5. Osteopathic Considerations for Geriatrics Flashcards
What are 3 osteopathic considerations for geriatric patients?
- Decreased ability to self-heal (d/t reduction of physiologic reserve and many comorbid conditions)
- Consider risk vs benefit (higher risk of SE and shorter life expectancy)
- 3. Give individualized care
Goals with Geriatric Patients in OMT
- Optimize function (to allow to walk, do daily activities)
- Avoid institutionalization (80% prefer to diet at home)
- Maintain sense of community
Treating geriatrics should be done in what positions?
1. Seated
2. Supine at 45 degrees
5 Model Approach in Geriatrics
- Neurological
- Metabolic-Energetic-Immune
- Circulatory/Respiratory
- Neuological: fall-risk assessment
- MEI: lymphatics (thoracic inlet)
- C/R: Parasympathetic/sympathetic
5 Model Approach in Geriatrics
- Biomechanical
- Behavioral
-
Biomechanical
- Improve function
- Gentle modified techniques
- Less position change
- Behavorial
How do we perform a fall-risk assessment?
- Get up and go test tests static and dynamic balance.
- Steps:
- Stand up
- Walk 3 meters
- Turn around and walk back
- Sit back down
- > 12 seconds = increase fall risk
Deconditioning gait changes in elderly
- Waddling gait (pelvis weakness)
Mechanical changes in low back/pelvis/LE => gait changes in elderly
- Antalgic gait (to avoid pain)
Neurological problems that cause gait changes in elderly
- Hemiparetic gait (post stroke)
- Steppage gait (foot drop)
- Shuffling gait (Parkinson)
How can we modify techniques for geriatric patients
- Use indirect techniques, instead of direct.
- Switch activating forces (BLT, FPR, CS)
- Avoid changes in positions bc many pts cannot lay flat or prone
- Limit amount of treatments bc they have poor reserve for compensation
Geriatric pt has a F RrSr direct barrier. How would we treat?
E RlSl Indirect barrier
Lymphatic in Geriatric patient
-
1. Seated thoracic inlet release MFR (direct/indirect barrier)
- Target deep fascia by putting thumbs posterior to 1st rib, 2 or 3 around clavicle.
- Check barriers
- Engage fascia
- Use activating force
- Follow until tissue creeps
- Reasses
How do we address sympathetics in geriatrics?
-
Seated Rib Raising ART
- Have pt drape arms over shoulder to support weight
- Doc place arms at angle of ribs
- Pull rib angles outward, while extending thoracic spin by elevating arms as you move up and down spin.
- Reassess
Watch for _______ when using seated rib raising ART in geriatrics
Age-related kyphosis and scoliosis
How do we address parasympathetics in geriatrics?
Treat OA with Stills (ex. E RlSr)
- Place index finger on right basiocciput to monitor OA
- Put in indirect barrier: Use the head to gently extend, Rl, Sr (Rotation and side bending is usually about 5-7 degrees)
- Compress until you feel softening at your index finger
- Take into direct barrier: Then gently flex, rotate left, side bend right into the direct barrier (gently without adding motion into C1)
- Reasses
Biomechanical:
- Decreased height => ____
- Decreased lean body mass => ______
- ↓ height => ↑ kyphosis
- ↑ lean body mass => change in pharmacokinetics
Common biochemical Dx in geriatrics
- OA (osteoarthritis)
Biochemical/MSK PE for geriatric pt for OA
- Eval gait and assess posture.
- ROM for UE/LR.
- Evaluate feet for ulcers/nail care.
- OSE of muscles and joints for SD
OA sx
- Gradual onset of joint pain, stiffness and limitation of motion that affects [hands, feet, knees and hip]
- Increase morbidity => LE disability.
When/who is OA most common in?
Increases with age; Women: rapidly increases >50 YO
Commonly presenting for OA
- Pain in 1 joint => multiple joints
- Deep ache with use
- Joint stiffness after inactivity (just waking up or sitting)
- Night pain, making it hard to sleep
OA treatment
- PAIN RELIEF (WL, walking aids, topical/oral anagelgics, OMT, intra-articular injections, orthopedic intervention)
- PREVENTION
- Multidisciplineary apprach: PCP, rheum, pyshcait, orthopedist, diettisi
According to research, how did OMT help a group of 29 geriatric patients with arthritis of the shoulder.
What technique did they perform?
Spencer technique
Over the course of the tx: both control and OMT groups have ↑ ROM and ↓ pain.
After treatment: ROM in OMT patients continued improve, while ROM in placebo in group ↓
What can go under “neurological” in the 5 factor model as a DDx for when we age ?
- Increased postural instability => falls and accidents
- Alterered gait => falls and accidents
Neurological PE for Geriatric Patient
- Reflexes
- Observe for asymmetrical test results (coud mean stroke)
- MMS exam to evaluate for cognition
What reflex may be absent in geriatric patients?
Ankle reflex
Parkinsons DZ
- Gender
- Age
- RF
- M
- Adults >40 YO
- Older age, FHx; smoking may be protective
Parkinsons PE
- Pill rolling tremor
- Bradykinesia
- Cogwheel rigidity
- Postural instability
- Shuffling gait
Parkinson Disease Tx and non pharm
- Levodopa
- Amantidine
- MAO-B inhibitors
- Anticholinergics
Eduation, emotional/psych support, exercise, PT/OT/Speech therapy, OMM
“Standard OMT acutely improves ________ in patients with Parkinson’s disease
Gait performance: ↑ stride length, cadence and max velocity of UE/LE
CV changes during aging (3)
- Calcification and stenosis => HTN
- Decreased elasticity of arteries
- Decreased baroreceptor reflex => orthostatic HTN
As we age, how do the following clinically manifest?
- Decreased costal cartilage
- Decreased alveolar surface area
- Decresed respiratory muscle strength
- Decreased costal cartilage => decreased clearance of secretions
- Decreased alveolar surface area => decreased maximum breathing capacity
- Decresed respiratory muscle strength => decreased maximum breathing capacity
- Hypertension Increases your chance of:
- Major risk factor for HTN
- MT, stroke, HF
- Kidney disease
Effect of OMT on autonomic tone as seen with changes in BP and activity of the fibrinolytic system
Cervical and thoracic ST
- < BP (by at least 3mm HG
- ↓ hemoconcentration and fibrinogen concentration
- ↑ fibrinolytic activity
Most common infectious cause of death _____
pneumonia
__________ in the elderly = 9-fold increased risk of death from pneumonia
– _____________ shortens length of hospital stay
- Immobility in the elderly => 9fold increased risk of death from pneumonia
- out of bed for 20 minutes
3 trials have shown that OMT has was affect on pneumonia?
OMT + standard ABX => decreases hospital stay; decreased mortality in OMT group compared to light touch/no touch + ABX
Metabolic/Energetic/Immune as we age
- Decreased gastric HCl production =>
- Colonic motility diminished =>
- Decreased calcium absorption =>
- Decreased hepatic biotransformation =>
- Decreased gastric HCl production => Altered digestion and drug absorption
- Colonic motility diminished => Constipation
- Decreased calcium absorption => Osteoporosis
- Decreased hepatic biotransformation => altered pharmakinetics
Metabolic/Energetic/Immune as we age
- Decreased renal mass =>
- Decreased renal blood flow
- Decreased bladder capacity =>
- Decreased renal mass => Alteration of drug pharmacokinetics
- Decreased renal blood flow
- Decreased bladder capacity => Urinary incontinence
M-E-I Diagnoses in Aging Population
- Constipation
- Increased susceptibility to infection
M-E-I PE in geriatric pt
- Inspect for inflammation
- Realize Sx may be absent or atypical
- Altered febrile response in some elderly frail ppl
Temperature
For healthy, community dwelling older adults: ______
For frail older adults:_______ single oral temp OR______ above baseline temp
Temperature
For healthy, community dwelling older adults: >38°C (100.4°F)
For frail older adults: >37.8°C (100°F) single oral temp OR >1.1°C (2°F) above baseline temp
Overuse of ABX causes what?
increases risk of resistance to C.Diff
Goal of OMT in elderly patient who an infection
- Remove impediments to lymphatic flow
- Mobilize lymph from congested tissue
• 8 patients with LE wounds (venous stasis ulcers) and edema were given what types of OMT. What were the ressults
-
Lymphatic OMT: thoracic inlet MFR, doming the diaphragm, pelvic diaphragm release, popliteal release and pedal pump for 10 minutes 2x/week
1. Surfac area of the wound and mean leg volume decreased during intervention phase
2. May have reduced edema and reversed trend of wound growth in patients with venous stasis ulcers.
Constipation occurs in 74% of nursing home residents due to daily laxative use.
PE?
OS Findings?
PE:
- History taking: onset and duration important
- Check for alarm symptoms (Hematochezia, + FOBT, WL, FHx colon cancer or IBS)
- Abdominal exam
- Rectal exam
- Colonoscopy indicated if alarm symptoms noted
OS Findings
- Visceromatic changes in T10-L2 => paraspinal TTA or SD
- Chapmans reflexes
What chapmans reflexes may be found in Constipation?
Anterior: antero-lateral thigh, along IT band
Posterior: L2-L4 TP extending laterally to iliac crests
OMT treatment for Constipation
- Increase colonic release
- NLize autnomic system
6 participants w/ chronic constipation were treated 6 times over a 4 week.
OMT was directed at ______________.
– All participants: _______
– Additional techniques used as appropriate: HVLA, ME, abdominal diaphragm release
Results?
thoracolumbar spine and abdomen
All participants were given ST, MFR, CS, mesenteric release
Statistically significant improvement across all three domains
Fall risk is a major factor in loss of independence.
Falls are the leading cause of injury among older adults in the United States
– increases in _____
– greater use of ____
– decline of______
– increases in nursing home placement
– greater use of medical services
– decline of functional status
All older persons who report a single fall should be observed as they:
- Stand from sitting WO using arms for support
- Walk seeral paces, turn and return to chair
- Sit back in the chair WO using arms
On the geriatric depression scale, what score = probable depression
>5/15
Mini-Mental State Exam
- Maximum score: ____
- Mild impairment: _____
- Moderate impairment: ____
- Severe impairment: ___
- Maximum score: 30
- Mild impairment: 21-29
- Moderate impairment: 10-20
- Severe impairment: < 9
In treating depression , ________ found a significant, clinically moderate to large beneficial effect
psychotherapy
what meds are the best for depression
SSRIs = better tolerated, ease of use, safety
Adjunctive OMT (+Paxil) in Women with Depression: what were the results
2 groups
OMT + paxil; OSE (placebo) + paxil => treated on individial Dx.
Results:
On the Zung Depression Scale, ALL OMT groups reverted to NL range by week 8; 70% of patients in control group = still had signs of moderate depression.
What should you consider in OMT with a patient with depression
- Treat SD/somatic complaints that are part of the atypical presentation of depression (Chronic pain (esp. LBP) often seen)
- Balance ANS (evaluation and treat OA/AA & sacrum)
- Cranial manipulation can work in depression & anxiety
LAte life depression is difficult to detect and causes what?
Atypical presentation
- Increased somatic complaints
- Cognitive change (pseudodementia)
- Sleep problems, fatigue, low energy
FPR Steps
- Dx
- Neutralize the sagittal plane (lordosis/ kyphosis)
- Place in indirect postion => add a faciltate force for 5 seconds and release
- (compression/ torsion/**traction)
- Release => peturn to neutral
Passive and non-repetitive
Stills Techniq
Patient = passive throughout all procedures (indirect => direct)
- Dx
- Put in indirect position (position of ease), while monitoring, slightly exaggerating position
- + Traction or compression (<5 lbs of pressure)
-
Put in direct: While maintaining force: => neutral position => RB (direct position)
- Force and motion will often mobilize the joint, may hear a “pop” or “click”
- Release force and go to neutral
BLT
- Position all the structures in “shifted neutral” position in all planes (position of ease)
-
Add activating force - breathing until air hungry
- tissue softening may be palpable
- Rechck motion in all planes; repeat until desires result
