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Posted by sailjamehra on May 24, 2009

1.1 INTRODUCTION

 

            With life, aging is an unavoidable consequence. Growth is the inevitable and remarkable process of life. All living animals undergo a series of changes after birth. There is an initial period of growth till adulthood is reached. With the passage of time the involution sets in and after a varied lifespan, all animals ultimately die. Thus the process of growth starts right from conception and continues till death. Old age is the final stage of lifespan.        

            No particular time can be set at which aging starts. Aging includes all the changes, which occur in the body with passage of time. The process of aging may be hastened in some individuals and delayed in others, but it must occur in each one of us.                                              

Abnormal wear and tear like repeated trauma, infections, excessive emotional excitement, dietary abuse and exhaustive activities may lead to premature aging.

Biologists have hypothesized several theories regarding the process of aging and its general consequences on human life.

In the process of aging normal physiological changes occur resulting in physical and psychological changes, which progressively deteriorate the quality of human life. At the same time the aging body is prone to many changes also. Due to these inevitable changes the quality of life of elderly is affected, calling for the need of a holistic approach to solve the problems presented by them and make their life better.

        This project “Physical therapy intervention and home based Rehabilitation for geriatric people” deals with various aspects associated with aging, its consequences and problems faced by geriatric people in activities of daily living. It discusses about the physical therapy treatment and rehabilitative procedures and provides the aged with simple and easy modified home programmes, which enable them to lead a more active, independent and healthy old age.         

 

1.2 DEFINITIONS

 

    

 AGING:

 

The process of aging is defined as

 

All changes occurring with the passage of time”.

 

The aging process is an integral part of continuous development of an organism. It is a composite part of one’s life.

 

SENESCENCE:  

 

It is the process of growing old leading to functional impairment and Death.

 

It is an expression used for in the vitality or lowering of biological efficiency that accompanies aging. Aging is inseparable from developmental processes.

 

GERIATRICS:

 

“It is the study of the old age, includes physiology, pathology, diagnosis and management of diseases of older patients.”

 

It is a relatively new specialty of medicine dealing with the curative, preventive and social aspects of problems, illnesses and diseases of elderly.

 

 

GERONTOLOGY:

 

“It is the scientific study of process of aging and includes biologic, psychological and sociologic sciences of elderly.”

 

 

 

REHABILITATION: 

 

It is the utilization of the existing capacities of the handicapped person, by the combined and co-ordinate use of medical, social, educational and vocational measures to optimize level of his functional ability.

 

1.3 THE AGING BODY

 

 

STAGES OF LIFE SPAN:

 

The aging process begins right at conception.

 

As the individual reaches advanced years the risk for physiological and functional impairment increases. Chronological age refers to the number of years a person has lived.

 

 

 

STAGE

SPAN

Pre-natal

Conception to birth

Infancy

Birth to end of second week.

Babyhood

End of second week to end of second year.

Early childhood

2 to 6 Years

Late child hood

6-10-12 Years

Puberty/ Pre – adolescence

10/12 – 13/14 Years

Adolescence

13/14 – 18 Years

Early adult hood

18  – 25 Years

Late adult hood

25 – 40 Years

Middle age

40 – 60 Years

Old age/ senescence

60 Years to death

 

(Tab1.1)

 

Consequences of Aging:

 

 

With age there is decline of energy, facilities and tissues. Different systems change at different rates in different people.

 

The time tables of development of cells, tissues and organs of body differ and similarly their timetables of aging.

 

In old age many pathophysiological changes are prevalent. It should be confirmed whether it is a normal physiology or any abnormality.

 

It is essential that people who work with elderly should be aware of specific diseases associated with aging as well as common complaints of aging and the problems of aged.

 

            Certain changes of aging like loss of height, dry wrinkled skin, thinning grey hair, diminished co ordination are of no major clinical importance where as some of the changes may produce severe clinical consequences and these are very important.

 

Need to study aging process:

 

Two major goals are defined by biologists for the need to study the process of aging:

 

1)     To prolong human life

 

2)     To significantly enhance viability throughout life span.

 

Categories of aging population:

 

According to world health organization

 

           Age (yrs)                     Category

 

1.       60 –74                                    Aged

 

2.       75 – 90                       Old

 

3.       90 +                            Very old

 

 

 

 

 

                           

 

 

 

 

 

2.1 THEORIES OF AGING

 

 

 

Regarding the process of aging, many theories are hypothesized.

           

            At cellular level, cells have a number of programmed divisions and doublings that undergo before beginning the process of dying (apoptosis).

 

 
SOME THEORIES OF AGING:

 

o   Biological Theories

 

o   Psycho Social Theories

 

 
 
Biological Theories:

 

o   Cross Linking Theory

 

o   Free Radical Theory

 

o   Immune Theory

 

o   Genetic Theory

 

o   Exhaustion Theory

 

o   Wear and tear Theory

 

o   Endocrine Theory

 

o   Single organ theory

 

 
Psycho Social Theories:

 

o   Activity Theory

 

o   Continuity Theory

 

o   Disengagement Theory

 

Biological Theories of Aging:

 

1. Cross Linking Theories:

 

a) Collagen Theory:          Proposed by Vertzer 

           

            States that irreversible aging of proteins such as collagen is responsible for the ultimate failure of tissues and organs.

 

b) Cross- Linking Theory:          Proposed by Bjorkstein

 

            States that as cells age, chemical reactions create strong bonds or cross linkages between proteins, which cause loss of elasticity, stiffness and eventual loss of function.

 

Summary:

 

Ø  According to these, chemical conversion of collagen form soluble to insoluble form occurs through cross – linkages causes a decrease in elasticity and cell permeability.

 

Ø  Passage of nutrients and wastes through blood capillary walls becomes more difficult as does diffusion to distant cells.

                                           

Ø  Tissues with in Lung, Kidney, Vascular and GIT system become less elastic.

 

Ø  Protein elastin also becomes less elastic and more soluble.

 

Ø  Cross-linking agents are ubiquitous in diet and environment.

E.g.: UV light from sun can cause damage to collagen and elastin in skin.

2. Free Radical Theory:           Proposed by Harman.

 

Ø  Free Radicals are often by products of chemical reactions in the body that can damage proteins and DNA with in the cell.

 

Ø  Environmental factors such as smog, gasoline and ozone can cause oxidation damage of tissues via free radicals as well.

 

Ø  In aging process, it is thought that free radicals accumulate and do damage faster than the cell can repair the damage.

 

Ø  Vitamin E and C act as antioxidants in cells to disarm free radicals.

 

3. Immune Theories:

 

a) Immunological Theory:       Proposed by Walford

 

Ø  Sates that immune system becomes less effective with age and viruses that incubated the body become able to damage body organs.

 

b) Auto Immune Theory: Proposed by Hallgreen & Yunis

 

Ø  Sates that a decrease in immune function may result in an increase in auto immune responses, which cause the body to produce antibodies that attack it self.

 

Ø  It also states that, the body does not recognize the proteins that are formed in body as a result of mutations in some cells and hence antibodies are produced against these new proteins, which land in Auto Immune Disease.

 

Ø  As age increases, the immune system fails to recognize the abnormal cells, allowing them to divide and multiply.

 

Ø  Immune system failure is thought to be associated with several late life diseases including cancer, diabetes and emphysema.

 

 

 

 

4. Genetic Theories:

 

a)     Programmed Senescence Theory:              Proposed by Hayflick

 

Ø  States that the organism is genetically programmed for a pre determined number of cell divisions, after which the cells or the organism dies.

 

Ø  It proposes that the life span of an individual is programmed into their DNA, based on life span of the relatives that came before you. Gender and race differences in life span also provide some evidence for this theory.

 

Ø  Worldwide women have longer life expectancy than men.

 

5. Exhaustion Theory:

 

Ø Proposes that there is a fixed store of energy available to body. As time passes, the energy available is depleted and as it cannot be restored, the organism dies.

 

6. Wear and Tear Theories:

 

a)     Wear and Tear Theory:       Proposed by Pearl.

 

Ø  States that humans like automobiles have vital parts that run down with time, leading to aging and death.

 

b)     Rate of Living Theory:        Proposed by Pearl

 

Ø  Proposes that the faster an organism lives, the quicker it dies.

 

 

 

 

 

 

 

c)     Stress Theory:                     Proposed by Lamb

 

Ø  On exposure to internal and external stressors including trauma, chemicals and build up of natural wastes, the cells wear out. This theory emphasized on physical wear and tear from sudden and unexpected stressors over which the organisms have no control.

 

Ø  This theory proposed that the organism copes with physical stressors through a 3 –stage process of – alarms, resistance and exhaustion. This process eventually leaves the organism weakened because of accumulation of successive stressful events over the life span.

 

Ø  As organisms age, they are no longer capable of fighting off the various insults as a result of accumulation of wear and tear.

 

7. Endocrine Theory:                Proposed by Korenchevsky

 

Ø Proposes that events occurring in hypothalamus and pituitary are responsible for changes in hormone production and response results in declination of organisms.

 

8. Single Organ Theories:

 

Ø Suggests that aging results primarily from lowered O2 supply to crucial tissues like brain.

 

Ø One theory regarding to thyroid gland proposes that, since the activity of thyroid gland declines with age, thus the metabolic processes at the cellular level that are regulated by the thyroid gland also slow down.

 

Ø Failure of sexual glands has also been postulated as primary cause for aging.

 

Ø However, only a little evidence shows that aging results due to diminished functions of any one single organ.

 

Conclusion:

 

Ø From all the above theories, it can be concluded that there is an increasing inability of the organism to adapt to the environment.

 

Ø Most of these hypotheses recognize aging as the progressive deterioration of the physiological processes necessary to sustain life and death as the ultimate failure of the organism to sustain equilibrium.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychosocial Theories:

 

1. Disengagement Theory:

 

Ø This theory proposes that aging involves mutual with drawl between the older person and others in the elderly person’s environment.

 

Ø This withdrawal relieves the elderly person of some of the society’s pressures and gradually reduces the number of people with whom he/she interacts.

 

Ø Usually in old age, individuals accept the inevitability of reduction in social and personal interactions.

 

2. Activity Theory:

 

Ø  According to this theory, maintenance of activities is important to most individuals as a basis for obtaining and perpetuating satisfaction, self – esteem and health.

 

Ø  In old age, reduction in some activities and attitudes results in a compensatory increase in others.

 

Ø  In elderly, levels of activity promote vigor and satisfactory adjustment and on the other hand, restricted activities tend to experience dissatisfaction in over all life.

 

Ø  As a whole, according to this theory, the best way to age is to stay actively both physically and mentally.

3. Continuity Theory:

 

Ø  According to this theory, people maintain their value, habits, and behaviour in old age. A great variety of behaviour is seen in elderly people.

 

Ø  A person who is accustomed to have people around him/her will continue to do so and the one who does not prefer, will not.

 

4. Sociological Theories:

 

            The concept of socialization during adult hood refers to the process by which individuals over the course of their adult lives, acquire ways to perform new roles, their way of adjustment to changing roles.

 

5. Roscow’s Role Theory:

 

Ø  Proposes that socialization is a continuous process that corresponds to developmental stages of life cycle. And this process continues until old age.

 

Ø  According to this theory the years of life at the end of life span become increasingly non-normative.

 

For Example:  Transition to old age is marked by rites of passage, such as retirement; social loses rather than gains, declining responsibilities, increasing dependency, and a sharp role discontinuity because society does not specify a role of the aged.

 

6. Psychological Theories:

 

Ø  These are usually extension of sociological and developmental theories.

 

Ø  According to these, the innate human needs and forces motivate thought and behavior with in a physical and social environment.

 

7. Jung Theory:

 

Ø  Jung proposed that the latter half of life has a purpose of its own. Quite apart from survival the development of self-awareness through reflective activity.

 

Ø  It stresses that the life review process clearly defines the growth potential for aged adult.

 

8. Neugarten Theory:

 

Ø  It proposes that increased reflection is characteristic of adult persons. There is a growth interest by adult in inner development during later life.

 

 

 

           

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.1 NORMAL PHYSIOLOGICAL CHANGES ASSOCIATED WITH AGING

 

                   It is important to define normal features of aging so that we have an appropriate baseline against which symptoms and signs in elderly people can be assessed. However very few people reach old age completely free of disease.

                  An important feature of aging is the increase in variation in function, so that particular feature may appear to undergo a moderate decline with age over all or it may remain unchanged in some or may be severely impaired in others causing severe problems.

                  Elderly persons require special care because of the unique challenges presented by physiology of aging. Often multiple problems present at once in elderly. How ever aging is not necessarily equated with sickness.

                  Some features of aging are age determined, i.e. they are inevitable, while others are age related i.e. they result from an accumulation of factors such as lack of exercise or poor diet, or are accelerated by habits such as cigarette smoking, heavy alcohol consumption or over exposure to sunlight. Age related changes can there fore be slowed or prevented by a healthy life style and this remains worth encouraging even when old age has been reached.

 

 

 

Integumentory System:

 

 

¨       Wrinkles and lines in skin

 

¨       Loss of elasticity

 

¨       Age spots

 

¨       Thin and fragile skin

 

¨       Nails become dry and brittle

 

¨       Lowered activity of oil and sweat glands

 

¨       Thinning and loss of sub cutaneous fat

 

¨       Decreased pigmentation

 

¨       Thinning of scalp hair and loss of hair color

 

¨       Increased facial hair

 

¨       Loss of pubic and axillary hair in women

 

¨       Growth of hair in ears and nose in aging males

 

¨       Decreased melanin production

 

¨       Sweat glands decrease in size and number

 

¨       Decreased collagen

 

¨       Decreased thickness of epidermis

 

¨       Decreased capillary fragility.

 

¨       Decreased nail growth

 

¨       Thinning of connective tissue.     

 

 

 

 

 

 

Respiratory System:

 

¨       Loss of elasticity in connective and epithelial tissues of lungs

¨       Shallow breathing

¨       Concomitant decrease in arterial O2  

¨       Progressive loss of intra alveolar septa

¨       Gradual decline in the number of alveoli

¨       Dilatation of residual alveoli and alveolar ducts.

¨       Calcification of costal cartilages.

¨       Progressive kyphosis

¨       Decreased number of cilia

¨       Decreased gas exchange

¨       Decreased vital capacity and tidal volume

¨       Increase in chest wall rigidity

¨       Decreased coughing ability

¨       Increase in production of mucus

¨       Decrease in strength of respiratory muscles

¨       Increased V/Q Mismatch

¨       Reduced immune function

Cardio Vascular System:

 

¨       Increased collagen and cross linking of connective tissue

 

¨       Decreased elasticity of vasculature.

 

¨       Increased peripheral vascular resistance.

 

¨       Increase in blood pressure

 

¨       Inadequate blood flow to heart muscle

 

¨       Increase in narrowing of lumen of blood vessels

 

¨       Diminished arterial circulation to all organs including brain and kidney

 

¨       Thickening of valves of heart and fibrosis

 

¨       Increased thickness of left ventricle

 

¨       Increase in stroke volume

 

¨       Decrease in elasticity of heart muscle and blood

 

¨       Decrease in cardiac reserve

 

¨       Increased vulnerability to arteriosclerosis

 

¨       Dilation of aorta

 

¨       Reduced number of pacing myocytes in sinu atrial mode

     

 

 Haemotopoietic and Lymph System:

 

¨       Hyper segmentation of polymorpho nuclear cells

 

¨       Markedly depressed Immunological function

 

¨       Reduced immune surveillance of T-lymphocytes

 

¨       Depressed function of B lymphocyte

 

¨       Senile purpura

 

¨       Elevated ESR value

 

¨       Increased level of plasma fibrinogen

 

¨       Increased plasma viscosity

 

¨       Decreased red blood cell production

 

 

Gastro Intestinal System:

 

¨       Decreased secretion of saliva

 

¨       Reduced salivary amylase secretion

 

¨       Reduced gastric secretion

 

¨       Decline of hepatic weight – after 70 years of age.

 

¨       Decrease in albumin, globulin ratio

 

¨       Loss of taste buds

 

¨       Decreased olfactory function

 

¨       Thinning of stomach mucosal layer

 

¨       Diminished enzyme and acid production

 

¨       Decreased gag reflex

 

¨       Decreased esophageal and gastro intestinal peristalsis.

 

Reproductive system:

 

Females:

¨       Decreased size of uterus

 

¨       Atrophy of edometrium

 

¨       Decreased size of vagina in length and diameter

 

¨       Reduced elasticity of vaginal walls

 

¨       Loss of vaginal rugae

 

¨       Decreased estrogen levels

 

¨       Decreased vaginal alkalinity

 

¨       Decline of ciliary components in fallopian tubes

 

¨       Labia major and minor shrink

 

¨       Reduction in clitoral size and sensitivity

 

¨       Reduced perineal muscle tone

 

¨       Breast muscle atrophy

 

¨       Accumulation of adipose tissue in breasts

 

Males:

 

¨       Decreased testosterone levels

 

¨       Decreased rate and force of ejaculation

 

¨       Decreased speed of gaining erection

 

¨       Reduced muscle strength

 

¨       Reduction in number of viable sperms

 

¨       Decreased sexual desire

 

¨       Enlargement of prostate

 

Musculo Skeletal System:

 

Muscle:

 

¨       Reduced muscle mass

¨       Decrease of maximal muscle strength

¨       Slowing of muscle reflexes

¨       Loss of flexibility

¨       Increase of relative number of slow oxidative fibers

¨       Increase of lipid content of muscle

¨       Size and number of muscle fibers decreases.

¨       Prolongation of latency, contraction period and relaxation period of muscle twitch.

Bones:

 

¨       Decrease of bone mass and brittleness

¨       Loss of bone through resorption

¨       Demineralization

¨       Decrease of bone minerals like calcium in bone matrix.

¨       Loss of tensile strength of bone

¨       Slowing of collagen fiber synthesis

¨       Loss of bone weight

¨       Decreased blood supply to bones

¨       Cartilage degeneration

Joints:

 

¨       Decreased production of synovial fluids in joints

¨       Thinning of articular cartilages

¨       Shortening of ligaments

¨       Loss of flexibility of ligaments

¨       Degeneration of joints

¨       Thinning of vertebrae and inter vertebral discs

¨       Reduced joint mobility

¨       Increased risk of fractures

¨       Bony growths at the edge of joint

 

 

 

 

Central Nervous System:

     

¨       Atrophy of brain

¨       Enlargement of ventricles

¨       Depigmentation and other degenerative changes in substantia Nigra

¨       Degenerative changes in lentiform nucleus

¨       Declination of number of neurons

¨       Gradual loss of dendrites in pyramidal cells of cerebral cortex

¨       Degeneration of schwaan cells

¨       Reduced cerebral blood flow

¨       Decreased cerebral oxygen utilization

¨       Loss of sense of vibration and elevation of thresh hold of most other sensations

¨       Sense of 2-point discrimination is affected

 

¨       Gradual decrease in stage 3 and 4 of NON-REM sleep

¨       Decrease of brain weight

¨       Declination of number of synaptic contacts

¨       Diminished presence of neurotransmitters

¨       Diminished neural glucose utilization

¨       Decrease of conduction velocity

¨       Diminished processing of information

Reflexes:

 

¨       Loss of ankle jerk in most of the elder people

¨       Other deep and superficial reflexes sluggish or absent

 

Special Senses:

 

Visual changes:

 

¨       Loss of elasticity of lens

¨       Decreased tear production

¨       Decreased night vision

¨       Decreased peripheral vision

¨       Decreased color perception

¨       Altered accommodation to light and dark

¨       Increased sensitivity to glare

¨       Thickening of lens – presbyopia

¨       Decreased color discrimination.

Hearing:

 

¨       Thickening of ear drum

¨       Excessive wax

¨       Decreased number of hair cells in inner ear

¨       Decreased ability to distinguish high frequency sounds.

Taste:

 

¨       Decreased number of taste buds per papilla

¨       Diminished ability to distinguish specific taste.

Smell:

 

¨       Decreased number of nasal sensory receptors

¨       Sense of smell is impaired.

 

Touch:

 

¨       Decreased number of receptors       

¨       Decreased ability to distinguish temperature and feel pain.

Endocrine System:

 

¨       Decrease of production of human- growth hormone by anterior- pituitary gland.

¨       Decreased activity of thyroid gland

¨       Increased level of thyroid – stimulating hormone

¨       Rise in blood level of PTH

¨       Decreased level of calcitonin

¨       Decreased production of cortisol and aldosterone

¨       Release of insulin is slowed down.

¨       Receptor sensitivity to glucose declines

¨       Atrophy of thymus gland

¨       Decreased out put of estrogens

¨       Less negative feed back inhibition of estrogens

¨       Decreased production of testosterone by testes

¨       Decrease in basal metabolic rate.

Urinary System:

 

¨       Decreased number of nephrons

¨       Decreased renal Mass

¨       Reduced renal perfusion

¨       Declined glomerular filtration rate and tubular resorption.

¨       Kidney function is diminished.

¨       Decreased blood flow to kidneys

¨       Increased concentration of urine

¨       Increased volume of residual urine

¨       Decreased sphincter control

¨       Decrease in Muscle tone of bladder.

Stature and Posture:

 

¨       Declination in height

¨       Kyphosis as well as slight flexion at hip and knee found.

¨       Thinning of inter vertebral discs.

¨       Loss of muscle mass of deltoid causes decrease of shoulder width

¨       Increase of pelvic diameter

¨       Increase of abdominal girth

¨       Decrease of head circumference

¨       Thicker ear lobes

¨       Broader nose

¨       Elderly people are characterized by short trunk and comparatively long extremities, which are reverse of those in childhood.

 

 

 

 

 

 

3.2 CONSEQUENCES OF PHYSIOLOGICAL

 CHANGES IN ELEDERLY

 

Integumentory System: (Skin, Hair, Nails):

 

¨       Wrinkling of skin and graying are hallmark of aging.

 

¨       Graying of hair is due to loss of melanin pigment.

 

¨       Macrophages become less efficient phagocytes- and decrease skin’s immune responsiveness.

¨       Decrease in sebaceous gland activity combined with the inability of aged skin to retain fluids, results in dryness of skin, which can increase itching.

¨       Lentigo senilus Brown “Age Spots” appears commonly on hand and arms or on face because of clustering of melanocytes (pigment producing cells).

¨       Skin becomes pale and loses its elasticity because of decreased vascularity.

¨       Decreased subcutaneous fat may give the face and hands hollow or gaunt appearance.

¨       Decrease in number of melanocytes causes loss of hair color.

 

¨       Loss of subcutaneous fat decreases aged person’s tolerance for cold.

 

¨       Bony prominences become visible.

 

¨       Decreased vascularity to the tissue layer that produces hair follicles causes baldness and hair loss.

¨       Deterioration of nerve fibers and sensory ending can result in decreased sensation especially in lower limb.

 

¨       Finger nails and toe nails become brittle and thickened.

 

¨       In women facial hair increases.

 

¨       Progressive loss of subcutaneous fat, muscle atrophy, loss of elastin fibers result in double chin, sagging Of eyelids and ear lobes, wrinkling of skin, especially in areas exposed to sun.

¨       Eyes seem to sink owing to disappearance of fat around orbits.

¨       Fatty tissue layer is subjected to greatest change with aging.

¨       E.g.: Veins and bones of hand become prominent under a parchment like skin. Deep hallows appear in the clavicular and axillary areas of body.

 

 

Neuro Musculo Skeletal Changes:

 

¨       Gradual reduction in speed and power of skeletal or voluntary muscle contractions.

¨       Decreased capacity for sustained muscle effort.

 

¨       Activities are carried out at a slower pace.

 

¨       Impaired balance.

 

¨       Steady decrease in muscle fibers leads to typical wasting appearance.

 

¨       Reaction time of a person is slowed down due to diminished conduction speed of nerve and decreased muscle tone because of diminished physical activity.

¨       Atrophy of spinal discs and muscle weakness result in slight loss of over all stature, stooping posture and kyphosis (Hump back of upper spine)

¨       Decrease of bone density along with increased brittleness of bone (osteoporosis) makes elderly people more prone for fractures.

¨       Osteoporosis is more frequent in people with:

o   Insufficient intake of dietary calcium

o   Menopause (in Women)

o   Prolonged immobilization

o   Lack of physical activity

¨       Degenerative changes occurring at joints make movements stiffer and restricted.

¨       Joint stiffness is aggravated by inactivity.

 

Respiratory Changes:

                          

Reduction in Respiratory Efficiency:

 

¨       Due to increased chest wall rigidity, volume of air inspired in is decreased.

¨       Weakness of respiratory muscles results in greater volume of residual air left in lungs after expiration, and inefficient coughing.

Mucous secretions:

 

¨       Tend to collect more rapidly in respiratory tree due to decreased ciliary activity. Thus susceptibility to respiratory infections increases in elderly people.

Dyspnoea:      

 

¨       Due to reduced arterial O2 and V/Q mismatch, dyspnoea occurs frequently with increased activity. Short, heavy and rapid breathing follows intense exercise, which is an attempt to compensate O2 debt in the muscles.

¨       Though this phenomenon is normal it occurs more frequently in aged because delivery and diffusion of O2 to tissues is diminished by changes is both respiratory and vascular tissues.

 

Cardiac Changes:

 

Blood Pressure:

¨       Reduced elasticity of systemic arteries and increased peripheral resistance cause a significant increase in systolic pressures and a slight increase in diastolic pressures. Normal B.P in aged: 110/70

 

Orthostatic hypotension:

 

¨       Because of decreased elasticity of heart muscle, and blood vessels, there is delay is the ability to adjust to rapid movement from lying to a standing position. This causes an abrupt drop of systolic blood pressure; known as Orthostatic hypotension.

 

Heart  & Rate:

 

¨       Working capacity of heart diminishes with age; this is particularly evident when increased demands are made on heart muscles, such as during periods of exercise or emotional stress.

¨       Heart rate of an aged person is slow in responding to stress and slow in returning to normal after periods of physical activity.

¨       Heart rate of an average old person is 62-65/ min

 

Valves:

 

¨       Tendency of valves to become harder, less pliable and weak results in reduced filling and emptying abilities.

¨       Changes in coronary arteries like narrowing of lumen, reduces the pumping action, which results in supply of progressively smaller amounts of blood to heart muscle.

¨       All these changes lead to shortness of breath on exertion and pooling of blood into systemic veins.

 

Changes in Arteries:

 

¨       Thickening of lumen of blood vessels – arteriosclerosis reduces the elasticity of smaller arteries and increases calcium deposits in muscular layer.

¨       Reduced arterial elasticity often results in diminished blood supply. For instance, to legs & brain, resulting pain in calf muscles on exertion and dizziness respectively.

Changes in Digestion:

 

¨       Decreased peristaltic movements land in constipation

¨       Decreased secretions of GIT like digestive enzymes, secretion of saliva, reduce the capacity of digestion.

¨       Decrease in number of absorbing rugae and rise in gastric PH.

¨       These factors affect and lower, absorption rate and slow down the process of absorption of nutrients and drugs.

¨       Decrease of muscle tone impairs faecal elimination.

¨       All these changes lead to indigestion and constipation in aged people.

 

Nutritive Changes:

 

¨       Loss of teeth, gum diseases and bone degeneration make eating difficult and uneasy for the elderly people.

¨       Chewing is difficult due to lost or loosened teeth, and hence modification of diet is required.

¨       Poor muscle tone, loss of digestive juices and impaired circulation land up with problems in digestion and elimination of wastes, as well as loss of appetite.

¨       Atrophy and decrease in number of taste buds takes away the pleasure and interest in eating.

¨       Because of the above-mentioned difficulties, the person’s dietary intake, way of eating and quantity are greatly disturbed and amount of food intake is reduced.

¨       These can lead to anemia, increased susceptibility to infections and malnutrition.

 
Changes in urinary elimination:

 

¨       Due to decreased renal mass and functioning, the excretory functioning of kidney also diminishes with age

 

¨       Decreased renal blood flow causes impairment of renal function.

¨       Enlarged prostrate in males and weakness of urethral sphincter and supporting muscles of bladder make the age to complain of urgency and increased frequency of urination.

¨       Decrease of number of nephrons adds to declination of glomerular filtration rate and tubular resorption causing a gross reduction in the functioning of kidneys.

¨       Due to decreased muscle tone of bladder associated with other reasons, the capacity of bladder and its ability of complete emptying diminish with age.

¨       Because of the above-mentioned phenomenon, the need for elderly to rise during night many times for urination (nocturnal Frequency) and retention of residual urine occur.

¨       These predispose the elderly more prone for urinary tract and bladder infections.

 

Changes in body temperature:

 

¨       Decrease in metabolic rate of body lowers down the body temperature as much as up to 950F.

¨       In a normal person or adult, a fall in heat of body is compensated by contraction of blood vessels on the surface and by shivering.

¨       But in elderly poor shivering reflex along with diminished metabolic processes fail to produce sufficient heat and greatly reduce their tolerance for prolonged exposure to cold.

¨       On the other extreme:

An adult body compensates for higher temperatures of body by

o   Slowing down of muscle activity to produce less heat           

o   Dilating of surface blood vessels

o   Sweating

 

 

Where as elderly people, due to

o   Sluggish sweating and

o   Sluggish circulatory mechanisms

Cannot cope up with loss of excess of body heat as youngsters do.

¨       Sub cutaneous fat helps a lot in adjustment of body temperature and loss of much of subcutaneous fat in elderly results in loss of natural insulation provided by it.

¨       Decrease in the number and activity of sweat glands causes a decline in the efficiency of body cooling mechanism hence elderly cannot be devoid of the excessive heat and so get exhausted.

¨       Sluggish circulatory processes make difficult for elderly to adjust in           environments of varying temperatures.

¨       Avoidance of excessive hot and cold temperatures is strongly necessitated for every one and especially for elderly.

¨       Sudden changes in temperature like sudden raise of room temperature or exposure to heated bath water causes blood vessels in skin and muscles to dilate and can result in temporary slowing of blood to brain, leading to a reversible state confusion.

 

Sensory or Perceptual Changes:

 

Changes of vision and in and around eye:

 

¨       Shrunken appearance of eyes due to loss of orbital fat

¨       Blink reflex is slowed down

¨       Poor muscle tone causes looseness of eyelids

¨       Loss of visual acuity

¨       Reduced power of adoption to darkness and dim light

¨       Decrease of accommodation to near and far objects.

¨       Loss of peripheral vision

¨       Difficulty in discriminating similar colors especially, blue, green and purple.

¨       Degenerative changes in eyes that begin in middle age lead to relative inflexibility of lens called presbyopia.

¨       As the lens ages, it becomes more opaque and less elastic. This reduces visual acuity and cause glare to be a problem. Surgical removal of cataracts is common at this age.

¨       Along with these changes and changes in ciliary muscles, the power of lens to adjust to near and far visions is reduced.

¨       Diameter of lens pupil is reduced thus restricting the amount of light entering the eye. This slows the reaction time to decrease in light or illumination, a problem compounded at night with driving.

¨       Reduced blood supply due to arteriosclerosis can diminish retinal function and reduced peripheral vision.

 

Changes in Hearing:

 

¨       Presbycusis i.e. loss of hearing ability related to aging affects 13% of people over 65 years of age.

¨       Presbycusis is the out come of changes in the structure of inner ear like changes in nerve tissue in the inner ear and thickening of eardrum.

¨       Presbycusis commonly seen among men than women might be because men are more frequently involved in noisy work environment.

¨       Hearing loss is greater in high frequency than the lower. Thus the old people with hearing loss usually hear speakers with low, distinct voices best.

 

 

 

Changes in taste and smell:

 

¨       The number of taste buds in the tongue decreases. Olfactory bulb responsible for smell perception at the base of brain atrophies.

¨       Hence they are less stimulated by food than the young.

¨       This affects the appetite and thus contributes to poor nutrition.

 

Changes in sensation of pain and touch:

 

¨       Loss of skin receptors takes place gradually producing an increased threshold for sensations of pain and touch.

¨       Capability of distinguishing hot from cold or intensity of heat is reduced in older people. Hence they are at a higher risk of burns and other injuries.

¨       Changes like loss of neurons, decreased blood supply and decreased electrical activity cause.

o   Altered sensory perception

o   Decrease in reaction time

o   Movement time for elderly

¨       Vestibular functioning decreases and elderly persons are more prone to falls and accidents.

 

Changes in sexual activity and reproductive system:

 

¨       Physical problems like Diabetes, arthritis, and heart and respiratory conditions affect the physical ability of an elderly person to participate in sexual activity.

¨       Testes are capable of producing sperms well into old age but there is a gradual decrease in the number of sperms produced.

¨       In females, abrupt cessation of menses in middle age during menopause and degenerative changes in ovaries are found. These changes in gonads are due to diminished secretion of ovarian hormones.

¨       Degenerative changes in gonads are very gradual in men

¨       Sex drives persist up to 70’s, 80’s and 90’s provided that health is good

¨       People who are active sexually during their middle adult hood or younger age, remain active during their later years

Sleep changes:

 

¨    Sleep is a state of altered consciousness or partial unconsciousness from which an individual can be aroused.

¨    It is necessary for biological restoration.

¨    Normal sleep consists of components: –

a)     Non- raid eye movement (NREM) sleep

b)     Rapid eye movement (REM) sleep

¨       The REM and NREM sleep alternate throughout night.

¨       As a person ages, the average total time spent sleeping decreases where a typical sleep period lasts for 7- 8 hours, in a normal adult.

¨       The percentage of REM sleep declines.

¨       The aged takes longer time to move through the relaxation stages of NREM sleep, the normal time being less than 1 hour to pass from stage 1 to 4 of NREM sleep.

¨       No. of awakenings and their duration increases.

¨       Usually the sleep of elderly is fragmented due to interruption like frequent nocturnal micturition, muscle cramps, mental stimulations from worries and extraneous noises.

¨       Noisy environments, unresolved fears, worries, also contribute to disturbances in sleep.

 

 

 

 

 

4.1 PSYCHOSOCIAL DEVELOPMENT

 

Psychosocial Development refers to the development of personality. Personality can be considered as the out ward (interpersonal) expression of inner self (intra personal).

 

Personality includes a person’s

­ Character

­ Behaviour

­ Family structure

­ Feelings

­ Temperament

­ Independence

­ Traits

­ Self esteem

­ Self concept

­ Ability to interact with others

­ Ability to adopt to changes

­ Sexuality

­ Grand parenting

­ Work and retirement

­ Leisure

 

Self Concept:

 

            It is developed by a continuous interaction between the individual and the environment. Loss of roles such as parent, spouse and workers often erode the elder’s sense of self and psychological well being.

            Elderly are often separated from their families, friends and work groups. In addition, physical illness or immobility makes them more difficult to socialize. These make the elderly unable to control their own lives and hence to feel incompetent.

 

The need to be creative and productive is particularly important to gain attention from others to compensate the decreased physical attractiveness.

The main determinants of happy old age are good health, adequate income, and useful role opportunities.

 

Sexual activity:

 

Determinants of sexual activity include: 

 

­ Present help status

­ Past and present life satisfaction

­ Social class

­ Married status

 

Ø  Older women, windows, divorced and those lacking of sexual partners go for   decline in sexual interest. On the other hand older men tend to go for second marriages.

Ø  Physiological changes associated with aging also account for decline in sexual activity,

Ø  Moreover lack of privacy, increased responsibility, and social factors interfere with the interest in participating in sex.

 

Widowhood:

 

Ill health, poverty coupled with normal social losses of old age, result in elderly widowed person with the prospect of becoming socially isolated.

 

Family Support:

 

            The relationship between children, parents and grand parents is influenced by a variety of factors like economics, distance, health and emotional health.

Professional career patterns result in separation of children, parents and elderly, in the aspect of having privacy and independence rather than adjusting to their children’s life style. But the disadvantage in this is greater the distances, fewer are the visits and so the interactions. This makes the elderly feel ignored and psychologically depressed.

 

Grand parenting:

 

            This is the most important role in the elder’s life providing them the sense of purpose, value and esteem.

 

Grand parenting is a benefit for the elder, their children and grand children, because the elderly provide advice and guidance for the young. Grandparent can extend his/her influence on the future generations; can even get his goals being achieved by his grand children.

 

Mingling and playing with grand children carries away their thoughts into their children, and make them feel happy and energetic.


Work and retirement:

 

Retirement from work, which a person has been forming since the last 25-30 years, is an expected but not an adjustable event.

 

Feeling of inactivity, being neglected and inferiority drench the recently retired elderly. It takes certain time to cope up with meaningful activities of leisure.

 

Pre retirement counseling programmes, alternative work patterns such as second careers etc., should be taken care of so that planned lives can be lead.

 

 

Leisure:

 

The five most common activities of leisure are:

­ Visiting friends

­ Watching TV

­ Doing odd jobs at home

­ Reading

­ Traveling.

            The capability to structure their free time depends on educational and economical status.

Women tend to adjust their leisure time more easily than men. One may create a new hobby; other may try to give their maximum time to their old hobbies, which was not possible in their working days.

Retirement:

 

            A majority of people over 65 is unemployed. However, some who are healthy continue to work on a full (or) part time basis.

    Work offers these people:

­ Better income

­ A sense of self worth

­ A chance to continue long established routines

­ Economic security

­ Self-dependence.

 

Some tend to enjoy this period because they no longer are governed by an alarm clock and they can get up when they please.  They spend much time resting (or) sleeping. On the other hand others who are being accustomed to activity most of their lives, find jobs, community projects, volunteer services, recreational pursuits (or) hobbies etc.

 

Economic change:

 

            The financial needs of elderly people vary from person to person. Though most of them need less money for clothing, entertainment, etc. but food and medical costs alone are often a financial burden.

 

            Adequate financial resources may enable the older person to remain independent. Women comparably are less independent than men. One should be aware of the economic independency (or) dependency of the client and the costs of health care i.e. low cost food and low priced medications etc.

 

Facing death and grieving:

 

                        A well-adjusted aging couple has great bond of affection closeness during the period of aging together and nurturing each other. When a mate dies, the remaining partner inevitably experiences feelings of loss, emptiness and loneliness. Some widows and widowers remarry.

 

 

 

 

 

 

 

 

 

 

 

 

4.2 COGNITIVE DEVELOPMENT

 

 

v Cognitive development refers to the manner in which people learn to think, reason and use language.

 

v It involves a person’s intelligence, perceptual ability and ability to process information.

 

v Cognitive development is an orderly sequential process, which starts right from the birth of human being.

 

v Intellectual capacity includes:

o   Perception

o   Cognitive ability

o   Memory and learning.

 

Perception:

 

v It is the ability to interpret the environment. It depends on the acuteness of senses. If the aging person’s senses are impaired the ability to perceive the environment and react appropriately is diminished.

 

v Perception may be affected by changes in the nervous system also.

 

Cognitive ability:

 

v It is the ability to know and is related to perceptual ability. Changes in the cognitive ability occur, as there are progressive changes in the cognitive structures with age. Examples are loss of neurons, decreased blood flow to brain, thickening of meninges, slowing down of brain metabolism, deposition of lipofuscin etc.

 

 

 

Memory:

 

v The ability to retain information is memory. It is suggested that older people remain mentally active to maintain cognitive ability at the highest possible level. A decline in intellectual abilities that interferes with social or occupational functions should always be advised to seek medical intervention.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.3 Moral & Spiritual Developments & Mental Health:

 

Moral Development:

 

Moral development is the complex process and involves learning what ought to be and what ought not to be done. Moral development is the pattern of change in moral behaviour with age. An elderly person obeys rules to avoid pain and displeasure to others.

 

       Cultural background, life experiences, gender, religion, socio economic status, all influences this moral development.

 

Spiritual Development:

 

        The spiritual component of growth and development refers to the individual’s understanding of their relationship with the universe and their perceptions about the direction and meaning of life.

 

        The older person’s knowledge becomes wisdom, an inner resource for dealing with both positive and negative life experiences.

 

Mental Health:

 

Dementia:

 

         It is the term used for a permanent or progressive organic mental disorder characterized by personality changes, confusion, disorientation, deterioration of intellectual functioning, loss of memory/impaired memory, judgement and impulses.

 

 

 

 

Primary dementia:

v This results from diseases that directly attack brain tissue.

v These are irreversible (should be treated symptomatically, and cannot be cured).  Examples are Alzheimer’s dementia, Parkinson’s disease etc.

 

Secondary dementia:

v It includes diseases that do not directly attack brain tissue but results in symptoms of dementia.

v It may result from diabetic keto acidosis, severe nutritional imbalance, severe dehydration, head trauma, depression, infections etc.

 

  Multi infarct dementia (MID):

 

v It results from multiple strokes.

Note:

 

  Secondary dementia and MID are reversible if the underlying disease is treated promptly whereas primary dementia is irreversible.

 

 

 

 

 

 

 

 

 

 

5.1 ABNORMAL PHYSIOLOGICAL CHANGES ASSOCIATED WITH AGING

 

Integumentory System:

 

§     Infections:

Bacterial    Erisipelas, Impetigo, necrotising fascitis

                         Erisipelas – acute streptococcal infection of skin

                         more common in elderly

Viral             Skin rashes, plantar warts

Fungal         Mycetoma (madura foot), zygomycosis

 

§      Abnormal cell growth

§      Tumors

Benign or malignant

§      Skin ulcerations

§      Pressure sores

§      Cracks of foot

§      Skin tears

§      Skin bleeding

 

Musculo skeletal system:

 

§      Excessive joint degenerations

§      Abnormal weakening of bones

§      Loss of height due to changes in vertebral column

§      Rheumatoid arthritis

§      Pathological fractures, stress fractures

      E.g.: fracture at neck of femur

§      Contractures of knee, tendo achilis etc.,

 

Cardio Vascular Diseases:

 

§      Hypertension causes thickening of tunica media.

§      Coronary artery diseases like arteriosclerosis.

§      Peripheral vascular diseases like DVT, Arteriosclerosis, and varicose veins.

§      Aneurysms:

1) Cerebral aneurysm:

a)     MCA artery aneurysm

b)     Internal Carotid artery aneurysm

2) Cardiac aneurysm:

a)     Ventricular aneurysm

b)     Aneurysm of aorta

§      Congestive heart failure

 

Nervous System:

 

§      Cerebrovascular diseases like stroke.

§      Degeneration of brain tissue like Parkinson’s disease, fibrosis of bone tissue (Multiple sclerosis).

§      Senile dementia and Alzheimer’s disease.

 

Respiratory system:

 

§      Abnormal decrease of muco ciliary movements.

§      Abnormal retention of secretions.

§      Increased shortness of breath.

§      Increased susceptibility to respiratory infections

 

Endocrine system:

 

§      Abnormal reduction of tissue sensitivity to insulin.

 

§      Increased risk of impaired glucose tolerance.

§      Abnormal decrease in out put of thyroid hormones causing hypothyroidism

§      Decreased basic metabolic rate.

 

Sensory System:

 

          Smell:

Deterioration of sense of smell – hyposmia. This can also be due to neurological changes like head injury, Alzheimer’s disease or Parkinson`s disease, certain drugs like antihistamines, analgesics or steroids and damaging affects of smoking.

 

Vision:

 

§      Degeneration of retina.

§      Increased thickness of lens.

Hearing:

§      Abnormal loss of sensitivity to high-pitched sounds.

 

Digestive system:

 

§      Reduced sensitivity to mouth irritations and sores.

§      Mal absorption.

§      Increased incidence of appendicitis.

§      Hemorrhoids.

 

Urinary system:

 

§      Urinary tract infections.

§      Inflammatory processes.

§      Increased production of urine.

§      Increased frequency of urination during night.

§      Painful urination.

§      Retention of urine or incontinence.

6.1 COMMON DISEASES AND DISORDELS OF ELDERLY

 

Certain disorders and diseases are exclusive and commonly encountered in elderly and become responsible for much of their disability.

 

Malignancy:

 

            Commonly occur in elderly than in younger ones.

v Acute lymphoblastic leukemia.

v Carcinoma of prostrate gland.

v Multiple myeloma

v Breast cancer

v Ovarian cancers

v Adino carcinoma of colon

v Osteosarcoma

v Lung cancer

v Carcinoma of rectum

 

Musculo skeletal system:

 

v Osteoporosis

v Pathological factures

v Stiffness

v Deformities

o   Kyphosis

o   Scoliosis

o   Lordosis

o   Kyphoscoliosis

v Pressure sores

v Demineralization

v Osteoarthritis of spine, hip, knees, elbows and shoulders.

v Cervical spondylosis

v Lumbar spondylosis

v Periarthritic shoulder

Cardiopulmonary system:

 

v Left ventricular hypertrophy

v Regurgitation of values like mitral, aortic, and pulmonary.

v Coronary artery disease

o   Results from arteriosclerosis, genetic, predisposition, high blood cholesterol, hypertension, smoking and sedentary lifestyle.

o   Severity of this may end up in myocardial ischemia and infarction most commonly of the left ventricle.

v Congestive cardiac failure

o   Extremely common disorder of elderly. Results from inadequate function of heart muscle. Hypertension and coronary heart disease predispose to heart failure. Shortness of breath and swelling of feet and ankles are the manifestations.

v Heart block:

o   Characterized by sudden slowing of heart rate.

v Aneurysms:

o   Balloon like dilatations of heart vessel.

o   Aneurysm of aorta is a major problem.

o   This condition is life threatening and needs surgical intervention.

v Peripheral vascular diseases

o   Varicose veins: –

Common in lower extremities and are results of fatty deposits in major arteries. The result is gradual narrowing of arteries => Inadequate blood supply => Pain in calves.

o   Burger disease

v Asthma

v Bronchitis

v Emphysema

v Pneumonia

v Tuberculosis

v Bronchogenic carcinoma

 

Nervous System:

 

v Stroke/ Cerebro vascular accident (CVA)

v Transient Ischaemic Attack (TIA)

v Senile Dementia

v Hypothermia

v Alzheimer’s disease

 

Special Senses:

 

Vision:

                       Cataracts

                                   Glaucoma

                                   Senile ocular degeneration

                                   Age related macular disease

                                   Presbyopia

                                   Myopia

                                   Astigmatism

 

Hearing:

                                   Deafness

 

 

Smell:

           Hyposmia

                       Anosmia

 

Taste:

                              Taste eversion

 

 

 

 

 

Digestive System:

 

v Hiatus hernia

v Gastritis

v Peptic ulcers

v Duodenal ulcers

v Gall bladder problems

v Cirrhosis

v Acute pancreatitis

v Cancer of colon.

v Piles

 

Endocrine System:

 

v Rise in PTH and fall in calcitonin level

v Decrease in bone mass leading to osteoporosis and increased risk of fractures.

v Decreased output of estrogens leads to osteoporosis, high blood cholesterol ad arteriosclerosis.

v Hypothyroidism / myxedema

v Diabetes milletus

 

Urinary System:

 

v Urinary tract infections

v Polyuria – excessive urine production

v Nocturia – excessive urination at night

v Dysuria  – painful urination

v Haematuria – blood in urine

v Urinary retention or incontinence.

 

 

 

 

 

Psychological Problems:

 

v Depression

v Feeling of being neglected

v Development of inferiority complex

v Alcoholism

v Tendency of committing suicide

Depression Scale

(Tab 6.1)

*1.

Are you basically satisfied with your life?

YES

NO

2.

Have you dropped many of your activities and interests

YES

NO

3.

Do you feel that your life is empty?

YES

NO

4.

Do you often get bored?

YES

NO

*5.

Are you hopeful about the future?

YES

NO

6.

Are you afraid that something bad is going to happen to you?

YES

NO

*7.

Are you in good spirits most of the time?

YES

NO

*9.

Do you feel happy most of the time?

YES

NO

10.

Do you often helpless?

YES

NO

11.

Do you often get restless and fidgety?

YES

NO

12.

Do you prefer to stay at home, rather than going out and doing new things?

YES

NO

13.

Do you frequently worry about the future?

YES

NO

14.

Do you fell you have more problems with memory than most?

YES

NO

*15.

Do you think it is wonderful to be alive now?

YES

NO

16.

Do you often feel downhearted and blue?

YES

NO

17.

Do you feel pretty worthless the way you are now?

YES

NO

18.

Do you worry a lot about the past?

YES

NO

*19.

Do you find life very exciting?

YES

NO

20.

Is it hard for you to get started on new projects?

YES

NO

*21.

Do you feel full of energy?

YES

NO

22.

Do you feel that your situation is hopeless?

YES

NO

23.

Do you think that most people are better off than you are?

YES

NO

24.

Do you frequently get upset over little things?

YES

NO

25.

Do you frequently feel like crying?

YES

NO

26.

Do you have trouble concentrating?

YES

NO

*27.

Do you enjoy getting up in the morning?

YES

NO

28.

Do you prefer to avoid social gatherings?

YES

NO

*29.

It is easy for you to make decisions?

YES

NO

*30.

Is your mind as clear as it used to be?

YES

NO

* Appropriate (no depressed)                         Score:         (Number of “Depressed”

                                                                                            Answers)

Norms

Normal                             5±4

Mildly Depressed           15±6

Very depressed              23±5

6.2 Geriatric Giants

 

The term “Geriatric Giants” refers to a set of symptoms and signs that occur in old age that may have as their cause any disease process.

 

v Immobility.

v Falls

v Incontinence

v Pressure sores

v Confusion  

                     

Immobility:

 

Despite of the causes, which make elderly immobile, the after effects of immobilization are serious.

 

They may be:                                                                                                                 

 

v Musculoskeletal- osteoporosis, joint stiffness, contractures, etc.

 

v Circulatory – deep vein thrombosis, pulmonary embolism etc.

 

v Skin- pressure sores.

 

v Postural hypotension – faintness and giddiness on standing up.

 

v Respiratory -hypostatic pneumonia, accumulation of secretions, dry and irritating cough.

 

v Urinary and bowel problems-renal caliculi, incontinence of urine and faeces.

 

v Apathy and depression. 

 

 

 

 

 

 

 

 

Falls in elderly:

 

Falls are major problems for elderly people, especially women.

 

Balance and ambulation require a complex interplay of cognitive, neuromuscular and cardiovascular function and the ability to adapt rapidly to an environmental challenge.

 

Causes of falls:

 

v Impaired balance

v Increased swaying

v Impaired vision

v Reduced strength`

v Impaired cognition

v Uneven and improper surfaces

v Environmental obstacles

v Impaired sensory input

v Impaired judgement

v Alcohol consumption

v Sedative medication

v Postprandial hypotension (peak 30 to 60 minutes after meal)

v Impaired regulation of blood pressure

v Impaired gait

v Vestibular dysfunction dementia

v Dementia

v Foot disorders like calluses deformities edema

v Reduced hearing

v Insomnia

v Urinary urgency

v Cerebro vascular disease

v Depression

 

Incontinence:

 

Incontinence is an involuntary loss of urine (or) faeces in an inappropriate place, i.e. loss of ability to control excretion and failure to identify or get to an acceptable place.

Causes of urinary incontinence include infection, stress incontinence, over flow, prostatism, neurogenic bladder, etc.

Causes of faecal incontinence include bowel disease such as carcinoma of rectum and laxatives abuse.

 

Pressure sore:

 

Necrosis of skin, adipose tissue and muscle caused by pressure occurs rapidly in acutely and chronically ill elderly people.

Pressure sores, commonly occur in bed ridden dehydrated and incontinent patients exposed to sustained pressure for longer periods of time.

 

Confusion:

 

The term confusional state describes abnormal mental state in which patient is disoriented in time, place and person etc. Delirium is an acute confusional state and Dementia is chronic confusional state.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.3 COMMON SYMPTOMS OF ELDERLY

 

 

v Forget fullness – most common complaint of elderly.

v Weakness and fatigability

v Diminishing vision or blindness.

v Deafness

v Dizziness

v Loss of appetite

v Shortness of breath

v Insomnia

v Constipation

v Aches and pains

v Disturbances of Gait and balance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.4      THE DOWNWARD SPIRAL OF               

                     PROBLEMS IN THE ELDERLY

 

Inactivity

Renal

Dysfunction

  Pulmonary

   Embolus

 Deep vein thrombosis

Pain

More weakness

Loss of weight

Lack of appetite

Constipation

Lack of strength to cook, eat, wash, dress do house work or shopping

Lack of self – interest

Muscle weakness

Incontinence

Depression

Heart Failure

Edema

Pneumonia

Contractures

Secretions

Accumulate

In lungs

 

Insomnia

(Chart 6.1)

 

 

 

6.5 CAUSES OF MORTALITY IN ELDERLY PEOPLE

 

 

Rank

Age 45 to 64 yrs

Age 65 yrs and older

1.

Cancer

Heart disease

2.

Heart disease

Cancer

3.

Accidents

Cerebro vascular disease

4.

Cerebro Vascular disease

Influenza / pneumonia

5.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease.

6.

Liver Disease

Arteriosclerosis

7.

Suicide

Diabetes mellitus

8.

Diabetes mellitus

Accidents

9.

Pneumonia or influenza

Liver disease

10.

Homicide

Kidney disease

       

 

(Tab. 6.2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.1 REHABILITATION

 

Definition:

 

Rehabilitation is the utilization of existing capacities of the handicapped person, by the combined and coordinated use of medical, Social, educational and vocational measures to the optimum Level of his functional ability.”

 

It makes life more meaningful, more productive and there fore worth while living.

 

Rehabilitation must, be started at the earliest possible time in order to ensure the best results. It is administered in conjunction with specific medical or surgical treatment of precipitating disease.

 

Rehabilitation deals with morbidity, it deals with quality of life.

 

The major components of rehabilitation are medical restoration and maintenance of health along with social psychological and economical adjustments.

 

Role of rehabilitation team:

(Tab 7.1)

Team member

Role

Doctor

Management of medial programmes, coordination of rehabilitation programmes.

Occupational

Therapist

Promotion of ADL e.g. eating, brushing, cooking, etc., assessment of home environment

Speech and language therapist

Management of speech and swallowing disorders.

Dietitian

Management of nutrition

Social worker

Organization of home support services (or) institutional care

Nurse

Reinforcement of rehabilitation programme, encouragement to regain independence, communication with relative and other professionals.

Physical therapist

Promotion of balance, mobility and upper limb functions.

 

 

 

Common Rehabilitation Interventions

 

 

`

`

Counseling

 

Educating

Advising

Drugs

Physiotherapy

Occupational therapy

Speech

Therapy

Appliances

Adaptations

Daily

Living aids

Listening

Encouraging

Hard

Rehabilitation

Soft

Rehabilitation

(Fig 7.1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.1 GERIATRIC REHABILITATION

 

Need:

 

This is as essential as rehabilitation of general population but with one important difference.

 

The process of geriatric rehabilitation must include modifications basing on the physiology and psycho sociology of aging patients.

 

The natural decline in the physiological functioning must be considered in both assessment and expectation.

 

In the words of Seneca

 

“ Old age is an incurable disease”.

 

Sir James Sterling Ross commented,

 

“ You don’t heal old age, you protect it, you promote it, you extend it”.

 

These are the basic principles of preventive and rehabilitation medicines.

The age related changes in learning and perception make progress slow, but with understanding and patience of the practitioner, the results can be very encouraging. For the elderly, activities of daily living become the primary area of focus.

Attainment of maximum performance in self-sufficiency and best psychological adjustment indicate that an older patient is rehabilitated. And the patient is expected to maintain this level.

 

 

 

 

 

 

8.2 SOME PEOPLE WHO LOOK AFTER THE ELDERLY

 

 

Ø  Bath attendant

Ø  Chiropodists

Ø  Church personnel

Ø  Continence advisors

Ø  Dentists

Ø  Doctors

Ø  Hair – dressers

Ø  Home help

Ø  Health visitors

Ø  Home help

Ø  Health visitors

Ø  Neighbors

Ø  Nurses

Ø  Occupational therapists

Ø  Opticians

Ø  Orthotists

Ø  Physiotherapists

Ø  Police

Ø  Social workers

Ø  Speech therapists

Ø  Stomach advisors

Ø  Voluntary services

Ø  Welfare rights officer

 

 

 

 

 

8.3 IMPORTANT ASPECTS OF REHABILITATION OF THE ELDERLY

 

The rehabilitation of elderly can be divided as:

 

1.      Health promotional measures

 

2.      Specific preventive measures

 

3.      Efficient Geriatric

 

I. Health Promotional Measures:

 

1.      Good Housing

 

2.      Nutrition

 

3.      Physical and mental stress management

 

4.      Promotion of sleep

 

5.      Intellectual Activity

 

6.      Social welfare measures

 

II. Specific Preventive Measures:

 

1.      Prevention of falls

 

2.      Reduction of obesity

 

3.      Periodic medical Check – Up

 

4.      Prevention of accidents

 

5.      Safety measures

 

III. Efficient Geriatric:

 

1.      Early Diagnosis

 

2.      Prompt Treatment

 

 

3.      Disability limitation

 

4.      Rehabilitation

 

I. Health Promotional Measures:

 

1. Good Housing:

 

A good House comprises of

     

Ø  Adequate Ventilation and lighting

Ø  In case of stairs, railings should be provided

Ø  Walls and roof should be strong and give protection from heat and should be free of cracks

Ø  Flooring should have rough chips and should not be slippery.

Ø  Sufficient number of doors and windows should be present for proper ventilation

Ø  A bedroom with attached bathroom is preferable.

Ø  Western commot and shower bath are recommended.

 

2. Nutritional Care:

 

            There is a need for adequate nutrition through out life, and this need is much more in elderly persons.

            Two extremes of nutritional imbalance are found in all age groups, as well as in elderly. They are poor nutrition and obesity.

 

Ø  Poor nutrition may be related to loneliness, depression and boredom, which may lead to malnutrition. On the other hand over eating in response to stress leads to obesity.

 

Ø  Sedentary life styles and reduced metabolic rate demand reduction in total calorie in take to maintain ideal body weight.

 

Ø  Avoid excess in take of sugar and salts, which can be due to decreased number of taste buds.

 

Ø  Soft and easily chewable diet should be provided to overcome difficulty of loosened teeth.

 

Ø  Easily digestible and less spicy food is best recommended.

 

Ø  Encourage much intake of fiber in diet like fresh green leafy vegetables to avoid constipation.

 

Ø  Encourage more fluid or water in take for ensuring proper digestion.

 

Ø  Maintain regular mealtimes to avoid gastric problems and to facilitate improvement of appetite.

 

Ø  Vitamins, calcium and iron can be supplemented from outside as most of the elderly are deficient of these.

 

3. Physical and mental stress Management:

           

Ø  Stress plays an important role in most physiological and psychological theories of aging.

 

Ø  Stress can speed up the process of aging

 

Ø  Physical stress includes heavy work, house hold duties, carrying of heavy weights etc.,

 

Ø  Physical stress can be overcome by following relaxation techniques, maintaining proper posture, intermittent periods of rest and easy methods of lifting and carrying heavy weights.

 

Ø  Simple way of overcoming physical stress is to have regular exercise for the body.

 

Ø  Though emotional stress in un avoidable in every period of life, it is much more in later years of life.

 

Ø  Sources of stress in later years of life are

 

o   Rapid environmental changes

o   Changes in life style like retirement or physical incapacity.

o   Active or chronic illness.

o   Loss of finances

o   Changes of house or locality

o   General lack of purpose of life.

o   Uncompleted responsibilities

 

Ø  Methods to over come metal stress are:

 

o   Interaction with people who are close to them

o   Practice of yogic exercises like:

§  Savasana

§  Padmasana

§  Mandukasana

§  Practice of Dhyana and Pranayama (controlled breathing)

o   Diverting attention towards new hobbies

o   Social service

o   Developing positive attitude of thinking    

 

4.  Promotion of sleep:

 

Ø  Day- time exercises are found to be are of the best promoters of sleep.

Ø  Good Nutritious diet that makes the stomach full helps in good sleep

Ø  Warm milk, Cocoa and other ordinary food preparations containing seratonin can be given to the aged person at bed time to fall a sleep with out use of hypnotic and sedative preparations.

Ø  Soft music, wine etc provide internal warmth and relaxation.

Ø  Proper bed, good ventilation, dim light and privacy are utmost important for promotion of sleep.

Ø  Avoiding daytime sleep is helpful to have a good sleep at night time.

Ø  Even warm baths before going to bed and back rubs induce sleep.

 

5. Intellectual activity:

 

Ø  Solving crossword puzzles, quiz programmes in leisure times, helping grand children in their education and going through magazines regularly fulfill the dual purposes – both recreation and keeping brain active.

 

 

 

6. Social welfare measures:

 

These include

 

§  National assistance

§  Supplementary pensions

§  Home care services

§  Meals on wheels services

§  Old folk’s homes

§  Service of health visitors

§  Access to clubs, hostels etc.

 

II. Specific Preventive Measures:

 

1. Prevention of falls:

 

Ø  Incase of reduced hearing – provide hearing aids.

Ø  Teach balance exercises, appropriate walking aids, correct size of foot wear with firm soles, if the cause for   falls is proprioceptive dysfunction and cervical degeneration disorders.

Ø  In-patients of dementia, falls can be prevented by supervised exercises and ambulation.

Ø  Balance and gait training, muscle – strengthening exercises and appropriate walking aids can prevent falls in case of muscles skeletal disorders.

Ø  Foot disorders causing falls can be prevented by trimming of nails and appropriate foot wear.

Ø  Postural hypotension can be prevented by dorsiflexion exercises, pressure graded stockings and by elevation of foot end of bed.

 

Architectural Barriers and Modifications:

 

                        Lighting:

          Adequacy of Illumination

                                              Accessible switches at room entrances

                        Floors:

               Non-skid flooring

               Carpet edges must be tacked down

               Cords out of walking path

               Small objects like clothes, shoes off the floor.

                        Stairs:

               Sufficient Lighting

               Switches at up and bottom of stairs

               Securely fastened bilateral hand rails

               Top and bottom steps marked with bright and contrasting tape.

               Step height should not be more than six inches.

               Steps should be in good condition.

               No objects should be leftover or stored on steps. 

               No sharp edges for steps

               Intermittent platforms if possible

                        Kitchen:

 

               Items and wardrobes should be easily reachable without unnecessary bending.

               Arrange a step stool to climb if necessary

 

Bathroom:    

           

               Grab bars for tub, shower and toilet

               Non skid rubber mat in tub,

               Raised toilet seat.

               Door locks removed to ensure access in emergency.

               Shower chair with handled shower

               Non-Skid flooring.

Yard and entrances:

 

               Repair of cracks in pavement and holes in lawn

               Removal of rocks, tools and other tripping hazards.

Foot wears:

               Shoes with firm, non skid, highly frictional soles

 

               Low heels

               Avoid loose slippers

Additional:

                  Bed at proper height

                  Spills on floor cleaned up promptly

                  Appropriate use of walking aids and wheel chairs by the needy.

 

2. Reduction of obesity:

a) Dietary Guidelines: –

           

            Keeping in concern coronary artery disease, it is advisable to follow few dietary guidelines to have a controlled body weight. They are: –

 

Ø  Reduce total fat from 42% – 30% of total calories

Ø  Increase polyunsaturated fats in diet.

Ø  Reduce content of saturated fat in diet

Ø  Reduce cholesterol to 300 mg/dl daily

Ø  Reduce salt intake to 12 – 16 gms to 5gm/ daily

Ø  Avoiding unnecessary fats in diet like chips, deeply fried curries, consuming more meat etc.

 

b) Walking, static cycling and swimming also help in reducing excess of weight.

 

3. Periodic medical check – Up:

 

Routine Health check ups: –

 

Ø  Yearly physical examination, urine analysis, stool test for occult blood.

 

Ø  Yearly visual examination.

 

Ø  Yearly audimetry, if hearing ability is at risk.

 

Ø  Yearly mammogram

 

Ø  Testicular and prostrate examination.

 

4. Prevention of Accident:

           

Ø  Consider and give additional care to prevent injury to muscles, bones and other body parts, which have grown fragile with age.

Ø  External appliances like spectacles, hearing aids, walking aids etc, should be used by the needy to prevent road traffic accidents.

Ø  Use devices of safe guard like slippers with good grips, hand grippers, side rails, at place of need to avoid accidental falls in home or place of residence.

Ø  Special care must be taken when working with fire incase of patients with forget fullness or decreased memory.

Ø  Do not use orthotic devices while driving.

Ø  Follow traffic rules to reduce the risk of accidents.

Ø  Assistance can be taken from the other pedestrians while crossing roads.

 

5.  Safety:

 

Ø  It is wise to look and walk care fully as there are increased chances of falling due to limited vision, diminished reflexes, brittle bones and muscle weakness.

Ø  In driving, always follow the principle of  Safety first, speed next”.

Ø  Proper and warm clothing in winter seasons to over come hypothermia.

Ø  Keep floor dry to the possible extent to prevent slipping.

Ø  Check the working condition of external appliance, if any to avoid injuries in case of any damage to them.

Ø  Medications and analgesics should be taken strictly following the prescription to minimize side affects and to prevent adverse affects.

 

III. Efficient geriatric:

 

1. General physical fitness:

 

Ø  Regular exercise, maintenance of personal hygiene and proper diet help to have good physical fitness of the body.

Ø  Endurance exercises can be given at a slow rate.

Ø  Games like golf serve the purpose of recreation as well as walking.

Ø  But competitive games should be never preferred, as they might be more strenuous.

 

            2. Education about the disease:

                It includes:

A.    Early diagnosis

B.     Prompt treatment        

 

A.           Early Diagnosis: –

 

Ø   Education about common diseases of elderly, their symptoms and signals.

Ø   Posters, booklets and television can provide this education.

Ø   Suspicion of any abnormality should be immediately brought to the notice of their family physician or other family members.

 

B.           Prompt treatment: –

 

Ø   Certain diseases of elderly like stroke, myocardial infarction, coronary occlusions, must be treated promptly.

 

Ø   Situations needing medical emergency should be taken to hospital by ambulance.

 

 

9.1 PHYSICAL THERAPY

 

It is defined as

 

“The use of physical means to reduce pain and to maintain or improve physical function.”

      Physical therapy provides individuals with the opportunity to achieve and maintain the highest level of body functioning possible, in order to remain as independently mobile as their condition will allow.

      The goals of physical therapy focus on maintaining, improving (or) restoring functions of the neuromusculoskeletal, pulmonary, and cardiovascular systems through physical procedures of intervention.

 

Specific Objectives of Physical Therapy:

1.                   To Provide active and passive exercises for increasing strength, endurance, coordination and range of motion.

2.                   Facilitating activities of daily living.

3.                   Stimulating motor activity and learning.

4.                   Applying physical agents for relief pain and to alter physiological status.

5.                   To improve cardio respiratory functions.

 

Scope of Physical Rehabilitation of the Elderly:

      Provision of a continuum of care right from beginning with prevention, through screening in the community, crisis intervention, short-and/ (or) long-term rehabilitation and ending with maintenance in a long-term care situation.

      Emphasis is laid on mobility (i.e. walking, stair climbing, use of devices),
coordination, posture,
and range of motion.  

 

 

The most common problems encountered by Physical Therapist:

q  Disabilities associated with arthritis

q  Amputation

q  Neurological problems

q  Orthopedics.

The physical therapist assists the patient mainly in movement restoration. Physiotherapy in elderly care is broad spectrum, challenging and rewarding.

Tasks of a Physical Therapist:

Evaluation of:

q  Symptoms of presenting complaint

q  Associated problems

q  Pain

q  Joint range of motion

q  Muscle strength

q  Cardio pulmonary status

q  Coordination

q  Balance

q  Gait

q  Posture

q  Assess the patient’s wheel chair need

Teaching:

 

q  Inducing confidence by reassurance.

q  Exercises to maintain and increase joint range, of motion.

q  Balance in sitting and standing.

q  Exercises to increase strength, endurance and coordination for other specific groups (or) the entire body.

 

 

 

Use of various physical therapy modalities:

 

q  Both superficial and deep heat.

q  Hydrotherapy technique

q  Electrical stimulation

q  Traction

q  Massage for pain relief.

q  Home evaluation to make the environment barrier free and accessible.

q  Progressive gait training with or without ambulatory aids.

The environment of treating the patient can be:

q  Acute unit (district general hospital)

q  Long stay units

q  Private nursing home

q  Sheltered housing

q  Old age homes

q  Day center or

 

q  Within the patients own home.

 

An insight of many healthcare professionals and others is required. Technical expertise in a wide variety of physiotherapy skills is necessary in order to maximize function.  Analytical skills are necessary to determine that individual goals are being achieved. Humanitarian skills are essential to enable the physiotherapist to decide when to treat, chat, listen or leave in peace.

Care of the Dying:

It requires an understanding of how a human comfort is obtained, e.g. passive movements including trunk turning, positioning in bed or chair, warmth, attention and eye to eye contact are important for the patient’s sense of well being. Communication may be by touch.

 

Mobility at Home:

Improving of mobility at home requires common sense and some determination to maximize the benefits of other professionals, e.g. the patient who cannot walk because of pain from in growing toe nails requires the chiropodist urgently.

q  Elderly fitness groups can be run by physiotherapist so that people are fitter longer and less dependent on family, friends (or) state.

q  Group therapy, music therapy and orientation therapy (identifying time of day, weather conditions) are important activities in day centers (or) day hospitals.

q  The physiotherapist may encourage horticulture therapy.

q  Any thing that brings smile to the face is important and laughter is one of the best forms of exercise (laughter is the best medicine).

q  The greatest fears of growing old, expressed by those who see the disabled elderly are loss of independence, self- esteem and dignity. There fore, it is important for the physiotherapist to take this into account by according respect and ensuring dignity. They should be cared for with courtesy and consideration.

q  Elderly care physiotherapy is, therefore, for the imaginative, caring physiotherapist.

 

Chest Physiotherapy:

Breathing Exercises:

q  These exercises are designed to retrain the muscles of respiration, improve ventilation, lessen the work of breathing, and improve gas exchange and oxygenation. 

q  Breathing exercises are only part of a treatment programme designed to improve the pulmonary status and improve the patients over all endurance and function in daily living activities.

Diaphragmatic Breathing:

q  It induces relaxed and controlled pattern of breathing.

q  The patient can be taught breathing control by correct use of diaphragm and relaxation of accessory muscles.

q  Diaphragmatic breathing exercises not only improve the efficiency of ventilation and decrease the work of breathing but also mobilize lung secretions during postural drainage.

 

             Localized Chest Expansion:

                     

q  These are useful for assisting in the removal of secretions and improving movement of the thoracic cage. Individual lobes of the lung are ventilated by these exercises.

Coughing and Huffing:

q  An effective cough is necessary to eliminate respiratory obstructions and keep the lungs clear.

q  It plays an important role in the treatment of patients with prolonged bed rest or immobilization.

Postural Drainage:

q  It is the means of mobilizing the secretions in the lungs to the central airways by placing the patient in various positions so that gravity assists in the drainage process.

q  Postural drainage therapy also includes the use of manual
techniques such as percussion and vibration, as well as voluntary coughing.

 

 

 

Note:

In the elderly patients, if the intercostals are found weak, coughing becomes less powerful and postural drainage plays an effective role to assist clearing secretions. Also there is a risk of cough syncope if the patient has a prolonged bout of coughing.

 

Heat Modalities:

IRR (Infrared radiations):

 

q  Relieves pain and muscle spasm.

q  Promotes superficial healing and repair.

q  Promotes tissue flexibility and reduces stiffness.

q  Increases the vascularity of the skin.

q  Promotes resolution of chronic inflammatory states.

q  Induces sedative effect.

q  Induces psychosomatic effects (a feeling of well being when the body surface is warmed).

 

Paraffin wax bath:

 

q  The temperature ranges from 420-520 C.

q  The temperature is often at a higher range for hands and rather lower for the feet.

Hydro collator packs:

 

q  These consist of a silicate gel, such as Betonite, enclosed in a cotton fabric container.

q  This gel absorbs large quantities of water which, if hot provides a considerable store of energy.

q  The temperature ranges from 420-440 C.

 

 

 

 

 

Activities and exercises:

If you want to know how flabby your brain is, feel your leg muscles”

q  The decline in the muscular function characteristic of the age can be prevented or reduced by physical exercises which not only improves the muscle function and properties but also that of heart.

q  Exercises not only improve the strength and circulation of cardiac muscle but also reduce severity of arteriosclerotic lesions and the incidence of thrombosis and embolism.

E.g. exercises of the leg muscles (peripheral heart) ages the circulation by facilitating the return of blood to the heart against gravity.

 

q  Walking, bicycling, swimming, etc.

q  Exercises should not be too strenuous and rest period should be taken if needed.

q  Rapid breathing and accelerated heartbeat should disappear within a few minutes after exercises.

Exercises should refresh rather than fatigue.

q  If active exercises are not possible, isometric exercises can be implemented to maintain joint mobility and muscle tone.

q  Exercises maintain bone calcification, helps to maintain muscle tone throughout the body.

q  Exercises reduce muscle tension and muscle pain.

q  Regular exercise decreases the risk of cardiovascular disease.

 

Examples of activities for group or individual work:

 

Sitting:

 

q  Sit up straight.

q  Turn head from side to side.

q  Identify five objects at different distances- two to right, one center, two to left.  Look at these as the number is called out, e.g. doorknob 1, window handle 2.

q  Place hands on shoulders, stretch arms up and bend.

q  Place hand on neck-push elbows back.

q  Place hands on shoulders, circle elbows back

q  Swing arms backwards and forwards.

q  Hold rope, push up towards ceiling, and place behind neck-up to ceiling and back to lap.

q  Pass rope from right hand to left behind back (over shoulder or behind waist).

q  Touch right little toe with left thumb or touch right knee outside with left thumb and vice versa.

q  Turn to touch chair back with both hands.

q  Alternate knee straightening and bending.

q  Alternate heel and toe- rising.

q  Stand- up, sit- down.

q  Stand up, turn round, and sit down.

q  One knee straighten-circle the foot-bend the knee-repeat with other leg.

q  Deep breath in -feel air filling around waist- hold-let all air out for 3 times.

q  Pass ball over the head, hand to hand and behind back.

q  Pass ball hand-hand.

q  Pass bean bag round left foot:

o   With right hand

o   With right foot

Repeat with other leg.

q  Pass ball with feet around the group or to different members of the group pass ball by hand round group.

 

Standing:

Feet apart:

q  Bend trunk side to side.

q  Stretch up tall-stretch arms back wards and turning thumbs to point backwards.

q  Weight transference foot to foot with head held high.

Feet in walk standing:

q  Weight transference foot to foot with head held high.

 

Mobility aids or Walking Aids:

q  Mobility aids are appliances used to help people who have difficulty in walking.

q  These mobility aids enable some of the body weight to be supported by the upper limbs and thus build of the stability and thus indirectly the mobility of the person.

 

Walkers:

q  Walkers are devices for ambulatory persons who need more support than a cane provides.

q  Walking frames (or) walkers are more stable than any others walking aids because their bases are quite large and the center of gravity falls with in the base.

    Canes or sticks:

            3 types of canes are in used these days.

        The Standard straight-legged cane.

        The Tripod Cane.

        The quadripod cane.

q  The cane is held on the stronger side of the body to provide maximum support and appropriate body alignment while walking. 

q  The length of the cane should permit the elbow to be slightly flexed. The person with weak upper limb cannot use cane effectively.

Wheel chairs:

q  A wheel chair is not just a ‘chair with wheels’. It is a second “home” to the person since he spends so much time in it.  The wheel chair should be designed for comfort and ease of manipulation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.1 ASSESSMENT OF GERIATRIC PATIENT

 

I) Subjective Information:

 

1. Patients problems/chief complaints

2. History and progression of present symptoms

3. Characters contributing to functional limitations

a)     Elements of life style

b)     Previous level of function

c)     Changes in function that resulted in referral to physical therapy

d)     Family, care givers, home

e)     Environmental factors including barriers that limit patient’s

f)      Ability to function at a prior level or in a prior setting

4. Personality

5. Use of drugs, alcohol, smoking

6. Previous physical illness

7. Previous occupations

8. Hobbies

9. Patien`ts goals with respect to physical therapy intervention

 

II) Objective assessment:

 

A) Chief complaint:

 

¨       Source of symptoms or dys function

¨       Pre disposing factors

¨       Aggrevating factors

¨       Relieving factors

B) Musculoskeletal Considerations:

¨       Joint range of motion

¨       Muscle : Strength

     Status

   Power

Girth

 

¨       Limb length disparity

¨       Funtional status

§      Any musculoskeletal deficits

§      Postural changes

o   Involved structural components

o   Involved functional components

 

c) Performance of functional activities of daily living:

 

¨       Mobility

 

§      Bed Mobility

§      Walking with or with out aids

§      Climbing stairs

 

¨       Transfers

 

§      Bed – Chair

§      Bed – Wheal Chair

§      Standing up and sitting down

§      Floor – Chair

 

D) Gait assessment:

 

¨       Deficits in gait cycle

¨       Critical factors affecting performance

¨       Level of independence

¨       Use of assistive device

¨       Need for orthotic/ prosthetic device

¨       Ability to negotiate a variety of surfaces like

§      Carpeted surfaces

§      Un even terrain

§      Stairs

¨       Status of weight bearing

 

 

¨       Functional parameters of gait

§      Distance ambulated

§      Distance covered per time.

 

E) Cognitive Status:

 

¨       Evaluation of patient’s alertness

¨       Orientation

¨       Mood

¨       Behaviour

¨       Concentration

¨       Self – esteem

 

F) Cardio Pulmonary status:

 

¨       Blood Pressure

¨       Heart Rate

¨       Heart sounds

¨       Pulse

¨       Breath Sound

¨       Respiratory Rate

 

G) Neurological Considerations:

 

¨       Co- Ordination

¨       Balance

¨       Sensation

¨       Relationship of musculoskeletal deficits and neurological deficits

¨       Stereognosis

 

H) Sensory Considerations:

 

¨       Vision

¨       Hearing

¨       Taste

¨       Smell

¨       Touch

Affect of these on geriatric patient’s activity

¨       Pain

o   Origin                 Neurological

                       Musculoskeletal

           Psychological

o   Effect on performance

o   Type

o   Location

o   Extent

 

I) Integumentory System:

¨       State of Skin

                   Nails

                    Hands

                   Teeth

 

J) Performance of activities of daily living:

¨       Self-care:     

Brushing

                                    Washing

                                    Toileting

                                    Bathing

                                    Dressing

                                    Eating and drinking

           

¨       Others activities:

                                    Moving around

                                    Shopping

                                    Chit chatting

                                    Leisure times

                                    Hobbies

                                    Gardening

                                    Household activities

 

Physiotherapists must identify functional restrictions and relate these to the causes.

 

K) Investigations:

 

¨       Urine tests

¨       Blood Cell Count, ESR, Electrolytes, Calcium, and glucose

¨       X- Ray          

¨       CT Scan

 

L) Special Tests:

 

¨       Joint Range

¨       Muscle Strength

¨       Co- Ordination

¨       Cardiovascular functions

¨       Respiratory function

¨       Neurological Tests

o   Sensation

o   Muscle tone

 

M) Special Consideration:

 

1.      Chronological age versus physiological age

o   Level of Activity – Sedentary Vs Active

o   I.Q. assessment

2.      Pharmacological Concerns

o   Evaluate use of prescription

o   Side affects of drugs.

Physiotherapy Management:

 

q  Identification of Problems:

 

q  Goal setting / aims:

o   Short term goals    

o   Long term goals

 

q   Implementation of Physical therapy plan:

 

        Plan should be reasonable with a probability of success

1.      Patient’s goals must be incorporated.

2.      Unreasonable patients expectations must be tempered with appropriate patient education.

3.      Ethical concerns must be addressed in implementation of treatment plan.

4.      Identify precautions and contra indications to physical therapy treatment.

5.      Specific modalities and techniques must be modified in accordance to the normal and pathological age related changes in various body systems.

6.      Identify a reasonable time frame for recovery.

7.      Recommendations should include lifestyle modifications and strategies for prevention of further deficits.

 

q  Monitoring:

 

                  Continuously monitoring and re-assess the patient of his/her associated problems

 

 

 

 

 

q  Evaluation:

 

o   Evaluate the outcome of specific intervention

o   List out and acknowledge the value of mutual experiences for future use.

 

The process of assessment continues through out the patient’s progress from initial contact to final discharge patients must be seen to perform goal. Oriented activities like cooking, dressing, washing etc., progress should be monitored from medical and nursing case to rehabilitation and social care.

 

 

 

           

 

                       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.1 PHYSICAL THERAPY MANAGEMENT OF A PATIENT WITH OSTEOARTHRITIS

 

This case study addresses the course of physical therapy intervention for Mrs. Rajya Lakshmi, a 65-year-old-woman with a diagnosis of Osteoarthritis (OA) of Right Knee .It out lines the physical therapy intervention of Mrs. Rajya Lakshmi who is referred to out-patient physical therapy by her family physician secondary to complaints of Right side knee pain.

 

Subjective Assessment:

 

q  Problem/Chief Complaints:

 

            Intermittent pain in right knee with occasional pain in Left knee.

 

q  History:

 

1.        Pain: -In Right knee for the past fives years, which progressively worsened in the last 5-6months.

2.        Knee swelling: – Occasional.

3.     Aggrevating Factors: –

o   Walking prolonged standing especially on sitting on floor.

o   Pain occasionally awakens her at night.

4.       Relieving factors:- Rest and pain medications.

5.      Ambulation:

o   Has difficulty in walking long distances, going up and down stairs, sitting and getting up from floor.

o   Mrs. Rajya Lakshmi uses no assistance devices for ambulation.

6.      Medications:

            “Nimulid” Tablets whenever she feels pain since the last 5 years.

7.     Associated problems:

o   LBA, parasthesia of lower extremities and neck pain occur following strenuous work.

 

 

o   She is diabetic for the past 8 years

8.     Previous treatment:

 

o   The patient had no therapy or education for her OA in the past.

 

q  Life style:

 

o   Patient lives with her healthy and active husband in a three-story home in ground floor with one bedroom having attached bathroom.

o   The house has an inclined platform to enter in.

o   Water tank is on third floor and she climbs up by taking assistance of rails –to check the tank once in 2-3 days.

o   She is a housewife since from the beginning of her married life.

 

q  Previous level of function:

 

o   She is active is performing household activities, attending to grand children, sharing manual work of relatives, whereas now she feels much difficulty in performing her own self care activities.

o   She spends some time in worship of God daily by sitting on floor and now she reduced her time of sitting on floor.

 

q  Alcohol/Smoking :-  She neither consumes alcohol nor smokes.

 

q  Toileting Activities:

 

o   She uses Indian commit for toileting activities and feels great difficulty in attending to them; and even bursts out into tears because of severe knee pain on right side.

q  Patient’s goals:

 

o   To attend toileting activities without any difficulty, to walk and sleep without knee pain and with out pain medication.

o   To be able to get down on to floor to do her household activities, to be with her grand children.

 

 

Objective Assessment:

 

Physical examination:

 

The patient walked to department accompanied by her husband.

 

q  Personality:

 

                     She is short and thin built.

                     Patient’s weight bearing is greater on left lower extremity.

                     No other associated deformities are noticed.

 

q  Musculo Skeletal Consideration:

 

o   Joint ROM of lower extremity:

 

           

Joint

 

Movement

 

Degrees

Right

Left

1.Hip Joint

 

 

 

2.Knee Joint

 

 

3.Ankle Joint

 

 

 

 

Flexion

Extension

Abduction

Adduction

Flexion

Extension

 

Plantar Flexion

Dorsi Flexion

Inversion

Eversion

 

100

15

35

25

90

5

 

30

15

20

15

 

110

20

40

30

110

5

 

35

20

25

20

 

 

o   Muscle Strength:

                       

Mrs. Rajya Lakshmi’s lower extremity strength measures 5/5 except for right knee extension, which is 3+ with minimal pain and left knee extension which is4+ without pain

 

Ø  No limb length disparity found.

Ø  The patient’s pain is purely dependent on movement.

Ø  Crepitus is noted in Right knee.

Ø  No swelling.

Ø  No tenderness.

q  Functional status:

Ø  All transfers are independent.

Ø  Takes support of side rails or place hands on knees to climb stairs.

Ø  Takes support of near by objects, and bends forward to stand from floor.

Ø  Walks without any aids independently.

 

q  Gait:

 

Ø  Decreased stance time on Right beg than on left leg.

Ø  Decreased right to left step length

Ø  Decreased weight bearing on right leg

 

q  Diagnosis:

 

   Problem list:

 

Ø  Pain in knees.

Ø  Decreased active ROM in knee flexion.

Ø  Decreased strength in knee extension on Right knee.

Ø  Abnormal walking pattern.

Ø  Depressed.

 

q  Summary statement:

                         

Ø  The patient is presented with chronic pain in right knee, secondary to OA.

Ø  This limits the patient’s ability to attend toileting, household activities works on floor, walking long distance and walk up and down stairs.

Ø  Pain interferes with her sleep.

Ø   The patient is unable to manage her knee problems at home because of limited knowledge.

Ø   Rehabilitation potential is good to achieve patient goals.

 

q            Treatment goals:

 

Short-term goals:

 

1.      To provide psychological support.

2.      Decrease right knee pain with ambulation and other non-weight bearing activities.

3.      To attend self care activities with out pain

4.      Perform written home programme with guidance.

 

Long-term goals:

 

1.      To promote confidence in patient

2.      Increase in active ROM of right knee flexion from 900 to 1050 and then to1200

3.      To increase active ROM of left knee flexion from1100-1150

4.      To enable the patient to perform home exercise program independently.

5.      Use of modalities and joint protection techniques.

6.      Patient ascends and descends stairs using step – to pattern when knees are painful.

7.      Preservation of existing ROM at all joints of body.

 

Treatment plan:

 

Examine x-ray film of right knee joint in lateral view and anteroposterior view.  

 

Ø  Narrowing of joint space.

Ø  Marginal osteophyte formation.

 

Implement physical therapy plan for 3-4 weeks.

 

 

Means:

 

1.      Psychological counseling with reassurance and encouragement.

2.      Apply heat modalities to reduce pain

                                                        i.            Hot packs

                                                     ii.            Moist heat by wax bath

                                                   iii.            Continuous ultrasound.

3.      Free exercise for hip, knee and ankles

a)     Hip—In standing with support swing lower limb front and back 

towards and away from body.

b)     Knee—Supine lying

o   Knee flexion and extension.

o   Combined hip and knee flexion and extensio

  High sitting———–swinging legs

                          Standing—————Knee flexion and extension

c)     Ankle and foot——-In supine lying and high sitting

§  Inversion and eversion

§  Plantar and Dorsi flexion

Perform these exercise 3-4 times/day with 10 repetitions each 

time.

 

4.      Gait training on level surface and stairs:

Instructed in use of cane to decrease pain in knees and to avoid gait deviation.

5.      For muscle strengthening:

a) Isometrics for quadriceps

                                                              i.      Place a towel roils under knee with knee extended on a supporting surface. Ask patient to press the towel downwards.

                                                           ii.      Quadriceps table exercise.

6.      Static bicycle:

            Monitor the intensity of exercise by palpating pulse and target heart rate, which should be 60-70% of maximum heart rate.

 

Education for OA and patient’s home management:

 

1.      Joint protection techniques: Use of assistance devices for ambulation to decrease weight-bearing stress on knee.

2.      Exercise programme: Initially 5 days per week for three 20-minute sessions.

 

                        This regime is continued for 2 weeks.

 

Advices:

 

q  Do not squat.

q  Use a suitable height stool for toileting and house hold activities.

q  Avoid prolonged standing and carrying heavy weights.

q  To use western type of commot.

q  Use stools for placing tub or bucket for bathing.

q  No single leg standing

 

Evaluation:

 

q  Pain is reduced.

q  Range of motion slightly increased.

q  Patient is confident and enthusiastic.

q  Able to perform household activities at more ease.

q  Decreased necessity of using meditations for pain relief.

q  Able to attend toileting with out any knee pain.

 

 

 

 

 

11. 2 PHYSICAL THERAPY MANAGEMENT OF A PATIENT WITH MYOCARDIAL INFARCTION

 

 

           This case study addresses the course of physical therapy intervention for MRS. CHINNAMMA a 69year old woman with a diagnosis of myocardial infarction. The initial phase of the case study outlines physical therapy intervention at the time of her admission into a coronary care unit. The next two phases give outline of physical therapy of MRS. CHINNAMMA after her discharge from the hospital.

 

I History:

 

1.Chief complaints:

q  Pain –

o   Chest pain

o   Angina

o   Myocardial infarction pain

o   Ischaemic pain

q  Dyspnoea

q  Fatigue

q  Palpations

q  Dizziness, syncope

q  Edema

 

2.Past medical history:

 

q  Had a previous attack of Myocardial infarction 10 years ago

q  Treated by medical management

q  No surgical intervention was necessitated

 

 

3.Personal history:

Smoking        No

Alcohol          No

Diet                Takes soft and non-spicy diet

4. Level of Activity:

a.      Past level of activity          – Very active in performing house hold

   activities

b.      Present level of activity      A significant decrease in the number of

   work attending

                            

II. Vital signs:

            1.Temparature                    970F

            2.Pulse rate                          60/min

            3.Respiration                       25 / min        

            4.Blood pressure                 150/100

           

III. Diagnostic tests:             

 

1.      ECG: – depressed ST segment

2.      Lab Tests: – LDL

                           HDL

3.      X-ray:-    AP/PA view shows

                        Cardiomegaly

                        Increased Broncho Vascular Markings

 

4.  2D –Echocardiography

                      Concludes

                                    Concentric left ventricular hypertrophy

                                    AV sclerosis (thickened)

                                    Mild aortic regurgitation + Mitral regurgitation

                                    Reduced left ventricular compliance

 

 

Cardiac Rehabilitation:

 

Phase I:-  In – Patient Cardiac Rehabilitation Protocol:

Day 1:

 

            Patient is in coronary care unit

Activity Level

q  Given complete bed rest

q  Exclusive supine lying/slightly elevated head end

q  I.V fluids pethadine morphine

q  Commot in bed

Day 2:

 

q  Same as day one

 

Day 3:

 

            Patient is in coronary care unit

 

Activity level

q  Complete bed rest

q  Brushing

q  Washing hands and face

q  Bedside commot

Day 4:

            Patient is assessed to be stable and so taken to ward

 

Activity level

 

q  Bed rest

q  Complete bed bath

q  Self-feeding

q  Monitored self care

 

 

 

 

Day 5:

 

Activity level:

           

q  Patient is taken for gradual half laying 3times in the entire day.

q  Wheel chair transference to bathroom with help.

q  Made to sit bedside for 30 minutes.

 

Day6:

 

Activity level:

 

q  Monitored ambulation.

q  Made to transfer from bed to chair for 3 times for 30 minutes.

q  Taken bath in bathroom by sitting on a stool and nurse supporting at the back.

q  Patient made to walk in room

Day7:

 

Activity level:

 

q  Patient made to have a small walk in corridor.

q  Shower bathing taken under supervision of nurse.

 

Day8:

 

Activity level:

 

q  Patient taken for a 5-minute walking

q  Patient made to climb up and down 3 steps in morning and 5 steps in evening with control pattern of breathing with a concise explanation and demonstration

           

Day 9:

 

            Low-level exercise tolerance test conducted on tread mill

While conducting this test, care must be taken that the heart rate should not exceed the maximum level.

The maximum heart rate for each age group is given below:

            Age                                         Maximum Heart Rate

1.         20-29 Years                          170 Beats per minute

2.         30-39 Years                         160                

3.         40-49 Years                          150                

4.         50-59 Years                          140                

5.         60-69 Years                          130                          

Report:

            Was normal                        

            Put to discharge

           

Phase II: – Out patient cardiac rehabilitation:

 

Aims:

 

1.      To increase exercise capacity and endurance in a safe and progressive manner.

2.      To continue exercise programs with a transition to home environment.

3.      To teach the patient to apply techniques of self monitoring to home activities.

4.      Relieve anxiety and depression.

5.      Improve patient’s knowledge of arteriosclerosis disease process and explain how personal health habits affect it .

 

Means:

 

1. Counseling and guidance:

           

q  Patient is given reassurance and confidence

q  Precautionary measures regarding heavy work, emotion activities of daily living are given

q  Patient is assured that she soon attains her near normal life

q  Guidance is given regarding modified simple techniques of self-care

2. Cooper’s six-minute walk test:

 

q  Actually this test to done to know the exercise tolerance of the patient.

q  In this case the first phase of the test is done i.e. 3 parts of each 2 minutes duration.

q  In the second two minutes the patient was able to cover only half of the distance she has covered in the first two minutes. So the test to stopped

 

3. Arm Ergometric Exercise

 

            Patient is explained about this exercise.

 

Phase III: – Out patient Cardiac Rehabilitation:

 

Aims:

 

1.      To improve physical fitness.

2.      To improve endurance level.

3.      To produce long-term reduction in coronary risk factors.

4.      To improve patient’s knowledge of her disease process and her role in health maintenance.

5.      Psychological intervention to reduce stress and adjust illness.

6.      To enhance patient’s quality of life.

7.      Advices on dietary management.

 

Means:

 

Home Programmers:      

 

Group activities:

 

As the patient MRS. CHINNAMMA is able together two of her neighbors who are able having a similar history of Myocardial infarction in the past, these people as a group are asked to perform certain exercises. Alterations are advised such that one day she visits a near by park another day market etc such that the places are at increasing distance.

 

Patient is taught about relaxation techniques like yoga & Dyana, which keep the body and mind sound.

                    

Walking

                        Double knee bending

                        Side flexion

                        Forward bending with breathing out

                        Shoulder bracing

                        Shoulder mobilization exercise

                        Chest mobilization exercise

Arm ergo metric exercises

 

 

Stair climbing:

           

q  Patient is asked to climb 10 steps up and down.

q  Improvement is made b increasing 2 steps per week.

 

 

Dietary management:

 

q  Patient is advised to taken low sodium content salt.

q  She is recommended to use less amount of salts and sugars.

q  Inclusion of plenty of fresh green leafy vegetables is a must above all these, the patient is advised to take small qualities of food 3-4 times a day.

 

 

 

 

 

 

 

 

Exercises for Arms

(Fig 11.1)

5armexer

 

 

 

    Wing Standing

6exerleg 

 

 

 

 

 

 

 

 

Bend standing

 

       Yard Standing

 

       Low wing Standing

 

Reach standing

       Stretch Standing

Exercises for Legs and Trunk

Fig.11.2

                                   


Lax stoop standing

 

 

Stoop Standing

 

 

 

Lunge Sideways Standing

 

 

 

Fallout standing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exercises for Spine

(Fig 11.3)

7spine

Crook Lying

 

 


Crook Lying With Pelvis Lifted

 

 

Forearm Support Prone Lying

           

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