Aging with Disabilities

Question 1

What is Ageism? 3 myths that go along with it:

Answer 1

“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”

Question 2

Epidemiology of aging:

1. at turn of century 1 of every ____ individuals was 65 years or older
2. By 1994, this increased to 1 out of _____ americans
3. Current projections indicate what for 2030?

Answer 2

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

Question 3

Distribution of the elderly is uneven across the US with 50% living in 9 states:

1. ____ has greatest number of people older than 65.
2. _____ has largest proportion of elderly
3. Estimated ethnic trends by 2050?

Answer 3

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

Question 4

Longevity continues to improve with average age of ____ years for Americans. Why?

Answer 4

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

Question 5

What is primary and secodary aging

Answer 5

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

Question 6

7 “general” changes in physiology of aging

Answer 6

1. Decreased reserve capacity of organ systems, which is apparent only during periods of exertion or stress
2. Decreased internal homeostatic control (blunting of the thermoregulatory systems, decline in baroreceptor sensitivity)
3. Decreased ability to adapt in response to different environments (hypo or hyperthermia)
4. Decreased capacity to respond to stress (exertion, fever, anemia)
5. Variation between healthy people of the same age is far greater than the variation that is due to aging alone
6. Difficult to determine if age decrements are linear over the entire age span or whether the rate of decline accelerates in later years
7. There is variation in the rate of decline of the various organ systems

Question 7

Hematologic physiology of aging:

1. It is NOT normal for:
2. Most common causes for anemia in the elderly
3. Discuss Sed Rate/CRP:
4. Functional changes related to anemia include: (3)
5. Medication issues:

Answer 7

Hematologic System

1. It is NOT normal consequence of aging to have a Hgb

Question 8

Physiology of normal aging: GI

1. ____ may occur.
2. Increased risk of (4)
3. Decreased ____ contraction

Answer 8

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

Question 9

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

Answer 9

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

Question 10

Physiology of normal aging: Pulm

1. _(3_declines with age even without pathology
2. Progressive _____ imbalance. due to:
3. Discuss pO2 in different positions
4. Max ____ consumption decreases with age: why
5. increased risk of:

Answer 10

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

Question 11

Phys of normal aging: CV

1. # 1 cause of:
2. HD worsened by (5) factors
3. Discuss changes in HR as we age (BOARD QUESTION)
4. discuss changes with contractility.
5. Increased risk of _____ with age

Answer 11

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

Question 12

Immunology: phys of normal aging (5)

Answer 12

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

Question 13

Endocrine: phys of normal aging (4)

Answer 13

Endocrine System
Decreased glucose tolerance
Changes in thyroid function
Decreased cortisol production
Decrease in serum testosterone and estrogen levels

Question 14

Thermoregulatory system: phys of normal aging (3)

Answer 14

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

Question 15

Sensory system: vision: phys of normal aging 4

Answer 15

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

Question 16

sensory system: hearing - phys of normal aging (3)

Answer 16

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

Question 17

neurologic system: phys of normal aging (5)

Answer 17

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

Question 18

MSK: phys of normal aging:

1. Progressive loss of muscle strength of about ___% per decade for LE muscles and ____% for UE muscles.
2. Tendons and ligaments are more prone to ____
3. What programs help with muscle strength? why
4. Contribution of what factors (3) impact strength
5. High prevalence of what two diseases (2)

Answer 18

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

Question 19

GU system: Phys of normal aging:

1. BPH occurs universally in men over:
2. be wary of _____ as presence of underlying disease
3. 4 changes in GU system
4. sexually? 3

Answer 19

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

Question 20

Integumentary system (6) changes in normal aging

Answer 20

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

Question 21

Psychosocial aging process (3)

Answer 21

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

Question 22

5 effects of acute hospitalization

Answer 22

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

Question 23

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)

Answer 23

1. Some experience a sudden change in function but most gradually decline over time
2. “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
3. Further loss worsened by stress of multiple losses to include friends and family, malnutrition, pain, and adverse drug effect

Question 24

function loss in elderly:

1. worsened by _____
2. What is “right of dependency”

Answer 24

1. 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

Question 25

Classification of Physical Functioning in older adults 75-12 (5)

Answer 25

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

Question 26

immobility linked to what 5 things

Answer 26

``` 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 ```

Question 27

1. Individuals with SCI tend to experience changes associated with aging at: _____

Answer 27

1. a younger age

Question 28

describe the model of aging past SCI: | 3 stages

Answer 28

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

Question 29

factors associated with aging with SCI (7)

Answer 29

``` Genetics Trauma Lifestyle Adaptations to stress Socioeconomic status Level of injury Age of onset of injury ```

Question 30

``` 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 ```

Answer 30

1. 58.4 2. 45.2 3. 40 4. 35 5 17.1

Question 31

``` 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 ```

Answer 31

1. 58 2. 45.8 3. 41 4. 37.4 5. 23.8

Question 32

``` 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 ```

Answer 32

1. 39.5 2. 27.6 3. 23.3 4. 19.9 5 7.3

Question 33

``` 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 ```

Answer 33

1. 39.5 2. 28.2 3. 24.2 4. 21.1 5. 11.4

Question 34

``` 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 ```

Answer 34

1. 22.2 2. 12.8 3. 9.9 4. 7.7 5. 1.5

Question 35

``` 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 ```

Answer 35

1. 22.2 2. 13.2 3. 10.4 4. 8.6 5. 3.2

Question 36

Nervous system concerns with aging with SCI (7)

Answer 36

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

Question 37

Things to do: SCI nervous system (5)

Answer 37

``` Things to do: Yearly motor / sensory exam Functional assessment (FIM) Hand / Upper Extremity assessment Gait (walking) assessment Pain assessment and appropriate management ```

Question 38

Respiratory system concerns with aging with SCI (7)

Answer 38

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

Question 39

Things to do: SCI resp system (6)

Answer 39

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

Question 40

MSK system concerns with aging with SCI (7)

Answer 40

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

Question 41

Things to do: SCI MSK system (4)

Answer 41

Joint assessment Equipment usage assessment Modification of equipment Implementation of protective maneuvers to preserve joints

Question 42

CV system: concerns for aging with SCI (10)

Answer 42

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

Question 43

Things to do: CV system with aging with SCI (5)

Answer 43

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

Question 44

Endocrine system: concerns for aging with SCI (2)

Answer 44

Increased glucose intolerance at a younger age and risk of diabetes Determine hormone replacement for both men and women

Question 45

Things to do: endocrine system with aging with sCI (3)

Answer 45

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

Question 46

GI system: concerns for aging with SCI (5)

Answer 46

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

Question 47

Things to do: GI with aging SCI (6)

Answer 47

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

Question 48

GU system: concerns for aging with SCI (7)

Answer 48

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

Question 49

Things to do: GU system with aging SCI (5)

Answer 49

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

Question 50

Integumentary systems: concerns for aging with SCI (6)

Answer 50

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

Question 51

Things to do: integumentary system with aging SCI (7)

Answer 51

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

Question 52

Psychosocial issues: aging with SCI (5)

Answer 52

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

Question 53

Things to do: psychosocial issues with aging SCI

Answer 53

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

Question 54

Preventative screening: Annual 1. Normal: (8) 2. SCI: (6)

Answer 54

``` 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 ```

Question 55

Preventative screening: 2-3 years 1. Normal: (5) 2. SCI: (6)

Answer 55

``` 1. Normal: CBC Comprehensive metabolic panel Cardiac risk assessment, starting at 40 Pap smear DEXA scan for individuals with osteopenia ``` 2. 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

Question 56

Preventative screening: 5 years 1. Normal: (4) 2. SCI: (3)

Answer 56

``` 1. Normal: Pulmonary function test (PFT) Lipid Profile and HgbA1C (yearly if on meds) Eye exam, starting at 40 Screening colonoscopy, starting at 50 ``` 2. SCI: The same as the “normal” aging concerns + Motor and sensory testing Review changes in life situation, including coping, adjustment, and life satisfaction

Question 57

Preventative screening: 10 years 1. Normal: (2) 2. SCI: (2)

Answer 57

Normal: Tetanus booster Colonoscopy SCI: same

Question 58

5 preventative measures after SCI

Answer 58

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

Question 59

4 issues with aging with BIU

Answer 59

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

Question 60

6 issues with aging with CP

Answer 60

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

Question 61

rehab issues in the elderly (6)

Answer 61

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

Question 62

5 forms we will see in business of medicine

Answer 62

``` Certificate of Medical Necessity for home care and equipment Family Medical Leave Act/FMLA paperwork Handicap placard application Depositions Life care plans ```

Question 63

5 issues for attacking deposition

Answer 63

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