Geriatric Rehabilitation

What would be the most appropriate assistive device? 78 y/o F S/P (L) TKA w/ severe RA of hands, shoulders, knees A.Large based quad cane B.Crutches C.Two-wheel walker D.Forearm supports attached to a two-wheel walker E.Wheelchair

Hoenig H. JAGS, 1997 & GRS.

Rehabilitation: Concepts Impairment Disability Handicap

Geriatric Rehabilitation General Aspects Identify the correct diagnosis ! Assess for comorbidities Involve the patient (& family) Team approach to care Prevent complications(A,B,C,…)

Geriatric Rehabilitation MD Therapists RN Other Patient SW, Dietary, PT, OT, SpT, RecT

Rehabilitation Techniques Exercise Assistive Devices Mobility aids Orthotics Adaptive methods/equipment.

Assistive Devices- Mobility Aids DeviceSupports Canes15-20 % of body weight Crutches100% of body weight Walker~ 50 % ( not 100 ) of body weight

Geriatric Rehabilitation Prevent complications A B C s A.Aspiration, Anorexia, inActivity B.Bedsores, C.Constipation, Contractures, Cognition D.DVTs, Depression, DUs E.Else: infections (UTI, Pneumonia), pain, incontinence

Geriatric Rehabilitation Specifics Joints –Elective replacements –Fractures Stroke General Medical Problems

Hip Fractures250,000/year Amputations 50,000/year

Spinal/Compression Fracture Mortality unclear Age-adjusted mortality 2.15 (FIT) (a) RR 1.66 F, 2.38 M (b) Life expectancy (c) Men:6.1 y (60-69y)1.4 y (>80) Women:1.9 y0.4 y (a) Osteoporos Int 2000;111: (b) Lancet 1999;353: (c) Arch Intern Med 1999;159:

Am J Med 1997; 103:12S-19S & Lancet 1999;353: Hip Fracture Mortality Acute:3% F 8% M die 1 year:20%F30-40 % M (<80 y) >50 % M (>80y) 2 year: Returns to rate of general population

Hip Fractures Outcome at 1 year 40% cannot walk independently 60% require assistance with ADL 80% need help with IADL.

Functional Recovery S/P Hip Fx Independent FunctionBefore6 months after Dress8649 Transfer9032 Walk across a room7515 Walk half a mile416 Percentage Able toPerfrom JAGS 1992;40(9):863.

Joints/Fractures Dx: fracture type determines surgical intervention –Pins/Screws/Plates –THA  Go to pictures

Intertrochanteric Fracture

Gardner’s 4 Lateral View AP View

Joints / Fractures Comorbidities: Osteoporosis Calcium & Vitamin D Hormone status: Estrogen, Testosterone Medications: Steroids, thiazides, “too late” for DEXA ?  use for f/u Other complications...

Joints/Fractures Complications A A – Activity (asap), B B – Look at skin! (NURSING!) C C – Laxatives (see pain below) D D – DVT prevention, Dislocation Multiple regimens—LMWH, Warfarin, Fondaparinax E E- Else Infections – Make sure foley out ASAP Pain– Not moving so it doesn’t hurt is NOT good pain control! (Use routine + PRN meds)

Amputation Common50,000/ year Level of amputation: BKA- - work by 40-60% AKA-- work by % Stump healing Contractures Risk of contralateral amputation - 2 years

700,000 strokes/ year Recurrence rate 7-10% annually

Stroke Diagnosis: Etiology (hemorrhage, thrombotic, embolic) Developing interventions in acute phase Location (frontal, posterior, left vs right) May be factor in deficits and treatments needed Coordinated care improves outcomes. Recovery: Proximal to distal Flaccid to spastic to recovery

Stroke Rehabilitation is complex due to the variety of causes and residual deficits Recovery and time needed to reach maximal recovery affected by the number of deficits. –Hemiparesis, hemianopsia & sensory deficits are less likely to ambulate (I) and will require a longer time than those with hemiparesis only

Stroke Comorbidities are often multiple: DM, Alcohol and Tobacco (withdrawal), Hypertension, Hyperlipidemia

Stroke Complications: A A Aspiration  Speech, LRI / Activity B B Watch skin, (NURSING!) C C Laxatives, prevent contractures, D D DVT prev, low threshhold for depression, E E Reflex sympathetic dystrophy (pain), infection, subluxation…

General Medical/ Deconditioning Dx: Comorbidities: Complications: