Aging with Disabilities Flashcards
What is Ageism? 3 myths that go along with it:
“Ageism”-negatively biased perceptions of older people by younger population in today’s youth-oriented society
Many myths surround aging
“Getting older means being ill”
“Older people are less physically and mentally active”
“Older people have a poorer quality of life”
Epidemiology of aging:
- at turn of century 1 of every ____ individuals was 65 years or older
- By 1994, this increased to 1 out of _____ americans
- Current projections indicate what for 2030?
At the turn of the century 1 of every 25 individuals (4%) was 65 years of age or older
By 1994, this had increased to 1 out of 8 Americans (12.6% or 33.2 million)
Current projections indicate that 80 million or 1 out of 5 Americans will be 65 years or older by 2030 with most growth between 2010 and 2030 creating the “elder boom
Distribution of the elderly is uneven across the US with 50% living in 9 states:
- ____ has greatest number of people older than 65.
- _____ has largest proportion of elderly
- Estimated ethnic trends by 2050?
Distribution of the elderly is uneven across the US with 50% living in nine states
California has the greatest number of people older than 65 but Florida has the largest proportion of elderly (18.6%)
Estimated ethnic trends by 2050 with decrease of whites to 67% with increase of older Hispanic (16%) and African Americans (10%)
The rate of growth of elderly appears to be greatest in developing countries
Longevity continues to improve with average age of ____ years for Americans. Why?
Longevity continues to improve with average age of 78.7 years for Americans
Delayed occurrence of death due to delay in onset and reduced lethality of diseases such as stroke, cancer, and MI
More individuals surviving with larger number of people living with disabilities
What is primary and secodary aging
Primary aging
Universal changes with aging independent of disease and environmental effects
Secondary aging
Includes lifestyle and environmental consequences and disease as part of the aging syndrome
7 “general” changes in physiology of aging
- Decreased reserve capacity of organ systems, which is apparent only during periods of exertion or stress
- Decreased internal homeostatic control (blunting of the thermoregulatory systems, decline in baroreceptor sensitivity)
- Decreased ability to adapt in response to different environments (hypo or hyperthermia)
- Decreased capacity to respond to stress (exertion, fever, anemia)
- Variation between healthy people of the same age is far greater than the variation that is due to aging alone
- Difficult to determine if age decrements are linear over the entire age span or whether the rate of decline accelerates in later years
- There is variation in the rate of decline of the various organ systems
Hematologic physiology of aging:
- It is NOT normal for:
- Most common causes for anemia in the elderly
- Discuss Sed Rate/CRP:
- Functional changes related to anemia include: (3)
- Medication issues:
Hematologic System
1. It is NOT normal consequence of aging to have a Hgb
Physiology of normal aging: GI
- ____ may occur.
- Increased risk of (4)
- Decreased ____ contraction
GI system
Presbyesophagus may occur
Increased risk of hemorrhoids
Increased risk of gallstones
Increased risk of aspiration due to less coordinated swallowing
Decreased smooth muscle contraction which may lead to constipation and retained stool in the rectum
Fecal incontinence usually seen as a result of bowel impaction
Increased risk of colon CA
Normal physiology of aging: Renal: 1. 3 changes occur over time 2. Can lead to (2) 3. \_\_\_\_ may occur leading to hypernatremia 4. \_\_\_\_ also poorly tolerated: sequelae
Renal System
Decrease in renal mass, number and functioning of glomeruli and tubules, renal blood flow and GFR which have major implications for drug excretion with prolonged half lives of many meds
Can lead to electrolyte imbalances and fluid balance and caution must be taken with rehydration as to not cause large volume expansion leading to CHF
Caution must be used in the use of contrast dyes due to risk of kidney injury
Blunted thirst mechanism is often times seen in the elderly which may lead to hypernatremia
Hyponatremia also poorly tolerated with noted confusion, lethargy, anorexia and weakness
Physiology of normal aging: Pulm
- _(3_declines with age even without pathology
- Progressive _____ imbalance. due to:
- Discuss pO2 in different positions
- Max ____ consumption decreases with age: why
- increased risk of:
Pulmonary System
In absence of pulmonary d/o, pulmonary capacity declines without major functional limitations at rest
Progressive decrease of VC, expiratory flow rate and FEV noted
Progressive ventilation-perfusion imbalance with aging due to the collapse of the small airways which results in linear decline in pO2
Due to altered thoracic mechanics, pO2 is lower in supine than in sitting or standing, no change is seen in pH or pCO2
Maximal oxygen consumption decrease with age but most likely due to underlying cardiac complications more so than pulmonary dysfunction
Increased risk of pneumonia noted as related to poor cough, decreased chest wall compliance and decreased mucociliary function
Phys of normal aging: CV
- # 1 cause of:
- HD worsened by (5) factors
- Discuss changes in HR as we age (BOARD QUESTION)
- discuss changes with contractility.
- Increased risk of _____ with age
Cardiovascular System
Heart disease remains the #1 cause of death for adults older than 65
Heart disease worsened by secondary factors such as smoking, stress, uncontrolled hypertension, obesity and lack of exercise
No change in resting HR but decreased maximal HR with exercise related to decreased chronotropic responses to adrenergic stimuli
Decreased inonotropic responses to adrenergic stimulus results in decrease myocardial contractility, and EF and increased risk of CHF
Cardiovascular system
Decrease in rate of early diastolic filling with greater dependency on filling thru atrial contraction thus most elderly more susceptible to effects of Afib or atrial tachycardia
Decreased baroreceptor sensitivity with increased incidence of orthostatic hypotension
Immunology: phys of normal aging (5)
Immunologic System
1Marked decline in immunocompetence
2Decline in lymphocyte proliferation in response to antigen stimulation
3Increase in circulatory antibodies and immune complexes with decreased antibody production as seen with attenuated responses to immunizations
4Increased susceptibility to infection related to above and co-morbidities
5Less active leukocytosis and often absent or only low grade fever in case of infection
Endocrine: phys of normal aging (4)
Endocrine System Decreased glucose tolerance Changes in thyroid function Decreased cortisol production Decrease in serum testosterone and estrogen levels
Thermoregulatory system: phys of normal aging (3)
Thermoregulatory System
Impaired temperature regulation due to combination of diminished sensitivity to temperature change and abnormal autonomic vasomotor control
Diminished sweating which can lead to heat exhaustion and heat stroke
Hypohidrosis may be aggravated by anticholinergic medications
Sensory system: vision: phys of normal aging 4
Sensory system-Vision
Deterioration of vision with presbyopia and physiologic miosis
Cataract formation, glaucoma, macular degeneration, diabetic retinopathy all commonly seen
Visual changes lead to many falls, especially at night
Routine eye exams recommended
sensory system: hearing - phys of normal aging (3)
Sensory System-Hearing
Gradual decline in hearing acuity/presbycusis
Most consistent with conductive hearing loss
Important to try to correct as can lead to social isolation, paranoid ideations or at times psychiatric reactions
neurologic system: phys of normal aging (5)
Neurologic System
Decrease in STM especially episodic memory and incidental learning
Loss of speed of motor activities
Decrease in the rate of central information processing
Impairments in stature, proprioception and gait
Decline in sensory nerve conduction velocity and rate of muscle contraction
MSK: phys of normal aging:
- Progressive loss of muscle strength of about ___% per decade for LE muscles and ____% for UE muscles.
- Tendons and ligaments are more prone to ____
- What programs help with muscle strength? why
- Contribution of what factors (3) impact strength
- High prevalence of what two diseases (2)
Musculoskeletal System
Progressive loss of muscle strength of about 14-16% per decade for LE muscles and 2-12% per decade for UE muscles related to overall decrease in muscle cross-sectional area and mass with age
Tendons & ligaments more prone to bruising or tearing with longer recovery time
Significant contribution of cellular, neural and metabolic factors that also can impact strength
Improvement of muscle strength noted in older individuals involved in structured high intensity resistance exercise program
High prevalence of osteoporosis and DJD
Increase risk of fractures, dislocations and loss of function
GU system: Phys of normal aging:
- BPH occurs universally in men over:
- be wary of _____ as presence of underlying disease
- 4 changes in GU system
- sexually? 3
GU System
1. BPH occurs universally in men over age 40
2. If incontinence present this should be regarded as a symptom of an underlying disease
Decrease in bladder capacity, inability to postpone voiding, detrusor contractility and urinary flow rate
Most retain sexual interest and desire and to a variable extent capability
More incidence of ED with need for medictions
Women may experience fragility and dryness of the vaginal wall and labia
Integumentary system (6) changes in normal aging
Normal Aging Process Loss of skin elasticity Loss of subcutaneous supporting and adipose (fat) tissue Loss of underlying muscle mass and bulk Easy skin tears and bruising More prone to development of PU Delayed skin healing
Psychosocial aging process (3)
Normal Aging Process
Increased risk of depression due to feelings of hopelessness, helplessness combined with underlying medical issues and loss of independence
Increased risk of suicide
Need to be cautious of alcohol usage and interactions with medications
5 effects of acute hospitalization
Disorientation/delirium
Atypical routines that may cause or worsen insomnia
Adverse side effect of medications
Adverse events
Loss of function and confidence complicated by limited or no family support upon return to home
Functional impact of aging: 1. most experience \_\_\_\_ decline 2. what is "frailty" 3 Physically impaired older patients tend to become \_\_\_\_ 4. further loss associated with (4)
- Some experience a sudden change in function but most gradually decline over time
- “Frailty”-a concept of more than the functional losses of older individuals but also represents a state of vulnerability resulting from the balance and interplay of medical and social factors
3 Physically impaired older patients tend to become socially isolated with can lead to exacerbation of medical problems, functional deficits and mental health issues - Further loss worsened by stress of multiple losses to include friends and family, malnutrition, pain, and adverse drug effect
function loss in elderly:
- worsened by _____
- What is “right of dependency”
- Worsened by devaluing of the disabled elderly by themselves or others, lack of interest by their health care professionals and limited opportunity for rehabilitation services
2Attitudinal obstacles such as “right of dependency” perceived as an earned virtue of longevity and the “apathy and fatigue” both mental and physical associated with multiple medical complications and hospitalizations
Classification of Physical Functioning in older adults 75-12
(5)
Classification of Physical Functioning in older adults 75-12
Physically elite-high risk and power sports
Physically fit-moderate physical and endurance sports, most hobbies
Physically independent-Light physical work, low demand activities, golf, driving, All IADLs
Physically frail-light housekeeping, some IADLs, may be homebound
Physically dependent-no or only some ADLs, needs home based or institutional care
*Spirduso, W. Physical dimensions of aging. 1995
immobility linked to what 5 things
Linked to mortality in mild-moderate head injury, incomplete motor functional spinal cord injury, cerebral palsy High risk of skin break down Contractures DVT Osteoporosis
- Individuals with SCI tend to experience changes associated with aging at: _____
- a younger age
describe the model of aging past SCI:
3 stages
Acute restoration phase-begins in acute rehabilitation and may last up to 2 years post injury
Maintenance phase-a variable but lengthy phase during which the person is able to maintain the level of function that was established following successful rehabilitation which usually lasts 15-20 years
Decline phase-occurs when the gradual onset of physiologic aging process and the degenerative effects of an overuse syndrome combine and interfere with function
factors associated with aging with SCI (7)
Genetics Trauma Lifestyle Adaptations to stress Socioeconomic status Level of injury Age of onset of injury
Life expectancy of persons with SCI: Age at injury 20 if survive first 24 hours: 1. usual life expectancy: 2. Para: 3. Low tetra: 4. High tetra: 5. Vent dependent
- 58.4
- 45.2
- 40
- 35
5 17.1
Life expectancy of persons with SCI: Age at injury 20 if survive first year: 1. usual life expectancy: 2. Para: 3. Low tetra: 4. High tetra: 5. Vent dependent
- 58
- 45.8
- 41
- 37.4
- 23.8
Life expectancy of persons with SCI: Age at injury 40 if survive first 24 hours: 1. usual life expectancy: 2. Para: 3. Low tetra: 4. High tetra: 5. Vent dependent
- 39.5
- 27.6
- 23.3
- 19.9
5 7.3
Life expectancy of persons with SCI: Age at injury 40 if survive first year: 1. usual life expectancy: 2. Para: 3. Low tetra: 4. High tetra: 5. Vent dependent
- 39.5
- 28.2
- 24.2
- 21.1
- 11.4
Life expectancy of persons with SCI: Age at injury 60 if survive first 24 hours: 1. usual life expectancy: 2. Para: 3. Low tetra: 4. High tetra: 5. Vent dependent
- 22.2
- 12.8
- 9.9
- 7.7
- 1.5
Life expectancy of persons with SCI: Age at injury 60 if survive first year: 1. usual life expectancy: 2. Para: 3. Low tetra: 4. High tetra: 5. Vent dependent
- 22.2
- 13.2
- 10.4
- 8.6
- 3.2
Nervous system concerns with aging with SCI (7)
Pain is reported to increase with age
Increased fatigue
Increased spasticity
Loss of strength and sensation
Change in gait and balance
Emergence of syringomyelia with loss of function, pain and increased spasticity
Early dementia if SCI present along with a TBI
Things to do: SCI nervous system (5)
Things to do: Yearly motor / sensory exam Functional assessment (FIM) Hand / Upper Extremity assessment Gait (walking) assessment Pain assessment and appropriate management
Respiratory system concerns with aging with SCI (7)
Can lead to worsening lung restriction
Leading cause of death for people with SCI
Reduced lung capacity as a result of high level injuries
Increased assistance required for pulmonary toilet to keep lungs clear
Increased secretions may lead to further risk of pneumonia and need for ventilator support
Increased risk of sleep apnea with age and weight gain
Increased kyphosis and scoliosis
Things to do: SCI resp system (6)
Things to do:
Increase activity
Get immunizations (pneumonia, flu)
Respiratory assessment with pulmonary function test (PFT)
Practice deep breathing with use of an incentive spirometer or flutter valve
Obtain a sleep study
Stop Smoking
MSK system concerns with aging with SCI (7)
Overuse of shoulders, elbows and wrist joints from WC use
Increased tear of ligaments from overuse
Increased risk of compression neuropathy such as carpal tunnel syndrome
Nearly all pediatric SCI patients develop scoliosis
Increased rate of osteoporosis due to loss of weight bearing
Increased risk of lower extremity fractures
Risk loss of independence
Things to do: SCI MSK system (4)
Joint assessment
Equipment usage assessment
Modification of equipment
Implementation of protective maneuvers to preserve joints
CV system: concerns for aging with SCI (10)
One of the leading causes of death in chronic SCI
Risk of heart disease magnified in patients with SCI
Increased risk of HTN 2x normal in adults with paraplegia
Decreased HDL levels
Increased TG
Increased glucose intolerance
Increased risk of autonomic dysreflexia and long term sequela of AD
Increased risk of deep vein thrombosis
Reduced exercise tolerance, more LE pooling
Increased homocystine and prostacyclin levels which may lead to increased incidence of stroke
Things to do: CV system with aging with SCI (5)
Recognize and treat autonomic dysreflexia
Increase physical activity
Eat a balanced diet
Cardiovascular assessment with EKG, lab monitoring of lipid function, echocardiogram, stress test if indicated
Smoking Cessation
Endocrine system: concerns for aging with SCI (2)
Increased glucose intolerance at a younger age and risk of diabetes
Determine hormone replacement for both men and women
Things to do: endocrine system with aging with sCI (3)
Blood levels every 2-3 years to examine fasting blood glucose and HgbA1C
Treat diabetes effectively
Labs every 2-3 years to determine hormone levels in both males and females and discuss hormone replacement if appropriate
GI system: concerns for aging with SCI (5)
Difficulty with accessibility to colonoscopy
Increased stool impaction which may lead to bloating, nausea/vomiting and stool incontinence
Decreased GI motility and increased time for bowel care
Increased risk of gallstone
GI difficulties increase risk of death
Things to do: GI with aging SCI (6)
Need for a routine bowel program that fits lifestyle and is socially acceptable
Need for routine colo-rectal screening and colonoscopy with proper bowel prep
Need for adjustments in medication and diet
Consider need for increased attendant care to assist with bowel care
Dietary modifications with more fruits and vegetables
Review of dietary habits and weight loss program if indicated
GU system: concerns for aging with SCI (7)
Used to be the major reason for death after SCI
Recurring bladder infections may lead to renal failure and the need for dialysis
Increased risk of bladder cancer
Increased incidence of bladder and kidney stones
Increased risk of leakage which may lead to skin breakdown
Decreased fluid intake which may lead to further infections and kidney stone production
Increased sexual dysfunction
Things to do: GU system with aging SCI (5)
Bladder program changes due to aging/change in functional abilities
Need for kidney and bladder ultrasound for kidney health every 2-3 years or annually if recurrent bladder or kidney infection
Cystoscopy for bladder cancer screening every 3-5 years and symptom dependent
Potential increase in attendant care needs
Assessment of sexual function and possible treatment options
Integumentary systems: concerns for aging with SCI (6)
Previous and recurrent pressure ulcers on sacrum, ischium, heels/ankles, greater trochanter
Prolonged healing process
Previous skin flaps or reconstruction
Increased risk of bruising and skin tears
Increased risk of burns
Increased risk of loss of function
Things to do: integumentary system with aging SCI (7)
Protect skin from injury
Daily skin inspection
Wear sunscreen and protect from extremes in temperature
Evaluate ability to do weight shifts and pressure relief
Equipment usage assessment
Modification of equipment
Smoking cessation
Psychosocial issues: aging with SCI (5)
SCI in general is a major life changing event which requires enormous adjustment by even the most stable individual
Difficult to adjust to the loss of bodily function and independence
Many positive changes occur within the first 2 decades after SCI, followed by a period of stability in some life areas, but decline with aging in some participation and health-related aspects of life
Successful adaptation is facilitated by family and peer support, education, availability of resources, assistive devices and realistic opportunities to participate in relationships and roles in the community
Life satisfaction and quality of life are vital concepts
Things to do: psychosocial issues with aging SCI
Discussion with the health care provider about change in mood which might also be affecting the person’s health
Be aware of counseling available in the community
Request a social work consult if available to determine any possible resources to help in the community
Preventative screening: Annual
- Normal: (8)
- SCI: (6)
1. Annual: Women-monthly self breast exam Men-monthly testicular self exam Annual physical exam Annual dental exam Annual mammogram starting at age 50 unless abnormal exam or family history Digital prostate exam and PSA starting at age 50 Fecal occult blood, starting at age 50 DEXA scan if on medications
2. SCI The same as the “normal” population + Daily skin exam Yearly BP check Yearly weight Flu vaccination DEXA scan if on medication for treatment of osteoporosis
Preventative screening: 2-3 years
- Normal: (5)
- SCI: (6)
1. Normal: CBC Comprehensive metabolic panel Cardiac risk assessment, starting at 40 Pap smear DEXA scan for individuals with osteopenia
- SCI:
“normal” aging concerns AND
Full history and physical (and review)
Urologic assessment-upper and lower tracts
Assess equipment and posture
Assess ROM, contractures, and functional status
Full skin evaluation
Preventative screening: 5 years
- Normal: (4)
- SCI: (3)
1. Normal: Pulmonary function test (PFT) Lipid Profile and HgbA1C (yearly if on meds) Eye exam, starting at 40 Screening colonoscopy, starting at 50
- SCI:
The same as the “normal” aging concerns +
Motor and sensory testing
Review changes in life situation, including coping, adjustment, and life satisfaction
Preventative screening: 10 years
- Normal: (2)
- SCI: (2)
Normal:
Tetanus booster
Colonoscopy
SCI:
same
5 preventative measures after SCI
Identify a health care provider close to home
Identify if other specialist available that care for individuals with SCI routinely
Determine if office and equipment is handicap and wheelchair accessible
Determine if lift available or needed to have a successful exam or test
Determine if special arrangements are need for special tests such as colonoscopy
4 issues with aging with BIU
Increased risk of developing AD with a history of TBI
Individuals with AD may be at increased risk of TBI (and other injuries) because of poor judgment
AD may be undiagnosed
Research shows that caregivers blame some TBI symptoms on aging
6 issues with aging with CP
Aging process begins earlier
Increased spasticity and fatigue
Loss of mobility and strength
40% get arthritis at an early age with risk of myelopathy
Impact of differently able: “Wear and tear” shifts
Increased loneliness and social isolation
rehab issues in the elderly (6)
Must be longitudinal in perspective and coordinated with other aspects of the individual’s health care, not episodic and in isolation
Must determine the appropriate treatment setting, timing and duration of care
Must help to facilitate access to all care
Important to continue individuals in a maintenance program to avoid functional decline
Incorporate patient and family teaching to assist with compliance of care
Provide long term follow up
5 forms we will see in business of medicine
Certificate of Medical Necessity for home care and equipment Family Medical Leave Act/FMLA paperwork Handicap placard application Depositions Life care plans
5 issues for attacking deposition
Unfortunately not if but when
Stick to what you know
Review your records in length prior to deposition
Know whether a video deposition or no
Listen carefully to the question as they will ask the same things many different ways
