PST 513 HOME AND INSTITUTIONAL CARE GERIATRICS PHYSIOTHERAPY.pdf

PST 513: HOME AND INSTITUTIONAL CARE OF GERIATRICS PATIENTS Mr O.O Tabiti Bowen University, Iwo Gerontology Gerontology This is the study of the aging process itself. The study of physical and psychological changes which are incident...

PST 513: HOME AND INSTITUTIONAL CARE OF GERIATRICS PATIENTS Mr O.O Tabiti Bowen University, Iwo Gerontology Gerontology This is the study of the aging process itself. The study of physical and psychological changes which are incident to the old age is call gerontology. Geriatrics Geriatrics is the branch of internal medicine that focuses on health care of the elderly. It aims mainly to promote health and to diagnosis , prevent and treat diseases and disabilities in older adults. CLASSIFICATION OF ELDERLY  Three groups have been identified: 1. Young-old: This group consists of the populations between 65 and 75 years of age. The young old are somewhat similar to middle-aged patients. They have minimum level of disability. Hence the research studies pertaining to exercise physiology are mostly carried out in this particular group. With the average life expectancy of about 15 to 20 years, physical therapy is aimed at primary prevention of diseases. For example, by participating in a weight loss program, the obese patients can reduce their risk for cardiovascular disease. Similarly an appropriate combination of endurance and strengthening exercises can slow down the rate of decline in neuromuscular functions. 2. Middle-old: The populations between 75 and 85 years of age are included in this group. They exhibit the occurrence of chronic diseases. Physical therapist should exert the aggressive efforts to deal with the problems like osteoporosis, diabetic neuropathy, falls, etc. There is a decline in additional years of life expectancy. Physiotherapy is directed at the improvement of functional status in the finite remaining years. CLASSIFICATION OF ELDERLY CONTD… 3. Old-old: This group comprises of the populations older than 85 years of age. With the average additional life expectancy of 5 to 6 years, the old-old have the limited survival benefits from screening tests or therapeutic interventions. Taking this into account, physical therapist should concentrate on achieving human comfort. For example, passive movements, including trunk turning, positioning in bed or chair, warmth, attention and eye-to-eye contact have the great significance for the happiness of patients. THE TEAM FOR GERIATRIC ASSESSMENT  Interdisciplinary or multidisciplinary approach is a key to geriatric assessment. The team has many members such as physician to assess medical fitness, physical therapist to assess physical fitness, occupational therapist to assess vocational status, speech therapist to assess speech problems, psychologist to assess the level of depression, dentist to assess oral hygiene, audiologist to assess hearing loss, ophthalmologist to assess eyesight, nurse to assess the status of personal care, dietician to assess nutritional status and social worker to assess the involvement of a patient with family or the community.  All of these members work together to develop a single treatment plan in the interdisciplinary team whereas in a multidisciplinary team individual members perform separate assessments, notes and treatment plans. Interdisciplinary approach is justifiable for a geriatric patient in nursing home, especially a frail old with multiple pathologies whereas in geriatric OPD multidisciplinary team with contribution of 4 to 5 members can produce a real picture. GERIATRIC PHYSICAL THERAPY IN DIFFERENT SETTINGS  GERIATRIC PHYSICAL THERAPY IN DIFFERENT SETTINGS Geriatric physical therapists are providing quality care to patients in multiple settings that include acute care hospitals, skilled nursing facilities, outpatient departments, rehabilitation centres, home health agencies and hospice settings. The over-all condition of a patient will decide the type of care setting. 1. Geriatric Physical Therapy in Acute Care Hospitals (In-patient care) This is particularly important for the elderly having multiple comorbid conditions. However, a patient with single event like stroke may also need acute care in hospital. The patient is usually monitored by the interdisciplinary team. Physical therapy should be started as early as the elderly is able to tolerate the therapeutic interventions, especially exercises. The early physical therapy intervention can prevent secondary functional loss and promote early restoration of function and thereby reduce the length of hospital stay. The patient should receive therapy for two hrs per day to have significant improvement. . GERIATRIC PHYSICAL THERAPY IN DIFFERENT SETTINGS CONTD… 2. Geriatric Physical Therapy in Skilled Nursing Facilities(Institutional care) A skilled nursing facility has staff and equipment to provide skilled nursing care and other health services. Geriatric physical therapist may provide her specialized services as an employee of a skilled nursing facility or as an independent contractor. Elderly patients who are not suitable for acute care in hospitals may be treated in a skilled nursing facility. The patient should be employed two half-hourly sessions of physical therapy per day. The treatment time may be increased after the reassessment of a patient. GERIATRIC PHYSICAL THERAPY IN DIFFERENT SETTINGS CONTD… 3. Geriatric Physical Therapy at Home Many patients prefer to have physical therapy at their home. Physical therapist may visit the patient for once or twice a day. The main advantage of this kind of provision is that it saves the time of caregivers. The caregivers do not have to bother to take a patient to physiotherapy clinic. However, there is a disadvantage in the sense that the necessary equipment can not be used at home. 4. Geriatric Physical Therapy in Outpatient Departments Outpatient department is the best option for the patients having the transport facility. However, it is not the suitable option for the frail elderly. Easy access to equipment and peer interaction are the main advantages for the patients being treated in outpatient departments. The purpose of institutional care, too, is to secure as well as possible functional abilities for an elderly client.  Geriatric physical therapy settings Inpatient medic al rehabilitation (rehabilitation units in acute care or Outpatient: rehabilitation hospitals, long term ( primary care, private practice, etc). care, nursing-home rehabilitation) Home health rehabilitation. BENEFITS OF THE HOME CARE PT FOR GERIATRICS PATIENTS I. The health care centres provide fall prevention classes and exercises. II. One-on-one sessions are very helpful for long-term senior residents as they can recover in quick time and adjust better to the home environment. Some may not prefer group classes as physiotherapist could find it difficult to give equal attention to all in the group. III. Seniors who are just out of hospital post surgery or a neurological disorder feel comfortable at home than at health centres. Comfortable environment is equally important for people aged above 65 to recover soon from treatment. IV. Exercise classes include some of the following types:  Endurance, Functional fitness training, Balance and flexibility training, Muscle strengthening  Cardio and respiratory exercises The classes are also based on the physical situation of the patients. In-home treatment will help therapists to keep a close watch on the progress of the patients. Physical therapy can reduce the risk of UTIs by improving bowel habits. Strengthening the pelvic floor and deep core muscles allows seniors to go to the bathroom more often and empty their bladders more effectively.. GERIATRIC PHYSICAL THERAPY PROGRAM  The geriatric population is unique in its wide variation from individual to individual in the effects of both aging and disease processes. The effective administration of Physical Therapy program can make the quality of life better for the patients belonging to this complex group. The important components of this program are: 1. Assessment 2. Goal-setting 3. Therapeutic intervention 4. Re-assessment  GERIATRIC PHYSICAL THERAPY PROGRAM CONTD… 1. Assessment  A comprehensive geriatric assessment, is often helpful before the initiation of a physical therapy program to assist with setting realistic goals with each patient. For example, assessment of communication skill is must while working with the older patient with cognitive deficits so as to know the difficulties of patient in problem solving and self-care. aims of geriatric assessment  Geriatric physical therapists encounter a wide spectrum of elderly patients, ranging from those who are frail and institutionalized to those who are functionally independent but require attention in outpatient departments and help addressfunctional problems of older persons GERIATRIC PHYSICAL THERAPY PROGRAM CONTD…. 2. Goal-Setting Functional independence is the ultimate goal of physical therapy intervention. This is particularly important in geriatric care, because the presence of acute as well as chronic illness in elderly individuals is often associated with loss of day-to-day function. To achieve this long-term goal, a physical therapist should establish several short-term goals: 1. To improve or maintain ROM of different joints. For example, a geriatric patient should have enough ROM at shoulder to dress up or to reach dishes in the cupboard. 2. To improve or maintain strength and endurance of muscles. For example, the patient should have sufficient muscle strength to lift a jug of milk, to make a bed, to make chapatti or to wash clothes. 3. To improve or maintain cardiovascular endurance so that a geriatric patient is able to do strenuous activities such as fast walk, cycling or swimming. 4. To improve or maintain ambulatory status of a patient so that a patient can go to toilet or for shopping independently. 5. To relieve pain. It has been estimated that over 85 percent of older adults have at least one chronic disease that may give rise to the feeling of discomfort or pain.24 Acute pain following surgery is also becoming quite common in geriatric patients CONTD… 3. Therapeutic Intervention  A number of physical therapy interventions may be employed in order to attain treatment goals: i. Range-of-motion exercise ii. Stretching exercise iii. Mobilization exercise iv. Strengthening exercise v. Aerobic exercises vi. Gait training vii. Orthotics viii. Electrotherapeutic modalities  The most common therapeutic interventions to relieve pain are exercises, orthotics, heat and cold modalities; and electrical stimulating currents. CONTD… 4. Reassessment  There should be ongoing reassessment while administering geriatric physical therapy program.  This enables a physical therapist to judge the effectiveness of treatment towards the goals set, with required modifications in the treatment strategies COMPONENTS OF GERIATRIC ASSESSMENT  Performing comprehensive assessment in the form of different components is another way to increase the efficiency of geriatric assessment. These components are: A. History taking B. Physical examination C. Functional status D. Mental status E. Emotional status F. Investigations COMPONENTS OF GERIATRIC ASSESSMENT CONTD… 1. History Taking Subjective information and personal history: Age, sex, education, occupation, socio-economic status, etc. Chief complaints: There may be more than one complaint reflecting the presence of multiple pathologies. Present physical illness: The speed of onset of illness, precipitating events. Previous physical illness: The presence of chronic diseases, previous surgeries or hospitalization. Drug history: List of prescribed and nonprescribed drugs taken by a patient, drug allergies. Nutritional history: Number of meals/day, contents of diet. Family history: The presence of major diseases in family, causes of death of family members. COMPONENTS OF GERIATRIC ASSESSMENT CONTD… 2. Physical Examination  It is an integral part of geriatric assessment. Physical therapist should make sure to check: Height and weight Orthostatic BP and pulse Edema Skin integrity, pallor Range of motion Muscle strength Sensory status Coordination Vision and hearing Oral cavity – no of teeth, loose teeth, caries  Snellen eye chart or Jaeger Card can be used for vision whereas to detect hearing loss, the therapist may whisper short sentences at the distance of 6 to 12 inches from behind the head. If needed, patient may be referred to a specialist for detailed check-up. COMPONENTS OF GERIATRIC ASSESSMENT CONTD… 3. Functional Status  This is a vital component of geriatric assessment because the information collected through the present functional status of a geriatric patient can be used as a baseline to measure future declines in function and to plan treatment strategy that can ultimately lead to an improvement in the quality of life.  Four elements of physical functional status are needed to be evaluated thoroughly and carefully: 1. Basic self-care and personal hygiene activities of daily living (ADLs) 2. More complex activities essential to live in community (IADLs) 3. Balance 4. Gait  ADLs and IADLs are assessed on the basis of self-report(Which outcome measures can you use?). Modified performance-oriented mobility assessment (POMA) is used for the assessment of balance and gait. COMPONENTS OF GERIATRIC ASSESSMENT CONTD… 4. Mental Status  Physical therapist has a key role as a member of the geriatric rehabilitation team and as a resource for other caregivers for the older patient with cognitive impairments. The therapist needs to have adequate knowledge to assess mental status, so that she can work with maximal efficiency and also enjoy clinical interactions with elderly. The term “dementia” is commonly used to describe the impairments in mental status. The Mini-Cog assessment instrument is briefer and has reasonable test characteristics to indicate the presence of dementia 5. Emotional Status  Many people get depressed at some time in their lives. However, in elderly, depression is the most common psychological problem. Geriatric depression scale (GDS) is used to assess the level of depression in elderly. COMPONENTS OF GERIATRIC ASSESSMENT CONTD… 6. Laboratory Testing  Clinical use of laboratory testing for geriatric assessment is a useful tool when combined with physical assessment. RISK FACTORS OF FALLS IN THE ELDERLY  Risk factors associated with the occurrence of falls in elderly are classified as (i) intrinsic or host factors and (ii) extrinsic or environmental factors. Intrinsic factors  – Poor balance – Weakness  – Foot problems – Visual impairment  – Cognitive impairment Extrinsic factors – Poor lighting – Slippery surface – Obstacles – No safety equipment – Loose carpets – Polypharmacy International Classification of Functioning, Disability and Health (ICF) ICF MODEL  Impairments: Problems in body function and s  Activity Limitations: Difficulties an individual may have in executing activitiestructure such as significant deviation or loss  Participation Restrictions(Handicap): Problems an individual may experience in involvement in life situations  Environmental factors:The physical, social and attitudinal environment in which people live and conduct their lives. These are either barriers to or facilitators of the person's functioning  GERIATRIC PHYSICAL THERAPY  An area of specialization that requires a specific set of advanced skills and knowledge that addresses the aging process.  Specialists in geriatric physical therapy understand the differences between ‘normal’ aging and pathological changes that commonly occur in the older adult.  Assisting the geriatric client can be hard task because of multisystem involvement and multiple comorbidities.  Special considerations such as psychosocial issues, environmental, frailty, nutritional, pharmacological and cultural factors must be accounted for in a successful rehabilitation process. GERIATRIC PHYSICAL THERAPY ROLE The primary goal of geriatric phy sica l therapy is to prevent, m a i n t a i n o r Assisting the individual to return to optimal living within their capabilities. rehabilitate an impairment or To achieve the highest level of functional mobility as possible within their environment while maintaining safety. functional limitation, w h i c h i s Enabling the older adult to enjoy a longer life by living it more independently and with less pain. accomplished with the applicatio n o f evidence-based scientific principles. GERIATRICS PHYSICAL THERAPY ROLE CONTD... combating and minimizing the accumulative disabling effects reducing institutionalization of of physical illness in association patients. with the aging process. Providing education for the Contributing to the comfort and patient and caregivers. well-being of the patient. GERIATRICS PHYSICAL THERAPY SETTINGS Inpatient medic al rehabilitation (rehabilitation units in acute care or Outpatient: rehabilitation hospitals, long term ( primary care, private practice, etc). care, nursing-home rehabilitation) Home health rehabilitation. COMMON GERIATRIC DISORDERS PT CASES Cardiovascular disorders: Respiratory disorders : asthma, hypertension, CHD, heart failure. COPD Neurological and cognitive conditions: Stroke, Parkinson's Musculoskeletal: osteoporosis, disease, dementia, delirium, OA, RA, falls, fracture, Alzheimer,depression, fear of incontinence falling Integumentary conditions: Pressure ulcers, diabetic ulcers, venous stasis ulcers, herpes zoster, malignant tumors  INDICATIONS FOR GERIATRIC PT REFERRAL  Recent fall or history of falls Open wound   Deficits in strength or range Neurological disorder  of motion  Balance deficits  Loss of mobility or ambulation requiring an  Decreased endurance for assistive device ADLs  Musculoskeletal pain  Bed bound status  Difficulty with transfers  Need for adaptive equipment to enhance safety and  Orthotic or prosthetic needs function  PRONE FOR INCRASED RISK INFECTIONS OF DEATH INCREASED PRONE FOR RISK OF INJURIES DISABILITY INCREASED PRONE FOR RISK FOR PSYCHOLOGIC DISEASE AL PROBLEMS PRONE FOR D EGENERATI VE DISORDERS 33  Lack of specialized and trained manpower No dedicated Geriatrics not health care yet a popular infrastructure specialty 34 GERIATRICS REHABILITATION  GR principles should focus on minimizing activity limitation and maximizing societal participation, even in situations where body structure and function cannot be restored to premorbid levels. This may require the use of aids, appliances, technical and environmental adaptations. Rehabilitation programmes should encompass the psychosocial components of health and wellbeing.  Principles of geriatric rehabilitation is essential in optimizing function that is essential as a fundamental of effective therapeutic outcome to older adults. GERIATRICS REHABILITATION CONTD…  Geriatric Rehabilitation (GR) aims to restore function or enhance residual functional capability and improving the quality of life in older people ie particularly those with disabling impairments and/or frailty. Current rehabilitation practice focuses on function and well-being, not exclusively on disease. Rehabilitation of older adults patients can assist in preserving functional independence and improving the quality of life.  After hospitalization, 11% of the older patients are referred to rehabilitation facilities. The increasing geriatric population, and the apparent increases in disability related to e.g musculoskeletal disorders, depression, diabetes, and neurologic disorder, affecting mobility-related activities in particular, will increase the needs for rehabilitation. GERIATRICS REHABILITATION CONTD…  Rehabilitation of the older adult should: emphasize functional activity to maintain functional mobility and capability; improvement of balance through exercise and functional activity programs (eg, weight shifting exercises, ambulation with direction and elevation changes, and reaching activities), good nutrition and good general care (including hygiene, hydration, bowel and bladder considerations, and appropriate rest and sleep), and social and emotional support GERIATRIC REHABILITATION Prevent complications A B C s A. Aspiration, Anorexia, inActivity B. Bedsores, C. Constipation, Contractures, Cognition D. DVTs, Depression, DFUs E. Else: infections (UTI, Pneumonia), pain, incontinence ASSISTIVE DEVICES- MOBILITY AIDS Device Supports  Canes 15-20 % of body weight  Crutches 100% of body weight  Walker ~ 50 % (not 100) of body weight ACSM RECOMMENDED EXERCISE FOR GERIATRICS  The American College of Sports Medicine (ACSM) recommends that healthy adults perform muscle strengthening exercises 2 to 3 times per week at an intensity level that fatigues the muscle within 8 to 12 repetitions. The higher the intensity and volume of training, the greater the increase in strength.  Institutionalized elders could safely perform progressive resistive training at intensities of 80% of one repetition maximum (1 RM), 3 sets of 10 repetitions, 3 times/week, and make significant gains in muscle strength. Exercise should begin at a lower intensity (30% to 50% of 1 RM) and progress gradually to the higher intensity(>70% of 1RM) over several weeks.  In general, significant strength gains are made in older adults within 12 weeks of high-intensity (>70% of 1 RM) resistance training. Strengthening programs should emphasize muscle groups(Quads, Gluteals, Erectors and Gastrocnemius) that are often weak in the elderly population and necessary for maintenance of independent living  AEROBIC EXERCISE Frequency - ≥ 5 days / week (moderate intensity physical activity) ≥ 3 days / week (vigorous intensity physical activity) 3 – 5 days/ week (combination of both) Intensity – On scale 0-10 for level of physical exertion, 5 – 6 for moderate intensity and 7 – 8 for vigorous intensity. Type – Any modality that does not impose excessive orthopaedic stress Walking, aquatic exercise, and stationary cycle exercise. Time – Moderate intensity : 30 – 60 minutes / day in bouts of 10 minutes each to total of 150 – 300 min / week Vigorous intensity: 20 – 30 minutes / day to total 75 -100 minutes / week ENDURANCE EXERCISE Frequency – ≥ 2 days / week Intensity – moderate intensity (5-6) Borg scale Type – Walking, stair climbing at self-selected comfortable pace. Time – It will be progressively increased according to the participant’s performance. Instructions while starting an endurance training program: Start out slowly and progress by increasing the time by 5 min or increasing the speed. Monitor intensity with a Rating of Perceived Exertion Scale (Modified Borg Scale). Wear shoes that offer support and are appropriate for the type of activity.  FLEXIBILITY EXERCISE Frequency – ≥ 2 days / week with a goal of 5 days / week. Intensity – Stretch to the point of feeling tightness or slight discomfort. Type - Any activities that maintain or increase flexibility using sustained stretches for each major muscle group. Time – 10 - 15 second hold and 5 repetitions – progressively increased till 30 – 60 seconds hold.  STRENGTHENING EXERCISE Frequency – ≥ 2 days / week Intensity – Light Intensity (30-50% of 1RM), Moderate Intensity (60- 70% of 1RM) Type – Progressive strengthening activities for major muscle group (delorme/oxford/ Macqueen)  NEUROMOTOR EXERCISE Frequency – 2 – 3 days / week The ACSM exercise Prescription guidelines recommend following activities – Progressively difficult postures that gradually reduce the BOS (Two-legged stand, semi tandem stand, tandem stand, one legged stand.) Dynamic movements that perturb the COG (tandem walk, circle turns) Stressing postural muscle groups (Heel stands, Toe Stands)  NEUROMOTOR EXERCISE Activit Level 1 Level 2 Level 3 Challenges y Upright stance with For each variation add Add arm movements to Close one eye, Static variations - wide, - sway - Close Balance narrow, semi tandem, Forward, backward Raise one arm at a time both eyes, turn Activities tandem and single and Lateral sway to front and then to head to right and leg stand. sides, raise both arms to then to left, front and sides Hold an item such as a book Sit-to-stand-to-sit, Perform wide-stance Tandem walking, walk Barefoot, One Dynamic walk walk, while eye Balance forward and perform narrow stance carrying an item, walk closed, Surface Activities Backward walk, walk on heels, with head turns change, walk on toes Obstacles Walk side to side Side step on heels, Sidestep while carrying Side step an on toes, Turn in a circle item, sidestep with head turns, perform crossover walk PST 513: MULTIDISCIPLINARY APPROACH TO GERONTOLOGY Mr O.O Tabiti Bowen university, Iwo WHAT IS A MULTIDISCIPLINARY TEAM  Multidisciplinary Team (MDT) is a team of professionals that includes representatives of different disciplines e.g. Physiotherapy, Occupational Therapy etc., who coordinate the contribution of each discipline with little overlap to assess and treat the patient separately with discipline-specific goals. Each discipline could function autonomously, working in parallel towards a shared goal; acknowledging one other’s contributions and sharing successes.  Multidisciplinary team, working is described as the main mechanism to ensure truly holistic care for patients and seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care.  Multidisciplinary teams (MDTs) are the mechanism for organising and coordinating health and care services to meet the needs of individuals with complex care needs. The teams bring together the expertise and skills of different professionals to assess, plan and manage care jointly. WHAT IS A MULTIDISCIPLINARY TEAM CONTD…  Through accessing a range of health, social care and other community services, MDTs focus on keeping people well and independent, delivering the right care at home or in the community to prevent unnecessary hospital care.  The patient’s progress within each discipline is communicated through written documentation and regular team meetings and as such does not emphasize an integrated approach to care. This type of team approach is predominantly what we see in an acute hospital setting and geriatrics home settings.  Each discipline works in parallel with clearly defined roles within the team and sets its own individual, specific goals with the patient and communicates these goals and outcomes with the team through written documentation or within team meetings where appropriate In most cases within an Acute Setting the team is Consultant / Physician-led COMPONENTS OF THE MULTIDISCIPLINARY TEAM  MDTs consist of practitioners and professionals from health, care and allied disciplines and sectors that work together to provide holistic, patient- centred and coordinated care and support.  The composition of MDTs varies depending on delivery models and settings but it may include: GPs, specialist doctors, nurses, physiotherapists, occupational therapists, pharmacists, social workers and care givers. MDTs also often include link workers or care navigators, who can support social prescribing by connecting individuals with local groups and community support services.  A holistic and integrated approach to care and support requires the coordination of multiple interventions and services, built around the complex continuum of patient’s needs, personal strengths and desirable outcomes. CONTD…  Multidisciplinary team approach Patients with disability (PWD) with family members Medical team – Physician, General surgeon, Orthopaedic surgeon, Obstetrician & Gynaecologist, Psychiatrist, Ophthalmologist etc Physiotherapist, Occupational therapist, Orthotist and Prosthetist, Speech therapist, Rehabilitation nurse, Clinical Psychologist, Nutritionist Socio-vocational team – Social worker, Health educator, Rehabilitation Geriatric Rehabilitation team Geriatric Rehabilitation team COMPONENTS OF THE MULTIDISCIPLINARY TEAM FOR GERIATRICS MANAGEMENT CONTD…  MDTs play an important role, bridging professional boundaries and breaking down the barriers of competing cultural and organisational differences. When successful, they enable comprehensive, continuous and seamless care services to be delivered. MDTs can ensure significant benefits for geriatrics such as: 1. joint assessments and care planning, informed by service users’ own goals and decisions 2. better communication and information-sharing across the team and with the service user 3. greater involvement of the service user, or their carers, in decisions about care 4. a single point of access through a key worker or named coordinator 5. rapid access to specialist expertise in the community, including urgent care in a crisis and at transitions of care (e.g. hospital discharge) 6/ access to a range of community services that support wellbeing, self-management and prevention (e.g. falls prevention services or home adaptations  What would be the most appropriate assistive device? 78 y/o F S/P (L) TKA w/ severe RA of hands, shoulders, knees. Which assistive aide is most appropriate? A. Large based quad cane B. Crutches C. Two-wheel walker D. Forearm supports attached to a two-wheel walker E. Wheelchair S/P(surgical procedure in the form of treatment) THANKS FOR LISTENING