1 Patient Care for Special PopulationsPT 240

2 Special Populations Geriatrics and aging Cardiovascular PulmonaryBariatrics Work hardening Lymphedema Wounds and burns Amputees and prosthetics Women’s Health/pregnancy Other systems

3 Objectives Cognitive Psychomotor AffectiveEtiology, pathology, precautions, data collection, interventions, safety awareness for each population Psychomotor Demonstrate interventions that are safe, effective, and within the POC for each population. Document data and interventions Affective Communication, respect, awareness of patient needs

4 Motor Changes that occur across our Life SpanHerzing University Orlando, FL

5 Objectives 1. Explain motor changes that occur across the lifespan and variability of motor performance amongst individuals 2. Examine the impact of health and fitness sustained over the lifespan on motor performance 3. Discuss the impact of age and age-related changes in exercise and training programs 4. Identify precautions in physical therapy interventions specific to the geriatric patient 5. Discuss and describe the progression of Alzheimer’s and senility

6 Myths on Aging

7 1AFE37F0-5ADD-C64B-B853-34CB5160AFEEAs people grow older, their intelligence declines significantly iRespond Question Multiple Choice F 1AFE37F0-5ADD-C64B-B853-34CB5160AFEE A.) True B.) False C.) D.) E.)

8 Current research suggests that intellectual performance in healthy individuals holds up well into old age. Average decline of most abilities once one is in their 80s. Little to no decline in intellect is associated with CV health, stimulating and engaging lifestyle and flexible attitudes/behaviors at midlife. Can modify intellectual decline

9 The majority of old people (65 or older) have Alzheimer's Disease.iRespond Question Multiple Choice F A1E A25-E345-A5C1-780E B A.) True B.) False C.) D.) E.)

10 Almost 90% of people who are 65 years old do NOT have Alzheimer’s disease.

11 All 5 senses tend to decline with age.iRespond Question Multiple Choice F F68D8F80-91C1-5F4D-BB8F-1956DE517B06 A.) True B.) False C.) D.) E.)

12 The threshold at which we take in stimuli increases with age.Average sensory processes decline. Hearing loss begins at age 20. Taste buds become less sensitive. After age 80, 75% of adults show impairments in sense of smell.

13 Most older people are living in nursing homes.iRespond Question Multiple Choice F 8A26937B-DB5E-F245-98DF-EAD711029CB8 A.) True B.) False C.) D.) E.)

14 Just over 5% of the 65 year old population occupy nursing homes and assisted living.Almost 50% of those 95 and older live in nursing homes.

15

16 Blood transfusions and unprotected sex put older adults at risk for HIV/AIDS as in other populations. As many at 10% of all persons diagnosed with HIV/AIDS are over 50 years of age.

17 Older workers cannot work as effectively as younger workers.iRespond Question Multiple Choice F 4DACABD8-D498-2A4F-B F186C A.) True B.) False C.) D.) E.)

18 Research identifies low turnover, less absenteeism and fewer injuries in older workersCharacteristics include loyalty, dependability, emotional stability, congeniality, and consistent work outcomes.

19 Most older adults consider their health to be good.iRespond Question Multiple Choice F 30A25E DF46-BFF7-9EEE60AA7C2B A.) True B.) False C.) D.) E.)

20 They do not compare current condition to former states, but rather to their peers who are “worse off” Less than 10% of non institutionalized persons over 70 years old are unable to perform one or more ADL

21 Physical strength declines in old age.iRespond Question Multiple Choice F 2CB2389D-5816-F34A-B A.) True B.) False C.) D.) E.)

22 Muscle mass decreases, membranes fibrose, fluid thickens.From age 30, muscle mass declines to almost 50% in old age. Research shows resistive exercise, weight bearing exercise, and aerobics can restore muscle strength, increase stamina, stabilize balance and minimize falls

23 Aging: definition The progressive and cumulative physiological, biological and functional changes in the body systems Common to all members of a given species Decline of homeostatic efficiency Life expectancy – 77.7 years old

24 Sedentary vs. Active B – bladder and bowel incontinence and retention; bedsores E – emotional trauma; electrolyte imbalances D – deconditioning of muscles and nerves; depression; demineralization of bones; decubiti R – range of motion loss and contractures; restlessness; renal dysfunction E – energy depletion; EEG activity increases S – sensory deprivation; sleep disorders; skin problems T – trouble in all systems

25 Systemic Complications with Bed Rest: Critical Thinking(pg 11 – Geriatric Rehabilitation) What happens to the following systems with bed rest? Neurosensory Cardiovascular Musculoskeletal Gastrointestinal Respiratory Functional

26 Case Study: GeriatricsSophia Petrillo

27 Case Study Discussion: SophiaCompare and contrast the three main theories of aging

28 Theories of Aging Developmental – Genetic Theories Nongenetic TheoriesAging is intrinsic in the organism Preprogrammed biological changes of tissues and cells that lead to aging Limits to cell division that can be performed Cell damage due to free radicals, poor nutrition or hydration Nongenetic Theories Environmental factors damage DNA Genetic mutation over time New Theories of Aging Theories relate to sleep, hormones, and genetic influences

29 6 Areas of Focus Anatomy and physiology changes that occur due to the aging process Pathologies and injuries common to geriatric population Tests and Measures used with Geriatric population PT intervention strategies commonly utilized with older clients Goals/outcome expectations for older adults Psychological issues that are unique to older adults and how to adjust intervention

30 Case Study Discussion: SophiaWhat characteristics does Sophia display that are part of the normal aging process? What are other normal aging characteristics? Refer to auditory lecture on Physiological Changes with Aging for more details.

31 1. Physiologic Changes and Adaptations Associated with AgingCellular changes Cartilage Muscular System Skeletal System Body Fat Composition Neurological system Sensory System Cognitive Changes Cardiovascular system Pulmonary system Integumentary system Gastrointestinal System

32 A. Cellular changes Total number of cells decreases with ageAging interferes with cell death Programmed cell death does not occur leading to cancer Accelerated cell death killing healthy good cells leading to Parkinsons and Alzheimers

33 B. Cartilage Thins with age Treatment Implications:Decreased hydration with increased fibrous growth leads to stiffness Treatment Implications: Weight bearing activities help maintain health of cartilage Maintenance of strength around joints can help decrease joint stress

34 C. Muscular system Muscle mass and strength decreases at a rate of about 30 percent between the ages of 60 and 90 Change occurs in muscle fiber type Change in the clear differentiation of fiber type Changes may be due more to decrease activity level and disuse that directly from aging

35 Muscular system (con’t)Decrease in recruitment of motor units. Decrease in the speed of the muscle. contraction and movement. Treatment Implications: Strength can be increased and maintained in the aging individual

36 D. Skeletal System Normal aging results in bone mass and density lossDecrease levels of activated vitamin D3 circulating in blood stream causes less calcium to be absorbed Have imbalance in osteoblast (bone builders) and osteoclast (bone breakdown) activity (> osteoclast activity) There is a decrease in tensile strength of bone (greater than 30 percent of women over the age of 65 have osteoporosis)

37 Skeletal System: con’tFemales lose about 30 percent of bone mass by age 70, males lose about 15 percent Joint flexibility is reduced by 25 to 30 percent by 70 years of age Treatment Implication: Weight bearing exercise can help maintain and improve bone strength Progressive resistive exercise has been shown to improve bone strength More prone to fracture  do fall prevention

38 E. Body Fat Composition Body fat increases in mid life and then decreases Body fat distribution changes  moves from under skin to areas (women – hips/thighs; men – abdomen)

39 F. Neurological System Atrophy of nerve cells in cerebral cortex  loss of cerebral mass Decreased cerebral blood flow and energy metabolism Delay in nerve conduction Neuronal loss and atrophy (30-50% loss of anterior horn cells, 30% loss of posterior horn)

40 Neurological System: con’tEffects on movement: Speed and coordination decreased Slow recruitment of motoneurons contributes to loss of strength Reaction time and movement time are increased Learning and memory affected Treatment Implications: Increase levels of physical activity Allow for increased reaction and movement time Allow for limitations of memory  one-step commands Provide adequate explanation/demonstration

41 G. Sensory Systems Vision – decline in visual acuity, presbyopia, increased sensitivity to light, loss of color discrimination, cataracts, glaucoma, senile macular degeneration, diabetic retinopathy Treatment – wear glasses if appropriate, work in adequate light, provide other sensory cues, safety eduation Hearing – 40% have hearing loss Treatment – check for hearing aids, minimize auditory distractions, speak slowly and clearly, face the patient, use nonverbal communication

42 Sensory Systems: con’tc) vestibular – degeneration in otoconia of utricle and saccule;diminished vestibular occular reflex resulting in diminished vestibular senstion Treatment – more dependent on proprioception for balance, might get blurred vision (VOR); decreased ankle strategy, increase in hip strategy and increased postural sway Diseases that can impact vestibular: Meniere’s disease, Benign paroxysmal positional vertigo, medications, CVA

43 Sensory Systems: con’td) somatosensory – decline in sensitivity to touch, temp, vibration, loss of joint receptor sensitivity, pain thresholds increase Treatment – allow extra time for responses, use touch to communicate, give extra feedback through sensation, teach compensatory strategies to prevent falls, AD

44 H. Cognitive Changes No uniform decline in intellectual abilitiesPerceptual speed decreases (require longer times to complete tasks) Short term memory impairments especially with novel tasks  new learning may take longer Treatment – use mass practice, decrease pace, use memory tools, increase physical activity, increase mental activity (use it or lose it), provide written instruction

45 I. Cardiovascular SystemChanges due to inactivity and disease Slight increase heart size Heart will increase cardiac output by increasing stroke volume to meet demands Loss of pace maker cells in sinoatrial node Blood vessels thicken Treatment – avoid quick changes in position; avoid exercise after meal; maximum HR decreased in elderly;

46 J. Pulmonary System Chest wall thickens, increased kyphosisLoss of elastic recoil of lungs Less effective oxygen uptake Pulmonary blood vessels thicken Decreased lung capacity Treatment – increased ventilatory cost of work at high intensity exercise; impaired cough; individualized exercise program essential; aerobic training important; increase daily activity

47 K. Integumentary SystemDermis thins Decreased vascularity Decreased sweating Skin grows and heals more slowly Decreased sensitivity to touch

48 L. Gastrointestinal SystemDecreased salivation, taste and smell along with inadequate chewing Reduced motility and control of lower esophageal sphincter and stomach Reduced ability for absorption of nutrients in small intestine

49 2. Pathological Conditions Associated with the Aging AdultA. Musculoskeletal System: Osteoporosis Paget’s Disease Fractures Degenerative arthritis/osteoarthritis Rheumatoid Arthritis

50 Case Study Discussion: SophiaDiscuss the similarities and differences between osteoporosis and Paget’s Disease. Discuss the similarities and differences between OA and RA. Given Sophia’s history, what type of exercises are appropriate for her and why?

51 a. Osteoporosis Disease process that results in reduction of bone massFailure of bone formation to keep pace with bone reabsorption and destruction Treatment – Promote maintenance of bone mass by including regular WB exercises Walking 30 min/day, stair climbing, weight-belts Postural/balance training Postural reeducation, stretching, balance ex, tai chi, gait training Safety education/fall prevention

52 b. Paget’s Disease progressive metabolic bone disease characterized by increased bone resorption and excessive, unorganized new bone formation Treatment Encourage regular CV and strengthening activity Postural exercises WB exercises Coordination and balance work AVOID: high impact activities

53 c. Fractures High risk of fractures in the elderly due to decreased bone density, age, comorbid diseases, dementia, psychotropic medications Common fractures in the elderly: Hip fracture, vertebral compression, stress fractures Treatment: Fractures heal more slowly Older adults at risk for complications (ulcers, pneumonia etc with hospitalization)

54 d. OA Non-inflammatory progressive, degenerative process affecting articular cartilage of synovial joints Eventually bony spurs develop Capsular thickening Typically affects WB joints (hips, knees, cervical and lumbar, DIP) Treatment Reduce pain; maintain ROM Balance training Aerobic conditioning and weight reduction Aquatic programs AD

55 e. Rheumatoid ArthritisDiffuse connective tissue disease resulting in inflammation of synovial membrane, release of proteolytic enzymes that perpetuate inflammation and joint damage Inflammatory changes in tendon sheaths Treatment – Decrease pain Increase/maintain ROM (do not stretch swollen joints) Joint protection – orthotics and splints Resistance exercises Exercise ADL’s gait

56 Joint Protection PrinciplesRespect fatigue Conserve energy Use good work postures Avoid pain Maintain joint alignment

57 Pathological Conditions Associated with the Aging Adult: con’tB. Neurological Disorders Stroke Parkinson’s

58 Case Study Discussion: SophiaBriefly describe the similarities and differences between delirium and dementia.

59 Pathological Conditions Associated with the Aging Adult: con’tC. Cognitive Disorders Delirium fluctuating attention state causing temporary confusion and loss of mental function, disorientation to place and time Dementia Loss of intellectual functions and memory causing dysfunction in daily living Depression Disorder characterized by depressed mood and lack of interest or pleasure in all activities and associated symptoms for a period of at least 2 weeks.

60 Pathological Conditions Associated with the Aging Adult: con’tD. Cardiovascular System Disorders Hypertension Coronary Artery Disease Angina Pectoris Myocardial Infarction Congestive Heart Failure Conduction System Disease (pacemaker dysfunction) Peripheral vascular disease Why??

61 Case Study Discussion: SophiaSophia’s medications include Lopressor and Lovastatin. What do these suggest about her medical history? What does it mean for her PT interventions?

62 Pathological Conditions Associated with the Aging Adult: con’tE. Pulmonary Disorders and Diseases Chronic Bronchitis Chronic Obstructive Pulmonary Disease Asthma Pneumonia Lung Cancer Why??

63 4. Tests and Measures for Balance and InstabilityHow many can you list and briefly describe? Have an understanding of the cut off score to determine risk Have an understanding of when each test might be more appropriate endurance cognition time/space limitations

64 Berg: <45 = risk TUG: >20 = risk Functional Reach: <10 = risk Dynamic Gait Index: <15 = risk

65 Common Problem Areas for Aging AdultsImmobility – Disability Falls and Instability Medication Errors Nutritional Deficiency Are these problems areas for Sophia currently? How do they impact functional independence? What can you do as a PTA to address these problems?

66 Case Study Discussion: SophiaIs Sophia currently a fall risk? Which characteristics noted in the evaluation led you to that answer? What other factors would place an individual at a fall risk?

67 A. Immobility - DisabilityCan result from diseases/aging process Limits in function increase with age Immobility leads to additional problems Pressure sores, contractures, bone loss, muscular atrophy, deconditioning, CV issues Interventions – Work towards patient’s goals Focus on optimum function and progression of physical daily activities Prevent further complications

68 B. Falls and Instability30% of persons over age of 65 fall Result in injuries and fractures (40% of admissions to nursing homes) Falls cause increased fear of falling, loss of confidence to function independently, reduced movement

69 Falls and Instability: con’tFactors influencing falls: Age (> age > falls) Sensory changes (vision, proprioception, hearing, vestibular) MS changes – weakness, decreased ROM NM – dizzyness, vertigo CV – orthostatic hypotension, hyperventilation Drugs Mental status changes Depression Fear of falling Setting: 3x as many falls for IP

70 Falls and Instability: con’tIntervention Evaluation by PT (fall hx: location, activity, time, symptoms, previous falls; physical level of functioning; tests and measures) Determine fall risk Intrinsic and extrinsic factors Eliminate fall risk hazards Increase functional mobility provide sensory compensation strategies Balance and gait training (AD’s) Functional training (transfers, turns, walking) Safety education Environmental modification

71 C. Medication Errors Factors leading to errors Implication of errorsMemory, fine motor skills, vision, compliance Implication of errors Safety, non-therapeutic levels, interactions with other meds Strategies to prevent errors Pill boxes, easy open bottles, reminder alarms, caregivers or nursing to assist

72 D. Nutritional DeficiencySensory impairments Taste, vision, smell Mobility Access to kitchen or location to eat or prepare meals Fine motor skills Preparation, opening packages Memory and cognitive skills Sequencing, safety for appliances Psychosocial depression

73 Case Study Discussion: SophiaWhat are treatment considerations? Include precautions, contraindications How do her medications affect your treatment plan?

74 4. Interventions and Treatment in the ElderlyLess aggressive in general More holistic in nature ie ankle sprain – look at hx of falls, CV problems, presence of vestibular/cognitive problems, flexibility due to prolonged rest, balance issues, gait training etc

75 Interventions: Mobility and Transfer TrainingRequire flexibility, strength, coordination, and integration of sensory information Work on initiating movement Work on sequencing Work on floor to stand (difficulty rising from the floor after falling is common and is associated with morbidity)

76 Interventions: Pre-GaitImprove trunk and extremity strength Hip rises Back extension Trunk twisting Hip extension Sit to stand Hip abduction SLS Knee extension WS PF Toe rises DF Hip hiking and leg swinging Lats Elbow extension Side-step and BW walking Pelvic tilts

77 Interventions: Static and Dynamic Balance ActivitiesControlled reaching in sitting and standing Leaning in all directions in sitting and standing Side to side FW BW Sitting posture control with external disturbances WS activities all directions

78 Interventions: Static and Dynamic Balance Activities: con’tStooping and bending Reaching and lifting Standing on high density foam Walk sturdy shoes Walk barefoot Varying ambulation surfaces Ramps Stairs Directional changes

79 Interventions: AD Focus on achieving mobility, increasing velocity of gait

80 Interventions: Gait Gait Parameter Normal Gait Aging GaitWalking speed 140 to 160 cm/sec 118 to 125 cm/sec Stride Length 150 to 160 cm/sec 126 to 140 cm/sec Stride width 8 – 10 cm Wider in older adults Swing-to-stance ratio 40:60 30:70 Walking cycle duration 1 sec free walking 1.25 sec free walking Cadence 110 steps/min free walking 132 steps/min fast walking decreases Foot clearance 1 – 2 cm Decreases or increases depending on pathology Heel strike and push-off Present Frequently decreased

81 Break into pairs Address two of these gait deviations with a treatment technique, intervention, or activity Remember precautions, contraindications, and medications in your treatment selections

82 Interventions: gait: con’tReduce deviations AD Improve efficiency and safety Increase endurance Combine mobility activities, standing, weight shifting, transfers, pre-gait, strengthening

83 Case Study Discussion: SophiaBreak into pairs Demonstrate 2 treatment activities or exercises for Sophia and the rationale for each.

84 6. Psychological ConsiderationsNormal decline due to aging versus dementia Many types of demetia Alzheimers Lewy Body Dementia Vascular Dementia Many more

85 Alzheimer’s Disease (alz.org)Stage 1: No impairment (normal function) Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease) The person may feel as if he or she is having memory lapses — forgetting familiar words or the location of everyday objects. Stage 3: Mild cognitive decline (early-stage Alzheimer's can be diagnosed in some, but not all, individuals with these symptoms) Friends, family or co-workers begin to notice difficulties in memory or concentration. Stage 4: Moderate cognitive decline (Mild or early-stage Alzheimer's disease)  Careful medical interview should be able to detect clear-cut symptoms in several areas: Forgetfulness of recent events, difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances, forgetfulness about one's own personal history, becoming moody or withdrawn, especially in socially or mentally challenging situations

86 Alzheimer’s Disease con’tStage 5: Moderately severe cognitive decline (Moderate or mid-stage Alzheimer's disease) Gaps in memory and thinking are noticeable, begin to need help with day-to-day activities. Be unable to recall their own address or telephone number or the high school or college from which they graduated Become confused about where they are or what day it is Need help choosing proper clothing for the season or the occasion Still remember significant details about themselves and their family Still require no assistance with eating or using the toilet

87 Alzheimer’s Disease con’tStage 6: Severe cognitive decline (Moderately severe or mid- stage Alzheimer's disease) Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. Lose awareness of recent experiences as well as of their surroundings Remember their own name but have difficulty with their personal history, distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver Need help dressing properly and may make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet Experience major changes in sleep patterns Need help handling details of toileting Have increasingly frequent trouble controlling their bladder or bowels Experience major personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior like hand- wringing or tissue shredding Tend to wander or become lost

88 Alzheimer’s Disease con’tStage 7: Very severe cognitive decline (Severe or late-stage Alzheimer's disease) In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases. Individuals need help with much of their daily personal care, including eating or using the toilet. They may also lose the ability to smile, to sit without support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid. Swallowing impaired.

89 Remember: It is difficult to place a person with Alzheimer's in a specific stage as stages may overlap.

90 Treatment considerationsMeet the individual where they are that day, physically and cognitively Recognize many with dementia “misremember”, rather than forget Dementia is much more than forgetfulness, it affects processing, sequencing, problem solving, critical thinking, and learning abilities How can these affect motor abilities?

91 Tips to consider Agree rather than argue Divert rather than reasonDistract rather than shame Reassure rather than lecture Reinforce rather than force Encourage rather than condescend Reminisce instead of remember Never say “I told you so”, instead repeat, regroup Never say “you can’t”, instead say “let’s do this”

92 Case Study Discussion: SophiaIf Sophia has Stage V Alzheimer’s Disease, how might you need to modify your treatments to be effective?