CARE PROTOCOL FOR WELL ELDERLYDefinitionWell elderly is a person that had gone through ageing process without anymedical illness or medication, accomplish ADL independently but somemay have arthritis, diabetes but the disease won’t limit them from involvedin activities.PREPARED BYADLIN HANI BINTI MAZLAN HANAFINUR AIMI BINTI ISMONUiTM kampus Puncak Alam
OverviewChanges experience due to ageing• Endocrine, Gastrointestinal and Metabolic Systems- decrease amount of total body water and total body fat- reduce in sense of taste and smell (decrease food enjoyment)• Integumentary system- change in skin d/t dry, wrinkled- uneven discoloration, loss elasticity, delay in wound healing- capillaries can be fragile and easily bruise• Cardiovascular system- cardiac output drops, heart rate slows, heart rate should exceed 60 b/min- degenerative process affect the ability heart to pump the blood- wall of heart become hypertrophy and lead to HPT, arteriosclerosis• CNS (central nervous system)- elderly experience 45% loss of cells in certain areas in brain- average of 6-7 % reduce weight of brain- elderly may have slower reflexes, decreased equilibrium, decreased perception oftouch and temperature
• Sense- deterioration of hearing and vision- pupils show a decrease in ability to accommodate to light- diminish hearing capability for high-pitched sounds• Respiratory System- result of alteration in respiratory muscle, normal elasticity, recoil of thorax- the lung tissue loses its elasticity- respiratory muscle lose their strength and coordination• Musculoskeletal system- bones become brittle, susceptible to fracture- joint lose flexibility, loss skeletal muscle mass- elderly become easy to fall d/t decrease joint mobility and muscle weakness
Scope• Guideline for physiotherapist toprovide appropriate, safe andeffective management for wellelderlyObjective• General- to assist physiotherapist in planningand implementing activities for well-elderly to enhance their quality of life• Specific- provide knowledge andunderstanding to manage the well-elderly- maintain independence in ADL andtheir social life- prevention of accidents and injuries- use of assistive and supportivedevices to suit the needs in specificenvironment- integrate into community
AssessmentA. History taking- general health- mental status- medical and surgical history- medication- occupation- social history – living independently/ with family- past historyB. Current history- quality of life at present moment (activity and life style)C. Observation- getting up from chair- posture in standing- gait- limping, waddling, circumduction- ambulation w or w/o aids- balance in sitting and standing- joint swelling and joint deformity- wearing spectacles or hearing aids
D. Palpation- skin temperature- skin texture- tenderness- any bony deformityE. Joint movement- AROM of limbs- PROM of limbsF. Muscle power/ coordination/ balance- oxford’s muscle strength grading system- finger-nose test- modified/sharpen Romberg Test- timed up and go test- functional reach test- berg’s balance test- steps test- chair rise test- arm curl test- 4 square test
G. Functional activities- self care activities : ADL- locomotion : walking, stairs climbingH. Neurological- reflexes- sensation- motor- proprioception- coordinationI. Short & long term goal- setting up STG and LTG based on the findings, capabilities of patients and theirpsychosocial needsNB generally the ultimate goals to be achieved :-maintain and enhance the functional independence in ADL- improve and maintain psychological well-being
KEMENTERIAN KESIHATAN MALAYSIAPHYSIOTHERAPY DEPARTMENTGERIATRIC ASSESSMENT FORMDR’S DIAGNOSIS ANTOMY CHARTDOCTOR MANAGEMENTPROBLEMPAIN SCALE : 1 2 3 4 5 6 7 8 9 10COMMENTS :SPECIAL QUESTIONGENERAL HEALTH :MENTAL STATUS :PMHX/ SURGERY :IX/ MRI/ XRAY :OCCUPATION :MEDICATION/ STEROIDS :1. Are you taking more than 4 meds Y/N2. New med within last 2weeks Y/N3. Are you on tranquilizer sleeping Y/Npills, anti depressant?4. While walking, did you experience any ofthe following?a. dizziness/ headache Y/Nb. vertigo Y/Nc. loss of consciousness Y/NCURRENT HISTORYPAST HISTORYOBSERVATIONNAME : AGE : SEX : M/F R/N: DATE :
SPECIAL QUESTIONS (cont…)5. Environmental problem e.gLighting, flooring probs. Y/N6. Any falls within last 12 monthsIf yes, how many times?______ Y/N7. Injuries within last 12 monthsIf yes, how many times?______ Y/N8. Continence- urinary Y/N- bowel Y/NPALPATIONNEUROLOGICALREFLEXES :MOTOR :SENSATION :CLEARING TESTS / OTHER JOINTSPHYSICAL EXAMINATIONMovementJoint active passivePHYSIOTHERAPIST IMPRESSIONSMUSCLE POWER SHORT TERM GOALFUNCTIONAL ACTIVITIESSPECIAL TESTS1. GET UP AND GO TEST2. MODIFIED RHOMBERG TEST3. TIME UP AND GO TEST4. FUNCTIONAL REACH TEST5. BERG’S BALANCE TEST6. STEP TEST7. CHAIR RISE TEST.LONG TERM GOALPLAN OF TREATMENTATTENDING PHYSIOTHERAPIST
FALL RISK SCREENING FORMDATE :NAME :AGE :I/C NO :GENDER :ADDRESS :RACE :FILL IN THE YES/NO FOR THE QUESTIONS BELOW YES NO1. Do you take any medication (including herbal)2. Do you take more than 4 medications daily?3. Have you taken any new medications in the past 2weeks?4. Do you sometimes feels dizzy when you stand up?5. Are you sometimes unsteady when you stand or walk?6. Do you use a cane or a walker?7. Do you sometimes have to rush to the bathroom?8. Have you fallen down in the past 3 months?9. Do you have poor vision?10 Do you have poor hearing?* If one or more of the above answers is yes, patient is considered to have risk of fall.
Functional Strength Arm Curl Test (ACT)-analysis of the patient’s upper extremity strength-1. Equipment- straight backed chair (height 17”), dumbbell (5lbs for women, 8lbs for men), stopwatch2. Starting position- pt sitting in the middle of chair with back straight and feet on floor.- the weight is held on dominant. (elb in extension by the side of pt’s torso, perpendicularwith the floor, wrist in neutral)3. Protocol- the pt is requested to turn the palm outward(supinate) while curling the arm thru thefull ROM and return to full extension.- in down ward position, the hand should returned to the original position (neutral wrist)- therapist demonstrate the test and allow twice practice from pt to ensure the correctform.- a 30 secs trial is performed and recorded.- therapist can help to keep the pt’s upper arm still against their body during the trial.- pt can squeeze the therapist’s fingers to stabilize the upper arm from moving to ensureFROM is achieved.4. Scoring- the total numbers of curls executed correctly within 30mins.5. Adaptations of hand use is required- unable to hold the dumbbell d/t medical condition, a Velcro wrist weight may be used.- unable to perform 1 repetitions, use the lighter weight and state on assessment form
Functional Reach Test ( FRT)- Analysis of the patient’s postural control-1. Equipment- a yardstick mounted on the wall at the sh. height.2. Starting position- position the yardstick at the level of pt’s acromion process.- pt stand with feet shoulder width apart and arm raised to 90degree (parallel to floor)3. Protocol- the pt is instructed to reach as far forward as possible w/out letting the feet raise fromthe floor.- location the middle finger is recorded.- trial distance : final number – start number.- perform 1 practice trial for patient understanding and 1 test trial for record.4. Instruction to the patient- please reach as far as you can without losing your balance.- keep your feet on the floor.5. Criteria to stop the test- patient’s feet lifted up or they feel forward.- therapist stands at the front because mostly patients fall forward with this test.5. Prediction- older adults who score < 6,7 inches indicate limited functional balance.- healthy people able to score > 10inches.
Intervention• The main treatment will be :i) Exercise Therapyii) Pain Managementiii) Patient Educationiv) General Fitness1. Exercise Therapy- Improves overall physical capacity and cardiovascular function in the elderly.- influences both life span and quality of life- offers way to maintain physical and mental healthTypes of exercise :i) mobilising exsii) strengthening exsiii) balance exsiv) relaxation exsv) breathing exsvi) proprioceptive exsvii) aerobic exsvii) stretching exs
2. Pain managementHelp to reduce pain for patients with neuro and musculoskeletal problemsType of modalities :i) Cold therapyii) Hot packiii) TENS/ EMS3. Patient Educationeducation programme sholud be include :i) Explanation on the conditionii) Advice on home exs programmeiii) Advice on prevention from getting worseiv) Prescription on exs4. FitnessEncourage patient to do regular exs 20-30 minutes per session, 3 x per weekexp : brisk walking and sport activities
EXERCISEPURPOSE :-1. CARDIOVASCULAR ENDURANCE- Improve circulation and heart muscle works effectively- Efficient lungs, muscles and other systems functions2. MUSCULAR ENDURANCE- Ability of muscle to perform action for longer period of time3. MUSCULAR STRENGTH- Strengthen the muscle and bones- Improve posture, prevent osteoporosis.4. FLEXIBILITY- Level of elasticity of muscles, tendons, joints and ligamentsBENEFITS1. Physical and psychological – reduce anxiety, improve appetite, alleviates minoraches/pain, increase muscle endurance, improve postural control, improve balance
AEROBIC EXERCISE PERIOD1. Involved rytmic , repetitive , dynamic exercise of large group muscles from 20-30mins2. Must within individual tolerance.Progression should be done to the individual capacity. (heart rate monitored accordingTarget Heart Rate)TARGET HEART RATE (KARVONEN FORMULA)THR : Target Heart RateMHR : Maximum Heart Rate (220 – age)RHR: Resting Heart Rate% Fitness Level50-60% - Never exercise before56-60% - Sometimes only61-70% - Exercise 3x per week71-85% - Regular exercise more than 3x perweek, under training program.e.g : 70 years old elderly with RHR 80bpm never exercise beforeTHR : RHR + %fitness level(MHR – RHR): 80 + 50%(220-70)-80: 80 + 35: 115b.p.m
3. Aerobic Exs : walking, brisk walking, treadmill walking, cycling, dancing running, sowing,stair climbing, and swimming4. Frequency 3-5 times per weekintensity : Heart rate should reach 115bpm (refer prev exmple)time : 20-30minsCOOLING DOWN PERIODPurpose :1. prevent blood pooling in extremities2. Prevent light headedness or fainting3. Prevent arrhythmias/ CR CxCharacteristic1. Repeating a warm p routine (assist venous return)2. Muscle recovery3. Period : 5-8mins
GUIDELINES ON CHOOSING AN EXERCISE PROGRAM1. Exs is according to one’s physical capability and pt’s needs.2. Exs should be enjoyable3. Consult a doctor beforehand. Patient with medical problem shouldadjust exs activity4. Alert with unusual symptoms ( chest pain, SOB, muscle cramps)5. Movt should be smooth and lively. (avoid jerky movt)6. Breathing Exs should be carried out within exs.7. Do not stop Exs suddenly (slow down)8. Move as much as possible (more complex movt)9. Fix a daily exs for yourself.
SAFETY1. Aerobic exs should be conducted after warm up and endswith cooling down to avoid muscle cramp, pain and injury2. Wear proper attire and shock absorbing shoes3. Exercise is safe (good ventilated room and no slippery floor)4. Avoid exs 2hours after heavy meals5. Avoid dehydration (drink a lot)6. Avoid exs when you are sick.7. Avoid exs on bad wheather (too hot, too cold, highlypolluted air, too dark)8. Avoid taking warm bath because it may interruptsphysiological cooling down mechanism.9. Stop exs when you have chest pain or breathlessness
DRUG USED AND EXERCISE (PRECAUTIONS)DIABETES MELLITUS• no exs when blood glucose above 20mmol/L and less than3.5mmol/L (exs range between 4-20mmol/L• if FBG > 20mmol/L, monitor the blood glucose level beforecommencing the exs.• exs should commence at least after half an hour aftermedications•Complications of acute DM- hyperglycemia : thirsty, polyuria, lethargy, nausea, vomit andsemi consciousness- hypoglycemia : hungry, headache, tremors, sweating andbehavioral changes. (provides any sweets)
HYPERTENSION• ensure blood pressure is stable before exs• Severe HPT or poorly controlled pressure should avoidisometric/ callisthenic exs (they should be monitored closely).• exs should commence at least after half an hour aftermedicationsMUSCULOSKELETAL PROBLEMS• Exs should be performed within pain-free ranges• Severe arthritis, joint problems should be supervised.
PRECAUTION1. Pt with DM, HPT, HD and MS problems should follow the criteriabefore they join the exs program.2. Screening (DM, HPT, HD and MS problems) should be done earlier3. Pt on regular medical check up4. Compliance to medication5. Evaluation should be carried out regularly
TIPS TO PREVENT FALLSPoor balance Balance training (taichi, gym ball exs)Muscle weakness of the legs Strengthening exs ( climbing stairs, walking and staticclimbing)Poor coordination Coordination training (taichi)Cluttered walkway Keep the walkway clearOil and water spills on floor Wipe all the spills immediatelyLoose rugs Replace with non slip rugsPoor lighting Maintain adequate lightingHigh Bed Height Select the suitable bed height (feet can reach thefloor while sitting)Unstable chairs with wheels Use stable chairs with suitable seat heightNo mobile chair without brakeSlippery floor Walk close with wall for supportTake special care when walking outdoorPoor vision Wear appropriate glassesHold handrail when climbing stairsInappropriate use of walking aids Use it correctly and seek professional advice if indoubt.