week 2 summary aging .pdf

2.1 aging changes in the cardiac arterial systems arterial wall structure arterial system increasing age = reduced contractility & elasticity of vascular walls and valves increase in thickness of arteries increased in collag...

2.1 aging changes in the cardiac arterial systems arterial wall structure arterial system increasing age = reduced contractility & elasticity of vascular walls and valves increase in thickness of arteries increased in collagen content decrease in elastin content of arterial walls increased lumen larger endothelial cells decreased # increased size of vascular smooth muscle cells loss of elastin and smooth muscle cells -contributes to less elastic & compliant arterial walls *analogy: like a rubber band that gets overstretched* lumen becomes wider and longer arterial walls get thicker and stiffer w less nitric oxide available to relax smooth muscle cells -predisposes individuals to atherosclerosis or HTN neither is considered normal in aging process veins increase in lumen size less elasticity less efficient valves (increasing change of blood pooling in extremities) >>, leads to increased falls, impaired cognition, incontinence, constipation, delirium, diarrhea and gastrointestinal bleeding  our role as a PT identify signs of polypharmacy drug reactions drug toxicity key subjective questions any new meds? timing of meds? -promote use of fewer drugs by addressing PT specific impairments or immobility ex: spasticity, pain or impaired orientation provide education to pt, caregiver and family to effectively provide useful knowledge seek interdisciplinary approach if impairments are not fully w/in our scope Summary Changes in pharmacokinetics and pharmacodynamics drive altered physiologic response to drugs with age, negatively impacting health and function  2.5 introduction to falls in aging what is a fall? Common Reactions - Some people confidently say "no" when asked if they fall - Others may pause, look inquisitive or guilty, and hesitate before saying "not really" World Health Organization Definition - A fall is inadvertently coming to rest on the ground, floor, or lower level - Excludes intentional changes in position to rest on furniture, wall, or other objects Salgado et al. (1994) Definition - A fall is coming to rest unintentionally on the ground or lower level - Not as a result of a major intrinsic event or overwhelming hazard Canadian Falls Prevention Curriculum Definition - A fall is unintentionally coming to rest on the ground, floor, or other lower level - With or without injury Combined Characteristics of a Fall - Inadvertent - Unintentionally landing on a surface lower than planned - With or without injury - In the absence of a major triggering event Nearfall - Commonly used term in clinical practice - Highlights challenges in balance or righting reactions a fall is a fall - Falls in older adults should not be considered accidents. - Instances of falls should not be minimized in importance. - Falls in the elderly can often be predicted and prevented. - A multifactorial approach is effective in preventing falls. - This approach involves thorough screening for risk factors. - It includes prescribing individualized interventions. - Education on prevention and recovery strategies is crucial. falls in the US - Falls are preventable and require intervention. - Studies indicate that 30% of adults over 65 years experience falls. - Up to 20% of these falls lead to serious injuries. - Self-reported fall injuries have risen since 2000. - Deaths from falls in elderly increased by 30% from 2007 to 2016 in the US. - One in four older adults in the US falls annually. - One in five of these falls results in head injury or fracture. - Three fall-related deaths occur per hour. - Projected to increase to 7 deaths per hour by 2030. - Nearly 300,000 older adults are hospitalized annually for hip fractures. - 95% of hip fractures are attributed to falls. - Women are disproportionately affected, with about 75% of hip fractures. - Falls increase healthcare costs and risk of other medical conditions. fall injuries below the surface - Statistics on falls often do not fully capture their extent or impact. - Reported falls include those in emergency rooms, hospitals, and mortality statistics. - Many falls go unreported and untreated. - Unreported falls can lead to decreased mobility confidence. - This can result in poorer physical health and limited community participation. - Social isolation and depression may also occur due to unreported falls. aging and falls Physiological changes with normal aging in older women contribute to increased falls risk. Central Nervous System: - Potential or decreased vestibular and visual input and processing. - Decreased executive function. - Increased risk-taking behavior. Peripheral Nervous System: - Decreased somatosensory input nerve signaling and processing. - Loss of motor neurons contributing to decreased muscle mass and strength. - Decreased autonomic nervous system function. - Contributes to impaired cardiac function and orthostatic hypotension. - Impaired cardiac performance and brain perfusion increase falls risk. Musculoskeletal and Endocrine Systems: - Decreased bone density. - Loss of muscle mass. - Altered neuroendocrine function. - Changes in pharmacokinetics and pharmacodynamics. management of falls - Addressing falls requires a multidisciplinary and holistic approach. - This approach includes falls detection, prevention, and management of falls response for community-dwelling older adults. - Primary care management of falls necessitates this comprehensive approach due to the numerous intertwined contributing factors. - Falls management should involve: - Screening for risk factors. - Providing individualized interventions to minimize these factors. - Implementing prevention strategies. - Steps for falls prevention: - Identify risk factors. - Educate individuals. - Reduce modifiable risk factors.  risk factors for falls Risk Factors for Falls Biological Risk Factors - Intrinsic factors related to the human body and aging: - Acute illnesses causing weakness, pain, nausea, or dizziness - Balance and gait deficits - Chronic conditions or disabilities (e.g., Parkinson's, diabetes) - Cognitive impairments (e.g., dementia, delirium) - Poor vision or muscle weakness - Reduced physical fitness Behavioral Risk Factors - Actions, emotions, or choices influencing falls: - Inappropriate use of assistive devices - Excessive alcohol consumption - Fear of falling, especially after previous falls - Choice of footwear or clothing - Inadequate nutritional intake (e.g., vitamin D, hydration) - Inappropriate medication use - Other risk-taking behaviors Environmental Risk Factors - Factors associated with the physical environment: - Community hazards (e.g., stair design, inadequate lighting, uneven pavement) - Home hazards (e.g., throw rugs, improper carpeting, electrical cords) - Weather conditions (e.g., ice, snow, maintenance of roads and pathways) Social and Economic Risk Factors - Socioeconomic determinants contributing to falls: - Lack of supportive social networks - Social isolation, depression - Limited family support or engagement in social activities - Financial constraints limiting home modifications - Poor socioeconomic status affecting environment, nutrition, healthcare access, and health literacy Summary Falling is considered a geriatric syndrome with multiple risk factors  2.6 assessment of falls risk outcomes measures falls screening and assessment annual checkup/first assessment ask if they’ve fallen in the last 12 months difficulty w walking or balance? ^helps to see if theyre fall risk another way to work these questions are you losing your balance bc of your legs? if yes, ask specifics and circumstances of a fall to determine what could be prioritized as a modifiable risk factor are they dizzy? any other sx’s? excessive hear of falling and medication review also warranted subjective outcome measures assessment/screen subjective balance assessment to test confidence vs performance activities specific balance confidence scale (ABC) series of 12 Q’s ask pts to self rate perceived ability or complete various tasks ex: walking, up and down stairs, walk in crowded spaces, stand up from chair, walk while holding heavy objects or on icy surfaces rating from 0-100% w total score being average confidence score 80% or less- activity restriction ^approximate mean for elderly w/in the community scores less than 67% have indicated fall risk accurately classifies 84% of fallers STEADI Algorithm Overview - Developed by Greater Los Angeles VA Geriatric Research, Educational, and Clinical Centers (2011) - Covered in Clinical Population Prevention and Health Components of STEADI Algorithm 3 Verbal Questions - Do you feel steady when standing or walking? - Do you worry about falling? - Have you fallen in the past year? 12-Item Checklist - Includes the three verbal questions - Urinary urgency - Difficulty getting up from a chair - Loss of sensation in the feet - Medication or mental health issues High Risk Indicators - Answer "yes" to any of the three verbal questions - Score of four or more out of 12 on the checklist Actions for Not at Risk Individuals - Educate patients on falls prevention - Assess vitamin D intake and recommend supplementation if needed - Refer to community exercise or falls prevention programs - Provide reassessments annually or if a fall occurs  quick STEADI: getting started w fall risk screening for older adults Importance of Preventative Education and Treatment - Vital for preventing early falls Screening for Fall Risk - Use the STEADI algorithm to identify at-risk individuals Further Assessments for At-Risk Individuals - Gait, strength, and balance: - TUG (Timed Up and Go) test - 30-second Sit to Stand test - Review: - Medications - Home environmental hazards - Orthostatic blood pressure - Visual acuity - Foot and footwear condition - Vitamin D intake - Comorbid conditions Interventions Based on Risk Factors - Provide specific interventions based on identified risk factors using the STEADI algorithm falls risk assessment and screening tool (FRAST) study by Mielenz et al. (2020) - Aim: Increase uptake of the STEADI program, recommended by the CDC, to promote community fall prevention programs among older adults - Goal: Simplify the STEADI screen Simplified Screening Process 3 Key Verbal Questions - Do you feel steady when standing or walking? - Do you worry about falling? - Have you fallen in the past year? Assessment Methods - TUG (Timed Up and Go) test - Gait and balance observation Risk Identification No Risk - Responds "no" to all three questions - TUG score < 12 seconds - No observable gait or balance deficits At Risk - Responds "yes" to any question - TUG score ≥ 12 seconds - Observable gait or balance deficit Research Findings - Simplified tool had moderate predictive validity compared to the full screen FRAST part 2 Fall Risk Assessment and Screening Tool (FRAST) - Itemizes various risk factors and assigns a point system - Determines overall falls risk Tool Characteristics - Time and resource-intensive - Relies on the individual to complete most items - Includes a home environment checklist - Includes a separate mood screening tool  Usefulness in Practice - Some items may be more useful than others - Consider selectively incorporating relevant items into practice Scoring and Risk Levels - Low Risk:Score of 0 to 4 - High Risk: Score of 5 or higher - Merits further review Automatic Risk Triggers - Female and over 75 years old - Triggers alert regardless of responses to other items - Sedentary daily routine combined with being female or 75 years old or older - Also triggers alert tinetti performance-oriented mobility assessment (POMA) Tinetti Performance-Oriented Mobility Assessment (POMA) - Indicates falls risk based on balance and gait assessment - Focuses on observed mobility - Does not include subjective information or other risk factors Scoring System - Total score out of 28 points - Higher score indicates lower falls risk - High Falls Risk:Score less than 19 out of 28 Similar Items Found In - Berg Balance Test - Mini BEStests - Dynamometry tests morse fall scale Morse Fall Scale - Recommended by the geriatric section of the APTA - Commonly used by non-rehab therapists - Often utilized by nurses or in acute care settings - Minimally used by physical therapists - Included as a "good to know" tool, not essential Scoring System - Totals 125 points - Higher scores indicate higher risk of falls - High Risk: Greater than 50 points other measures Outcome Measures for Detecting Falls Risk - Various measures can be used for older adults or other populations - Important to have multiple tools in the toolbox Selecting an Outcome Measure - Consider the individual's circumstances - Assess: - Patient's current status - Capacity for improvement - Patient's goals - Choose the most appropriate measure(s) - Determine what is most informative in the current care setting - Base selection on the general idea of the items involved in each outcome measure Summary Multiple outcome measures exist to assess falls risk with varied emphasis on different risk factors  2.7 Assessment of Fall Risk Falls intervention program can be initiated by PT made by Alba Alvon multifactorial approach - medication rvw/hx - hx/screen for OP, dep, incontinence, cardiac sx ↓ PT assessment of - strength, balance, mob, gait, footwear, environmental hazards, cognition, vision, cardiac, neuro fxn ↓ interventions assigned heels Footwear worn study >4.5 cm 50% shoes inadequate support postural 60% no cushion sway 28-38% barefoot/socks indoors decreased lat stab Poor footwear hip fx Athletic shoes falls lowest risk decreased gait velocity/stride length (loose in rear) Ideal Shoe & Height: 2.5cm - - thin hard soul w/ high back - velcro/laces for better balance/performance T Altering shoes helps w/ deformities, protect from pressure ulcers, comp for decreased fxn can check how fit if take sole out and step on it bumps = good for peripheral neuropathy  Study Enviornmental Hazards rugs, mats most danger slippery floors, steps Study of top 3 worst bathrooms bedrooms stairs Turn on lights!!! Environmental Hazards Outside poorly maintained/cluttered areas bad think of socioeconomic impact S She said to know this Summary - home & community environment should be assessed & adapted to mitigate know risk factors for falls 2.8 Exercise for Fall Prevention Cochrane review all types of exercise reduce risk of falls by 23% & # of ppl experiencing falls by 15% Balance & Fxnal exercise reduce by 24% and # experiencing 13% Tai Chi reduce by 19% & experiencing by 20% MOST EFFECTIVE multimodal: balance, resistance training reduce by 34% & # experiencing 22% Grade A evidence for exercise for intervention for falls/balance strength, balance, gait training min hours = 50 hrs over 6 months to reduce risk mod/challenging balance training = reduce rate of falls by 25% Fall Program Resources master of balance Tai Ji Quan: Moving for better balance stepping on stay active & independent for life (SAIL) fallsTalk/FallsScape Otago Exercise program: home based/frail/severe balance problems Otago made in new zealand (reduce falls) 17 strength, balance, & aerobic exercises 3x week certified PTs deliver & progress for 6-12 months w/ 2 week check in indivual/group inexpensive/medicare cover complete -> community based fall prevention program static/dynamic balance ex, strengthen knee ext/flex, hip abd, ankle df/pf fxnal STS & mobility Study as effective as PT w/ adults in assisted living facilities most effective reducing falls for >80 y/o reduced by 30-66% adherence telehealth & integrate ex to everyday acitivities improves motivation - feedback, gaming, performance monitoring, remote support, guidance/education linking to activities implements a behavioral change  Increased age/falls higher likelihood of cognitive impairment - can effect adherence multicomponent exercise based intervention - exercise & cognitive exercise 15-20 min mild to mod dementia anyone can administer find right motivation and base on cognitive/physical needs can make it work individual/group Summary collaborate w/ other healthcare ppl 2.9 Continuum of Care Debate if continuum from healthy aging to disease or if separate Dao - Continuum interventions can be done to slow but not prevent aging process - mental/cognitive/social health stressors reduced increased longevity of life can be matched Health Care before manage dx as manifests problem is that they develop over time before actually popping up -> accelerated aging has already begun combat aging as a whole - address all age dx at one time - creates age friendly societies and healthy aging Continuum of Care more emphasis later when interventions dont work as well - SNF, LTC, end of life care - reacting at this point doesn’t help bc they’re less mobile, less active, less cognitive fxn, less participation if we address earlier in adulthood/childhood more success reading graph as go down in graph need more acute care or coordinated care to help w/ dx need comprehensive geriatric assessment through the care Long Term Care Availability day programs - adults who feel lonely/isolated/cant be home alone - prevents caregiver burnout - arts/crafts/outtings/mental stim/ss/health screening home care - help w/ ADLs - meds/wound care indep living - need more help but have privacy group homes - smaller scale like indep living but specialized - more affordable/less health care SNF - decreased fxn, prolonged med tx, goal return to  Role of PT in Home Health work w/ pt, caregiver, & other disciplines to be covered by medicare: homebound, confined to home (use AD, contra leaving etc) - taxing effort leaving home promote independence in ADL, increase mob w/in home, promote reintegration into community, minimize further complications caregiver training, resource recs, equipment rec Role of PT in Acute minimize hospital acquired issues - delirium, falls, pneumonia, reduce readmissions work w/ healthcare team - airway clearance, caregiver training, pain management, home assessments, socioeconomic support, reassessing for dc Role of PT in inpatient rehabilitation 3 hrs pt everyday 5x week 2 rehabs: OT, PT, SP higher fxn, good prognosis medicare/aid 60% of pt must have one of the dx - stroke - sc injury - congenital deformity - amputation - major trauma - femoral fx - TBI - other neuro (parkinson’s, polyneuropathy, RA, systemic vascularity w/ jt inflammation) - severe OA - TKN/THA goal: optimize mobility for dc equip, family education/training, prevent rehospitalization, address secondary impairments Role of PT in LTC facilities more time to determine dx or need more skilled health services improve fxnal ability but not as intense not covered by medicare/aid unless qualify for some OP visits not the most affordable Summary transitioning care key to comprehensive provision services important for dx disposition/planning  2.10 Pallative Care Palliative Care support to pt and families thru dying process in home, acute care, LTC provide sx management, education on end of life options, care planning for living at home, counselling & support, & assistance to access care or other resources elgibility depends on dx of life limiting dx / end stage chronic dx focus on QOL & comfort for pts but can offer curative tx Hospice = subset final stages of life ending illness support for family. any location but normally home pain management, ADL assistance, emotional, psyc, spiritual support eligible-less than 3 months, DNR, bed/chair bound focus on comfort, get most out of remaining time PT shifts role twrd pt & family management, support, pt advocacy w/ interdisciplinary team caregiver support, cultural religious beliefs and acknowledging complex psychosocial variables study: profesional role to educare on hospice/ palliative care, advocate for change in healthcare policy/coverage Successful Palliative Care guided discussion, pt & support system, collaborative goal setting, PT interventions, reassessments rehab light: exercise/fxnal training at slower rate - 1-2 per week, goal to improve fxn over time - chemo, infxn, acute fxnal decline skilled maintenance Rehab Models - continue task even if need assistance bc it hold value to them - need PT to do the handling supportive care - enhance pt comfort, improve QOL, no goal of fxn improvement - massage, guided imagery, education, ROM, psychosocial supp case management - dont need/want PT but will be reassessed to see if needed rehabilitation in reverse - educate when fxn decline, equip, transfer train Advance care directive provide med team/family on how to proceed if incapacited update w/ new dx aka living will legal about resuscitation, vent, PEG, medication  2.11 Death with Dignity Voluntary End of Life - MaiD (Medical Assistance in Dying) - Healthcare workers who legally facilitate the death of someone who no longer wants to live with a health condition - Other Terms - Voluntary euthanasia, death w/ dignity, physician assisted death, medically assisted - Term implies ability to choose time & place of ones death - Highly debated topic - Poor QOL - Unbearable suffering - Desire for autonomy & quality of death - “With dignity, 1 can accept ones fate & go gently into the night” or - “Fight tooth & nail until death & then rest” - Routes - One route is cognitive acceptance - Other is philosophical acceptance Worldwide Legality - Cognitive acceptance of death is more widely accepted - Especially in chronic disability - MAiD - Process is legal with strict circumstances, some more restrictive than others -Euthanasia - Netherlands 1st country to legalize euthanasia in 2002 - 11 places in US, Germany, Switz, Belgium, Luxembourg, Spain, Columbia, Canada, Australia, New Zealand MAiD in Canada - Updated after 2016 - Eligibility - Based on age, 18+ - Government funded healthcare - Have capacity to make own decisions - Irremediable medical condition - Had to be voluntarily requested w/ consent - Published Statistics - Average age seeking: 75.2 years - 9,375 requests were made, 78.8% fulfilled - 2.5% pulled request, 6% deemed ineligible, 2.7% died before receiving MAiD - 85% lost ability to engage in meaningful activities - 80% lost ability to perform ADLs - Significant rise in requests for MAiD The US - Seattle Cancer Care Alliance Study - 114 inquired about the program - 26.4% initiated the program, but did not follow thru - 35% received the prescription for lethal meds but some did not take it - Families had a feeling of control - Reasons - Loss of autonomy, inability to engage, loss of dignity, uncontrolled fear/pain - Studies - People who do not opt in for MAiD experience - higher lvls of pain, depression, anxiety, dyspnea Predictors of MAiD Acceptance - Associated factors - Younger age, non-religious beliefs, higher lvl of education, higher income - Possible factors - Divorced, having ALS or cancer, depression, having ageism beliefs Brittany Maynard - Figurehead of Death with Dignity movement - Diagnosed with brain cancer, terminally ill - Allows her to make the decision when enough is enough Gloria Taylor - Canadian advocate for medically assisted dying - Diagnosed w/ ALS in 2009 - Wasn’t legal at all when she was diagnosed - Has home support workers twice a day/7 days a week - No desire to live life in drug induced haze - Impacts her ability to spend time with grandchildren - Dr. Dao explanation - Gained exemption to seek MAid, - Died due to infection of perforated colon Physician-Assisted Death in Dementia & Mental Health Conditions - Dementia - Viewed less favorably by public & healthcare providers - May not have the cognitive capacity to make their own decision - Mental Health - Highlighted during the COVID-19 pandemic - Raise ethical & moral concerns - Comprehensive assessment of disorder & eligibility - Should have an oversight process Opposing Arguments - Slippery Slope - Ineffective & unethical - Lack of Self-Determination - Inadequate palliative care - Pain & depression management would help ease suffering - Medical Professionalism - Means vs. Ends  2.12 TED Talk BJ Miller - Formal relationship with death - Long run as a patient - American Healthcare System, has a fair share of dysfunction - Purpose - Reach out across disciplines to invite design thinking - Bring intention & creativity to experience of dying - Suffering unites care giving & care receivers - Pallative Care - Comfort & living well at any stage - Don’t need to be dying to benefit for this care - Works at Zen Hospice Project - Little ritual to help shift prospective - Minutes of sweet, simple parting image - Hospitals - Not a place to live and die in - Designed for acute trauma & treatable illnesses - Need to create something new, vital - Key ingredients - Policy, education & training, systems, bricks & mortar - Loving time by the way of our senses - As long as we have 1 sense, possibility to access what makes us feel human - Set sights on well being - Make life more wonderful, less horrible - Asking we make space, physical psychic room to allow life to play itself all the way out - Can’t solve for death - Always find a shock of beauty or meaning with what you have left of life - Learn to live well, not in spite of it, but because of it