PT in geriatric

1. PT IN GERIATRICS
DR. JAYA CHANDRA (PT)
LECTURER
SCMAT

2. AGEING
•Ageing is deterioration in structure and function of body cells, tissues and
organs of an organism.
•It implies loss of vitality, reduced ability to withstand environmental insults and
increased chance of dying with time.
PHYSIOLOGICAL CHANGES AND ADAPTATIONS DURING AGEING
Musculoskeletal changes:
•muscle mass and strength decrease at a rate of about 30% b/w age of 60-90
•Decrease water content in cartilage
•Reduction in bone mineral density
•Loss of height
•Decrease in speed of movement
•Reduced joint activity and ROM and incresed risk of fractures.

3. Neuromuscular changes:
•Atrophy of neuron
•Depletion of dopamine level
•Decreased reflexes
•Increased postural sway
•Reduction in transmission speed of myoneural junction
•Reduced nerve conduction velocity
•Reduced balance and co-ordination
Neurosensory changes:
•Decrease in sweating
•10-20% decrease in brain weight by age of 90.
•Reduced mechanoreceptors
•Reduced hearing capacity
•Reduced sense of smell and taste
•Reduced vision

4. Cardiopulmonary changes:
•Decrease in cardiac output by about 0.7% a year after around 30 yrs of age
•Reduced arterial elasticity
•Increased vascular resistance
•Decreased lipid metabolism which may increase risk of heart diseases
•Ventricular wall stiffness
•Diastolic abnormality
• Heart valve thickens and becomes stiff
•Reduced oxygen saturation
•Reduced elasticity in lungs and chest wall
•Reduction in vital capacity
Renal changes:
•Reduced filtration rate
•Loss of control over urinary bladder

5. BENEFIT/NEED FOR EXERCISE INTERVENTION IN ELDERLY
•Reduce risk of heart diseases, diabetes, hypertension, weight problems,
anxiety, depression.
•Increase stamina
•Maintain healthy weight
•Reduce the chance of fall
•Maintain muscle mass
•Control joint movement
•Better mental health
•better self-esteem
•Better sleep pattern
•Better QOL

6. MAIN CONCERNS
 1. ASSESSMENT
 2. GOAL-SETTING
 3.THERAPUTIC INTERVENTION
 4.RE-ASSESSMENT

7. GERIATRIC ASSESSMENT
 AIMS:
Better recognize common geriatricdisorder.
Plan an effective treatmentprogram.
Improve over all health and functionaloutcomes.
Reducevulnerability tosubsequent illness.
Provide better quality oflife.
THETEAM:
many members work together to develop a single treatment plan

8. EFFICIENCY OF ASSESSMENT
Problem area Screening measure Abnorma
l
response
Mobility Note the time after asking the patient: ’RISE FROM THE
CHAIR, WALK 20FT, TURN , WALK BACK TO THE CHAIR
AND SITDOWN’
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?

9. EFFICIENCY OF ASSESSMENT
Problem 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

10. COMPONENTS OF ASSESSMENT
 HISTORY TAKING: GeneralGuidelines
Remember that patient having age related changes in one or more body
system.
Keep the pace slower thanusual
Introduce yourself in start of historytaking
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.

11. 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 hear what is beingsaid
Provide glasses ifneeded
Speak at eye level facing thepatient
Never treat the elderly as is achild
Respect elderly as anindividual.

12. 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.

13. PHYSICAL EXAMINATION
HEIGHT, WEIGHT, BMI
ORTHOSTATIC BP AND PULSE
SKIN INTEGRITY, PALLOR
RANGE OF MOTION
MUSCLE STRENGTH
SENSORY STATUS
COORDINATION
VISION AND HEARING

14. GOAL-SETTING
Functional independence is the ultimate goal.
Torelieve pain
Toimprove or maintain ROM of different joint
Toimprove or maintain strength and endurance of movement
Toimprove or maintain cardiovascular endurance
Toimprove or maintain ambulatory status

15. THERAPEUTIC INTERVENTION
RANGE OF MOTION EXERCISES
Flexibility decreases with age and joint become stiff
Development of contracture, it develop within 1 week of inactivity
1. Passive ROM: therapeutic benefits
Tomaintain range of motion
Toprevent complication of inactivity such as –
- contracture formation
- cartilage degeneration
-deep vein thrombosis etc

16. 2. Active ROM: therapeutic benefits
Topreserve joint function
Tomaintain physiological elasticity and contractility of muscle
Tomaintain and improve ROM
Toinduced muscle relaxation
Todecrease pain
Toincrease circulation and thereby preventing DVT.
Toprovide sensory feedback from the contracting muscle
Toprovide a stimulus for bone and joint tissue integrity
Toimprove neuromuscular coordination

17. 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

18. 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
Tocause synovial fluid motion, this is the vehicle for bringing
nutrients to the avascular portion of the articular cartilage
Toprevent painful or degenerative stasis when a joint is swollen or painful
Toelongate hypomobile capsular and ligamentous connective tissue
Tomechanically distend the shorten tissue

19. 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

20. STRENGTHENING EXERCISE
 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

21. STRENGTHENING EXERCISE
 3. mechanicalresistance:
Equipment ranges from simple tocomplex
Incase of old-olds(>85 years) this equipment should not be used, as it my result in to
muscle soreness or inhibition
 INTENSITY OFEXERCISE
Start with base line assessment ofintensity,
Popular method is find out repetitionmaximum(RM)
 FREQUENCYANDDURATION
For each level of intensity, session are 2- 3 time aweek
A single session consist of 3 set of 10RM
Resistance can be increase when 1 or 2 sets done in a smooth manner

22. STRENGTHENING EXERCISE
 REST INTERVALS
Patient should rest for 1- 2minutes between sets in a same session
 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

23. AEROBIC EXERCISES
This endurance activities that do not require excessive speed or
strength but do have a beneficial effect on cardiovascular system
Therapeuticbenefits-
Improvement in maximal cardiovascular functiona lcapacity:
Improvement in the energy level
decrease LDL and triglyceride level increase in
HDL
Improvement in the bodycomposition
Reduction in fat mass and increase in musclemass
Reduction in disability
Psychosocial well-being
Improvement in functional status
Reduction in risk of developing age-related changes

24. AEROBIC EXERCISES
 EXERCISE PROGRAM
1.warm-up:5-7 min
to reduce the chances of injury
2. Protocol:
mode-walking, stationary bicycling, jogging
intensity- 60% of MHR,
duration- 30 minute,
frequency- 5 days in a week
3.Cool down: 10 min
 Toexpedite the recovery process after aerobic exercis
 Toprevent injury
Protocol: slow walk for 5 minutes and slow exercises

25. GAIT TRAINING
 The purpose is to make a patient walk at functional speed.
Factors contributing the physical therapy intervention
altered gait of patient
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,

26. GAIT TRAINING
4.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. ,

27. 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

28. 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:
Toprovide mobilization or to control movement
Tosupport a weakened structure
Toprevent deformity and correct anatomical alignment
Topromote ambulation and assist motion to improve body
function
Torelieve pressure on areas andto reduced pain

29. 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 ofhip adduction and
flexion

30. PRECAUTIONS WHILE EXERCISING
•Vigorous exercises should be avoided.
•Always start with low intensity exercises and very gradually progress to
moderate.
•Never exercise empty stomach.
•Always keep water alongwith during exercise
•Never exercise immediately after meals
•Comfortable clothing.
•Comfortable footwear to avoid any injuries.
•Vitals should be monitored continuously while exercising.
•Decrease work load if any sign of fatigueability is there.
•Immediately terminate the exercise if any discomfort like dyspnoea, dizziness,
chest tightness or pressure, nausea, pain, etc. are seen.

31. 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.

32. SCALES FOR ASSESSMENT

33. 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 self
A-Needs help, soiling or wetting while asleep more than 1week
D- Completely unable to use toilet
B. Feeding:
I- Able to completely feed self
A- Feed self with assistance
D- Completely unable to feed self or need parenteral feeding
C. Dressing:
I- Able to select cloths, dress and undress self
A-Need assistance D-dependent

34. BASIC ACTIVITIES OF DAILY LIVING
 D. Grooming: (neatness, hair, nails, face, clothing)
I- Able to groom well without help A-Needs
assistance in grooming
D-Completely unable to care for appearance
E. PhysicalAmbulation:
I-Able to get in/out of bed, roam around without help A-Needs human or
mechanical assistance
D-Completely unable to get in/out of bed/chair, walk
F. Bathing:
I- Able to bathe(tub, shower) without assistance
A-Need assistance for getting in and out of tub or washing more than one body part
D- Completely unable to bathe self

35. INSTRUMENTAL ACTIVITIES OF DAILY BY:
LIVINGM.P. LAWTON & E.M. BRODY
 A. Ability to usetelephone:
I-Able to operate telephone on own initiative
A-Answered telephone but needs special phone or assistance in getting number dialing
D- Unable to use telephone at all
B. Shopping:
I-Able to take care of all shopping needs independently
A-Able to shop but needs to be accompanied on any shopping trip D- Unable to shop
C. Preparing meals:
I-Able to plan and prepare meal independently A-Unable to cook
full meal alone
D-Unable to prepare any meal
D. Housekeeping
I-Able to maintain house independently
A-Able to do light work bt need assistance with heavy task D-Unable to do any
house work

36. INSTRUMENTAL ACTIVITIES OF DAILYLIVING
 E. Laundry
I-Able to launder independently
A-Launder small items such as socks, handkerchief
D-Unable to launder at all
F.Travelling
I-Able to drive own car or travel independently
A-Needs assistance for travelling
D-Unable to travel
G. Responsibility for own medication
I-Able to take medication in correct dose and time
A-Able to take medication if it is prepared in advance
D-Unable to take medication
H. Ability to manage finances
I-Able to maintain finance s independently eg. Pay bills
A-Able to manage day to day purchases but needs assistance
D-Unable to handle money

37. MINI-COG ASSESSMENT INSTRUMENT
 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.

38. MINI-COG ASSESSMENT INSTRUMENT
 Scoring
Give 1 point for each recalled word after the CDT distractor. Score 1– 3.
A score of O indicates positive screen fordementia.
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 fordementia.
The CDT is considered normal if all numbers are present inthe
correct sequence and position, and the hands
readably display the requestedtime.

39. 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

40. 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 arealmost
always depression.

41. THANK YOU