1. Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc. PHYSICAL THERAPY FOR THE OLDER ADULT Chapter 13

2. 2 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Demographics  The population of those over the age of 65 is growing rapidly as life expectancies have increased.  Globally, the world’s 65-and-older population is expected to triple by 2050!  As people live longer, they tend to display more physical and/or medical conditions requiring a PT’s expertise.  Activities of Daily Living (ADLs) = activities such as bathing, cooking, and dressing.  Instrumental Activities of Daily Living (IADLs) = activities such as using public transportation and shopping  ADLs and IADLs are skills that allow older people to be less dependent on caregivers. GENERAL DESCRIPTION

3. 3 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Demographics  Well Elderly = people 65 years of age and older who are not experiencing physical limitations or who have age- related changes not significant enough to affect function.  Frail Elderly = people over age 65 with conditions that significantly impair daily function or who require frequent medical intervention.  PT goals = to regain mobility skills or to modify the environment to maximize the individual’s function. GENERAL DESCRIPTION

4. 4 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Settings  People with acute medical conditions such as pneumonia, cardiovascular dysfunction or hip fractures will be treated in hospitals.  People with conditions such as stroke, Parkinson’s disease, or amputation may be seen in rehabilitation centers (if they are medically stable).  PTs and PTAs in long-term care facilities generally provide two types of services:  1) Rehabilitative services to improve skills so people can return to their own homes or allow less dependence on caregivers  2) Functional maintenance programs to assist in maintaining skills they currently possess and prevent further limitations or disability.  Healthy older people who want to maintain, regain or improve their physical status may attend exercise classes at senior centers. GENERAL DESCRIPTION

5. 5 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Roles for PTs and PTAs with Older Adults  Regardless of the setting, PTs serve as educators for older adults, family members, and other professionals.  PTs may also act as consultants or advocates for older people to ensure accessibility to all environments.  Adaptive equipment = equipment that allows an individual to perform a functional task with increased ease or independence (e.g. a grab bar near the shower or toilet).  Assistive device = a device that provides the individual with assistance during periods of mobility (e.g. a cane).  PTs may also act as a manager or researcher, using their educational background to take on additional responsibilities to serve their clients. GENERAL DESCRIPTION

6. 6 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Age-Related Changes  Age-related changes that occur in “normal” ageing can vary with each individual.  While there are biological changes associated with ageing, many changes related to ageing are actual a result of the reduced activity and sedentary lifestyle of many elderly people.  The PT has an important role in evaluating older adults to determine what impairments and functional limitations can be addressed or which disabilities can be minimized through physical therapy (e.g. using assistive devices). GENERAL DESCRIPTION

7. 7 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Age-Related Changes  Physical changes in older adults are often the result of poor posture, gait changes, and decreased strength and flexibility.  Hypokinesis = decreased activity or movement  Sarcopenia = decreased muscle mass  Connective tissue becomes stiffer and less hydrated.  With decreased activity, muscles become shortened and affect posture.  Bone becomes weaker and less dense.  Weight-bearing joints degenerate over time.  The CNS shows a reduction in conduction velocity. GENERAL DESCRIPTION

8. 8 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Age-Related Changes  Several of the sensory systems display changes affecting mobility and personal safety.  Visual acuity is reduced, affecting near/far-sightedness and color/light differentiation.  Cataracts and macular degeneration are common issues.  Presbycusis = “old people’s hearing;” a term referring to decreased ability to perceive higher pitches or distinguish between similar sounds.  Age-related changes reduce the amount of tactile information the individual receives from his/her environment. GENERAL DESCRIPTION

9. 9 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Age-Related Changes  Age-related changes in the cardiovascular system include hypertension, decreased function and work capacity, and decreased response to stress.  Limitation in balance and increased risk of falling are common in older adults.  Fear of falling may cause older adults to become isolated or more sedentary.  Cognitive changes related to dementia are possible but not assumed for all older people. However, changes in memory and abstract thinking are common.  Psychosocial changes are common related to retirement, loss of a spouse, or psychiatric disorders. GENERAL DESCRIPTION

10. 10 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Osteoarthritis (OA)  By far the most common problem for older people.  African-Americans have a higher rate of OA.  Patients complain of morning stiffness and pain with movement.  Maintaining at least a moderate amount of activity is helpful.  Rheumatoid Arthritis (RA)  A disease of the immune system causing chronic inflammation.  More common in women than men, age 40-60 years.  Characterized by enlarged joints (red and warm) COMMON CONDITIONS

11. 11 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Rheumatoid Arthritis (RA) cont’d.  Progression of the disease results in limited ROM, joint deformity and eventual joint destruction.  PT goals = pain relief, increased joint movement, assistive devices to facilitate independence, and rehabilitation following joint surgery.  Total joint replacements may be required to improve function.  Strengthening is done before and after surgery.  Education regarding guidelines, assistive devices, and the importance of exercise should be provided. COMMON CONDITIONS

12. 12 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Osteoporosis  Extremely common in older adults  Resulting from low bone mass (decreased mineralization of bones due to decreased bone cell production and increased resorption of bone).  Risk factors = age, postmenopauseal state, low body weight, family history, lack of physical activity, smoking, lack of calcium and vitamin D, and some medications.  More common in whites than African-Americans  Most important problem is fractures, especially of the wirst and hip.  PT’s role is prevention. COMMON CONDITIONS

13. 13 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Hip Fracture  Most commonly caused by osteoporosis or accidental falls.  Considered to be a public health problem, as only 33% of people in one study regained their pre-fracture status regarding their ADLs 1 year after the fracture.  PTs have an essential role in preventing osteoporosis and hip fractures, as well as rehabilitation, educating patients in the use of assistive devices and helping patients regain additional functional skills (such as showering and transferring in and out of automobiles) after fractures have occurred. COMMON CONDITIONS

14. 14 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Diabetes  Affects 10-20% of Americans over 60 (this number is rapidly increasing).  A disease of insufficient insulin action, affecting the efficient transport of glucose in the body.  Common complications = renal failure, diabetic neuropathies, neuropathic skin ulcerations, atherosclerosis, and retinopathies (leading to blindness).  Amputations may occur with the development of gangrene from foot ulcers.  For those with Type II diabetes (non-insulin dependent), management through diet and exercise is important. COMMON CONDITIONS

15. 15 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  History  Begin by asking for their view of their current problem, as their perception of the seriousness of the problem is important to consider when developing a plan of care.  Previous or current employment, recreation/hobbies, availability of transportation and insurance coverage are all important considerations.  Systems Review  Tests and Measures  Similar to the exam of any individual, but some procedures may have to be adapted.  Keep in mind the potential for age-related changes. EXAMINATION

16. 16 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Tests and Measures con’t.  Strength is examined in terms of function.  Based on the person’s activity level, some deficits may be expected.  Observed postural changes may be caused by actual structural changes.  Neurologic testing includes sensory testing, two-point discrimination, proprioception, and visual and auditory testing.  Static balance (use Romberg’s test) and dynamic balance (using gait and functional mobility) should be examined.  Functional Reach Test can predict the likelihood of falling. EXAMINATION

17. 17 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Tests and Measures con’t.  Gait examination should always include the use of any required assistive device or footwear.  Cardiovascular and pulmonary function testing should be done before and after treatment.  Determination of pain related to movement, including location, intensity and circumstances can be determined using the VAS (Visual Analog Scale).  Self-reporting measures include the Functional Status Questionnaire (FSQ) and the Functional Status Index (FSI) which assess the person’s ability to perofrm functional activities. EXAMINATION

18. 18 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Tests and Measures con’t.  Information about the environment in which the older person lives is essential, including setting and access to and from the residence.  Ground surface, curbs, stairways, handrails, size of door openings, door handles/latches, furnishings, kitchen and bathroom fixtures, distance between frequently used rooms.  Morbidity skills and safety must be assessed by the PT and recommendations should be made regarding the need for assistive devices.  The person’s cognitive changes greatly influence how the PT provides instructions and how much practice is needed.  Be sure to assess the setting to which the person will return and their available social support. EXAMINATION

19. Table 13-1. Physical therapy examination for an older person. (Data from American Physical Therapy Association [APTA]: Guide to physical therapist practice, revised ed 2, Alexandria, Va, 2003, APTA.)

20. Figure 13-7. Gait assessment using a quadruped cane after a stroke. (Courtesy Bruce Wang.) GAIT ASSESSMENT

21. 21 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  PT completes detailed evaluation  Determines whether the patient will benefit from PT  Determines the diagnosis that directs the course of rehab.  Remember, older adults generally have multiple diagnoses.  Assesses signs, symptoms, or syndromes resulting from the pathologic condition.  Develops a prognosis estimating maximum level of improvement the patient will experience. EVALUATION, DIAGNOSIS, PROGNOSIS

22. 22 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Procedural intervention  Set meaningful goals with the expectation of improved function.  Examples of interventions include therapeutic exercise, functional training, physical agents and mechanical modalities, and manual therapies.  Instruction  Provide factual information about the effects of aging on the various body systems to give the person a background from which to judge changes he or she is experiencing.  Education also plays a role in motivation, as well as social interaction and technological developments. INTERVENTION

23. 23 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Modification  Focused on improving daily function.  Programs should incorporate normal movement patterns.  Other health conditions and common medications taken by older persons may necessitate modifications.  Environmental modification and adaptive equipment  Simple changes in environment (improved lighting, removing rugs, moving furniture) may make the person safer and allow them to be more independent.  Teaching of health promotion, wellness, and prevention  “Wellness Fairs” can be planned with a local senior center. INTERVENTION

24. 24 Copyright © 2012, 2007, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.  Communication with members of the health care team  Helps in selecting the most appropriate strategies and reinforcing the goals of other disciplines to assist in patient progress.  Setting  PT needs to make sure that enhanced performance on objective tests in the therapeutic setting will translate to improvement in daily function in the home environment. INTERVENTION

25. Figure 13-8. Resistive exercises to increase strength, in this case in the hip and knee musculature, are effective in the elderly. (Courtesy Bruce Wang.) RESISTIVE EXERCISE

26. Figure 13-9. Gait training is enhanced by using parallel bars in a clinical setting. (Courtesy Bruce Wang.) GAIT TRAINING