Pt in geriatric

PHYSIOTHERAPYINGERIATRIC

PRESENTED BY: DR.SHILPA K PRAJAPATI

CONTENTS 1. ASSESSMENT

2. GOAL-SETTING

3. THERAPUTIC INTERVENTION

4. RE- ASSESSMENT

GERIATRIC ASSESSMENT AIMS:

Better recognize common geriatric disorder.

Plan an effective treatment program.

Improve over all health and functional outcomes.

Reduce vulnerability to subsequent illness.

Provide better quality of life.

THE TEAM: many members work together to develop a single

treatment plan

EFFICIENCY OF ASSESSMENTProblem area

Screening measure Abnormal response

Mobility Note the time after asking the patient: ’RISE FROM THE CHAIR, WALK 20FT, TURN , WALK BACK TO THE CHAIR AND SIT DOWN’

Unable to task 15 second

Physical disability

1.Have you had any fall in last year? Yes to all six

2.Do you have trouble with the activities of personal life like bath, dress, toilet or eat?

Questions

3.Do you have trouble with light house hold work like cooking?

4. Do you have trouble with heavy house hold work like washing cloths?

5.Are you able to go out for shopping or to see a family friend?

6.Are you able to do strenuous activities such as cycling or fast walking?

EFFICIENCY OF ASSESSMENTProblem area screening measure Abnormal

response

Vision Test each eye with Snellen eye chart, with glasses if applicable

Can’t read 20 /40

Hearing Whisper short sentences at 6-12 inches

Unable to hear

Urinary incontinence

Do you have problem with urine leaks?

Yes to the question

Nutrition , weight loss

Have you lost weight ? If yes, how much?

Loss of 5 per cent

Weight /BMI BMI< 21

Memory Name 3 objects ask to recall in 5 min

If remember <3

Depression Have you often been bothered by feeling sad or depressed?

Yes to the question

COMPONENTS OF ASSESSMENT

HISTORY TAKING: General Guidelines Remember that patient having age related changes

in one or more body system.

Keep the pace slower than usual

Introduce yourself in start of history taking

Address each individual as per her/his preference. Sir, Madam, Mr., Mrs. Use rather than grandma or grandpa

Adopt the most effective way of communication such as eye contact, gentle touch or loud voice.

COMPONENTS OF ASSESSMENT

- Do not discuss the case with relative to the questions as if he is not allow to participate in discussion. Never ignore the presence of elderly

Ensure that patient can hearing what is being said

Provide glasses if needed

Speak at eye level facing the patient

Never treat the elderly as is a child

Respect elderly as an individual.

COMPONENTS OF ASSESSMENT Subjective information and personal history:

Age/sex Education/occupation Socioeconomic status etc.

Chief complaints: reflecting the presence of multiple pathologies

Present physical illness: chronic disease previous surgeries or hospitalization

Drug history: prescribed or non-prescribed drugs, drug allergies Nutritional history: number of meals/day, contents of diet

Family history: major disease in family, cause of death of family members.

PHYSICAL EXAMINATION

-Height, weight and BMI

Orthostatic BP and pulse -Edema

Skin integrity, pallor -Rang of motion

Muscle strength -Sensory status

Coordination -Vision and hearing

FUNCTIONAL STATUS 1. Basic self-care and personal hygienic activities of daily

living(BADLs) Here; I-Independent, A-Assistance requires, D-Dependent

2. More complex activities essential to live in community(IADLs)

3. BalanceModified performance oriented mobility assessment( poma)

GAIT SCORE =_____/12, BALANCE SCORE =_____/16

TOTAL SCORE (Gait + Balance ) =_____/28

{< 19 high fall risk, 19-24 medium fall risk, 25-28 low fall risk} 4. Gait 5.Mini-cog assessment instrument

GOAL-SETTING

Functional independence is the ultimate goal.

To relieve pain

To improve or maintain ROM of different joint

To improve or maintain strength and endurance of movement

To improve or maintain cardiovascular endurance

To improve or maintain ambulatory status

THERAPEUTIC INTERVENTION RANGE OF MOTION EXERCISES

Flexibility decreases with age and joint become stiff

Development of contracture, it develop within 1 week of inactivity

Passive ROM: therapeutic benefits To maintain range of motion To prevent complication of inactivity such as - contracture formation - cartilage degeneration -deep vein thrombosis etc

RANGE OF MOTION EXERCISES Active ROM: therapeutic benefits

To preserve joint function

To maintain physiological elasticity and contractility of muscle

To maintain and improve ROM

To induced muscle relaxation To decrease pain

To increase circulation and thereby preventing DVT.

To provide sensory feedback from the contracting muscle

To provide a stimulus for bone and joint tissue integrity To improve neuromuscular coordination

STRETCHING EXERCISE

1. Static stretching: the muscle tendon unit under a slow, gentle stretch that is maintain for a period of 20 to 60 seconds

2. proprioceptive neuromuscular facilitation stretching: the inhibition technique that attempt to reduce muscle tone The most popular technique is Hold-Relax

3.Ballistic stretching: it is contraindicated in - elderly individuals - sedentary individuals - musculoskeletal pathology and - chronic contracture Because,

the high velocity, high intensity movement are difficult to control. Tissue weakened by immobilization or disuse, can be injured easily Dense connective tissues of chronic contracture become more brittle

and tears more readily

MOBILIZATION EXERCISE

Joint mobilization stretching technique: specially use for restricted capsular tissue

Therapeutic benefits To stimulate the mechanoreceptors that may inhibit the

transmission of nociceptive stimuli at the spinal cord or brain steam level

To cause synovial fluid motion, this is the vehicle for bringing nutrients to the avascular portion of the articular cartilage

To prevent painful or degenerative stasis when a joint is swollen or painful

To elongate hypomobile capsular and ligamentous connective tissue

To mechanically distend the shorten tissue

STRENGTHENING EXERCISE

Force-generating capability is prerequisite for performing many everyday activities.

Therapeutic benefits The increase in muscle strength Improve in neuromuscular co-ordination Improve stability of joint An increase in bone mineral density Lessen the amount of stress placed on the

joints that are mostly affected by degenerative process in older adults


TYPES OF RESISTANCE: 1. body weight:

Body weight offers sufficient resistant for initial training, similar to active ROM.

Progression can be done by performing exercises in different positions

2. manual resistance: The main disadvantage of this exercise is that

the amount of resistance can not be measured quantitatively.

But experience therapist very well judge the amount of resistance


3. mechanical resistance: Equipment ranges from simple to complex Incase of old-olds(>85 years) this equipment should not

be used, as it my result in to muscle soreness or inhibition

4.intensity of exercise: Start with base line assessment of intensity, Popular method is find out repetition maximum(RM)

5.Frequency and duration: For each level of intensity, session are 2- 3 time a week A single session consist of 3 set of 10RM Resistance can be increase when 1 or 2 sets done in a

smooth manner


6.Rest intervals: Patient should rest from 1- 2minutes between

sets in a same session

7. mode of exercise: Functional strength is affected not only by the

absolute ability to generate force but also by the ability to generate force across the varying lengths of the muscle during movement.

So the strengthening exercise include dynamic exercise as well as static exercises

AEROBIC EXERCISES

This endurance activities that do not require excessive speed or strength but do require on cardiovascular system

Therapeutic benefits Improvement in maximal cardiovascular functional

capacity: Older people can increase vo2 max to the same relative degree as young people

Improvement in the energy level: decrease LDL and triglyceride level increase HDL.

Improvement in the body composition Reduction in fat mass and increase in muscle mass

AEROBIC EXERCISES

Reduction in disability: improve stability of joint and thereby reduce

disability

Psychological well-being: lessen depression and improve belief in self-efficacy.

Improvement of functional status

Reduction in the risk of developing age-related disease like coronary heart disease, HT, Atherosclerosis,

Diabetes and osteoporosis.

AEROBIC EXERCISES

EXERCISE PROGRAM 1.Aerobic warm-up: 5-7 min

Indication: to reduce the chances of injury

2.aerobic conditions: Protocol: mode,

intensity- 60% of MHR, duration- 30 minute, frequency- 5 days in a week

3.Cool down: 10 min Indication: To expedite the recovery process after aerobic

exercise To prevent injury Protocol: slow walk for 5 minutes and slow exercises

GAIT TRAINING

The purpose is to make a patient walk at functional speed.Factors contributing

the altered gait of patient

physical therapy intervention

1.difficulty in rising from sitting

2.Increased thoracic kyphosis with flexion in lower cervical spine and extension in upper cervical spine-

3.Unequal weight distribution-

place feet close to chair by flexing knees >90d,bend forward in sitting, push from chair,strengthening of triceps & latissimus dorsi,adaptation height of chair

correction in cervical spine position in sitting,postural control training, visual feedback in standing, Hold-Relax

weight in all directions- forward, Backward, side ways- for equal distribution in standing, decreasing the size of support, eg. alternately raising on toes and heels, standing on balance board, eccentric contractions of quadriceps and gluteals, biofeedback

GAIT TRAINING4.Increased stiffness and/or tightness of soft tissues in trunk, hip, knee and ankle-

5. Difficulty in maintaining weight bearing postures-

6. Foot clearance problems-

suitable heat modality , joint mobilization with precaution in case of osteoporosis, Hold-Relax, passive stretching or self stretching

rhythmic stabilization , standing on different types of surfaces like foam, concrete to alter sensory input, standing with eyes closed, isometric contraction of the postural extensor muscles in shortened range against resistance , assess foot wear , hard sole, well fitted , lace- up shoes with thick, absorbent socks are preferred, recommended walking aid according to deficits and needs of patient

faradic stimulation to ankle dorsi flexors, hip hiking in parallel bar, weight shifting to forwards and backwards, ankle mobilization to increase DF. , strengthening of ankle dorsi flexors

GAIT TRAINING

7.Difficulty with reciprocal swing of legs-

8. Decrease strength of muscles –

9. Decrease cardiovascular endurance –

10. Decrease push-off –

trunk rotation on mat, trunk twisting in sitting and standing, 4-point gait drills

resisted exercise with therabands or weights, training on isokinetic device ,PNF technique

administration of aerobic exercise in graded manner

strengthening of planter flexors ,ankle mobilization to increase planter flexion, standing on toes

ORTHOTICS The responsibility of physical therapist is to identify

abnormal positions and movements that are responsible for; pain, Misalignment of body segment, Difficulty in maintaining weight bearing position, Unequal weight distribution and Gait deviation

Indications: To provide mobilization or to control movement To support a weakened structure To prevent deformity and correct anatomical alignment To promote ambulation and assist motion to improve body

function To relieve pressure on areas and to reduced pain

ORTHOTICS

Principles: There should be a practical balance between the objective

that are ideally desired and the tolerance of elderly patients

The basic principle refers to the application of force to the involved body segments.

Comfort and tolerance are important for an elderly patient Attempting biomechanical control is not appropriate in

most of geriatrics, Plastic orthosis is the choice in elderly patient, AFOs are well tolerated by elderly individual HKAFOs usually not recommended, as they are

cumbersome A hip orthosis is used to restrict the movement of hip

adduction and flexion

RE-ASSESSMENT

There should be ongoing reassessment while administering geriatric physical therapy program.

This enables to judge the effectiveness of treatment towards the goal set, with a required modification in the treatment strategies.

REFERENCES

1.principles of Geriatric Physiotherapy By: Narinder Kaur Multani & Satish Kumar Verma

The core of Geriatric Medicine By: Leslie S. Libow & Fredrick T. Sherman

Rehabilitation of the older person Third edition by: Amanda squires and

Margaret Hastings

THANK YOU..

BASIC ACTIVITIES OF DAILY LIVING(Here; I-Independent, A-Assistance requires, D-Dependent)

A. Toilet:I- Able to get to, on and off toilet, cleans selfA-Needs help, soiling or wetting while asleep more than 1weekD- Completely unable to use toilet

B. Feeding:I- Able to completely feed selfA- Feed self with assistanceD- Completely unable to feed self or need parenteral feeding

C. Dressing:I- Able to select cloths, dress and undress selfA-Need assistanceD-Completely unable to dress and undress self

BASIC ACTIVITIES OF DAILY LIVING D. Grooming: (neatness, hair, nails, face, clothing)

I- Able to groom well without helpA-Needs assistance in groomingD-Completely unable to care for appearance

E. Physical Ambulation:I-Able to get in/out of bed, roam around without helpA-Needs human or mechanical assistanceD-Completely unable to get in/out of bed/chair, walk

F. Bathing:I- Able to bathe(tub, shower) without assistanceA-Need assistance for getting in and out of tub or washing

more than one body partD- Completely unable to bathe self

INSTRUMENTAL ACTIVITIES OF DAILY BY: LIVINGM.P. LAWTON & E.M. BRODY

A. Ability to use telephone:I-Able to operate telephone on own initiativeA-Answered telephone but needs special phone or assistance in getting number

dialingD- Unable to use telephone at all

B. Shopping:I-Able to take care of all shopping needs independentlyA-Able to shop but needs to be accompanied on any shopping tripD- Unable to shop

C. Preparing meals:I-Able to plan and prepare meal independentlyA-Unable to cook full meal alone

D-Unable to prepare any meal

D. HousekeepingI-Able to maintain house independentlyA-Able to do light work bt need assistance with heavy taskD-Unable to do any house work

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

E. LaundryI-Able to launder independentlyA-Launder small items such as socks, handkerchiefD-Unable to launder at all

F. TravellingI-Able to drive own car or travel independentlyA-Needs assistance for travellingD-Unable to travel

G. Responsibility for own medicationI-Able to take medication in correct dose and timeA-Able to take medication if it is prepared in advanceD-Unable to take medication

H. Ability to manage financesI-Able to maintain finance s independently eg. Pay billsA-Able to manage day to day purchases but needs assistanceD-Unable to handle money

MODIFIED PERFORMANCE ORIENTED MOBILITY ASSESSMENT( POMA)

- Balance Tests - Initial instructions: Subject is seated in hard, armless chair. The

following maneuvers are tested. 1. Sitting Balance Leans or slides in chair =0

Steady, safe =1 _____ 2. Arises Unable without help =0

Able, uses arms to help =1 Able without using arms =2 _____

3. Attempts to Arise Unable without help

=0 Able, requires > 1 attempt =1 Able to rise, 1 attempt =2

_____


4. Immediate Standing Balance (first 5 seconds) Unsteady (swaggers, moves feet, trunk sway)=0 Steady but uses walker or other support =1 Steady without walker or other support =2 _____5. Standing Balance Unsteady =0 Steady but wide stance( medial heals > 4 inches apart) and uses cane or other support =1 Narrow stance without support =2 _____

6. Nudged (subject at maximum position with feet as closetogether as possible, examiner pushes lightly on subject’ssternum with palm of hand 3 times)

Begins to fall =0Staggers, grabs, catches self =1Steady =2 _____


7. Eyes Closed (at maximum position of item 6) Unsteady =0 Steady =1

_____

8. Turing 360 Degrees Discontinuous steps =0 Continuous steps =1 _____

Unsteady (grabs, staggers) =0Steady =1 _____

9. Sitting DownUnsafe (misjudged distance, falls into chair) =0Uses arms or not a smooth motion =1Safe, smooth motion =2 _____

BALANCE SCORE: _____/16


- Gait Tests -Initial Instructions: Subject stands with

examiner, walks down hallway or across room, first at “usual” pace, then back at “rapid, but safe” pace (using usual walking aids)

10. Initiation of Gait (immediately after

told to “go”Any hesitancy or multiple attempts to start=0 No hesitancy=1

_____


11. Step Length and HeightRight swing foot

Does not pass left stance foot with step =0Passes left stance foot =1 _____Right foot does not clear floor completely

With step =0Right foot completely clears floor =1

_____

Left swing footDoes not pass right stance foot with step =0Passes right stance foot =1_____Left foot does not clear floor completely

With step =0Left foot completely clears floor =1 _____


12. Step SymmetryRight and left step length not equal (estimate) =0Right and left step length appear equal =1 _____

13. Step ContinuityStopping or discontinuity between steps =0Steps appear continuous =1 _____

14. Path (estimated in relation to floor tiles, 12-inch diameter;observe excursion of 1 foot over about 10 ft. of the course)

Marked deviation =0Mild/moderate deviation or uses walking aid =1Straight without walking aid =2 ____


15. TrunkMarked sway or uses walking aid =0No sway but flexion of knees or back or

Spreads arms out while walking =1No sway, no flexion, no use of arms,

and no Use of walking aid =2 _____16. Walking Stance

Heels apart =0Heels almost touching while walking =1 _____

GAIT SCORE = _____/12, BALANCE SCORE =

_____/16

TOTAL SCORE (Gait + Balance ) = _____/28

{< 19 high fall risk, 19-24 medium fall risk, 25-28 low fall risk}

MINI-COG ASSESSMENT INSTRUMENT

1) Inside the circle, please draw the hours of a clock as they normally appear

2) Place the hands of the clock to represent the time: “ten minutes after eleven o’clock”

The Mini-Cog Assessment Instrument for Dementia The Mini-Cog assessment instrument combines an uncued 3-

item recall test with a clock-drawing test (CDT).

Mini-Cog can be administered in about 3 minutes, requires no special equipment, and is relatively uninfluenced by

level of education or language variations.


Administration 1. Instruct the patient to listen carefully to and remember

3 unrelated words and then to repeat the words.

2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock

circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the

hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional

instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the

recall distractor.

3. Ask the patient to repeat the 3 previously presented word.


Scoring Give 1 point for each recalled word after the CDT distractor. Score

1–3.

A score of O indicates positive screen for dementia.

A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.

A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

A score of 3 indicates negative screen for dementia.

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands

readably display the requested time.

GERIATRIC DEPRESSION SCALE (MOOD SCALE)

Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO

2. Have you dropped many of your activities and interests? YES / NO

3. Do you feel that your life is empty? YES / NO

4. Do you often get bored? YES / NO

5. Are you in good spirits most of the time? YES / NO

6. Are you afraid that something bad is going to happen to you? YES / NO

7. Do you feel happy most of the time? YES / NO

8. Do you often feel helpless? YES / NO

GERIATRIC DEPRESSION SCALE (MOOD SCALE)

9.Do you prefer to stay at home, rather than going out and doing new things? YES / NO

10. Do you feel you have more problems with memory than most? YES / NO

11. Do you think it is wonderful to be alive now? YES / NO

12. Do you feel pretty worthless the way you are now? YES / NO

13. Do you feel full of energy? YES / NO

14. Do you feel that your situation is hopeless? YES / NO

15. Do you think that most people are better off than you are? YES / NO

Answers in bold indicate depression. a score > 5 points is suggestive of depression and should warrent a follow-up interview. Scores > 10 are almost always depression.

Pt in geriatric

Health & Medicine

intensity of exercise

aerobic exercises reduction

strengthening exercise

mode of exercise

slow exercises

weight loss

level of intensity

aerobic conditions