dependent, e.g., new learning. f. Learning: all age groups can learn; learning in older adults affected by: (I) Increased cautiousness.(prediction about the result of the courses))‫الخوف من النتيجة (الفشل‬ (2) Anxiety.(psychological states) (3) Pace of learning.( mode of learning)‫نوعية التعلم‬ (4) Interference from prior learning. ( previous learning)‫ثقافة المتلقي‬  2. Interventions to slow or reverse changes a. Correction of medical problems b. Improve health: diet, smoking cessation. c. Increase levels of physical activity. d. Provide effective strategies to improve motor learning and control. A. Improve health. (1) Correction of medical problems: imbalances between oxygen supply and demand to CNS, e.g., cardiovascular disease, hypertension, diabetes, hypothyroidism. (2) Pharmacological changes: drug re-evaluation; decreased use of multiple drugs; monitor closely for drug toxicity. (3) Reduction in chronic use of tobacco and alcohol. (4) Correction of nutritional deficiencies. (vit.B6, B-12 and anti oxidant vit. E and C). sea food, meat , green vegetables, fruit and eggs (5). Increase physical activity. (6). Increase mental activity.(new language, new courses) (a)Keep mentally engaged "Use it or Lose it e.g., chess, crossword puzzles, high level of reading. (b) Engaged lifestyle: socially active, e.g. clubs, travel, work. (7). Auditory processing (hearing loss) may be decreased: provide written instructions. a. Provide stimulating, "enriching" ‫مثرية‬ environment;(improve quality of life) (8). Reduction of stress: counseling‫ الحوار‬and family support.  Increase levels of physical activity, stress functional activities and activity programs. (1) Gradual increase in intensity of activity to avoid injury. (2) Adequate warm ups and cool downs; appropriate pacing and rest periods. c. Provide strength training. (2) Significant increases in strength noted in older adults with isometric and progressive resistive exercise regimes. (2) High-intensity training programs (70-80% of one- repetition maximum) produce quicker and more predictable results than moderate intensity programs; both have been successfully used with the elderly. (3) Age not a limiting factor: significant improvements noted in frail, institutionalized 80 and 90 year-olds Age related changes on sensory system  Vision a. Aging changes: There is a general decline in visual acuity gradual prior to sixth decade, rapid decline between ages 60 and 90 visual loss may be as much as 80% by age 90. (1) Presbyopia: ‫طول النظر‬visual loss in middle and older ages characterized by inability to focus properly and blurred images, due to loss of accommodation, elasticity of lens. (2) Decreased ability to adapt to dark and light. (3) Increased sensitivity to light and glare.  Vision (4) Loss of color discrimination, especially for blues and greens. (5) Decreased pupil responses, size of resting eye pupil increases. (6) Decreased sensitivity of corneal reflex: less sensitivity to eye injury or infection. (7) Oculomotor responses diminished: restricted upward gaze, reduced pursuit eye movements ptosis (dropping upper eye lid) may develop due to muscle weaknesses upward gaze (1) Cataracts: opacity, clouding of lens due to changes in lens proteins; results in gradual loss of vision: central first, then peripheral; increased problems with glare; general darkening of vision; loss of acuity, distortion‫تشويش‬.Cross-linkage disorders binding glucose and protein under presence of oxygen (2) Glaucoma: increased intraocular pressure, with degeneration of optic disc, atrophy of optic nerve; results in early loss of peripheral vision (tunnel vision), progressing to total blindness. (3) Senile macular degeneration: loss of central vision associated with age-related degeneration of the macula compromised by decreased blood supply or abnormal growth of blood vessels under the retina; Initially patients retain peripheral vision; may progress to total blindness. 4.Diabetic retinopathy: Damage to retinal capillaries, growth of abnormal blood vessels, damage of retinal capillaries, hemorrhage leads to retinal scarring and finally retinal detachment; central vision, impairment; complete blindness is rare. Clinical implications/compensatory strategies. (1) Examine vision: acuity, peripheral vision, light and dark adaptation, depth perception, eye fatigue, eye pain. (2) Maximize visual function: assess for use of glasses,( need for environmental adaptations). (3) Sensory threshold are increased: allow extra time for visual discrimination and response. (4) Work in adequate light, reduce glare; avoid abrupt changes in light, e.g., light to dark 5) Decreased peripheral vision may limit social interactions, physical function: Stand directly in front of patient at eye level when communicating with patient. (6) Assist in color discrimination: use warm colors (yellow, orange, red) for identification and color coding. (7) Provide other sensory cues when vision is limited: e.g., verbal descriptions to new environments, touching to communicate you are listening.(touch and hearing) (8) Provide safety education; reduce fall risk.  Hearing a. Aging changes: Occur as early as fourth decade; Affects a significant number of elderly (23% of individuals aged 65-74 have hearing impairments and 40% over age 75 have hearing loss; rate of loss in men is twice the rate of women, also starts earlier). (1) Outer ear: buildup of cerumen (ear wax) may result in conductive hearing loss; common in older men. (2) Middle ear: minimal degenerative changes of bony joints.  Hearing (3) Inner ear: Significant changes in sound sensitivity and understanding of speech. Maintenance of equilibrium may disturbed with degeneration and atrophy of cochlea and vestibular structures, loss of neurons. Cochlea is the sense organ the translate sound into nerve impulse to be sent to the brain(cochlear nerve), and filter the sound so you can hear and under stand speech even in very noisy rooms. Hearing (Structure of the ear)  The vestibular apparatus The vestibular apparatus, which in each ear includes the utricle, saccule, and three semicircular canals. The utricle and saccule detect gravity (information in a horizontal, and a vertical orientation respectively). The semicircular canals, which detect rotational movement, are located at right angles to each other and are filled with a fluid called endolymph.  The vestibular apparatus When the head rotates in the direction sensed by a particular canal, the endolymphatic fluid within it lags behind because of inertia, and exerts pressure against the canal’s sensory receptor. The receptor then sends impulses to the brain about movement from the specific canal that is stimulated. ( Vestibular nerve) When the vestibular organs on both sides of the head are functioning properly, they send symmetrical impulses to the brain.  Endolymph Endolymph is the fluid contained in the membranous labyrinth of the inner ear. The major companent in endolymph is potassium. High potassium content of the endolymph means that potassium, is carried as the de-polarizing electric current in the hair cells. It is mainly this electrical potential difference that allows potassium ions to flow into the hair cells during mechanical stimulation of the hair bundle.  The Resting Membrane Potential In neurons K+ and organic anions are typically found at a higher concentration within the cell than outside. Whereas Na+ and Cl- are typically found in higher concentrations outside the cell. This difference in concentrations provide a concentration gradient for ions to flow down when their channels are open.  During depolarisation voltage gated sodium ion channels open due to an electrical stimulus. As the sodium rushes back into the cell the positive sodium ions raise the charge inside the cell from negative to positive. The raised positive charge inside the cell causes potassium channels to open, K+ ions now move down their electrochemical gradient out of the cell. As the K+ moves out of the cell the membrane potential falls and starts to approach the resting potential.  Vestibular /balance control. Aging changes: Degenerative changes in utricle and saccule; Loss of vestibular hair-cell receptors; Decreased number of vestibular neurons; Vestibular ocular reflex (VOR) decreases; Decrease stability of retinal image leading to blurred vision. Begins at age 30, accelerating decline at ages 55- 60 resulting in diminished vestibular sensation.  Vestibulo-ocular reflex The vestibulo-ocular reflex (VOR) is a gaze stabilizing reflex: The sensory signals encoding head movements are transformed into motor commands that generate compensatory eye movements in the opposite direction of the head movement, thus ensuring stable vision. Vestibulo-ocular reflex 13_25 - YouTube.mkv  Vestibular /balance control 1) Diminished acuity, delayed reaction times, longer response times. (2) Reduced function of vestibular ocular reflex (VOR): Affects retinal image stability with head movements, produces blurred vision.  Vestibular /balance control b. Additional loss of vestibular sensitivity with pathology. (1) Meniere's disease: episodic attacks characterized by tinnitus, dizziness, and a sensation of fullness or pressure in the ears; may also experience sensorineural hearing loss. (2) Benign paroxysmal positional vertigo (BPPV): brief episodes of vertigo (less than1 minute) associated with position change of the head: the result of degeneration of the utricule that settle of the posterior semicircular canal; common in older adults. (3) Medications: Antihypertensives (postural hypotension) ⬌sudden drop of blood pressure. Anticonvulsants; tranquilizers, sleeping pills, aspirin, NSAIDS. (4) Cerebrovascular disease: Vertebrobasilar artery insufficiency –atherosclerosis, TIAs, strokes. (5) Cerebellar artery stroke, lateral medullary stroke. Difficulty walking, including problems with balance  Vestibular /balance control Cerebellar dysfunction: hemorrhage, tumors ( neuroma, meningioma); degenerative disease of brainstem and cerebellum; progressive supranuclear palsy. Ataxia (impaired muscle coordination). (6) Migraine. (7) Cardiac disease. c. Clinical implications/compensatory strategies. (1) Increased incidence of falls in older adults. (2) Refer to section on falls and instability.  Somatosensory Aging changes. (1) Decreased sensitivity of touch: Associated with decline of peripheral receptors, Atrophy of afferent fibers: Lower extremities more affected than upper. (2) Proprioceptive losses: Loss of movement and position sense due to disease of the peripheral or central nervous system. Increased thresholds in vibratory sensibility, Beginning around age 50: Greater in lower extremities than upper extremities, Greater in distal extremities than proximal.  Somatosensory b. Additional loss of sensation with pathology. (1) Diabetes, peripheral neuropathy. (2) CVA, central sensory losses. (3) Peripheral vascular disease, peripheral ischemia. c. Clinical implications/compensatory strategies. (1) Examine sensation: check for increased thresholds to stimulation, sensory losses. (2) Allow extra time for responses with increased thresholds. (3) Use touch to communicate: maximize physical contact, e.g., rubbing, stroking, stretch, tapping.  Somatosensory (4) Provide augmented feedback through appropriate sensory channels, e.g., walking on carpeted surfaces may be easier than on smooth floor.‫اشياء خشنة‬ (5) Teach compensatory strategies: Environmental modifications to bypass impairment to prevent injury to anesthetic limbs, falls. Provide assistive devices as needed for fall prevention. Provide biofeedback devices as appropriate (e.g., limb load monitor).  Taste and smell a. Aging changes. (1) Gradual decrease in taste sensitivity. (2) Decreased smell sensitivity. b. Additional loss of sensation. (1) Smokers. (2) Chronic allergies, (3)Respiratory infections. (4) Dentures. (5) CVA, involvement of hypoglossal nerve.(12th cranial nerve which innervate the tongue) c. Clinical implications/compensatory strategies. (I) Examine ability to identify odors, tastes sweet, sour, bitter, salty) ‫الحامض المر‬ (2) Decreased taste, enjoyment of food leads to poor diet and nutrition. (3) Older adults frequently increase use of taste enhancers: e.g., salt or sugar and appetizers. (4) Decreased home safety: e.g., gas leaks, smoke. CARDIO VASCULAR AND PULMONARY SYSTEM OBJECTIVES Upon completion of this lecture , the student will be able to the know about the Age related changes on cardiovascular system Clinical implications Interventions to slow or reverse the changes why changes in typeII fibres are more ? Age-related changes Cardiovascular System Changes due more to inactivity and disease than aging. A- Heart muscle 1-Accumulation of lipofuscins ( brown heart); 2-Cardiac hypertrophy left ventricular wall. B-. Cardiac valves thicken and stiffen. c. Changes in conduction system: Loss of pace maker cells in SA node. d. Changes in blood vessels: 1-Arteries thicken. 2-Less distensible. 3- Slowed exchange capillary walls. (Stiffness) 4- Increased peripheral resistance.⬌⬆ BP E. Decline in neurohumoral control 1-Autonomic nervous system(sympathetic and parasympathetic control). (CONTROL BP) 2-Humoral (Hormonal) mechanism include circulating catecholamine, the renine angiotensin-aldosterone system, and vasopressin mechanism (antdiuretic hormone). F-Blood changes 1-Increase blood coagulability. (clotting formation). 2-Decrease blood volume. (stasis of blood, increase blood viscosity and decrease activity of fibrinolytic system) 3-Decrease Coronory blood flow. (increase risk of angina pectoris and infarction) 4- Increase resting hear rate (RHR) systolic greater than diastolic. (⬇⬇decrease stroke volume) D. Changes in blood pressure: Reduced baroreceptor (mechanoreceptors) sensitivity presented on the aortic arch and carotid sinus and vascular elasticity. Blood pressure control:- High blood pressure lead to activation of mechanoreceptors result in an inhibition of the vasomotor center of the medulla Inhibition of vasomotor centre in medulla Increase vagal stimulation result in Vasodilatation and decrease HR, cardiac contractility ⬌⬇⬇ BP E. Increased fatigue; anemia common in elderly. F. Systolic ejection murmur common in elderly. I. Possible ECG change : loss of normal sinus rhythm; longer PR & QT intervals; wider QRS, increased arrhythmias.  Clinical implications Cardiovascular responses to exercise: 1-Changes in heart rate acceleration, deceleration (dysfunction of sympathetic and parasympathetic systems) 2-Decrease maximal oxygen uptake. 3-Reduced exercise capacity. 4- Increased recovery time. 5- Decreased stroke volume. 6-Decreased myocardial contractility. B. Maximum heart rate declines with age (HR max = 220- age). C. Cardiac output decreases, 1% per year after age 20: due to decreased stroke volume. Pulmonary System Age-related changes A. Chest wall stiffness. decrease chest mobility, deformity of chest wall ( kyphosis). Declining strength of respiratory muscle results in increased work of breathing. B-lung changes 1- Elastic recoil decreased 2-Decreased lung compliance. 3. Changes in lung parenchyma: 4-Alveoli enlarge, become thinner; fewer capillaries for delivery of blood. C-pulmonary blood vessels: thicken, less distensible. D. lung volume changes 1-Decline in total lung capacity: 2-Residual volume increases, 3-Vital capacity decreases. 4-Forced expiratory volume (air flow) decrease.  Pulmonary System Altered pulmonary gas exchange: oxygen tension falls with age (at a rate of 4mmHg/decade. Pa02 at age 70 is 75mmHg, versus 90 mmHgat age 20). Blunted ventilatory responses of chemoreceptors: Central chemoreception refers to the detection of changes in CO2/H+ within the brain and the associated effects on breathing. In the conscious animal the response of ventilation to changes in brain interstitial fluid (ISF) pH is very sensitive In response to respiratory acidosis: (CO2 stimulate chemoreceptors to increase rate and depth of breathing and cardiac contractility and hearty rate. Blunted defense/immune responses: – Decreased ciliary action to clear secretions. – Decreased secretory immunoglobulins – Decreased alveolar phagocytic function.  Clinical implications a. Respiratory respones to exercise similar to younger adult at low and moderate intensities; b. At higher intensities, responses include:- Increased ventilatory cost of work, Greater blood acidosis, Increased likelihood of breathlessness, Increased perceived exertion. Interventions to slow or reverse changes in cardiopulmonary system a. Examination prior an exercise program is essential (1) Exercise tolerance testing protocol (ETT) is important. (2) Many elderly cannot tolerate maximal testing; (3)Submaximal testing commonly used. (4) Testing and training modes should be similar (1) Choice of training program is based on: fitness level, presence or absence of cardiovascular disease, musculoskeletal limitations, individual's goals and interests. (2) Prescriptive elements (frequency, intensity, duration, mode) are the same as for younger adults. (3) Walking, chair and floor exercises, modified strength/flexibility calisthenics well tolerated by most elderly. (4) Consider pool programs ( exercises, walking, swimming) with bone and joint impairments. (5) Consider multiple modes of exercise (circuit training) on alternate days to reduce likelihood of muscle injury, joint overuse pain, and fatigue.  calisthenics workout - ÈÍË Google.mkv Standing Exercises for Older Adults - YouTube.mkv Senior Fitness - 99 year old keep fit teacher - Lesson 2 - YouTube.mkv Ateliers form'équilibre - YouTube.mkv Seated Exercises for Older Adults - YouTube.mkv Workout Ideas - Intense Group Training.mp4 Circuit Training - Exercises Ideas.mp4 Aerobic training programs can significant (1) Decreases heart rate at a given submaximal power output. (2) Improves maximal oxygen uptake (V02max). (3) Greater improvements in peripheral adaptation, muscle oxidative capacity then central changes; major difference from training effects in younger adults. (4) Improves recovery heart rates. Aerobic training programs can significant (5) Decreases systolic blood pressure, may produce a small decrease in diastolic blood pressure. (6) Increase maximum ventilatory capacity: vital capacity. (7) Reduces breathlessness, lowers perceived exertion. (8) Psychological gains: improve sense of well- being, self-image. (9) Improves functional capacity.  Improve overall daily activity levels for independent living (1) Lack of exercise is an important risk factor in the development of cardiopulmonary diseases. (2) Lack of exercise contributes to problems of immobility and disability in the elderly. Osteoporosis OBJECTIVES Upon completion of this lecture , the student will be able to the know about the Osteoporosis Etiological factors Clinical Features Examination Interventions Osteoporosis Definition Osteoporosis was defined as 'a progressive skeletal disorder, that results in reduction of bone mass; a failure of bone formation (⬇osteoblast activity) to keep pace with bone reabsorption and increase destruction (⬆osteoclast activity).  The bone Formed of collagen soft frame work and calcium phosphate tensile strength of bone. Formed of outer layers cortical bone and inner layers trabecular bone → honey comb like appearance. The bone like a bank→ deposit and withdraw. Deposit during childhood and adulthood by osteoblast cells. Withdraw after third decade by osteoclast cells Etiologic factors (1) Hormonal deficiency: estrogens or androgens. (2) Nutritional deficiency: inadequate calcium, impaired absorption of calcium; excessive alcohol, caffeine consumption. (3) Decreased physical activity: inadequate mechanical loading. (4) Diseases that affect bone loss: hyperthyroidism, diabetes, hyperparathyroidism, rheumatoid arthritis, liver disease, certain types of cancer. (5) Medications that affect bone loss: corticosteroids, thyroid hormone, anticonvulsants ,catabolic drugs, some estrogen antagonists, chemotherapy. (6) Additional risk factors: family history, Caucasian ! Asian race, early menopause, thin/small build, smoke Vitamin D Vitamin D is essential for strong bones, because it helps the body use calcium from the diet. Vitamin D synthesized in the skin upon exposure to sunlight ultraviolet convert 7-dehydrocholesterol to vitamin D3 then in the liver hydroxylated to 25 hydroxy vitamin D3 (25(OH)D3) , then in the kidney 1,25 dihydroxy vitamine D (1,25(OH)2D3) (active form vitamin D). Traditionally, vitamin D deficiency has been associated with rickets, a disease in which the bone tissue doesn't properly mineralize, leading to soft bones and skeletal  Parathyroid Hormone Vitamin D and Parathyroid Hormone regulate calcium and phosphorus homeostasis, Drop in blood calcium con.→ stimulate parathyroid hormone from parathyriod gland → stimulate 25 OH vitamin D into 1,25 dihydroxy vitamin D → Correct calcium and phosphorus level. 1. Mobilization of calcium from bone. 2. Increase intestinal absorption of dietary calcium, 3. Increase reabsorption of calcium filtered by the kidney, and increase phosphorus excretion by the kidney. Primary hyperparathyroidism Primary hyperparathyroidism occurs because of some problem with one or more of the four parathyroid glands. A cancerous (malignant) tumor is cause of primary hyperparathyroidism. Secondary hyperparathyroidism Severe calcium deficiency. Severe vitamin D deficiency. Chronic kidney, liver failure Causes of Vitamin D Deficiency: A strict vegan diet Limited exposure to sunlight Kidneys cannot convert vitamin D to its active form Liver cannot convert vitamin D to its active form Digestive tract cannot adequately absorb vitamin D. Certain medical problems, including Crohn's disease, and celiac disease Obesity. Vitamin D is extracted from the blood by fat cells Tests for Vitamin D Deficiency: Vitamin D blood test. A level of 20 nanograms/milliliter to 50 ng/mL is considered adequate for healthy people. A level less than 12 ng/mL indicates vitamin D deficiency. Calcium: Calcium is a mineral that is an essential part of bones and teeth. The heart, nerves, and blood-clotting systems also need calcium to work. Calcium is used for treatment and prevention of low calcium levels and resulting bone conditions including osteoporosis (weak bones due to low bone density), rickets (a condition in children involving softening of the bones), and osteomalacia (a softening of bones involving pain). Normal serum Calcium: The corrected total serum calcium concentration is normally 8.5- 10.2 m /dL. Normal value of phosphorus is 2.5 – 4.5 mg /dl DEXA Scan (Dual X-ray Absorpt-iometry) to Measure Bone Health The most common test doctors use is called dual energy X- ray absorpt-iometry (DXA or DEXA). A DXA scanner is a machine that produces two X-ray beams. One is high energy and the other is low energy. The machine measures the amount of X-rays that pass through the bone from each beam. This will vary depending on how thick the bone is. Based on the difference between the two beams, your.doctor can measure your bone density DXA Scan Results: T-score of -1.0 to +1 = normal bone density T-score between -2.5 and -1.0 = low bone density, or osteopenia (which is bones are weaker than normal but not so far gone that they break easily, which is the hallmark of osteoporosis). T-score of -2.5 or lower = osteoporosis  Clinical features (1)-Bone loss is about 1% per year (starting for women at ages 30-35, for men ages 50-55), accelerating loss in post-menopausal women, approximately 5% per year for 3-5 yrs. (2)-Structural weakening of bone. (3)-Disability to support loads. (4) High risk of fractures. (5) Inner layers trabecular bone more involved than cortical bone; common areas affected: (a) Vertebral column. (b) Femoral neck. (c) Distal radius/wrist, humerus c. Examination. (a) History, physical exam, nutritional history. (b) Bone density tests. (c)X-rays for known or suspected fractures. (1)Medical record review..Physical activity/fall history )2( Assess dizziness: Dizziness )3(.Handicap Inventory Sensory integrity: vision, )4( ,hearing, somatosensory.vestibular; sensory integration Motor function: strength, )5( endurance, control motor.ROM/flexibility )6(.Postural deformity )7( Feet: hammer toes, hallux valgus lead to )a( antalgic gait Postural kyphosis, forward )b(.head position Hip and knee flexion )c(.contractures.Postural hypotension )8(.Gait and balance assessment )9(  Interventions (I) Medications. (a) Evista. (b) Fosamax (alendronate). (c) Calcitonin. Evista. Selective (o)estrogen receptor modulators it works by acting as an oestrogen agonist in bone and an oestrogen antagonist in areas like the breast and uterus.( act like estrogen) Hormone replacement therapy HRT,, is an anti-resorptive therapy and works by stimulating the oestrogen receptors on the bone cells HRT is best prescribed for the five or so years during and just after the menopause (prophylactic treatment) It is associated with very slight increases in the risks of developing breast cancer, venous thromboembolism (VTE), cardiovascular disease and strokes. Interventions (2) Promote health, provide counseling. (a) Daily calcium intake. 1000 mg premenopause. 1500 mg after age 50 years of age. (b) Daily vitamin D intake. 200 IU premenopausal.= 134mg 400 IU after menopause 600 IU after age 75. (c) Diet: low in salt, avoid excess protein: inhibits body's ability to absorb calcium. (3) Maintain bone mass Exercise. Exercise has two important roles in the prevention of fractures. Firstly it is shown to aid bone density. Secondly it tones and strengthens muscles, thereby ensuring good balance, coordination and skeletal support. Loading the skeleton with physical weights or bodyweight stimulates the osteogenic cells, Many people are not used to doing any regular exercise and would need to start very gently and carefully Mode of Exercises: (a) Weight bearing (gravity-loading) exercises: stimulates the osteogenic cells walking (30 min/day); stair climbing; jogging use of weight belts to increase loading. (b) Resistance exercises, e.g., hip and knee extensors, triceps. weight lifting Strengthens muscles, thereby ensuring good balance, coordination and skeletal support (4) Postural balance training (a) Postural reeducation, postural exercises to reduce kyphosis, forward head position. (b) Flexibility (stretching) exercises. (c) Functional balance exercises, e.g., chair rises, standing kitchen sink exercises (e.g. toe raise, unilateral stance, hip extension, hip abduction) (d) Tai Chi. (e) Gait training.  Standing Exercises for Older Adults.mp4 Exercises at the Kitchen Sink-- Part 1.mp4 Exercises at the Kitchen Sink-- Part 2.mp4 Walking sequence to improve gait and balance..mp4 (5) Safety education/fall prevention (a) Proper shoes: thin soles, flat shoes enhance balance abilities (no heels). (b) Assistive devices: cane; walker as needed. (c) Fracture prevention: counseling on safe activities; avoid sudden forceful movements, twisting, standing, bending over, lifting, supine sit-ups.  References National Physical therapy Examination review & Study guide by Susan B. O’sullivan, PT, EdD and Raymond P.Siegelman.2008 Geriatric physical therapy by Andrew.A. Guccione.Mosby,2nd Ed  References Geriatric physical therapy by Andrew.A. Guccione.Mosby National Physical therapy Examination review & Study guide by Susan B. O’sullivan, PT, EdD and Raymond P.Siegelman.  References National Physical therapy Examination review & Study guide by Susan B. O’sullivan, PT, EdD and Raymond P.Siegelman.2008 Geriatric physical therapy by Andrew.A. Guccione.Mosby,2nd Ed