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

1. Marc Evans M. Abat, MD, FPCP, FPCGM
Head, Center for Healthy Aging, The Medical City
Clinical Associate Professor, Section of Adult Medicine, Department of
Medicine, PGH
Visiting Consultant, Manila Doctors Hospital, St. Luke’s Medical Center

5. But the truth of the matter is….

6. 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

7. Prevalence of Disability in the
Elderly

8. Estimated Number of Disabled Males in England and
Wales by Age Group and Type of Disablitiy
90000
80000
70000
60000
Physical
50000
Cognitive
40000 Combined
30000
20000
10000
0
64-74 years 75-84 years ≥85 years
BMJ 1999;318:1108

9. 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

10. Benefits of Rehabilitation in the
Elderly

11. Rehabilitation for COPD Patients
Hong Kong Med J 2004;10:312-8

12. 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

13. 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

14. 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

15. Goals of Rehabilitation in the
Elderly

16. J Rehabil Med 2011; 43: 156–161

17. Challenges in Rehabilitating an
Elderly Patient: Physiologic Changes
in the Elderly

18. 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

19. Respiratory
• ↓decreased elastic
recoil (decreased lung
elasticity)
• ↑chest wall stiffness
• Decreased respiratory
muscle endurance
Increased work of breathing
Easy fatigue with effort

20. Cardiac
• poor heart rate response with
effort
• ↑vascular stiffness
• ↑ventricular stiffness
• Conduction system
degeneration
• Valvular degeneration
• ↓β-adrenergic
responsiveness
• ↓baroreceptor sensitivity
Easy fatigue with effort
Increased/exaggerated blood pressure response
Orthostatic hypotension with changes in position

21. 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

22. • 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

23. • 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

24. Decreased muscle strength
Decreased muscle endurance
Limitation in joint flexibility
Increased propensity for pain
Musculoskeletal effects on gait and
balance

25. 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

26. • Increased reaction
time
• Decrease in size of
peripheral nerves
decreased sensation
• with aging, information
processing and
memory retrieval slow
but are essentially
unimpaired

27. Balance deficits may have a central etiology
Propensity for orthostasis due to decreased
cerebral blood flow
Need to give time for information processing
Decreased touch sensation and proprioception
Need for gradual, graded and patient
rehabilitation to achieve improvements

28. Challenges in Rehabilitating an
Elderly Patient: Effects of Geriatric
Syndromes

29. 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

30. • 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

31. Dementia
• memory impairment
causing
cognitive, functional
and behavioral
deterioration

32. Cognitive Behavioral Functional
Difficulty Agitation and Loss of muscle
following aggression strength
directions during
rehab Depression Cardiovascular
deconditioning
Hallucinations Lack of
and delusions motivation
Other abnormal
behavior

33. Delirium
• Acute confusional
state
• Waxing and
waning, varies
throughout the day
• May by hyperactive
or hypoactive

34. 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

35. Medications Adverse Effects
Sedatives, antihistamines Drowsiness, balance problems,
risk for falls, delirium
Antihypertensives Orthostatic hypotension
Eye drops Visual problems
Diabetes medications Low energy levels due to low
blood sugar
Diuretics Hypotension, incontinence

36. Incontinence
• Inability to control
urination and
defecation for a socially
convenient time
• Related to other
problems like social
withdrawal and falls

37. Management Issues in
Rehabilitation of the Elderly

38. Approaching an Older Patient for
Rehabilitation
• Proper
communication
– Treat as a respected
adult
– Address properly
– Simple but direct to
the point
– Demonstration

39. • Overcome sensory
barriers
– Using eyeglasses
– Using hearing aids
– Well-lighted exercise area
– High-contrast color
schemes
– Talking in a modulated
tone and speed

45. 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

46. Functional Reach

47. Other Considerations
• Escalate your therapy!!!!!!!!!!!!
• Discern between true pain/discomfort vs.
“acting out”
• Clearly define and prioritize goals, time frame
and other expectations

48. • Coordinate with the primary care physician
regarding
– Medication effects
– Other pertinent co-morbidities