Geriatric Conditions and OT

Question 1

2 ways that the growing number of older adults (OAs) will impact OT practice:

Answer 1

greater life expectancy = more OAs surviving w illness/disease

demographic changes related to gender, income, institutionalization, living arrangements

Question 2

More ways that the growing number of OAs will influence OT practice:

Answer 2

• diversity within aging population
• prevalence of chronic conditions
• limitations in ADL/IADL performance
• cognitive impairment
• psychosocial issues re: age-related issues and contextual features
• demand for healthcare
• need for social support
• costs for healthcare
• demand for public funding
• out of pocket health costs

Question 3

3 factors that underscore successful aging:

Answer 3

1. avoiding disease and disability
2. sustaining high cognitive and physical function
3. engagement with life

Question 4

Four most-frequently reported medical conditions in later life:

Answer 4

• arthritis
• heart disease
• hearing impairment
• orthopedic impairment

*not on our study guide, but seems like a good thing to know

Question 5

Age-related physical changes you should be aware of when assessing a person 85+ w/ a sedentary lifestyle:

*Know at least 5

Answer 5

• Sensory losses: hearing and vision
• Efficiency of kidneys in filtering wastes (lowered efficienct means reduced threshold for drug toxicity)
• Lean body mass (increased fat % plus “less water” (?) can affect drug absorption and lead to high blood levels / excessive effects of meds)
• Lungs: the become less elastic, less efficient in gas exchange, making breathing more difficult
• Cardiovascular capacity: lowered levels affect endurance for demanding activity
• Bone density / muscle mass: Decreases lead to decreased strength
• Skin integrity: compromises leads to skin breakdown, tearing, and infection
• CNS changes: (slower response time)
• Somatosensory changes: decreased sensitivity in smell, taste, vestibular systems raise risk of poisoning, falls, thermal / mechanical injuries

Question 6

Client factors you should observe/screen immediately when meeting an older adult client for the first time:

*Know at least 5

Answer 6

1. Changes in cognition, especially memory

• Attention
• Perception

2. Global mental functions

• Orientation
• Temperament
• Energy

3. Neuromusculoskeletal

• Postural alignment
• Righting and supporting
• Control of voluntary movements

4. Respiratory function
   * Rate, rhythm, depth of respiration
5. Voice and speech functions
6. Skin functions

Question 7

Risk factors for Alzheimers Disease (AD)

Answer 7

• Age
• Family history
• Previous head trauma
• Lower educational levels
• Down syndrome
• Female

Question 8

What percentage of OAs have psychiatric disorders?

Answer 8

Approximately 22% of individuals 65+ meet diagnostic criteria for a mental disorder.

Question 9

Most common mental disorders in OA population:

Answer 9

1. Anxiety (11.5%)
2. Severe cognitive disorder (6.6%)
3. Depressive disorders (4.4%)

Question 10

What about alcohol abuse and personality disorder?

Answer 10

less common but still cause for concern

Question 11

True or False: Older adults have almost zero risk of suicide

Answer 11

FALSE: Suicide is a major risk factor in late-life depression

Question 12

Be able to list at least three typical mistakes an entry-level therapist may make in assessing the functional performance of an older adult.

Answer 12

It is not unusual for an entry-level therapist to attempt to evaluate all aspects of ADLs, perhaps following a checklist from top to bottom without regard for the client’s needs. The experienced clinician is able to select a few key ADLs from the checklist or a key standardized assessment that efficiently covers an array of tasks.

The entry-level clinician may focus on the newly acquired disability and not consider the ways in which other age-related changes, pathological conditions, or performance contexts affect function. The more experienced clinician evaluates for age-related changes, gathers pertinent history of prior pathological conditions, and considers the potential effect.

Entry-level clinicians tend to focus primarily on current problems and may not consider interaction of age-related problems, preexisting deficits, and current problems with regard to the OA’s function in the discharge environment. The more experienced clinician consistently attempts to consider age-associated factors and all of the relevant factors in the client’s performance contexts when determining the effect of OT recommendations on both the client and the family. A more sophisticated approach is to help the family prioritize the list of recommendations for home and environmental modifications.

The complexity of a case made determination of a client’s potential for rehabilitation a cumbersome task for the entry-level therapist, who may need to consider each goal carefully and review methodically whether the client has the potential to attain it. The entry-level therapist may attempt to treat every problem even when improvement may not be possible. The experienced clinician is more skilled in weighing multiple factors and has a repertoire of previous successful clinical interventions against which such complex cases may be compared. To the entry-level therapist, the experienced therapist may seem to work on an intuitive level. In fact, what appears to be intuition is actually a series of clinical reasoning decisions based on evidence from evaluation, previous cases, and reports from literature.

The entry-level clinician may be tempted to inform the OA of the intervention goals, but the experienced clinician will collaborate with OAs and their families in establishing goals. The experienced clinician will be able to articulate the differences and the similarities between the client’s and the therapist’s goals and will negotiate agreement with the client. The entry-level clinician may have difficulty accepting a client’s refusal to work on some intervention goals. The experienced clinician accepts these differences in cultural and social values and focuses on the goals that the client feels are pertinent.

Question 13

List several ways that an OT can help an older adult age successfully “in place”.

Answer 13

Home modifications, DME, therapeutic exercise for strengthening and endurance,

Question 14

Know the DSM-V criteria for neurocognitive disorder per Jodi’s lecture.

Answer 14

Significant decline from previous performance in at least 1 cognitive domain (e.g. complex attention, executive functioning, learning & memory, language expression, perceptual motor, social cognition)

Diagnosis of delirium of other mental disorder is excluded

Major: interference with independence in everyday activities

Mild: greater effort involved in IADL independence (e.g. needs accommodations and/or compensatory strategies)

Question 15

Be able to differentiate among the Power-of-attorney and Guardianship legal definitions.

Answer 15

Power of attorney (health): makes decisions for clients only as related to health and medical issues

Durable power-of-attorney: gives legal authority to make decisions for client should he/she become incapacitated

Guardianship: Court appoints person to make all decisions for person who has been deemed incompetent to make own decisions

Question 16

List 5 risk factors for Alzheimer’s Disease.

Answer 16

Age

Family history

Previous head trauma

Lower educational levels

Down syndrome

Female

Question 17

Why are “senility” and “dementia” considered inappropriate terms to describe neurocognitive disorder in an aging person?

Answer 17

The term senility perpetuates stereotypical impressions that progressive cognitive decline occurs in normal aging. Such ideas prevent early recognition and accurate diagnosis of dementia. Early signs of what could really be a dementing illness have been erroneously attributed to the normal aging process and identified as senility.

Question 18

Impaired memory is the signal feature of AD, but what other cognitive-perceptual functions can be damaged by this disease?

Answer 18

Apraxia (impaired ability to perform planned motor movement)

Aphasia (speech and language problems)

Agnosia (impaired to recognize previously familiar objects)

Impaired executive function (impaired ability to initiate, plan, organize, safely implement, and judge and monitor performance)

Visuospatial dysfunction

Question 19

Be able to describe changes in ADL-IADL performance across the four stages of AD.

Answer 19

Stage 1: Very mild to mild cognitive decline

Feels loss of control, less spontaneous; may become hostile if confronted with losses

Mild problems with memory and less initiative; difficulty with word choice, attention, and comprehension; repetition sometimes necessary; conversation more superficial; mild problems with praxis

Seems socially and physically intact except to intimates; decline in job performance

Stage 2: Mild to moderate decline (problems from stage 1 are exacerbated)

Use of denial, labile moods, anxious or hostile at times; excessive passivity and withdrawal in challenging situations; possible development of paranoia

Moderate memory loss, with some gaps in personal history and recent or current events; decreased concentration; possible tendency to lose valued objects; difficulty with complex information and problem solving; difficulty learning new tasks; visuospatial deficits more apparent

Need for supervision slowly increases; decreased sociability; moderate impairment in IADLs that are complicated and mild impairment in some ADLs (e.g. finances, shopping, medications, community mobility, cooking complex meals); no longer employed; complicated hobbies dropped

Stage 3: Moderate to moderately severe decline in cognition (problems from stage 2 are exacerbated-difficulties involving physical status more)

Reduced affect, increased apathy; sleep disturbances; repetitive behaviors; hostile behavior, paranoia, delusions, agitation and violence possible if client becomes overwhelmed

Progressive memory loss of well-known material; some past history retained; client unaware of most recent events; disorientation to time and place and sometimes extended family; progressively impaired concentration; deficits in communication severe; apraxia and agnosia more evident

Slowed response, impaired visual and functional spatial orientation

Unable to perform most IADLs; in ADLs, assistance eventually needed with toileting, hygiene, eating, and dressing; beginning signs of urinary and fecal incontinence; wandering behavior

Stage 4: Severe cognitive decline and moderate to severe physical decline

Memory impairment severe; may forget family member’s name but still recognizes familiar people; can become confused even in familiar surroundings

Gait and balance disturbances; difficulty negotiating environmental barriers; generalized motoric slowing

Often unable to communicate except by grunting or saying single word; psychomotor skills deteriorate until unable to walk; incontinent in both urine and feces; unable to eat; often becomes necessary to place client in nursing home at this time

Question 20

List five ways a caregiver can cope with personality and behavior changes in a loved one who has AD.

Answer 20

Respite care

In-home support services

Support groups

Environmental adaptations

Therapeutic interpersonal approaches

Question 21

List at least three ways to protect a person with AD who tends to wander.

Answer 21

Address, if possible, the cause, e.g., fatigue, fluids, nutrition, caffeine intake

Distract with positive or soothing stimuli and activities (e.g., exercise, rocking chair)

Provide visual stimuli to prevent escape (e.g., curtains over doorknob, stop signs, dark rug)

Never lock a person in unattended

Enroll person in safe return program of AD association; radio transmitter wristband; GPS; implants

Question 22

What are some ways that AD impacts a person’s ability to drive?

Answer 22

Inability to remember directions

Using poor judgement due to impaired executive function

Mood and personality changes; agitation, anxiety, irritability, paranoia, delusions, violence, and depression all affect emotional regulatio

Confusion; disorientation; impaired concentratio

Visual/spatial orientation issues; judging parking, stopping at intersection

Reaction time is slower; apraxia

Inability to recognize road signs; agnosia

Question 23

What functional activities should an OT focus on in early stages of AD?

Answer 23

Create volunteer/work tasks

Maintain safe IADL through appropriate supports

Establish supportive social network with family and community

Promote engagement in leisure of choice

Encourage physical exercise and wellness behavior

Promote routines

Enhance memory and reinforce engagement in occupation (calendars, notes)

Question 24

What functional activities should an OT focus on in middle stages of AD?

Answer 24

Maximize ADL through compensatory and environmental adaptations

Train caregivers to conduct activities

Create supervised leisure opportunities

Pursue appropriate community-based programs adult day services

Maintain routines

Avoid learning new tasks to decrease agitation

Maintain socialization

Use orientation activities e.g., photo albums, pictures

Encourage stretching, walking, and other balance activities

Question 25

What functional activities should an OT focus on in later stages?

Answer 25

Maintain client factors to participate in ADL with caregiver support

Modify approach to social participation to promote human contact

Prevent co-morbidities of reduced movement during sleep (biomechanical issues—positioning and ROM)

Review names of family and friends

Encourage assisted ambulation

Provide controlled sensory stimulation: sound, touch, vision, olfaction to maintain reality

Question 26

List motivating principles of OT intervention with older adults.

Answer 26

Maintain an environment of mutual trust, respect and acceptance of differences. Each older individual has lived a long life, rich with experience, and this experience should be respected during intervention. Treatment activities should always be age appropriate. Many older adults enjoy treatment activities that are fun and playful, including games and crafts. These activities should be assessed carefully, to be sure that they are appropriate for each individual client. If an older adult complains that an activity is childish, significant benefit from participating will probably not be achieved.