GERIATRIC REHABILITATION

I. General Medical Background

A. Definition
Geriatrics is the branch of medicine that focuses on health promotion and the
prevention and treatment of disease and disability in later life.
It is to be distinguished from gerontology, which is the study of the aging
process itself.
The term comes from the Greek "geron" meaning "old man" and "iatros"
meaning "healer."
The geriatric population is generally considered as the population of patients
who are in the older adult group, particularly those whose ages are from !
years and onward.
B. Classification
"o current classification systems e#ist as to geriatrics in general. $owever,
they can be classified as to the conditions that occur amongst this population,
such as%
a. In&uries
b. 'hronic diseases
c. (ther conditions
) 'ommunicable
) Maternal
) *erinatal
) "utritional
C. Epidemiology
+apidly e#panding numbers of very old people represent a social
phenomenon without historical precedent.
,s of -..-, /nited "ations 0 1epartment of *ublic Information research had
found the following%
The worldwide number of persons aged . years or older is estimated to
be .! million.
) That number is pro&ected to grow to almost - billion by -.!., when the
population of older persons will be larger than the population of
children 2.)34 years5 for the first time in human history.
!46, the largest share of the world7s older persons, live in ,sia. 8urope
has the ne#t largest share, with -4 percent.
Basing on the classification as to the conditions that occur amongst the
geriatric population, a study in -..- by the *opulation +eference Bureau had
found differences have been noticed depending on the development status of
the countries that they live in%
In developing countries%
) In&uries 23-65
) 'hronic diseases 24465
) (ther conditions 24465
In highly developed countries%
) In&uries 2965
) 'hronic diseases 265
) (ther conditions 2:!65
,s of -..;, the /< 'enter for 1isease 'ontrol had identified the following%
,t least :.6 of the ,merican older population had at least 3 chronic
condition.
It is pro&ected that by -.=., -.6 of the /< population will be of the older
adults.
) $ealth care spending will increase to -!6 due to this demographic
shift.
3
,s of -.., the *opulation +eference Bureau had placed the older adult
population of the *hilippines at =.4! million 246 of the total population5.
D. Etiology
1ifferent etiologic factors predispose the older population to become
susceptible to the conditions affecting them which are usually due to age)
related factors, such as%
a. Biologic factors
) Multiple diseases
) 1econditioning
) 'ontractures
) *olypharmacy 2intake of many pharmacologic agents5
) <ubclinical organ dysfunction
b. *hysiologic factors
) 'ognitive deficits
) 1epression
) ,typical presentations
) Motivation
c. <ocial factors
) "egative views of aging
) >ess fre?uent referrals
) @inancial barriers
E. Patopysiology ! Patomecanics
,ging, itself, is not a disease. $owever, it is important to understand that
many physiologic changes occur as the individual grows older, such as%
a. Body composition changes
) Gradual loss of lean tissue
) Increase in fat by =.6 of body weight at age :.
) >oss of bone mineral
) $igh prevalence of osteoporosis and osteoarthritis
b. *ostural changes
) *rogressive anterior thrust of the head
) 8#tension of cervical spine
) *rotraction of the scapula
) ,ccentuated thoracic kyphosis
) <traightening of lumbar spine
) Increased hip and knee fle#ion
) 1ecreased ankle dorsifle#ion
) $and deformities
) 1iminished arm swing
) <horter step length
) In men% widening of standing base
) In women% knee varus deformity with narrow standing base
) <hift of center of gravity
) Increased postural sway
) Impaired balance
) 1ecreased righting refle#es
) Increased reaction time
c. Integumentary changes
) 1ecreased moisture content, epidermal renewal, elasticity, blood
supply, sensation
) <usceptibility to in&ury, infection
) ,trophy of sweat glands
) Arinkling
d. 'ardiopulmonary changes
) 1ecrease in cardiac reserve, contractility, heart rate
) Increased B*
) Mild decrease in pulmonary function
-
) 1ecline in vital capacity, ma#imum voluntary ventilation, e#piratory flow
rate, and forced e#piratory ventilation
) Increase in residual volume and functional residual capacity
) *rogressive ventilation perfusion imbalance
) 1egenerative stiffening of rib cage with intercostals and abdominal
weakness
) 1iminished hypercapneic and hypo#ic ventilatory responses
e. /rological changes
) /rinary fre?uency, hesitancy, retention, nocturia
) +educed bladder capacity
) *rostatic hypertrophy
) +educed creatinine clearance
f. $ydration changes
) -!6 decrease in thirst perception
g. Body temperature changes
) Impaired thermoregulation
) Impaired febrile response to infection, inflammation
) More susceptible to hyperthermia and hypothermia
) 1iminished sweating
h. "eurological changes
) 8ye signs
o <mall, irregular pupils
o 1iminished reaction to light and near refle#es
o 1iminished range of movement on convergence and upward gaBe
o <lowed pursuit movements with cogwheeling
) Motor signs
o Tendency to tremor
o Gait% short stepped or broad based with diminished associated
movements
o 1ysmetria
o atrophy of interossei
o increased muscle tone% legs more than arms, pro#imal more than
distal
o 1iminished muscle strength legs more than arms, pro#imal more
than distal
) <ensory signs
o 1iminished vibratory sense distally, legs more than arms
o 'hange in proprioception
o Mild increased in light touch, pain and temperature thresholds
o Impaired double simultaneous stimulation
) +efle# signs
o 1iminished or absent ankle &erks
o +eduction in knee, biceps and triceps refle#es
o >oss of abdominal refle#
o Babinski7s sign may not occur in -.6)-!6
i. $ematological system changes
) ,nemia due to protein)energy malnutrition, malignancy, chronic
diseases and acute inflammatory disorders
&. Gastrointestinal system changes
) *resbyesophagus
) <light decreased force of smooth muscle contraction
) 1ecreased salivary flow
) 1ecreased sense of taste
) Impaired rectal perception of feces
) 'onstipation due to low dietary fiber and fluid intake, sedentary habits,
intrinsic bowel function diseases
=
) @ecal incontinence due to overflow incontinence secondary to fecal
impaction, decreased sphincter tone, cognitive impairments, and
diarrhea
k. $epatic system changes
) *rogressive decrease in liver siBe and hepatic blood flow
) <lowed hepatic biotransformation in microsomal o#idation and
hydrolysis
l. +enal system changes
) 1ecrease renal mass, number and functioning of glomeruli and
tubules, and glomerular filtration rate
) Impaired ability to concentrate or dilute urine
) Impaired sodium concentration
) 1ecreased ability to e#crete an acid load
) Culnerable to hyponatremia, hyperkalemia, dehydration, and water
into#ication
m. Immunologic system changes
) Increased autoantibodies and immune comple#es
) 1ecreased antibody production
n. 8ndocrine)metabolic system changes
) Gradual decrease in glucose tolerance
) +isk for untreated hyperglycemia, osmotic diuresis, dehydration,
hyperosmolar nonketoic coma or ketoacidosis
) 1ecreased production rate and metabolic clearance rate of thyroid
hormone
) *rogressive decrease in cortisol production
) 1ecreased estrogen levels in postmenopausal women
) ,ltered male libido, potency, and se#ual arousal.
o. <ensory changes
) 1eterioration of vision
) 'ataract formation
) 1ecline in hearing acuity
) 1ecrease in sense of smell
p. 'entral nervous system changes
) 1ecrease in siBe and weight of brain
) 1ecreased cerebral blood flow and autoregulation
) @ewer night)time hours of stage 4 and rapid eye movement 2+8M5
sleep
". Clinical #anifestation$s%
,gain, it is important to restate that aging is not a disease process. The
physiologic changes stated above would be, more or less, the clinical
manifestations of the aging process.
G. Complication$s%
1ue to the susceptibility of the older population to ac?uire the conditions
affecting their age group, these would be the areas of most concern for health
care professionals.
The following conditions would most particularly be the primary complications
of aging, also known as the D! IEs of GeriatricsE, the DGeriatric FuintetE, and the
D( 'omple#E. These are%
a. Intellectual impairment
b. Impaired mobility
c. Incontinence
d. Impaired homeostasis
e. Iatrogenic drug reaction
(ther common complications of aging would be%
a. ,mputation
b. ,rthritis
c. Burns
4
d. 'ancer
e. 'ardiovascular disorders
f. 'hronic pain
g. 'hronic pulmonary disease
h. 'ontractures
i. 1econditioning
&. 1isc disorders
k. @racture
l. $ead in&ury
m. Trauma
n. Goint replacement
o. >ymphedema
p. "europathy
?. (steoporosis
r. *ain syndromes
s. *arkinsonEs disease
t. *ostural disorders
u. *ressure sores
v. <pinal cord in&ury
w. <pinal stenosis
#. <troke
H. Diagnosis
/sual diagnostic procedures performed for geriatric patients are the following%
a. @rom the medical history%
) 1rug history
) 1ietary history
) Incontinence history
b. @rom the physical e#amination%
) *elvic and breast e#aminations in women
) +ectal e#amination in both male and female
) 'heck urinary incontinence, distended bladder, perineal sensation and
bulbocavernososus refle#es in male
c. @rom laboratory e#aminations%
) 8rythrocyte sedimentation rate
) @asting glucose test
) <erum creatinine
I. Diffe&ential Diagnosis
1ifferential diagnostic testing is performed more often in geriatric patients due
to their susceptibility to many conditions and the possible occurrence of
having multiple conditions.
It is imperative to note though that there are some common errors 2either from
the patientEs or health care practitionerEs side5 that compromise the
development of a proper database for an ill elderly patient, such as%
<ymptoms may be attributed to Dnormal agingE
"ew symptoms may be attributed to a chronic problem
1rug to#icity may not be considered
@ear that a symptom, if revealed, might result in hospitaliBation
<toicism due to the concern for cost or discomfort of evaluation
'onsidering a patient as Dtoo oldE to undergo evaluation
'lassical or typical manifestation of illness may not be present
>onger time re?uirement for evaluation may not be considered
'. P&ognosis
@raming the definition of the outcome is very important for the success and
professional rewards of the geriatric rehabilitation.
Their ?uality of life can be maintained or improved through appropriate
!
rehabilitation methodologies and social support from family and
community.
Most elderly patients live in the community with ages :! and above, only 3!6
of men and -!6 of women live in a nursing home.
1ischarge data reveal that over :!6 of these patients are discharged to a
non)institutional setting.
II. Medical Management
A. Pa&macologic
*harmacologic interventions in geriatric conditions are largely specific to each
condition. <ome e#amples of conditions, together with their appropriate
pharmacologic interventions, are the following
a. @emale atrophic vaginitis
) 8strogen
b. Incontinence
) (#ybutinin 2smooth muscle rela#ants5
) ,nticholinergics 2propantheline5 for detrusor instability with the risk of
infection
) 'alcium channel blockers
) Imipramine
c. <leep disorders
) Tricyclic antidepressants in low doses at night
) MinimiBe anticholinergics 2notriptyline, do#epin, benBodiaBepine,
diphenhydramine5
d. 1epression
) Tricyclic antidepressants 2do#epin, notriptyline, desipramine5
o Initially in low doses at night and increased gradually
e. ,gitation
) ,lpraBolam, Imipramine, and buspirone
o @or controlling an#iety syndromes
) Tricyclic antidepressants 2do#epin5
) ,ntipsychotics
f. *ain
) >ong term opiate analgesics for malignant and chronic disabling pain
that is unresponsive to other medications
) Tricyclic antidepressants or anticonvulsants for neuropathic pain
g. $ypotension
) +eview of medications is important, particularly of nitrates,
antihypertensives, levadopa, diuretics, phenothiBines, and tricyclic
antidepressants
) $igh sodium diet and fludrocortisone acetate 2a synthetic
mineralocorticoid5 for plasma e#pansion in the absence of congestive
heart failure
) "<,I1s to inhibit prostaglandin synthesis
) 'lonidine or midodrine 2H)- adrenergic agonists5
) *ropranolol 2I)- vasodilatory receptor blocker5
) *indol 2I)adrenergic antagonist with intrinsic sympathomimetic activity5
) *henylpropanolamine 2sympathomimetic5
B. #edical ! ()&gical
There are 3. basic principles to be followed when handling geriatric patients.
These are enumerated as the DGeneral *rinciples of Geriatric MedicineE and
are as follows%
a. Individuals become more dissimilar as they age, belying any stereotype of
aging.
b. ,n abrupt decline in any system or function is always due to disease and
not to Jnormal agingK.
c. "ormal aging can be attenuated to some e#tent by modification of risk

factors.
d. J$ealthy old ageK is not an o#ymoron.
e. The onset of new disease in the elderly generally affects the most
vulnerable organ system.
f. 1isease in older patients often presents at an early stage because of their
impaired compensatory mechanism.
g. $omeostatic mechanisms are often compromised, multiple abnormalities
are amenable to treatment, and small improvements in each may yield
dramatic effects.
h. Many findings that are abnormal in younger patients are relatively
common in older people and may not be responsible for a particular
symptom.
i. The diagnostic Jlaw of parsimonyK often does not apply because
symptoms in older people are due to multiple cases.
&. Treatment and prevention are more effective in an older patient who is
more likely than a younger one to suffer the adverse conse?uences of the
disease.
There are inherent principles that should be considered in geriatric
prescription in all health care professions%
,scertain level of function 2functional assessment5
,scertain available resources and options
,void immobiliBation
Be aware of altered physiological reactions
1etermine patientEs goals, motivation
1etermine familyEs e#pectations 2psychosocial issues5
1ifferentiate between delirium, dementia, and depression
8mphasiBe functionL management not diagnosisL cure
8mphasiBe task)specific e#erciseL simplify program
8ncourage socialiBation and stimulation
MinimiBe medications
+ealiBe that function may not be regained
+ecogniBe that patients have multiple interacting impairments
/nderstand that improvement occurs in slow increments
<urgical intervention in geriatrics is usually reserved only for specific
conditions that this age group encounters.
III. *hysical Therapy 8#amination, 8valuation M 1iagnosis
A. Points of Empasis in E*amination
Because normal aging produces changes in all physiologic systems, all
components of the physical therapy e#amination are usually included.
1epending on the presence of a condition, there will be more emphasis on
e#amination components that are specific to these conditions.
/sual physical therapy e#amination procedures in geriatrics though have
additional emphasis on the following aspects due to the impact that these
have on the daily lives of geriatric patients%
a. ,ctivities of daily living
) @unctional 1isability Testing
) NatB Inde# of Independence in ,ctivities of 1aily >iving
) Barthel Inde#
) +apid 1isability +ating <cale
) @unctional ,utonomy Measurement <ystem 2<M,@5
) @unctional Independence Measure 2@IM5
) (lder ,merican +esources and <ervices <cale 0 Instrumental
,ctivities of 1aily >iving 2(,+<)I,1>5
b. 'ognitive status
;
) Mini)Mental <tatus 8#amination 2MM<85
c. 1epression
) Geriatric 1epression <cale
d. Gait and Balance 2including vestibular function5
) ,ctivity)specific Balance 'onfidence <cale
) @unctional +each Test
) Gait <peed
) Timed)<tands Test
) Timed /p and Go 2T/G5
) Aalk TestO-)Minute, )Minute, 3-)Minute, <elf)paced, <huttle
) Berg Balance <cale
e. (ther
) 8uropean Fuality of >ife <cale 28uroFo>)!15
) $ealth /tilities Inde# 2$/I Mark-P=5
) "ottingham $ealth *rofile
) +eintegration to "ormal >iving Inde# 2+">5
) Test dEQvaluation des Membres <upRrieurs des *ersonnes ,gRes
2T8M*,5
B. P&o+lem List
In general, geriatric problems are specific to the conditions that are present in
the individual patient. $owever, = of the D! IEs of GeriatricsE stated above are
addressable by physical therapy, which are%
a. Impaired mobility
) This could be due to several factors, such as%
o Aeakness due to%
) 1isuse of muscles
) Malnutrition
) 8lectrolyte disturbances
) ,nemia
) "eurologic disorders
) Myopathies
o <tiffness due to%
) (steoarthritis 2most common cause5
) *arkinsonEs disease
) +heumatoid arthritis and other connective tissue disorders
) ,ntipsychotic drugs
o *ain in general
o *oor balance due to%
) General debility
) "eurologic causes
) (rthostatic hypotension
) 1rugs
) *rolonged bed rest
o *sychological factors, such as%
) <evere an#iety
) 1epression
o Mi#ed
) , combination of the above is possible
b. Incontinence
) 8ither urinary or fecal
c. Impaired homeostasis
) /sually directly attributable to the physiologic changes occurring in
aging
) May also be due to conditions present in the individual patient
In addition, the risk of loss of balance and falls is also one of the primary
problems in this population that is addressable by physical therapy.
:
@alls are a result of - ma&or causes which usually interact with each other.
These are%
) Intrinsic deficits, such as%
o Impaired sensory input
o Impaired &udgment
o Impaired cardiovascular regulation
o >ong reaction time
o Impaired gait
o *oor balance
) 8nvironmental challenges P obstacles
o ,ny structure that poses a threat to a patientEs safe performance of
any functional activities
+arely are falls due to only 3 of the above)stated causes.
C. Pysical Te&apy Diagnosis
*T diagnosis may fall into any of the diagnostic labels depending on the
condition present in the individual patient.
Most often, geriatric patients fall into multiple diagnostic labels due to their
susceptibility to conditions and the possibility of ac?uiring multiple conditions.
Geriatric patients who do not have a medical condition are usually considered
as primary prevention or risk reduction cases, which are%
a. *rimary preventionPrisk reduction for skeletal demineraliBation
b. *rimary preventionPrisk reduction for loss of balance and falling
c. *rimary preventionPrisk reduction for cardiovascularPpulmonary disorders
d. *rimary preventionPrisk reduction for integumentary disorders
I,. *hysical Therapy *rognosis 2including *lan of 'are5 M Intervention
A. Plan of Ca&e
@or geriatric patients with medical conditions%
*T goals for geriatric patients with medical conditions will depend on the
condition present
The total number of patient sessions under a single episode of care for
geriatric patients with medical conditions will usually be specific to the
condition present
@or geriatric patients with no medical condition P complication%
*T goals will be the following%
) Improve mobility
o Goals will be addressed toward the specific cause of poor mobility
) Improve continence
) Improve homeostasis
) +educe risk for loss of balance and falls
The total number of patient sessions under a single episode of
maintenance and prevention for geriatric patients will usually last until the
rest of the remaining years of the patient
B. Inte&-entions
*T intervention is directed toward the addressable problems of uncomplicated
2without a medical condition5 cases.
a. Impaired mobility
) <pecific intervention is necessary to the particular underlying cause of
the impaired mobility
o *T intervention may be performed in the following underlying
causes of impaired mobility%
) Aeakness 0 muscle strengthening e#ercises
) <tiffness 0 neuromuscular inhibition, then facilitation techni?ues
) *ain 0 pain management interventions
) *oor balance 0 balance training techni?ues, including vestibular
rehabilitation
9
o (ther underlying causes have to be addressed by other health care
professionals
) *revention is the best *T intervention to offset impaired mobility which
may be addressed through%
o *rescription, application, and, as appropriate, fabrication of devices
and e?uipment 2assistive, adaptive, orthotic, protective, supportive,
and prosthetic5
o *atient education on the effects of immobiliBation
b. Incontinence
) If due to sphincter weakness%
o Muscle reeducation techni?ues 2i.e. NaegelEs e#ercise5
o 8lectrical stimulation
) If due to detrusor muscle underactivity%
o *atient education on application of augmented voiding techni?ues
2applying suprapubic pressure5
c. Impaired homeostasis
) ,lthough normal in aging, may be improved through the regular
performance of e#ercise
o @or *Ts, this may mean the regular performance of a patient of
general endurance e#ercises
d. +isk of loss of balance and falls
) Balance training e#ercises
) Cestibular rehabilitation
) Gait training 0 to alleviate fear of falling
) 8nvironmental assessment and modification, if necessary
) *atient education on compensatory techni?ues, including training on
proper falling techni?ues
3.