Geriatric Rehabilitation

Geriatric Rehabilitation
“Speaking generally,
all parts of the body which have function,
if used in moderation
and exercised in labors to which each is accustomed,
become healthy and well developed and age slowly.
But, if left unused and left idle,
they become liable to disease,
defective in growth and age quickly.”
 Geriatrics
Geriatrics
• A branch of gerontology and medicine
which deals with the clinical,
rehabilitative (remedial), psycho-social
and preventive aspects of illness in
elderly people.

Gerontology
• The scientific approach to all aspects of
aging (health, sociological, economic,
behavioural, environmental)
History of Geriatric
Medicine
• Term “Geriatrics”: Coined by
American physician Dr Nascher in
1907
• Pioneer of Geriatric Medicine: Dr
Marjory Warren (West Middlesex
Hospital, UK) in 1935. She practiced
comprehensive geriatric assessment
and rehabilitation
 Aims of Geriatric
Rehabilitation
• Maintenance of health in old age by
high level of engagement and
avoidance of diseases.
• Early detection and appropriate
treatment of diseases.
• Maintenance of maximum
independence consistent with
irreversible disease and disability.
• Sympathetic care and support during
 Important Concepts in
Aged Care
• To keep the elderly in their own homes for
as long as possible with appropriate
support for themselves and their
caregivers.
• To provide appropriate continuity of care
from the acute hospital setting through to
the community setting.
• To develop a wide range of options
providing help and support to the elderly.
• To increase links between those services
involved in care for the aged and
disabled.
Special Characteristics of
Diseases in Old Age
• Senescence
• Impaired homeostasis
• Atypical features
• Non-specific presentation
• Multiple pathology
• Multiple etiological factors
• Unreported illnesses
 Modified
Manifestations
• Atypical
• Non-specific
• Insidious Onset
• Silent existence
• Missed diagnoses
 The Giants of
Geriatrics
The Big Three ‘I’s
•Intellectual failure
•Instability and immobility
•Incontinence
 Geriatric
Assessment
• Medical
• Mental: AMT (Abbreviated Mental
Test), MMSE (Mini-Mental State
Exam)
• Functional: ADL (Activities of
Daily Living), IADL (Instrumental
ADL)
• Social
 The Multi-disciplinary
Geriatric• Supporting
• Core Members:
Team Members:
– Geriatrician – Podiatrist
– Nurse (+NS, CNS) – Speech Therapist
– Social Worker – Dietitian
– Prosthetic &
– Occupational
orthotic specialist
Therapist
– Psychogeriatrician
– Physiotherapist
– Clinical psychologist
– Volunteer
• By Consultation:
– Pastoral care
– All subspecialties of
medicine
– Other specialties
 Hospital-based
Geriatric Services
• Acute care
• Assessment
• Rehabilitation
• Continuity care (long stay care)
• Respite care
• Geriatric Day Hospital
• Specialist clinic
• Domiciliary visits
 Community-based
Geriatric Services
• District-based Assessment/ Rehabilitation
Teams:
– CGAT (Community Geriatric Assessment
Teams)
– PGT (Psycho-geriatric Teams)
• CNS (Community Nursing Service)
• CPNS (Community Psychiatric Nursing Service)
• CPT/COT (Community PT/OT)
 Community Support
• HOME HELP Services
• DAY CARE CENTRES
SERVICE • ELDERLY HEALTH
CENTRES
– Integrated Home
• VISITING HEALTH
Care Service TEAMS
• MEALS SERVICES • HEALTH VISITS
– Meals-on-wheels • Other Visiting
Services
– Canteen service
– Welfare agencies
• SOCIAL CENTRES – Volunteer groups
FOR THE ELDERLY – Telephone hot
• HOLIDAY CENTRES line
• SOCIAL
NETWORKING:
– Social Welfare
Prevention of the Dysfunctional Syndrome: Conceptual Model

Functional Older Person

Acute Illness,
Possible Impairment

Hospitalization

Depressed Mood
Negative Expectations ARC Unit

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

Improved Mood Decreased Iatrogenic

Reduced Impairment
Positive Expectations Risk Factors

Functional Older Person

Conceptual Model of the Dysfunctional
Syndrome
Functional Older Person

Acute Illness
Possible Impairment

Hospitalization
Hostile Environment
Hostile Environment
Depersonalization
Depersonalization
Bed Rest
Rest
Starvation
Starvation
Medicines
Medicines
Procedures
Procedures

Depressed Mood Physical

Negative Impairment
Expectations

Dysfunctional Older Person

 Improving Care of Patients with Chronic
Illness:
The Wagner Model
• Chronic Care takes place in 3 galaxies:
• Community
• Health Care System and Payment Structure
• Provider Organization; clinic, loose network of
providers
• Six Essential Elements
• Community Resources and Policies
• Healthcare organization
• Self-Management Support
• Delivery System Design
• Decision Support
• Clinical Information Systems
 Wagner’s Chronic Care Model

Community
Resources Health System
and Policies Organization of Health Care
Self- Decision Delivery Clinical
Management Support System Information
Support Design Systems

Productive Prepared,
Informed,
Interactions Proactive
Activated
Patient Practice Team

Improved Functional and Clinical Outcomes

 The Nature of Chronic Conditions
Requires a New Mind-set
Public Primary Acute Long­term
Health Care Care Care

Health Condition Onset
Capacity Accelerated Normal
Progressive Conditions
Loss of Health Reserves Aging

Disability
Complex care management
Acute Event
Time Death
• Obesity • Hypertension • Hip fracture • Incontinence
Risk • Tobacco and • Rapid weight • Stroke • Confusion
   alcohol    gain/loss • CHF • Caregiver burnout
Factors • Pollution • Hyperglycemia • COPD • ADL/IADL decline
Interrelated needs require ongoing, coordinated care interventions .
 Successful aging
• A process by which deleterious effects of aging
are minimized, preserving function until
senescence makes continued life impossible

• To be distinguished from usual aging

(characterized by accumulation of diseases and
impairments of the elderly)
 Stages of Development
• Infancy- Consistency of caregivers → trust and
hope.
• Early Childhood- Self-regulation, autonomy,
control of external events → sense of self-control;
developing willpower
• Play Age Childhood- Initiation of events → sense
of gender identity, direction and purpose
• Primary School Age Childhood- Sense of
industry, productivity, competence → sense of
self-worth.
• Adolescence- Transformation of body → sense of
a distinctive self-identity
 Stages of Development
• Young Adulthood- Previously learned values &
skills are focused to meet goals related to
intimacy & vocation.
• Middle Adulthood- Productivity, caretaking,
generativity
• Older Adulthood- Successes & failures from
previous stages are accepted, integrated. The
individual has achieved a sense of life's meaning;
accepts the meaning of death as a part of the life
cycle.
 Principles of Rehabilitation in Aging
ARNDT-SCHULZ PRINCIPLE
• The application of---------
b. Subthreshold stimulus → no change in the system
c. Suprathreshold stimulus → increased physiologic function of
system
d. Supramaximal stimulus → reduces function causes damages
• Application to the aging individual:
– Suprathreshold increases with age - more stimulus required
to produce a response.
– When suprathreshold is reached the response is more volatile
with increasing age.
– Peak response is less in elders and usually requires less
stimulus than in youth.
– A stimulus within the suprathreshold range for younger
patients may be a subthreshold of supramaximal stimulus for
elders.
– The suprathreshold range in elders is considerably narrower
than in younger individuals.
 Principles of Rehabilitation in Aging
LAW OF INITIAL VALUES
• A/c to this law, with a given intensity of stimulation; the
degree of change produced tends to be greater when the
initial level of that variable is low; and that the higher
the initial value, smaller will be the change produced.
• In younger individuals, biorhythms are relatively well
coordinated, and thus, a particular stimulus is likely to
produce a relatively consistent response when time of
day/month/season is held constant
• In older individuals, biorhythms are less well
coordinated; the elder’s response to a given stimulus is
less predictable than for youth
• Even though variability is greater among elders,
patterns of low and high responsivity are still usually
identifiable. Effort should be made to identify optimal
times for activities and individualize the schedule for
each individual.
 DEMENTIA – TREATMENT
Problem management – to manage behavior problems

- be concrete with patient -don‘t - use sedative as needed

provide choices
- Avoid decision-making tasks
- avoid anxiety-producing
situations
- do not expect too much
- do not over-stimulate
- do not permit fatigue
- limit intake of stimulants/
coffee
- provide ample fluid & high
fiber diet
- have an element of danger
(cooking)
- do not initiate hearing
aid
- don't change from
bifocal to trifocal
- do not take patient on
vacation to strange
places
- play golden oldies
- sew name/address labels
into clothing
- keep doors locked and
windows secure
 DEMENTIA – TREATMENT
Problem management – Environmental/Behavioral treatments
• Environmental/Behavioral treatments attempt to reduce
contextual demands on the patient so that problem behaviors are
prevented and negative consequences are reduced.
• Implement-
― structured routines
― appropriate socialization and recreation
― reassurance and comfort
― Reality Orientation: consistent, repetitive cueing individually
and in group about person, time, place, environmental events
• encourages patient to rehearse
• Use memory books charts and calendars
Not recommended for many middle and later stages because it is
ineffective and is a stressor – increasing agitation
 Intelligence Rehabilitation
Clock Drawing Test

Normal

Mild
Cognitive
Impairment
Moderate
Cognitive
Impairment
Severe
Cognitive
Impairment
 Intelligence Rehabilitation
Intelligence
Fluid intelligence:
complex relations; short-term
memory; abstract reasoning
memory span, inductive reasoning,
figural relations
probably more dependent on the
person's biology than crystallized
not as dependent on instruction
ability to perceive complex relations
ability to use short-term memory
ability to perform abstract
reasoning
this sort of intelligence is thought to
decline most with age
Crystallized intelligence:
thought to be dependent on social
and cultural learning
is one's ability to understand one's
cultural heritage
measured by number facility, verbal
comprehension, general info.
dependent on openness to new
learning, amount of learning, extent
of formal learning opportunities
will continue to grow throughout life
in many individuals
Intelligence Rehabilitation
Memory enhancement techniques

–attention/awareness
–self-instruction
–controlling the physical environment
–tagging
–organization/chunking
–stress reduction (exception: flashbulb memory)
–logging
–imagery for stress reduction
 Aging Rehabilitation :Nutrition
• Energy: decrease with age; nutrient density
• Protein: remain constant: watch intake
• CHO/fiber: constipation
• Fat
• Water
• Vitamin D
• B6: immune function
• B12: atrophic gastritis
 Aging: Drug & Nutrient
Interactions
• Consult Clinicians
• No. of Meds/ Doses of drugs
• Long term therapy
• Nutritional status
• Body composition & functional changes
• Compliance of individual
• alter food intake: effect appetite

• reduce absorption of nutrients

• alter metabolism/excretion of nutrients

 Nutrition & Aging Brain
• Neurotransmitters:
send/receives messages
chemical agent
released by neuron to act on neurons...
made by nutrients
precursors = amino acids; requires Vitamins /Minerals
 Nutrition & Aging Brain
• Nutrients involved in neurotransmitters:
B6 B12 Folate Vit C

• Nutrients for Normal Function:

Iodine Fe Cu Zn

• Protein
 Nutrition & Aging Brain
• Memory B12, Vit C
• Problem Solving Riboflavin, folate, B12
Vit C
• Dementia Thiamin, Niacin, Zn
• Cognition Folate, B6, B12, Fe
• Degeneration of B6
Brain Tissue
 Nutrition & Aging Brain
Treating Depression
• Complex and multifaceted approach
involving:
– Cognitive therapy
– Behavioral/functional interventions
– Emotional/social treatment
– Pharmacotherapy
– Electroconvulsive therapy (ECT)