Aging Rehabilitation

8/14/2019 Aging Rehabilitation

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Geriatric Rehabilitation


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Speaking generally,

all parts of the body which have function,

if used in moderation

and exercised in labors to which each is accustomed,

become healthy and well developed and age slowly.

But, if left unused and left idle,

they become liable to disease,

defective in growth and age quickly.

Geriatric Rehabilitation


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GeriatricsGeriatrics

A branch of gerontology and medicinewhich deals with the clinical,

rehabilitative (remedial), psycho-socialand preventive aspects of illness in

elderly people.

Gerontology The scientific approach to all aspects of

aging (health, sociological, economic,

behavioural, environmental)


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History of Geriatric

Medicine Term Geriatrics: Coined byAmerican physician Dr Nascher in

1907

Pioneer of Geriatric Medicine: DrMarjory Warren (West Middlesex

Hospital, UK) in 1935. She practiced

comprehensive geriatric assessmentand rehabilitation


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Aims of Geriatric

Rehabilitation Maintenance of health in old age byhigh level of engagement and

avoidance of diseases. Early detection and appropriate

treatment of diseases.

Maintenance of maximumindependenceconsistent with

irreversible disease and disability.

Sympathetic care and support during


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mpor an oncep s nAged Care

To keep the elderly in their own homes foras long as possible with appropriatesupport for themselves and theircaregivers.

To provide appropriate continuity of carefrom the acute hospital setting through tothe community setting.

To develop a wide range of options

providing help and support to the elderly.

To increase links between those servicesinvolved in care for the aged and

disabled.


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Special Characteristics of

Diseases in Old Age Senescence

Impaired homeostasis

Atypical features

Non-specific presentation

Multiple pathology Multiple etiological factors

Unreported illnesses


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Modified

ManifestationsAtypical

Non-specific Insidious Onset

Silent existence

Missed diagnoses


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The Giants of

GeriatricsThe Big Three Is

Intellectual failureInstability and immobility

Incontinence


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Geriatric

AssessmentMedicalMental: AMT (Abbreviated Mental

Test), MMSE (Mini-Mental StateExam)

Functional: ADL (Activities ofDaily Living), IADL (InstrumentalADL)

Social


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The Multi-disciplinaryGeriatric Team

Core Members:Geriatrician

Nurse (+NS, CNS)

Social Worker

OccupationalTherapist

Physiotherapist

By Consultation:

All subspecialties ofmedicine

Other specialties

Supporting Members: Podiatrist

Speech Therapist

Dietitian

Prosthetic &orthotic specialist

Psychogeriatrician

Clinical psychologist

Volunteer

Pastoral care


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Hospital-based

Geriatric Services Acute care

Assessment

Rehabilitation Continuity care (long stay care)

Respite care

Geriatric Day Hospital Specialist clinic

Domiciliary visits


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Community-basedGeriatric Services

District-based Assessment/ Rehabilitation

Teams:

CGAT (Community Geriatric Assessment

Teams)

PGT (Psycho-geriatric Teams)

CNS (Community Nursing Service)

CPNS (Community Psychiatric Nursing Service)

CPT/COT (Community PT/OT)

C it S t


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Community SupportServices HOME HELP

SERVICE Integrated Home

Care Service

MEALS SERVICES Meals-on-wheels

Canteen service

SOCIAL CENTRESFOR THE ELDERLY

HOLIDAY CENTRES

DAY CARE CENTRES

ELDERLY HEALTHCENTRES VISITING HEALTH

TEAMS

HEALTH VISITS Other VisitingServices Welfare agencies

Volunteer groups Telephone hotline

SOCIAL

NETWORKING: Social Welfare


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Prevention of the Dysfunctional Syndrome: Conceptual Model

Functional Older Person

Acute Illness,Possible Impairment

Hospitalization

ARC Unit


Improved Mood

Positive ExpectationsReduced Impairment

Decreased Iatrogenic

Risk Factors

Prehab Program

Prepared environmentPatient-centered, interdisciplinary care

Multi-dimensional assessment and non-pharmacologicprescription

Home planning/informal networkMedical review

Depressed Mood

Negative Expectations


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Conceptual Model of the Dysfunctional

Syndrome


Acute Illness

Possible Impairment

Hospitalization

Hostile Environment

Depersonalization

Bed Rest

Starvation

Medicines

Procedures

Depressed Mood

NegativeExpectations

Physical

Impairment

Dysfunctional Older Person

Hospitalization

Hostile Environment

Depersonalization

Bed Rest

Starvation

Medicines

Procedures

mprov ng are o a en s w ron c


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mprov ng are o a en s w ron cIllness:

The Wagner Model

Chronic Care takes place in 3 galaxies: Community

Health Care System and Payment Structure

Provider Organization; clinic, loose network of

providers

Six Essential Elements

Community Resources and Policies

Healthcare organization

Self-Management Support

Delivery System Design

Decision Support

Clinical Information Systems


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Wagners Chronic Care Model

Health SystemOrganization of Health Care

CommunityResources

and Policies

Self-Management

Support

Decision DeliverySupport System

Design

ClinicalInformation

Systems

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Improved Functional and Clinical Outcomes


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Hip fracture

Stroke

CHF

COPD

HealthHealth

CapacityCapacity

The Nature of Chronic Conditions

Requires a New Mind-set

Time

Disability

Acute Event

AcceleratedLoss of Health Reserves

Hypertension

Rapid weight

gain/loss

Hyperglycemia

Progressive Conditions

Condition Onset

Public

Health

Primary

Care

Acute

Care

Long-term

Care

RiskRisk

FactorsFactors

Incontinence

Confusion

Caregiver burnout

ADL/IADL decline

Obesity

Tobacco and

alcohol

Pollution

Death

NormalAging

Complex care management

Interrelated needs require ongoing, coordinated care interventions.


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Successful aging

A process by which deleterious effects of agingare minimized, preserving function untilsenescence makes continued life impossible

To be distinguished from usual aging(characterized by accumulation of diseases and

impairments of the elderly)


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Stages of Development

Infancy- Consistency of caregivers trust andhope.

Early Childhood- Self-regulation, autonomy,control of external events sense of self-control;

developing willpower Play Age Childhood- Initiation of events senseof gender identity, direction and purpose

Primary School Age Childhood- Sense of

industry, productivity, competence sense ofself-worth.

Adolescence- Transformation of body sense ofa distinctive self-identity


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Stages of Development Young Adulthood- Previously learned values &

skills are focused to meet goals related tointimacy & vocation.

Middle Adulthood- Productivity, caretaking,generativity

Older Adulthood- Successes & failures fromprevious stages are accepted, integrated. Theindividual has achieved a sense of life's meaning;accepts the meaning of death as a part of the life

cycle.


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Principles of Rehabilitation in Aging

ARNDT-SCHULZ PRINCIPLE The application of---------

b. Subthreshold stimulus no change in the systemc. Suprathreshold stimulus increased physiologic function of

system

d. Supramaximal stimulus reduces function causes damages

Application to the aging individual:

Suprathreshold increases with age - more stimulus requiredto produce a response.

When suprathreshold is reached the response is more volatilewith increasing age.

Peak response is less in elders and usually requires lessstimulus than in youth. A stimulus within the suprathreshold range for younger

patients may be a subthreshold of supramaximal stimulus forelders.

The suprathreshold range in elders is considerably narrowerthan in younger individuals.


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A/c to this law, with a given intensity of stimulation; the

degree of change produced tends to be greater when theinitial level of that variable is low; and that the higherthe initial value, smaller will be the change produced.

In younger individuals, biorhythms are relatively well

coordinated, and thus, a particular stimulus is likely toproduce a relatively consistent response when time ofday/month/season is held constant

In older individuals, biorhythms are less wellcoordinated; the elders response to a given stimulus is

less predictable than for youth Even though variability is greater among elders,patterns of low and high responsivity are still usuallyidentifiable. Effort should be made to identify optimal

times for activities and individualize the schedule foreach individual.

Principles of Rehabilitation in Aging

LAW OF INITIAL VALUES

DEMENTIA TREATMENT


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DEMENTIA TREATMENTProblem management to manage behavior problems

- be concrete with patient -dont

provide choices- Avoid decision-making tasks

- avoid anxiety-producingsituations

- do not expect too much- do not over-stimulate

- do not permit fatigue

- limit intake of stimulants/

coffee- provide ample fluid & high

fiber diet

- have an element of danger

(cooking)

- use sedative as needed

- do not initiate hearingaid

- don't change frombifocal to trifocal

- do not take patient onvacation to strangeplaces

- play golden oldies

- sew name/address labelsinto clothing

- keep doors locked andwindows secure


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Environmental/Behavioral treatments attempt to reduce

contextual demands on the patient so that problem behaviors areprevented and negative consequences are reduced.

Implement-

structured routines

appropriate socialization and recreation

reassurance and comfort

Reality Orientation: consistent, repetitive cueing individuallyand in group about person, time, place, environmental events

encourages patient to rehearse Use memory books charts and calendars

Not recommended for many middle and later stages because it isineffective and is a stressor increasing agitation

DEMENTIA TREATMENTProblem management Environmental/Behavioral treatments

I lli R h bili i


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Intelligence Rehabilitation

Normal

ModerateCognitiveImpairment

MildCognitiveImpairment

SevereCognitive

Impairment

Clock Drawing Test


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Intelligence RehabilitationIntelligence

Fluid intelligence:

complex relations; short-termmemory; abstract reasoning

memory span, inductive reasoning,

figural relationsprobably more dependent on theperson's biology than crystallized

not as dependent on instruction

ability to perceive complex relations

ability to use short-term memoryability to perform abstractreasoning

this sort of intelligence is thought todecline most with age

Crystallized intelligence:

thought to be dependent on socialand cultural learning

is one's ability to understand one'scultural heritage

measured by number facility, verbalcomprehension, general info.

dependent on openness to newlearning, amount of learning, extent

of formal learning opportunitieswill continue to grow throughout life

in many individuals


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Memory enhancement techniques

attention/awareness

self-instruction

controlling the physical environment

taggingorganization/chunking

stress reduction (exception: flashbulb memory)

logging

imagery for stress reduction

Intelligence Rehabilitation


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Aging Rehabilitation :Nutrition Energy: decrease with age; nutrient density

Protein: remain constant: watch intake

CHO/fiber: constipation

Fat

Water Vitamin D

B6: immune function

B12: atrophic gastritis

Aging: Drug & Nutrient


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Aging: Drug & Nutrient

Interactions Consult Clinicians

No. of Meds/ Doses of drugs

Long term therapy

Nutritional status

Body composition & functional changes

Compliance of individual

alter food intake: effect appetite

reduce absorption of nutrients

alter metabolism/excretion of nutrients


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Nutrition & Aging Brain Neurotransmitters:

send/receives messages

chemical agent

released by neuron to act on neurons...

made by nutrients

precursors = amino acids; requires Vitamins /Minerals


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Nutrition & Aging Brain

Nutrients involved in neurotransmitters:B6 B12 Folate Vit C

Nutrients for Normal Function:Iodine Fe Cu Zn

Protein


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Nutrition & Aging Brain Memory B12, Vit C

Problem Solving Riboflavin, folate, B12

Vit C

Dementia Thiamin, Niacin, Zn

Cognition Folate, B6, B12, Fe

Degeneration of B6

Brain Tissue


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Complex and multifaceted approach

involving:

Cognitive therapy Behavioral/functional interventions

Emotional/social treatment

Pharmacotherapy Electroconvulsive therapy (ECT)

Nutrition & Aging Brain

Treating Depression

Documents

Aging Rehabilitation