4. Components of geriatric rehab
• Accommodation
-to the irreversible effects of aging
-requires education of patient and family
• Prevention of disability & the restoration of
function
-exercise
-“use it or loss it” concept (Bortz)
• Medical treatment of impairment
-cure when possible or stabilize
5. Physiology of normal aging
Body composition
• Gradual loss of lean tissue (loss of
muscle mass)
• Increase in fat
• Bone mineral is lost
6. Postural changes of aging
• Progressive anterior thrust of the head
• Extension of cervical spine
• Accentuated thoracic kyphosis
• Straightening of lumbar spine
• Scapular protraction, ulnar deviation of wrist
• Increase hip and knee flexion and decrease in
ankle dorsiflexion
• Functional effect---------- shift of COG
7. Gait
• Men small steps with a wide base
• Women waddling style of gait with a
narrow walking and standing base
• Decrease in swing phase
• Increase in period of double support
increase energy cost slower walking
speed
8. Normal neurological changes
• Tendency to tremer
• Atrophy of interossei
• Diminished muscle strength (LL>UL)
• Increased muscle tone( LL>UL)
• Diminished vibratory sense distally
• Increased threshold for light touch, pain,
temp
• Diminished or absent ankle jerks
9. Skin changes
• Decrease moisture content
• Decrease Epidermal renewal
• Decrease Elasticity
• Decrease sensitivity to touch, pain and
temp
more susceptible to injury
10. Cardiopulmonary changes
• Decreased cardiac reserve
• Decrease contractile function and heart
rate
• Decrease response to exercise
• Decrease in pulmonary function and
vital capacity
13. Principles………..
• Ascertain level of function.
• Differentiate between Delirium, Dementia and
Depression.
• Determine the patient’s significant goals and
motivation.
• Be aware of altered physiological reactions.
• Ascertain available resources and options.
15. Principles………….
• Encourage socialisation and
stimulation .
• Minimize medication.
• Realize that function may not be
regained.
• Understand that improvement occurs in
small increments
16. Ascertaining the Level of Function
• Document the patient status initially and
serially ( help in early diagnosis and
treatment)
• Assessment tools
-Functional Independence Measure
-Lawton Instrumental ADL Scale
-Gait and Balance instruments
17. Position Changes included in the Functional
Mobility Assessment
• Getting up from chair
• Sitting down in chair
• Withstanding nudge on sternum
• Turning neck
• Reaching up
• Bending over
18. Gait Assessment Checklist
• Stride length and width,
• Equality of weight bearing on both sides
• Equality of leg length
• Level pelvis
• Gait Apraxias
• Footwear and Assistive devices.
19. FALLS
• Falls and near-falls occur in more than
30% of people aged 65 years or older
• Injuries occur in 10-20% of falls
• 3-5% of injuries result in fractures
• Approximately 90% of fractures in the
hips, pelvis, and forearms result from fall
• Fear of another fall immobility
weakness and isolation
20. Risk factors for falls
• Visual impairment
• Nervous system impairments
•Reducing righting reflexes,
proprioceptive input & cerebral functions
•Increased reaction time
•Lessened awareness of vibration , touch
& temp.
•Increased distractibility
24. Audiovestibular dysfunction
• Removal of cerumen
• Audiological evaluation
• Hearing aid
• Reduction in back ground noise
• Avoidance of drugs affecting the
vestibular system
• Neurological & ENT evaluation
• Habituation exercise
25. Proprioceptive dysfunction
• Screening for Vit. B12 def.
• R/o cervical spondylosis
• Balance exercise
• Appropriate walking aid
• Correctly sized footwear with firm
soles
• Home safety assessment
26. Dementia
• Detection of reversible causes
• Avoidance of sedative or centrally
acting drugs
• Supervised exercise & gait training
• Home safety assessment
27. MUSCULOSKELETAL DISORDERS
• Appropriate diagnostic evaluation
• Balance & gait training
• Muscle strengthening exercises
• Appropriate walking aids
• Home safety assessment
29. Postural hypotension
• A common cause for falls
• Aging is associated with impairment of
the baroreflex.
• Changes in baroreceptor sensitivity,
heart rate response, vascular
compliance, vasopressin, renin,
angiotensin, and renal concentrating
abilities
30. Nonpharmacologic treatment for PO
• maintain adequate fluid intake,
• exercise regularly in horizontal position
(swimming and bed exercises such as
moving feet up and down to activate
calf muscle pump)
• change posture slowly and avoid
standing still.
31. Nonpharmacologic treatment for PO
• Patients on prolonged bed rest need to
increase the amount of time they spend sitting
up each day
• Fitted elastic hose or compression stockings
may enhance cardiac output and BP on
standing,
• Eat small meals frequently and avoid standing
up suddenly after eating.
• Avoid hot showers or excessive heat.
• Avoid straining during micturition and defecation
32. Drugs used in PO
• Midodrine (sympathomimetic
vasoconstrictor)
• Fludrocortisone
• Dihydroergotamine
• Erythropoietin
• Octreotide
• Pacemaker therapy.
34. Pain
Proper pain history
•Special care regarding secondary
gain or hidden agenda
• hearing loss, dementia, pseudo
dementia & underreporting of
symptoms can influence the
accuracy of information
35. • Musculoskeletal pain- m.c. Type
• Spinal problems are common causes
• Spondylitic changes- up to 82%
• Cervical spondylitic myelopathy- (m.c.c.
of spinal cord dysfunction in patients over
of 55)
• Shoulder pain -25%( soft tissue)
• Elbow , wrist & hand pain, medial or
lateral epicondylitis, median or ulnar
nerve entrapment
37. Arthritis
• OA is more common (knee>hip)
• In older people
–Smaller muscle fiber & fewer horn
cells
–Tendons , ligaments & capsule lose
elasticity-
•Resulting in decrease joint ROM
•Sense of stiffness
38. Fractures
• Osteoporosis & falls –imp causes for
fractures esp hip and wrist
• Wt bearing and ROM are important issues
• Subcapital Hip fracture
Repair by pinning
Restricted wt bearing for 6 weeks
39. –Hemiarthroplasty-
•Restriction in hip motion to prevent
dislocation ( no flexion greater than 90
degree, no adduction past the midline
& no internal rotation)
•Restricted wt bearing for 6 weeks
•In cemented hemiarthroplasty wt
bearing not restricted
41. Traumatic brain injury
• Falling- m.c.c. of traumatic brain injury
in people >65 years
• Alcoholism –precipating factor in males
• Advancing medical and neurological
illnesses
increase severity & mortality
• Protection from a second fall is major
goal to prevent further TBI & fracture
42. Traumatic brain injury
• Intensive rehabilitative program that include
•Physical therapy
•Cognitive rehabilitation
•Behavioral management
•Dysphagia management
•Communication treatment
•Fall prevention
43. Parkinson's disease and MNDs
Attention to
•Dyspahgia
•Respiratory problem
•Self care
•Balance & mobility
•Nutrition
•Psychotherapy
44. Peripheral NS impairments
• Elderly patients have decreased or lost
vibratory sense(82%) & ankle jerk
• Drug related & toxic neuropathies,
nutritional & alcoholic neuropathies &
post herpetic, diabetic, entrapment,
carcinomatous & paraproteinemic
neuropathies are common
• Carefully timed exs and energy
conservation are important
45. Visual impairment
• Vision is a major factor contributing to balance
& is an important factor in the risk of falling
• Poor vision often result in social isolation,
impaired morale & a decreased sense of well
beings
• Cataracts, age –related macular degeneration,
glaucoma & diabetic retinopathy are amenable
in varying degrees to visual rehabilitative
services
46. Hearing loss
• Incidence- 25-50%
• Audiometric evaluation
• Hearing aid can be given but often
patient refuse to wear hearing aids
because of sound distortion, impaired
dexterity in their use or adjustment,
uncomfortable fit
47. PVDs
• Intermittent claudication
• Chronic venous insufficiency
• Lymphedema
• Management
-Proper foot care including shoe
modification
-Compression garment
-Daily cleaning of feet with mild soap
-Daily inspection of feet with mirror
48. Foot disorders
• In elderly Decrease shock absorption &
spring abilities
(Bony disfigurement, joint disorders, muscle
imbalances, & skin & toe-nail disorders)
• Insensitive feet ulceration & less healing
• Management
-Strengthening & physical therapies
-Proper foot care
-Proper shoe selection with orthosis
-Podiatric treatment
49. Bladder dysfunction
• Common complication,
• devastating to patient‘s self-esteem &
family
• Frequent cause of fall particularly at
night time
50. Bladder dysfunction ;Assessment
•Complete history
•Careful neurological , pelvic, rectal &
mental status examination
•Urine R/M & C/S , Serum Creatinine &
post-voidal residual volume of urine
•Voiding diary
•Cystometric studies if indicated
51. Bladder dysfunction: Treatment
• Treat the cause
• Timed voiding programme
•Initially at very short interval(15-20
min.) with progressive increase as
indicated
• Modification of technique
•Patterned urge-response toileting
(PURT)
•Functional incidental training (FIT)
52. Bladder dysfunction: Treatment
• Surgical procedure for BPH &
sphincter incompetence
• Anticholinergics (propantheline) for
detrusor instability
• Direct smooth muscle relaxants-
oxybutynin, calcium channel blocker &
impramine
54. Sexual functions
Sexual activity is affected by
• Age- related changes in hormones
• Alteration in vision, hearing & smell
• Negative social attitude towards sexuality in
elderly
• Erectile & ejaculatory changes
• Vaginal dryness & dysparuenia
• Urinary stress incontinence
• Decrease in muscle strength & endurance
• Limitation in movement from OA
58. Minimizing medications
• Maintain a high index of suspicion for
medication toxicities
• Obtain accurate over-the-counter and
prescription histories
• Review that each medication is still
indicated
• Record a clear diagnosis for which each
medication, especially psychotropic
medication, is prescribed
60. Assessment of home safety profile
• Identify problem areas such as floors,
carpets, lighting, stairs, toilet seat, bed
and chair height, gas range
• Recommend appropriate modifications
61. home safety profile………..
• Elevated toilet seat
• Grab bars on the wall next to the toilet
• Non-slip tiles in bathrooms
• Non-skid floor mats
• Adjustment of bed height distance from
patella to floor
62. home safety profile………..
• Replacement of low chairs with more
suitable ones
• Marking of on/off positions of gas
range with luminescent markers
• Use of hand-held reach tools to retrieve
objects on shelves
