2. DIDACTIC OBJECTIVES
1. Compare unique aspects of care for geriatric and hospitalized patients
2. Compare unique challenges faced when treating geriatric and hospitalized
patients.
3. Describe the importance of addressing cultural and social aspects of the patient
4. Describe common clinical cardiac conditions and considerations in the geriatric
and hospitalized patients.
5. Describe common clinical pulmonary conditions and considerations in the
geriatric and hospitalized patients.
6. Describe common clinical surgical conditions and considerations in the geriatric
and hospitalized patients.
7. Describe common clinical musculoskeletal conditions and considerations in the
geriatric and hospitalized patients.
8. Compare the examination and treatment of the geriatric and hospitalized
patients applying osteopathic principles and procedures for given clinical
scenarios: cardiac etiologies, pulmonary etiologies, surgical etiologies, and
musculoskeletal etiologies.
3. DIDACTIC OBJECTIVES
9. Describe the considerations of diet/nutrition, functional capacity, and
polypharmacy as they relate to the geriatric patient
10. Describe special considerations in both the geriatric and hospitalized patient.
11. Describe important anatomic structures and functions as they relate to disease
processes in the geriatric and hospitalized patient for cardiac, pulmonary,
surgical, and musculoskeletal etiologies.
12. Describe the role of the abdominal diaphragm, pelvic diaphragm and abdominal
wall to respiration, pressures, and fluid movement in the chest and abdomen.
13. Describe the articulatory treatment model
14. Describe the respiratory-circulatory treatment model
15. Describe the neurologic treatment model
16. Describe the lymphatic treatment model and lymphatic treatment protocols
17. Define appropriate treatment guidelines of osteopathic care for the geriatric and
hospitalized patient populations
4. RECOMMENDED
READING
• "Treatment of the Acutely Ill Hospitalized Patient”, by
Hugh Ettlinger, Foundations for Osteopathic Medicine,
2nd ed., pp. 1135-1142
• "The Hospitalized Patient," by Samuel Yoakum,
Somatic Dysfunction in Osteopathic Family Medicine,
pp 201-215
• "The Geriatric Patient," by K.E. Nelson, A. L.
Habenicht, N. Sergueef, & J. Allgeier, Somatic
Dysfunction in Osteopathic Family Medicine, pp 167-
182
• Special Video Interview on Blackboard
5. OUTLINE
• The Geriatric Patient
• The Hospitalized patient
• Challenges
• Special System
Considerations in both
groups
• A Treatment Approach
6. BIG PICTURE
• Looking at aspects that bridge both
groups
• Importance of addressing cultural and
social aspects to the patient.
9. CHALLENGES IN TREATING
GERIATRIC PATIENTS
• Deconditioning
• Decompensation of aging
• Challenges with self
care/compliance
• Difficult socioeconomic
status
10. THE HOSPITALIZED
PATIENT
• Acute on chronic diseases
• Often Elderly
• Multiple systems affected
• From ER to Surgical unit to
ICU
• Need for individualized
treatment and care
• Traumatic for patients and
their families
11. CHALLENGES IN TREATING
HOSPITALIZED PATIENTS
• Challenging
environment
• “Fragile” patients
• May have little time
• Big picture, what is
best?
13. CARDIAC
CONSIDERATION
S
• Acute Myocardial Infarction (MI) & post
MI care
• Congestive Heart Failure
• Open heart surgery/heart procedures
(angiography/angioplasty/stent)
• Rates of heart disease, complications, and
procedures
• Research of OMT to rib cage following
CABG procedures may increase vascular
return and potentially decrease pulmonary
congestion in the post operational period
(O-Yurvati et al., JAOA, 2005)
14. PULMONARY
CONSIDERATIONS
• COPD (w/exacerbation)
• Pneumonia
-Noll et al. studied 406 patients treated for pneumonia
across seven community hospitals.
• Decreased in length of stay
• Decreased duration of intravenous antibiotics
-MOPSE study (2007)
• Double-blinded, randomized controlled clinical trial
• Designed to evaluate the efficacy of OMT as an
adjunct to the current pharmacologic treatment of
elderly patients hospitalized for pneumonia.
• OMT groups had reduced length of hospitalization,
while in older subjects there was a reduction in
mortality
16. SURGICAL CONSIDERATIONS
• Post-thoracic surgery
• Sternotomy, lung resections,
mastectomy
• Post-abdominal surgery
• Bowel resection, cholecystectomy
• Post orthopedic surgery
• Hip and knee replacement
• Patients can be treated with OMT pre
and post operatively (*pedal pump)
20. MUSCULOSKELETAL
CONSIDERATIONS
• GERIATRIC: Deconditioning/Postural changes,
Decreased muscle tone, Compound disease
(osteoporosis, osteoarthritis, DDD)
• HOSPITALIZED: Muscle strain from altered
mechanics and being inpatient for extended
period of time. Rib/muscle dysfunction
mimicking chest pain
• Eg. Chronic conditions, even Parkinsons or
Diabetes have physical manifestations
• Use of more pain medications is problematic or
make plan to address in OP
Nelson, SDOFM, 2nd Ed.
23. SPECIAL CONSIDERATIONS
GERIATRIC PATIENT
• Functional capacity
• Assess with intake evaluation
• Diet and Nutrition
• Habits, physical mobility (food acquisition and prep),
dental health, economic disadvantages.
• Vitamin D and Calcium, encouraged to get enough
caloric intake, especially protein, adequate hydration,
multivitamins.
• Polypharmacy
• NSAID’s can cause AKI, cardiac SE, and GI upset,
nearly CI in the elderly
Nelson, SDOFM, 2nd Ed.
24. SPECIAL CONSIDERATIONS IN THE
GERIATRIC & HOSPITALIZED
• Anxiety & Depression
• Death & Dying
• Development of patient-
physician relationship and
patient-family relationship
• Simple osteopathic
procedures can have a big
impact
“Health often becomes a fragile and
intermittent state, and pain and functional
limitations are constantly present. Add to
this the fact that life’s goals may have gone
unmet, and that cherished relationships
have been lost, and it is a wonder that the
elderly are not universally depressed.”
-Nelson, SDOFM
Nelson, SDOFM, 2nd Ed.
27. ROLE OF
RESPIRATION
• Changes in intrathoracic pressure fluid
movement from head/neck and abdomen.
• Action on central venous flow and
pressure influence the emptying of the
thoracic duct & right lymphatic duct
• During Inhalation – spinal curves
straighten, sacrum rotates with base
moving posteriorly
• During Exhalation – spinal curves
enhance, sacral base moves anteriorly
28. PELVIC DIAPHRAGM AND
RESPIRATION
• During Inhalation - Descends
with the abdominal diaphragm to
create space for abdominal
viscera
• Works with anterior abdominal
wall to stabilize abdominal
pressure
• Post abdominal surgery
patients lose abdominal wall
contribution to this process
• Increased resistance reduces the
effectiveness of the diaphragm
and reduces inferior vena cava
flow
• Pelvic diaphragm and sacral
motion are essential for proper
coordination
30. TREATMENT
MODELS
ARTICULATORY
• It is important to remember that
the acute segmental facilitation
is seen in the soft tissues
• The underlying treatment is for
the tissues sending somatic
Nociceptive information back to
the spinal cord
• Paraspinal myofascial
elements of each region, due
to autonomic influences
33. Location of Ganglia:
Cervical
• Anterior to cervical articular
pillars
Thoracic
• Anterior to heads of ribs
Lumbar
• Anterior to the bodies of the
lumbar vertebrae
• Medial to edge of psoas
NEUROLOGIC TX
MODEL:
SYMPATHETIC CHAIN GANGLIA
34. TREATMENT MODEL
LYMPHATIC
• Improve extrinsic pumping
capacity
- Diaphragms create alternating
pressure gradients
- Lymph flows longitudinally, remove
horizontal strains: Abdominal &
pelvic diaphragm, thoracic inlet,
tentorium cerebelli, arches feet
- Remove muscular restrictions so
skeletal muscles can have
improved function
37. TREATMENT GUIDELINES
GERIATRIC & HOSPITALIZED
• Appropriate treatment individualized to the
patients capacity
• More Frequent treatments/Dosing
• Short time periods of treatment
• Less forceful techniques (MFR, BLT)
• Once daily is commonly appropriate
(minutes)
• Treat only areas most likely to impede the
healing process (lymphatic flow and
autonomic considerations)
• As patient improves, treatments can be
spread out with longer intervals, and longer
treatment durations
38. CONCLUSION
• The Geriatric and Hospitalized patients
• Anatomic Structure and Function relationships
Manipulative prescription
• To be complete need to be conscious about the mind
and spirit aspects of patient care
• Dosing & Contraindications
39. REFERENCES /
DISCLOSURE
1. "Treatment of the Acutely Ill Hospitalized Patient”, by Hugh Ettlinger,
Foundations for Osteopathic Medicine, 2nd ed., pp. 1135-1142
2. Drake RL, Vogl W. Gray’s anatomy for students. In: Head and Neck Back.
Churchill Livingstone; 2014.
3. "The Hospitalized Patient," by Samuel Yoakum, Somatic Dysfunction in
Osteopathic Family Medicine, pp 201-215
4. "The Geriatric Patient," by K.E. Nelson, A. L. Habenicht, N. Sergueef, & J.
Allgeier, Somatic Dysfunction in Osteopathic Family Medicine, pp 167-182
The copyrighted materials available in this PowerPoint are for educational
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Editor's Notes
Great chapters on specialties
highy recommend this book
WTII: 2.Social history and addressing this area is going to be very important in these groups
3. Beause these groups are complex, how you deliver healthcare will depend on capacity of patient and many times will require outside help
For example: A patient who had surgery in the hospital, what if they cant walk, how do they take care of themselves at home? What if that person is also elderly without any family? This is a basic example of what we will be discussing today and from a holistic perspective (osteopathic perspective) is part of addressing Mind/Body/Spirit, its how we deliver effective healthcare.
Tenet #1: The body is a unit; the person is a unit of body, mind, and spirit.
Tenet #4: Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.
Social questions
•Have you been without a home at any time in the past year?
•Has there been a time in the past 6 months when someone in your home skipped at least one meal because there wasn’t enough money to buy food?
•Who prepares meals in your home?
•Can you safely walk in your neighborhood?
•How do you get your medications (ex: online, neighborhood pharmacy, samples) and who gets them for you?
Challenges. Decreased capacity and chornicity. Compounding medical problems over time.
An injury is recoverable when you are young, but what about decades later without full recovery.
Decreased support system
Chronicity is a manifestation of the technology and individual’s ability to compensate for stress
Many chronic medical problems concomitant
Back pain on top of everything else hard for the patient but might not be for a healthy patient.
Image:
wwwassets.rand.org
Concerns with elderly: how do they live out their days with food
Image: beginningwiththeendfilm.com
-Patient encounters in the hospital are typically quite different from those in the clinic setting,
presenting unique challenges to the clinician and a number of unique barriers to the integration of osteopathic thought processes in management.
-everything tends to be protocol based thesis days
-The presence of somatic dysfunction may also help to explain vague or suspicious sounding symptoms and avoid expensive workups of very simple situations.
*What are the look of these patients through an osteopathic eye
LANDING A PLANE AND TAKING OFF AGAIN
Image: pchonline.org
WT2
Your understanding of anatomy will be the key to helping you with your treatment. And even if you don’t do manipulation in the hospital
Image:i.ytimg.com
NOT AN ALL INCLUSIVE LIST
Pre and post surgical intervention or in the outpatient. Ederly don’t move so well after these procedures, being in the hospital and having these procedures done is draining on patients, what recommendations do you make in the post care that is to help them RECOVER, not any disease, just recover better and faster.
LYMPHATIC DRAINAGE OF THE HEART
Smoking
Image: gallery.ctsnet.org
WT2: The bigger picture.What recommendations to make to PCP
PNA, WHAT PERCENTAGE IS VIRAL
In addition to improved patient safety and satisfaction, these benefits also decrease overall cost to the system as a whole, which is an increasingly important, albeit secondary, consideration.
Chronic care - fluid movement and congestion
Smoking
Image: pearsonhighered.com
WT2: Seems straighf tforward to consider anatomy, but many times in clinical practice, for example COPD exacerbation or PNA, giving ABX and/or steroids for their condition, yes you know the problem in the lung, but you don’t consider the structure/function relationships, everything that you’ve been learning the past 2 years. How does the rib cage affect diaphragm movement and aeration of the lungs, this is why its important to keep this in your mind because if you do then you might consider OMT as an adjunct treatment.
Example: Sternotomy: think about the distruption of anatomy, that patient needs to recover, disease has been fixed but that doesn’t mean the work is done.
Muscle fatigue due to increased work of breathing which can lead to respiratory failure
A concern with people who have asthma, COPD, pulmonary edema, lung shock, and those recently off ventilators (C3-5)
Thoracic compliance
Heart in relation to sternum
Phrenic nerve compromise within the msk system
Lung relation to diaphragme and ribs
Image: copyright Grey’s Anatomy Student Edition
Nowhere more than in surgery does disrupted anatomy matter more
Anatomy is disrupted, autonomic reblaancing, causing pain (many pain syndromes are associated with all these procedures), other syndromes like ileus
OMT for autonomic reblancing and return to function, optimizing fluid drainage from area.
We tend to think that once the surgery is done or medication is given that is the end of the story, but its not, the patient isn’t back to normal yet. The whole recover process is one you will be facilitating as a doctor.
Immobilization
Ongoing studies on the effects of exercise programs pre and post op, if they can show some benefit, couldn’t OMT have some good
What surgery actually entails
Decreased gastric and intestinal motility
Pain… requiring more medications
Surgeons want patient up and moving as soon as capable. If walking is used to help post op ileus
As a surgeon “well surgery went fine” sorry your in pain” fu with pcp
Image: mmcts.oxfordjournals.org
Disruption of these anatomic points. An integrative perspective, disruption of structure and function.
Image: copyright Grey’s Anatomy Student Edition
TO HAVE AN APPRECIATION FOR DISRUPTED STRUCTURES, abdominal wall has been distrupted, diaphram has artificially moved
Image: copyright Grey’s Anatomy Student Edition
It is common knowledge that an optimized diet coupled with exercise may be employed to improve muscle tone and mass, as well as prevent osteoporosis, reduce hyperlipidemia, maintain cardiovascular health, and enhance the efficacy of medical therapies for disease processes like diabetes.
Decades of compound affect, compensation
Loss of muscle mass decreased stamina and functional capacity
Spinal mechanics/pelvic dysfunction/short leg, and decompensated posture
Postural imbalance and gait instability periph. input if decreased can affect posture (also visual labyrinthine, and somatosensory input) risk of falling, all of this combined with postural compensation for muscle weakness contributes to imbalance
his imbalance results in pelvic unleveling with compensatory type I, group lateral curve, spinal mechanics above the pelvis.
when you sit for hours or go on a breaking bad binge on the couch for hours, maybe have some strain
if you see it from patient perspective
Image: westsubpainrelief.com
Adequately convey information
Image: i.huffpost.com
Physical mobility may be impaired, further interfering with food acquisition and preparation. Energy expenditure is decreased, thereby decreasing caloric requirements,
diet and exercise increase muscle tone and mass, prevents osteoporosis, reduce hyperlipidemia, cardiovascular health and improve glucose control
Poor dental health, hyposecretion of the gastric mucosa, and senescent decrease in the production of enteric enzymes all interfere with the absorption of nutrients.
no quick changes
Physical symptoms that they might have found unacceptable in their younger days become normative, so they do not complain about them. Chronic lower urinary tract infections, low grade upper respiratory infections, and dental sepsis can result in malaise that does not necessarily present as a specifically localized complaint. —> simple ROS
GOING TO SEE PATIENTS AT THEIR WORST YOU SHOULD BE PREPARED
Possibly the most important therapeutic agent in the treatment of many older patients is the personal interest of their physician.
The basis for this is understanding and appreciation for structure and function
MIND BODY SPIRIT
Image: copyright Grey’s Anatomy Student Edition
The problem: lymph transport from below
the heart has to occur against gravity and
against a positive hydrostatic pressure
(‘uphill gradient’),
• The solution: valves, muscle contractions,
the respiratory diaphragm, motricity!
Image: Foundations of Osteopathic Medicine
Organ prolapse
Image: Foundations of Osteopathic Medicine
The basis for this is understanding and appreciation for structure and function
MIND BODY SPIRIT
If direct attention to spinal segment and treat articular tissue first thus deal directly with the facilitated segment.
Image: copyright Grey’s Anatomy Student Edition
Image: copyright Grey’s Anatomy Student Edition
Keep it simpleLymphatic Protocol – treating diaphragslymphatics take movement, in the hospital this is decreased, caution in the case of those with RF or CHF
Dosing
-Goal – promote homeostasis and self healing
-ICU - Patients may go hours, days, or even weeks without gaining consciousness, all the while increasing lymphatic and venous stasis.
-ICP and pedal pump
-Each intervention requires energy from patient
-Treat only most important dysfunctions – i.e. those that seem to most impede the homeostatic processes
-Leave unrelated problems (sometimes the longstanding problems) for outpatient care
-Short periods of treatment
-Look for changes in TTCs following treatments, for signs of improvement
-During any inflammatory process, increased capillary permeability allows an efflux of protein into the interstitial spaces, producing an exudative swelling - CAREFUL NOT TO OVERDUE IT.
the cranio-cervical junction is of importance for postural balance, mechanical perturbation, head-flexed (tilted from the erect) position has been shown to increase postural Instability
upper thoracic flexion contributes further to the head-flexed position and also necessitates low to midcervical compensatory extension, placing stress on an area of the spine that is frequently unstable and osteoarthritic;
the thoracic cage (thoracic inlet, ribs, vertebrae, and thoracoabdominal diaphragm) for efficiency of respiratory function and the return of venous blood and lymph to the heart;
the lumbar pelvic and abdominal areas to promote lower gastrointestinal regulation.
Image: copyright Grey’s Anatomy Student Edition
Image: copyright Grey’s Anatomy Student Edition
Keep it simpleLymphatic Protocol – treating diaphragslymphatics take movement, in the hospital this is decreased, caution in the case of those with RF or CHF
Dosing
-Goal – promote homeostasis and self healing
-ICU - Patients may go hours, days, or even weeks without gaining consciousness, all the while increasing lymphatic and venous stasis.
-ICP and pedal pump
-Each intervention requires energy from patient
-Treat only most important dysfunctions – i.e. those that seem to most impede the homeostatic processes
-Leave unrelated problems (sometimes the longstanding problems) for outpatient care
-Short periods of treatment
-Look for changes in TTCs following treatments, for signs of improvement
-During any inflammatory process, increased capillary permeability allows an efflux of protein into the interstitial spaces, producing an exudative swelling - CAREFUL NOT TO OVERDUE IT.
the cranio-cervical junction is of importance for postural balance, mechanical perturbation, head-flexed (tilted from the erect) position has been shown to increase postural Instability
upper thoracic flexion contributes further to the head-flexed position and also necessitates low to midcervical compensatory extension, placing stress on an area of the spine that is frequently unstable and osteoarthritic;
the thoracic cage (thoracic inlet, ribs, vertebrae, and thoracoabdominal diaphragm) for efficiency of respiratory function and the return of venous blood and lymph to the heart;
the lumbar pelvic and abdominal areas to promote lower gastrointestinal regulation.
Image: copyright Grey’s Anatomy Student Edition
If we take a neurologic approach we treat the tissues around these areas because we cant touch the ANS
Image: copyright Grey’s Anatomy Student Edition
For both populations
Decide which areas of the patient’s body are most impairing the homeostatic balance
Which techniques are best suited, or appropriate, to the individual case
Quantity of treatment tolerable to patient
Image: www.tampabay.com
Understanding of First osteopathic tenant and social aspects
How do you take care of the patient globally? Medicine is about more than just the diagnosis.
Understanding of Structure and function will help to look deeper physically
In lab we are going to review procedures that bridge both populations
