Final Flashcards
Pain Classifications by clinical management
Transient
Acute
Chronic pain due to cancer
Chronic pain due to nonmalignant diseases
Pain Classifications by presumed source
Nociceptive
Neuropathic
Mixed/unspecified
Psychiatric
Why does medication efficacy decrease with age?
Reduction in renal and hepatic clearance with age
Increased time needed for elimination of pharmaceutical agents
Elderly: increased fat mass, lower muscle mass, lower water
Start low, go slow, and follow-up
Psychological Support
Psychophysiological (biofeedback)
Behavioral approaches
Acceptance-based approaches
Behavioral Approaches
Relaxation Training
Operant conditioning
Cognitive-behavioral therapy
Acceptance-based
When is TENS best utilized?
When used during functional movements
When used at acupoint sites
When are thermal agents best used?
adding exercise to heat treatment = improved function
Patient Specific Functional Scale
Up to 3 patient selected activities
MCID: varies by diagnosis, 2-3 is reasonable
Brief Pain Inventory
Regular: 32 items
Short form: 9 items
Copyrighted, need permission to use
FABQ predictor for SI manipulation:
less than 19, increase success
FABQ predictor for stabilization:
less than 9 decrease success
Oswestry Low Back Disability Questionnaire
Self-report measure scored 0-100, higher number = greater disability
Scores 80 and over = bed-bound or exaggerating
MCID = 10
Hospice
has specific requirements, including the fact that a patient is no longer seeking curative treatments
Qualifications for Medicare Hospice Benefit:
Physician must provide certification of a terminal condition with a prognosis of less than 6 months
Patients must certify that they are no longer seeking curative measures for their condition
Patients must be entitled to Medicare Part A services (inpatient)
Begin with 2 initial 90-day periods, which can then be followed by unlimited 60-day periods as long as documentation supports continued need
A patient may revoke their hospice benefit if they decide to pursue curative measures
When doe hospice IDT team meetings occur?
These must occur at least every 2 weeks to determine any changes to the current plan of care
Who is founder of modern hospice movement and why?
Dame Cicely Saunders, MD Once a physician, she researched and took more training in pharmacology to find a way to provide continual analgesia
PT in hospice and palliative care:
rehab light rehab in reverse case management skilled maintenance supportive care
Rehab light
Patient has multiple co-morbid items, maybe a recent treatment and long course of disease. Patient may be experiencing adverse effects of treatment interventions like chemo, surgery, or radiation.
PT might start at once weekly or every other week.
Home exercise program is important.
Progress toward goals might be very slow, but should be measurable over weeks or months.
Rehab in reverse
Utilizing skilled patient and family instruction as a person moves through the transitions from an independently mobile level to a more dependent one as the disease progresses and as strength and balance wane.
May necessitate need for use of equipment, including wheelchair, bedside commode, shower bench.
As time goes on, may need to educate family or caregiver on proper positions for comfort and skin care management
PRN visits
Problem solving functional decline
Case Management
Providing long-term, ongoing care for challenging and changing conditions.
This model is useful in palliative and hospice care, with patients that are relatively stable, but gradually declining over weeks or months
Skilled Maintenance
Under hospice rules, when activities provide for significant quality of life, they are considered skilled care.
Consultation with the IDT is important to establish a care plan that provides for the frequency needed, as well as patient and family support through the process of letting go of activities during the course of care
Composition
number of generations that make up the family and various roles that the individuals play inside and outside the family system
Governance process
the rules” inside the family; including communication, relationships, behaviors, and power
Organization
refers to interdependent subsystems or “connections” of members as well as their position within the life span
Resilience
the term used to describe the outcome and effectiveness of coping
What is the most important component of driving?
vision
Homebound status:
Required by Medicare A and B for treatment
Leaving home would be extremely difficult
Occasional excursions outside the house allowed
Who can collect data at start of care in home health?
PT, Skilled Nursing, and SLP
Components of OASIS
Consent and emergency plan/advanced directives Emergency Planning Medication Reconciliation Health Risk Screening Home Safety Assessment Functional Assessment and Musculoskeletal Assessment Goal Setting Physician Verbal Order
Inpatient Rehab Facilities
Reasonable and necessary care and significant rehab potential
Require the coordinated care of at least two therapy disciplines (PT, OT, SLP)
Required to participate in minimum of 3+ hours therapy per day, at least 5 days per week
Payment in IRF:
PPS
based on FIM scores
60% must have qualifying diagnosis
CMS-13
Stoke
Spinal cord injury
Congenital deformity
Amputation
Major multiple trauma
Fracture of femur (hip fx)
Brain injury
Neurological disorders (MS, Parkinson’s, etc)
Burns
Active, polyarticular rheumatoid arthritis, psoriatic arthritis…
Systemic vascularities with joint inflammation, resulting in significant fxnl impairment
Severe or advanced OA (Involving 2+ major weight bearing joints)
Knee or hip jt replacements (bilateral, extremely obese (BMI of 50), 85+ years old)
Skilled Nursing
PPS
RUG levels
Ultra High Rehab
720 min/ week + 1 discipline 5 days/ week + 1 discipline 3 days/ week
Very High Rehab
500 min/week + 1 discipline 5 days/ week
High Rehab
325 min/ week + 1 discipline 5 days/ week
Medium Rehab
150 min/ week + 5 days any combination of 3 rehab disciplines
Low Rehab
45 min/ week + 3 days any combination of rehab disciplines + restorative nursing 6 days/ week
Long Term Care:
Once skilled benefit is exhausted (>100 days) or when residents no longer require skilled intervention, they transition to an LTC resident.
Leading causes of LTC admission: decreased cognition, incontinence, increased falls, decreased functional status.
Modified Physical
Performance Test
test for frailty
Modified Physical Performance Test not frail
32-36
Modified Physical Performance Test mild frailty
25-32
Modified Physical Performance Test moderate fraility
17-24
Modified Physical Performance Test no longer independent
<17
Categories in Modified Physical Performance Test
book lift put on and off coat pick up a penny chair rise turn 360 50 ft walk one flight of stairs four flights of stairs progressive romberg
Motor Control
Ability to regulate or direct movements
Gross motor control
Ability to make large, general movements
Requires proper coordination and function of muscle, bones, and nerves
Cerebellum
correction of movement and coordination
Basal ganglia
selection of desired movements, initiation of movements, and inhibition of competing movements
Brainstem
postural control and basic/ gross movements
Motor cortex
planning, initiation, and direction of voluntary movements
Primary motor cortex
initiates signals that are involved in execution of movement
Secondary motor cortices
additional areas involved in motor function
Subconscious pathway
allows for subconscious control of muscle tone, balance, eye, hand, and upper limb position
Motor System Impairments
Paresis Abnormal tone Fractionated movement deficits Ataxia hypokinesia
Sensory System Impairments
Somatosensory loss
Perceptual deficits
Motricity Index
Uses standard MMT of 3 specific UE and 3 specific LE segments
Used to assess paresis impairment
Provides a standard MMT score that is objective
UE segments
shoulder abduction, elbow flexion, pinch grip
LE segments
hip flexion, knee extension, ankle dorsiflexion
Age-Related Changes Muscle Changes:
Decline of body protein reserves
Diminished capacity to meet protein synthesis demands
Loss of muscle mass with gains in fat mass
Preferential atrophy of fast-twitch (type II) fibers
Protein Requirements in Elderly
0.8 g/kg/day protein recommended for adults
1.0 to 1.3 g/kg/day recommended for elderly
20g to 30 g per meal
Frail Elderly Exercise Prescription
3x/week
3 sets of 8-12 reps
Start 20% 1RM, progress to 80% of 1RM
No adverse events/injuries reported
Program 1 Consideration
1 RM = 50 pounds leg press
3 sets of 8, 3x/week, 10 pounds (20% 1 RM)
Total volume = 720
Program 2 Consideration
1 RM = 50 pounds leg press
3 sets of 8, 1x/week, 30 pounds (60% 1RM)
Total volume = 720
Chondroid:
cartilaginous, articular cartilage, labrum, meniscus
Fibrous
tendons and ligaments
Fibrous Structure Changes
Information on normal aging of fibrous structures limited
Fibrous structures thought to demonstrate increased stiffness and decreased elasticity with age
Animal models suggest decreased tensile strength with age
Bone Changes
Thickness and density of subchondral bone tends to decrease with age
Increased osteoclast activity and decreased osteoblast activity -> risk of osteopenia/osteoporosis
Bone’s ability to absorb load compromised with osteopenia and osteoporosis
Stage I OA
doubtful
minimum disruption
10% cartilage loss
Stage II OA
mild
joint space narrowing
occurrence of osteophytes
Cartilage breakdown
Stage III OA
moderate
moderate joint space reduction
gaps in cartilage can expand until they reach the bone
Stage IV OA
severe
joint space greatly reduced
60% of cartilage already lost
large ostephytes
Interventions for Joint Mobility
Stretching
Strengthening
Manual Therapy
Therapeutic Exercise
Age related changes in the heart
Increase adipose tissue
Increase collagen content
Decrease muscle cells (myocytes)
Decrease innervation/nerve conduction tissue
Decrease sympathetic modulation of HR
Results in decrease excitability, decrease cardiac output, venous return and an INCREASE in dysrhythmias.
With the walls of the heart becoming less compliant results in:
Declines in Left ventricle expansion and contractility (i.e. reduced end diastole volume)
Results in decreased ejection fraction (Frank-Starling law
Increased atrial size correlates to:
Left ventricular compliance
increased workload on the atria
hypertrophy of the aorta
What is stroke volume dependent upon:
contractility
preload
afterload
Factors Affecting Aerobic Activity
Age
Gender
Training
Physiological Make Up
What is needed for optimum aerobic performance:
slow twitch muscle fibers
mitochondria
myoglobin stores
Factors Influencing Aerobic Capacity in the Older Adult
deconditioning
age related physiological changes
specific pathology
Angina Scale
- Mild, barely noticeable
- Moderate, bothersome
- Moderately severe, very uncomfortable
- Most severe or intense pain ever experienced
Dyspnea Scale
- Light, barely noticeable
- Moderate, bothersome
- Moderately severe, very uncomfortable
- Most severe or intense dyspnea ever experienced
Claudication Scale
- Definite discomfort or pain, but only at initial or modest levels (established, but minimal)
- Moderate discomfort or pain from which the patient’s attention can be diverted (e.g., by conversation)
- Intense pain (short of grade 4) from which the patient’s attention cannot be diverted
- Excruciating and unbearable pain
Forward Head Posture
Tight suboccipitals
Weak cervical flexors
Head is in front of line of gravity
When do height changed start to occur?
around age 45
Height changes per year
Decrease of ~0.1% per year in women and ~0.02% in men»_space; 2” lost over a lifetime
Therapeutic Exercise to correct postural faults
Core strengthening
Extremity postural exercise
Specific stretches for trunk and extremities
Conditioning and endurance exercise
Major Depressive Episode (at least 5+ sx present during 2 wk period
Depressed (sad) mood
Markedly diminished interest or pleasure in all, or most, activities
Weight loss or weight gain when not dieting or decrease or increase in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, recurrent suicidal ideation, a suicide attempt or plan
Two Very Effective Questions to screen for depression in clinical setting
Over the past two weeks, have you ever felt down, depressed or hopeless?”
“Have you felt little interest or pleasure in doing things?”
Models of Depression
Cognitive model
Learned-Helpless Model
Interpersonal Model
Neurobiological Model
Cognitive Model
Based on empirical observation
Correlation between negative feelings of self and depression
Set goals
Learned-Helplessness Model
Tends to be seen in patients who are pessimists
Neglect healthful behaviors
Interpersonal Model
Overdependence on others + loss or negative life event
Caring for spouse who was previously/ currently abusive
Neurobiological Model
Changes in speech, motility, and cognition
Disturbance of neurotransmitters, especially serotonin
A lot of the medications for depression are based on this model
Clues to Identifying Depression in the Older Adult
Unexplained or aggravated aches and pains Hopelessness Helplessness Anxiety and worries Memory problems Weight loss Loss of feeling of pleasure Slowed movement Irritability Lack of interest in personal care Tiredness, listlessness
Common Mistakes in Working with a Patient with Dementia
Don’t assume that everything that you see is the result of their dementia
Don’t discount the person’s opinion
Don’t rely just on verbal communication
Don’t provide too much information – small steps
Polypharmacy
Excessive or inappropriate use of medication
5+ medications
Vicious cycle
Altered gastrointestinal function (absorption) due to:
Decreased gastric acid
decreased stomach emptying
decreased absorbing area
decreased motility
Distribution altered due to
Decreased body water
decreased lean body mass
decreased plasma protein
increased body fat
Hepatic metabolism altered due to
decreased liver mass
decreased liver blood flow
decrease enzyme activity
Renal excretion altered due to
decrease kidney mass
decrease kidney blood flow
decrease tubular function in nephron
Pharmacodynamics
Study of how the drug affects the body
Absolute exercise contraindication
unstable angina
uncontrolled cardiac dyrhythmias causing symptoms of hemodynamic compromise
uncontrolled symptomatic heart failure
acute or suspected major cardiovascular event
acute infection
Change in ECG suggestive of MI
Relative exercise contraindication
known cardiac disease severe arterial hypertension tachydysrhythmia or bradydysrhythmia electrolyte abnormalities uncontrolled metabolic disease chronic infectious disease mental or physical impairment
Absolute indications for terminating exercise
drop in systolic BO of 10mmHg moderately severe agina increasing nervous symptoms signs of poor perfusion subject's desire to stop monitor equipment ST elevation sustained ventricular tachycardia
Mini Mental State Exam
MDC – 5 point change over 5-10 year period
Mini Mental State Exam no impairment
< 24
Mini Mental State Exam mild impairment
18-23
Mini Mental State Exam severe impairment
<17
Geriatric Depression Scale normal
0-4
Geriatric Depression Scale mild depression
5-8
Geriatric Depression Scale moderate depression
9-11
Geriatric Depression Scale severe depression
12-15
Clock Drawing Test
can score as incorrect vs. correct or on a scale from 1-10
< 3-5: cut-off score
TUG cutoff risk for falls for community
> 13.5 seconds
10 meter walk test cut off for community ambulators
0.8 m/sec
5 time sit to stand fall risk cut off
15 seconds or greater
Activities Balance Confidence Scale
80% or above no risk of fall, 50-80% greater risk for falls
6 minute walk test MCID
50 meters
Mobility disability:
Defined as the inability to walk a ¼ mile or climb a flight of stairs
Slippery Slope
Fun
Function
Frailty
Failure
Most important predictor of subsequent institutionalization :
leg strength
Overload
If too much stress is placed on a tissue, then it is susceptible to injury or even death
Underload
If too little stress is placed on a tissue, then the tissue loses its ability to adapt to stresses; it atrophies
ACSM Guidelines Strength
60-70% of 1 RM for novice
80-100% of 1RM for advanced
1-3 sets 8-12 reps for novice
2-6 sets 1-8 reps for advanced
ACSM Guidelines Power
Light load preferred, 0-60% of 1RM
1-3 sets of 3-6 reps
ACSM Guidelines Frequency
Novice: 2-3 days/week
Advanced: 4-6 days/week
Exercise older adults need:
2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week AND weight training: muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms)…
OR
1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week AND weight training: muscle-strengthening activities on 2 or more days a week that work all major muscle groups …
OR
An equivalent mix of moderate- and vigorous-intensity aerobic activity AND weight training: muscle-strengthening activities on 2 or more days a week that work all major muscle groups
Adult learners require
Choice – provide options
Voice – listen to their needs
Relevance – connect learning to valued interests
Ownership – work collaboratively on goal setting
Age Changes in Motivation
Self regulation
positive emphasis
stronger adherence to behavior changes
positive self concept
Self regulation
greater ability to control thoughts, emotions, behaviors with age
Positive emphasis:
elderly respond better to emphasizing positive and short-term outcomes
Stronger adherence to behavior change
elderly slower to initiate change but more likely to adhere to changes
Positive self-concept
elderly less likely to conceptualize selves as personally deficient
Transtheoretical Model of Change
Precontemplation Contemplation Preparation Action Maintenance Termination
Precontemplation
Individual has no intention to take action within next 6 months
Contemplation
Individuals intends to take action within the next 6 months but has not made a commitment to action
Preparation
Individual intends to take action within the next 30 days and has taken behavioral steps in this direction
Action
Individual changes overt behavior for less than 6 months
Maintenance
Individual has changed behavior for more than 6 months and prevents relapse
Termination
Individual has no temptation to relapse
Who is the senior athlete?
Former competitive athletes
Lifelong athletes, “sports people”
Nonathletes that start exercising later in life (after 40)
Young-old
65-74 years
Old
75-84
Old-old
85-99
Bone/joint changes with age
Deterioration of joint surfaces
Breakdown of collagen fibers
Decrease in viscosity of synovial fluid
= loss of flexibility and increase in joint stiffness
Muscular system changed with age
Decrease in size, number and type of muscle fibers, especially type II.
Change in percentage of type 1 predominant amounts to relative increase in endurance and decrease in force production/power, especially in women, especially in UE
Macrotrauma
Fewer collision injuries
More likely to avulse muscle/bone than strain muscle or rupture ligament
Time needed for recovery can be devastating to senior athlete
Microtrauma
Elderly more susceptible due to:
Stiffer collagen
Arthritic changes in WB joints
Lower muscle mass/shock absorption
Domains of Wellness
Physical
Psychological
Social
Exercise benefits
Reduce bone density loss (if WB)
Counteract loss of lean muscle mass/strength loss
Improve flexibility
Improve body composition
Emotional wellness
sense of well-being, ability to cope with ups and downs
Spiritual wellness
provides meaning and connects oneself to something greater
Intellectual wellness
ability to learn, self-efficacy
Psychological Wellness
emotional
spiritual
intellectual
Fall Risk Assessment Recommendations
Use of structured note template
Recommend home safety evaluations
Increase attention to high risk medications
Use STEADI materials
Increase public health messaging about falls and preventability
STEADI recommendation
lower body weakness difficulties with gait and balance use of psychoactive meds postural dizziness poor vision problems with feet/shoes home hazards
Typical Gait Changes in Older Adults
Decreased gait speed
Decreased step or stride length
Increased stance time and double-limb support time
Increased variability of gait (step or stride time, length, width, frequency, or velocity)
Decreased excursion of movement at hip, knee, and ankle
Stance time during gait
60%
Swing time during gait
40%
Hip ROM requirements for gait
30 degrees flexion to 10 degrees extension
Knee ROM requirements for gait
0 to 60 degrees flexion
Ankle ROM requirements for gait
20 degrees plantarflexion to 10 degrees dorsiflexion
What percentages of people over the age of 65 fall yearly?
1/3
half of these fall multiple times
What does self selected gait speed correlate with?
with life expectancy in elderly
Slow gait more correlated with future emergence of dementia than subjective cognitive impairment
Successful aging
Absence of disease
High cognitive and physical functioning
Active engagement with life
Usual aging
Suboptimal
Chronic health problems
Frailty
Weight loss: 10 pounds or more over year (unintentional)
Self-reported exhaustion 3 or more days/week
Grip strength lowest 20% (<23 pounds women, <32 pounds men)
Walking speed lowest 20% (<0.8 m/s)
Activity lowest 20% (<270 kcal/wk women, <383 kcal/wk men); sitting/lying most of day
3 of 5 meets clinical criteria for frailty
