Aging Rehabilitation

Geriatric Rehabilitation

Geriatric Rehabilitation “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.”

Geriatrics Geriatrics • A branch of gerontology and medicine which deals with the clinical, rehabilitative (remedial), psycho-social and preventive aspects of illness in elderly people.

Gerontology • The scientific approach to all aspects of aging (health, sociological, economic, behavioural, environmental)

History of Geriatric Medicine • Term “Geriatrics”: Coined by American physician Dr Nascher in 1907 • Pioneer of Geriatric Medicine: Dr Marjory Warren (West Middlesex Hospital, UK) in 1935. She practiced comprehensive geriatric assessment and rehabilitation

Aims of Geriatric Rehabilitation • Maintenance of health in old age by high level of engagement and avoidance of diseases. • Early detection and appropriate treatment of diseases. • Maintenance of maximum independence consistent with irreversible disease and disability. • Sympathetic care and support during

Important Concepts in Aged Care • To keep the elderly in their own homes for as long as possible with appropriate support for themselves and their caregivers. • To provide appropriate continuity of care from the acute hospital setting through to the community setting. • To develop a wide range of options providing help and support to the elderly. • To increase links between those services involved in care for the aged and disabled.

Special Characteristics of Diseases in Old Age • • • • • • •

Senescence Impaired homeostasis Atypical features Non-specific presentation Multiple pathology Multiple etiological factors Unreported illnesses

Modified Manifestations

• Atypical • Non-specific • Insidious Onset • Silent existence • Missed diagnoses

The Giants of Geriatrics The Big Three ‘I’s •Intellectual failure •Instability and immobility •Incontinence

Geriatric Assessment

• Medical • Mental: AMT (Abbreviated Mental Test), MMSE (Mini-Mental State Exam)

• Functional: ADL (Activities of Daily Living), IADL (Instrumental ADL)

• Social

The Multi-disciplinary Geriatric• Supporting Team Members:

• Core Members: – Geriatrician – Nurse (+NS, CNS) – Social Worker – Occupational Therapist – Physiotherapist

• By Consultation: – All subspecialties of medicine – Other specialties

– – – – – – – –

Podiatrist Speech Therapist Dietitian Prosthetic & orthotic specialist Psychogeriatrician Clinical psychologist Volunteer Pastoral care

Hospital-based Geriatric Services • • • • • • • •

Acute care Assessment Rehabilitation Continuity care (long stay care) Respite care Geriatric Day Hospital Specialist clinic Domiciliary visits

Community-based Geriatric 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)

Community Support • DAY CARE CENTRES • HOME HELP Services SERVICE – Integrated Home Care Service • MEALS SERVICES – Meals-on-wheels – Canteen service • SOCIAL CENTRES FOR THE ELDERLY • HOLIDAY CENTRES

• ELDERLY HEALTH CENTRES • VISITING HEALTH TEAMS • HEALTH VISITS • Other Visiting Services – Welfare agencies – Volunteer groups – Telephone hot line • SOCIAL NETWORKING: – Social Welfare

Prevention of the Dysfunctional Syndrome: Conceptual Model Functional Older Person Acute Illness, Possible Impairment Hospitalization Depressed Mood Negative Expectations

ARC Unit Prehab Program

Prepared environment Patient-centered, interdisciplinary care Multi-dimensional assessment and non-pharmacologic prescription Home planning/informal network Medical review

Improved Mood Positive Expectations

Reduced Impairment Functional Older Person

Decreased Iatrogenic Risk Factors

Conceptual Model of the Dysfunctional Syndrome Functional Older Person Acute Illness Possible Impairment Hospitalization Hostile Environment Hostile Environment Depersonalization Depersonalization Bed Rest Rest Starvation Starvation Medicines Medicines Procedures Procedures

Depressed Mood Negative Expectations

Physical Impairment

Dysfunctional Older Person

Improving Care of Patients with Chronic Illness: 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

Wagner’s Chronic Care Model

Community

Health System

Resources and Policies SelfManagement Support

Informed, Activated Patient

Organization of Health Care Decision Support

Delivery System Design

Productive Interactions

Improved Functional and Clinical Outcomes

Clinical Information Systems

Prepared, Proactive Practice Team

The Nature of Chronic Conditions Requires a New Mind-set Public Health

Health Capacity

Primary Care

Acute Care

Long­term Care

Condition Onset Accelerated Loss of Health Reserves

Normal Aging

Progressive Conditions

Disability Complex care management

Acute Event

Risk Factors

• Obesity • Tobacco and    alcohol • Pollution

• Hypertension • Rapid weight    gain/loss • Hyperglycemia

Time

• Hip fracture • Stroke • CHF • COPD

Death

• Incontinence • Confusion • Caregiver burnout • ADL/IADL decline

Interrelated needs require ongoing, coordinated care interventions

.

Successful aging •

A process by which deleterious effects of aging are minimized, preserving function until senescence makes continued life impossible

•

To be distinguished from usual aging (characterized by accumulation of diseases and impairments of the elderly)

Stages of Development • Infancy- Consistency of caregivers → trust and hope. • Early Childhood- Self-regulation, autonomy, control of external events → sense of self-control; developing willpower • Play Age Childhood- Initiation of events → sense of gender identity, direction and purpose • Primary School Age Childhood- Sense of industry, productivity, competence → sense of self-worth. • Adolescence- Transformation of body → sense of a distinctive self-identity

Stages of Development

• Young Adulthood- Previously learned values & skills are focused to meet goals related to intimacy & vocation. • Middle Adulthood- Productivity, caretaking, generativity • Older Adulthood- Successes & failures from previous stages are accepted, integrated. The individual has achieved a sense of life's meaning; accepts the meaning of death as a part of the life cycle.

Principles of Rehabilitation in Aging ARNDT-SCHULZ PRINCIPLE • The application of--------b. Subthreshold stimulus → no change in the system c. 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 required to produce a response. – When suprathreshold is reached the response is more volatile with increasing age. – Peak response is less in elders and usually requires less stimulus than in youth. – A stimulus within the suprathreshold range for younger patients may be a subthreshold of supramaximal stimulus for elders. – The suprathreshold range in elders is considerably narrower than in younger individuals.

Principles of Rehabilitation in Aging LAW OF INITIAL VALUES • A/c to this law, with a given intensity of stimulation; the degree of change produced tends to be greater when the initial level of that variable is low; and that the higher the initial value, smaller will be the change produced. • In younger individuals, biorhythms are relatively well coordinated, and thus, a particular stimulus is likely to produce a relatively consistent response when time of day/month/season is held constant • In older individuals, biorhythms are less well coordinated; the elder’s 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 usually identifiable. Effort should be made to identify optimal times for activities and individualize the schedule for each individual.

DEMENTIA – TREATMENT Problem management – to manage behavior problems

concrete with patient -don‘t - use sedative as needed provide choices - do not initiate hearing aid - Avoid decision-making tasks - don't change from - avoid anxiety-producing bifocal to trifocal situations - do not take patient on - do not expect too much vacation to strange - do not over-stimulate places - do not permit fatigue - play golden oldies - limit intake of stimulants/ - sew name/address labels coffee into clothing - provide ample fluid & high - keep doors locked and fiber diet windows secure - have an element of danger (cooking) - be

DEMENTIA – TREATMENT Problem management – Environmental/Behavioral treatments • Environmental/Behavioral treatments attempt to reduce contextual demands on the patient so that problem behaviors are prevented and negative consequences are reduced. • Implement― structured routines ― appropriate socialization and recreation ― reassurance and comfort ― Reality Orientation: consistent, repetitive cueing individually and 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 is ineffective and is a stressor – increasing agitation

Intelligence Rehabilitation Clock Drawing Test Normal Mild Cognitive Impairment

Moderate Cognitive Impairment

Severe Cognitive Impairment

Intelligence Rehabilitation Intelligence Fluid intelligence: complex relations; short-term memory; abstract reasoning memory span, inductive reasoning, figural relations probably more dependent on the person's biology than crystallized not as dependent on instruction ability to perceive complex relations ability to use short-term memory ability to perform abstract reasoning this sort of intelligence is thought to decline most with age

Crystallized intelligence: thought to be dependent on social and cultural learning is one's ability to understand one's cultural heritage measured by number facility, verbal comprehension, general info. dependent on openness to new learning, amount of learning, extent of formal learning opportunities will continue to grow throughout life in many individuals

Intelligence Rehabilitation Memory enhancement techniques

–attention/awareness –self-instruction –controlling the physical environment –tagging –organization/chunking –stress reduction (exception: flashbulb memory) –logging –imagery for stress reduction

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 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

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

Nutrition & Aging Brain • Nutrients involved in neurotransmitters: B6 B12 Folate Vit C • Nutrients for Normal Function: Iodine Fe Cu Zn • Protein

Nutrition & Aging Brain • Memory • Problem Solving • Dementia • Cognition • Degeneration of Brain Tissue

B12, Vit C Riboflavin, folate, B12 Vit C Thiamin, Niacin, Zn Folate, B6, B12, Fe B6

Nutrition & Aging Brain Treating Depression • Complex and multifaceted approach involving: – Cognitive therapy – Behavioral/functional interventions – Emotional/social treatment – Pharmacotherapy – Electroconvulsive therapy (ECT)