Challenges in rehabilitation of the elderly patient


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Some of the challenges that can be encountered in the rehabilitation of the older patient

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Challenges in rehabilitation of the elderly patient

  1. 1. Marc Evans M. Abat, MD, FPCP, FPCGM Head, Center for Healthy Aging, The Medical CityClinical Associate Professor, Section of Adult Medicine, Department of Medicine, PGHVisiting Consultant, Manila Doctors Hospital, St. Luke’s Medical Center
  2. 2. But the truth of the matter is….
  3. 3. Outline• Prevalence of disability in the elderly• Benefits of Rehabilitation in the Elderly• Goals of Rehabilitation in the Elderly• Challenges in Rehabilitation of the Elderly Patient in terms of – Physiologic Changes in the Elderly – Pathologic Changes in the Elderly• Management Issues in Rehabilitation of the Elderly
  4. 4. Prevalence of Disability in the Elderly
  5. 5. Estimated Number of Disabled Males in England and Wales by Age Group and Type of Disablitiy90000800007000060000 Physical50000 Cognitive40000 Combined300002000010000 0 64-74 years 75-84 years ≥85 years BMJ 1999;318:1108
  6. 6. ADL and IADL difficulties• High level of disability, 28.2%• Females and those in the advanced ages generally showing some difficulty in ADLs and IADLs 70 60 % with ADL/IADL difficulty 50 40 male 30 female 20 10 0 60-64 65-69 70-74 75-79 80+ Age Cruz, G.T. 2007. Philippine Population Review, 6(1): 87-101
  7. 7. Benefits of Rehabilitation in the Elderly
  8. 8. Rehabilitation for COPD Patients Hong Kong Med J 2004;10:312-8
  9. 9. Fig 2 Effect of inpatient rehabilitation specifically designed for geriatric patients on functional improvement at hospital discharge and at follow-up. Bachmann S et al. BMJ 2010;340:bmj.c1718
  10. 10. Fig 3 Effect of inpatient rehabilitation specifically designed for geriatric patients on admissions to nursing homes at hospital discharge and at follow-up. Bachmann S et al. BMJ 2010;340:bmj.c1718
  11. 11. Fig 4 Effect of inpatient rehabilitation specifically designed for geriatric patients on mortality at hospital discharge and at follow-up. Bachmann S et al. BMJ 2010;340:bmj.c1718
  12. 12. Goals of Rehabilitation in the Elderly
  13. 13. J Rehabil Med 2011; 43: 156–161
  14. 14. Challenges in Rehabilitating anElderly Patient: Physiologic Changes in the Elderly
  15. 15. Sensory• Blurring of vision due to error of refraction and presbyopia• Poor contrast distinction• Decreased hearing• Propensity for vestibular disequilibrium Communication difficulties Difficulty to do activities that rely on vision Inner ear changes may predispose to balance difficulties
  16. 16. Respiratory• ↓decreased elastic recoil (decreased lung elasticity)• ↑chest wall stiffness• Decreased respiratory muscle endurance Increased work of breathing Easy fatigue with effort
  17. 17. Cardiac • poor heart rate response with effort • ↑vascular stiffness • ↑ventricular stiffness • Conduction system degeneration • Valvular degeneration • ↓β-adrenergic responsiveness • ↓baroreceptor sensitivity Easy fatigue with effortIncreased/exaggerated blood pressure responseOrthostatic hypotension with changes in position
  18. 18. Musculoskeletal• ↓skeletal muscle mass in relation to body weight by 30-40% – Non-linear – Accelerates with age – Decrease in fiber number and size – Accompanied by altered innervation
  19. 19. • Loss of muscle strength – Up to 60% loss of grip strength – Slower time to peak tension and slower relaxation• Decrease in muscle glycolytic enzymes with age
  20. 20. • Decreased bone density• Degenerative joint changes• Joint cartilage changes – Decrease in tensile strength – Bound water content decreases – Decrease in proteoglycan units and fragmentation of polymers• Variable resistance to manipulation
  21. 21. Decreased muscle strength Decreased muscle endurance Limitation in joint flexibility Increased propensity for painMusculoskeletal effects on gait and balance
  22. 22. Nervous System• Decreased brain weight, age-related neuronal loss – Not uniform – Tends to occur in the largest neurons • Cerebellum: more for the Purkinje cells • Subcortical regions: locus ceruleus, substantia nigra• Decreased blood flow by 20%• Alteration in cerebral autoregulation
  23. 23. • Increased reaction time• Decrease in size of peripheral nerves decreased sensation• with aging, information processing and memory retrieval slow but are essentially unimpaired
  24. 24. Balance deficits may have a central etiology Propensity for orthostasis due to decreased cerebral blood flow Need to give time for information processingDecreased touch sensation and proprioception Need for gradual, graded and patient rehabilitation to achieve improvements
  25. 25. Challenges in Rehabilitating anElderly Patient: Effects of Geriatric Syndromes
  26. 26. Geriatric syndromes• refer to multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational challenges• Emphasizes multiple causation of a unified manifestation
  27. 27. • Education Committee Writing Group (ECWG) of the American Geriatrics Society recommends that undergraduate students should be trained profoundly in the 13 most common geriatric syndromes dementia inappropriate osteoporosis prescribing of medications depression incontinence sensory alterations including hearing and visual impairment delirium iatrogenic problems immobility and gait disturbances falls failure to thrive pressure ulcers sleep disorders
  28. 28. Dementia• memory impairment causing cognitive, functional and behavioral deterioration
  29. 29. Cognitive Behavioral Functional Difficulty Agitation and Loss of muscle following aggression strengthdirections during rehab Depression Cardiovascular deconditioning Hallucinations Lack of and delusions motivation Other abnormal behavior
  30. 30. Delirium• Acute confusional state• Waxing and waning, varies throughout the day• May by hyperactive or hypoactive
  31. 31. Medication Effects/Polypharmacy• Multiple medications, especial ly if a patient has many co-morbid diseases• Multiple and interacting effects, many of which may be undersirable
  32. 32. Medications Adverse EffectsSedatives, antihistamines Drowsiness, balance problems, risk for falls, deliriumAntihypertensives Orthostatic hypotensionEye drops Visual problemsDiabetes medications Low energy levels due to low blood sugarDiuretics Hypotension, incontinence
  33. 33. Incontinence• Inability to control urination and defecation for a socially convenient time• Related to other problems like social withdrawal and falls
  34. 34. Management Issues inRehabilitation of the Elderly
  35. 35. Approaching an Older Patient for Rehabilitation• Proper communication – Treat as a respected adult – Address properly – Simple but direct to the point – Demonstration
  36. 36. • Overcome sensory barriers – Using eyeglasses – Using hearing aids – Well-lighted exercise area – High-contrast color schemes – Talking in a modulated tone and speed
  37. 37. Timed Get Up and Go Test• Prepare the following: – Armless chair – A marker 10 feet away from the chair• Procedure: 10 ft. Rise from chair Sit down again Walk to the marker on the floor Return to the chair Turn
  38. 38. Functional Reach
  39. 39. Other Considerations• Escalate your therapy!!!!!!!!!!!!• Discern between true pain/discomfort vs. “acting out”• Clearly define and prioritize goals, time frame and other expectations
  40. 40. • Coordinate with the primary care physician regarding – Medication effects – Other pertinent co-morbidities