Geriatrics I Flashcards
Define gerontology
- Greek “Heron” for old man, scientific study of the process of aging & the particular problems of old people
Define geriatrics
- A healthcare specialty field focusing on care & treatment of older persons
While greater life expectancy is good resource for families, it can be thought of as a burden on the healthcare system (True/False)
True
Define physical limitation
- Difficulty with any of the 8 activities
- Walk a 1/4 mile, walk up 10 steps w/o rest, stand/be on feet for 2 hrs, sit for ~2 hrs, stoop/bend/kneel, reach up over head, use fingers to grasp/handle small objects, lift/carry something as heavy as 10 lbs
Why do older adults have difficulty seeking out preventive medicine/receive preventive care
- Lack of knowledge amounts elderly & healthcare providers
- Lack of drive
- Lack of family support
What 2 generations is our current knowledge of geriatrics based on
- Maturists and baby boomers
Describe successful aging
- Avoiding disease & disability
- Maintaining high physical & cognitive function
- Active engagement i social & productive activities
Describe usual aging
- Living with intrinsic unavoidable components of aging & pathological conditions
Describe optimal aging
- Maximizing functional capacity despite having chronic conditions
Describe the slippery slope of aging
- Fun -> Function -> Frailty -> Failure
What are the functional age categories for those ≥75
- Physically Elite: compete in high risk & power sports
- Physically Fit: participate in most endurance activities & sports
- Physically Independent: walking, gardening, low demand sports, social dancing
- Physically Frail: can perform some IADLs (grocery shopping) & all ADLs
- Physically Dependent: some ADLs, may need caregiving
Modifiable factors related to decline in all body structures/functions from aging
- Physical activity
- Nutrition
- Stress (inflammatory effects on tissues)
Why do people age differently
- Potentially enough tissue reserve in each system to get through 80-90 years without infirmity
- No unifying theory of aging
- ~ 50% of the decline with age has a genetic basis the remainder is the consequence of lifestyle, physical inactivity
Physical activity and its effect on aging
- Level of physical training may determine pattern of decline in health status even in individuals with same genetic potentials
- Improvements in physical activity (cardiorespiratory + muscular) might be a primary goal for geriatric rehab
Slides 17-20
Underlying age related physiologic changes affecting CV function
- Heart: electrical = frequency/regularity for people >65 can become abnormal; mechanical = heart becomes fatty, larger, less efficient, which alters force, velocity & length tension relationships
- Decreased elasticity of blood vessels result in chronic increase in vascular diameter & vessel wall rigidity, prone to HTN
- Autonomic dysregulation of HR at rest or with activity
Pathologies that can aggravate decline in the cardiovascular system
- A-fib
- CAD (atherosclerosis)
- Diabetic neuropathy (affecting autonomic nerves supplying the heart)
- CHF
- MI
- HTN
- Limb paralysis
- Disrupted peripheral flow (PAD)
- Reconditioning (effect on ANS)
Anatomic changes to pulmonary tissue due to aging
- Alveolar size increases
- Surface area for gaseous exchange decreases
In what ways is the effects of aging on pulmonary tissue similar to emphysema
- Increased distance b/w airspace walls
- Decreased surface area of airspace wall
- Decreased elastic recoil
- Increased expiratory airflow resistance
- Decreased diffusing capacity
Physiologic changes to expiratory pulmonary function due to aging
- Decline in forced expiratory volume per second (FEV)
- Takes longer & more effort to get air out of lungs
Underlying age related physiologic changes affecting lung function
- Stiffer chest wall
- Increased lung tissue compliance
- Lower max expiratory flows
- Lower max inspiratory flow
- Increased FRC and RV, lower VC, but stable TLC
- Lower diffusing capacity
- Lower PO2 and SpO2/SaO2 as a consequence of V/Q mismatch
- 70 y/o associated with pathology
- Lower respiratory muscle strength & endurance
- Increased airway reactivity
Clinical symptoms of COPD
- Shortness of breath (SOB)
- Increased respiratory rate (RR)
- DOE
- Pink puffers
- Barrel chest
- Hypoxia
- Inspiratory crackles
- Becomes clinical after 20-30 pack years of smoking
What is the most common obstructive disease in older adults
- COPD: harder to breathe out due to obstruction of airway by inflammation or mucus production
What is used to assess COPD severity
- GOLD criteria (Global initiative for obstructive lung disease) Must of <0.7 ratio to be defined as COPD for all stages***
- Severity of COPD measured by spirometric pulmonary function test
- Stage I = Mild; Stage II = Moderate; Stage III = Severe; Stage IV = Very severe
What is the most common restrictive disease in older adults
- Idiopathic pulmonary fibrosis (IPF)
- Harder to breathe in due to restriction of lung expansion
Symptoms of IPF
- Shortness of breath
- DOE
- All lung volumes are smaller
- FEV1/FVC >0.8 in spirometry
Effects of age on muscle performance
- Progressive denervation & impaired regeneration muscle: 50% decline in alpha motor neurons and motor units >65 years, Enlargement of remaining motor units, Decreased availability of satellite cells
- Deficits in absolute force & specific force generation (per cross sectional area)
- Muscle activation deficits: Reduced central drive to agonist muscles, Increased co-activation of antagonists
- Deteriorating muscle quality & metabolism: Infiltration of fat and other connective tissue, Insulin resistance
Define sarcopenia
- Primarily defined as age related loss of muscle mass & strength but now considered a clinical condition with genetic & lifestyle/environmental contributors (nutrition/activity/inflammation)
Whole muscle changes related to sarcopenia
- Decreased muscle mass, replaced by increased fat mass
- Decreased muscle strength (particularly lower extremities)
- Slowing of muscle contractile properties and rate of force development
- Reduced rate of cross-bridge cycling
- Alterations on excitation and contraction coupling
- Increased compliance of muscle’s tendinous attachment
Muscle fiber changes related to sarcopenia
- Type II (fast twitch) are lost more than type I (slow twitch)
- Fiber necrosis
- Fiber type grouping – enlargement of motor units
- Reduction in type II muscle fiber satellite cell content
Functional consequences of sarcopenia
- Harder to perform daily activités
- Decreased participation in community activities
- Difficulty with IADLS, ADLs, increasing need of help from caregivers
Sarcopenia’s role in the vicious cycle to frailty
- Sarcopenia -> lack of protein reserves -> disease -> decreased ability to meet protein requirements to recover from disease (loss of physiological reserve) -> further sarcopenia -> frailty
Frailty is defined as a clinical syndrome in which 3 or more of what 5 factors are present
- Unintentional weight loss (10 lbs in the past year)
- Self reported exhaustion
- Weakness (grip strength)
- Slow walking speed
- Low physical activity
Pathologies that can progress age related decline in muscle performance
- Diabetes – loss of anabolic action on muscle
- Metabolic syndrome – abd obesity, insulin resistance, dyslipidemia, HTN
- Chronic obstructive pulmonary disease (COPD)
- Cancer
- Congestive heart failure (CHF)
- Arthritis
- Kidney disease
- Stroke
- Parkinson’s disease
Decline in ______________ & _____________ with or without disease can be reversed in older adults to a large extent with physical rehab
- Cardiopulmonary
- Muscle performance
- Cardiorespiratory fitness training (aerobic endurance), strength training, and functional activity training can help reverse
Risks associated with starting exercise/physical activity in older adults
- Sudden cardiac death and/or acute MI
- Higher risks for sedentary older adults, older adults with CV/pulmonary/metabolic comorbidities and vigorous levels of exercise
- Overall risks are still very low
1 MET is equal to how many ml of O2
- 1 MET = 3.5 ml O2/kg body weight/min
Even though absolute MET for the same kind of activity remains same regardless of age, the relative exercise intensity (% VO2 max) required for that activity will __________ with age.
- Increase
Older people need to work at a _________ % VO2 max than younger people to perform an activity of same absolute MET value
- Higher
What heart related values decline with age and which remain equivalent
- VO2max or HRmax decline with age
- HRR and VO2R remain equivalent
Assessment of geriatric patient with impaired aerobic endurance/cardiorespiratory fitness
- Pre-participation: PAR-Q; CV/pulmonary/metabolic risk factor assessment
- Pre-exercise evaluation: Vital signs, lipid profile, pulmonary function, meds/Beer’s list
- Health related fitness testing
Major signs/symptoms of CV, pulmonary, metabolic disease
- Pain and/or anginal equivalent: ‘constricting’ feeling in neck, jaw, arms, etc
- SOB at rest or mild exertion (DOE): LV dysfunction or COPD
- Dizziness or syncope: CAD, aortic stenosis
- Orthopnea or PND: LV dysfunction
- Ankle edema: HF, chronic venous insufficiency, kidney/liver problems (generalized edema)
- Palpitations/tachycardia: fever, anemia, anxiety states
- Intermittent claudication: atherosclerosis, CAD, diabetes
- Known heart murmur: may be innocent, exclude hypertrophic cardiomyopathy, aortic stenosis
- Unusual fatigue/SOB with usual activities
Positive risk factors for CVD
- Age: Men >45yr, women >55yr
- Family hx: MI, sudden death before 55
- Cigarette smoking
- Sedentary lifestyle (not participated in moderate ex, 3d/wk, last 3months)
- Obesity: BMI (>30 kg/m2) or waist girth (>40in for men, >35in for women)
- HTN: systolic >140mmhg and/or diastolic >90mmHg
- Dyslipidemia: High LDL (LDL >130) or low HDL (<40) or total cholesterol (>200)
- Prediabetes: Impaired FG (>100 and <125) or impaired GTT (2 hour values)
Negative risk factors for CVD
- High HDL: ≥60 mg/dl
Slide 52 clinical decision making based on risk category
Conditions for which exercise testing is recommended
- Unstable or new or possible Sx of CVD
- Diabetes and at least one of the following: Age 35, Type II DM >10 yr duration, Type I DM >15 yr duration, Hypercholesterolemia, HTN, Smoking, Family Hx of CAD in 1st relative <60 yr, Presence of microvascular disease, PAD, Autonomic neuropathy
- End stage renal disease
- Pts with symptomatic/Dx pulmonary disease: COPD, asthma, interstitial lung disease, or cystic fibrosis
Absolute exercise contraindications
- Unstable angina
- Uncontrolled cardiac dysrhythmia
- Uncontrolled CHF
- Acute infection
- Recent change in resting ECG
Relative exercise contraindications
- Known significant cardiac diseases
- Tachy/Brady dysrhythmia
- Chronic infection
Absolute indications to stop exercise
- Drop in SBP >10 mmHg with increase in workload with signs of ischemia
- Signs of poor perfusion
- Moderately severe angina
Relative indications to stop exercise
- Drop in SBP >10 mmHg with increase in workload w/o signs of ischemia
- Increasing chest pain
- Fatigue
- Shortness of breath
- Wheezing
Normal ranges for pre-exercise evaluation of vital signs
- Resting HR: 60-100 bpm
- Resting BP: 100-140/70-90
- SpO2: ≥ 90%
Possible causes of abnormal findings in pre-exercise evaluation of vital signs
- Resting Brady: beta blockers, AV block, cardiac dysrhythmia
- Resting tachy: hypotension, A-fib, ventricular tachy
- Systolic HTN: uncontrolled HTN, Systolic hypotension: orthostatic hypotension, A-fib, HF
- O2 desaturation: impaired O2 diffusion through alveolar capillary
Purposes of health related physical fitness testing
- Baseline data about pt’s present health.fitness level
- Educate pt about their current health status
- Data for developing individualized exercise prescriptions, reasonable goals, plan of care
- Baseline for follow up data to evaluate progress
Components of health related physical fitness testing
- Anthropometric testing – to measure body fat: BMI, Circumferences, Densitometry
- Cardio-respiratory fitness testing
- Muscular fitness testing
- Flexibility testing
What are the BMI cutoffs
- Normal: 18.5-24.9
- Overweight: 25-29.9
- Obese: ≥30 (increased risk of CV, diabetes, mortality
- Obesity paradox: people with CHF have improved survival rate when BMI is ≥30
- BMI <18.5 increases mortality risk
- Does NOT distinguish b/w fat, muscle, bone
Circumference measurements to determine android or gynoid obesity
- Android = around abdomen
- Gynoid = around hips/thighs
- Waist to hip ratio (WHR): for older adults, high risk for men = >1.03 and women = >0.90
- Increased risk for HTN, Type II Dm, CVD
Describe skinfold measurements
- Skinfold thickness correlates well with % body fat
- Dependent on clinician expertise
- Sites: abdomen, triceps, chest, tight, medial calf
- 7 and 3 site formulas to measure body density
- Formula to measure % body fat: % fat = (457/body density) - 414.2
Describe cardiorespiratory fitness testing
- Ability to perform large muscle, dynamic, moderate-vigorous intensity exercise over prolonged period of time
- Performed by VO2max directly but not always feasible due to equipment, space, risks, training needs
- VO2max plateau may not be observed in CVD or pulmonary disease
- Submit exercise tests usually performed/preferred for older adults
- Modes of testing include field tests, treadmill tests, cycle ergometer tests
Purpose for submit exercise testing and parameters to monitor
- Purpose is to determine HR response to exercise to estimate max work rate or VO2max/peak
- Parameters: HR, BP, RPE, dyspnea, angina, claudication, ECG, expired gas if available
Steps fro performing cycle ergometer test
- Obtain resting HR & BP
- Pt positioning on ergometer – 25 degrees flexion at maximal leg extension
- 2-3 min warm up
- 2-3 min stages with appropriate increments in workload.
- HR recorded in the last minute as it reaches steady state
- Test termination: when pt reaches 70%HRR (or 70-85% HRmax) or shows adverse symptoms (moderately severe angina or dyspnea or intense claudication pain) – more in handout
Describe relationship of 6MWT and assessing cardiorespiratory fitness
- Predicts VO2 & survival rate in heart failure (HF) & COPD
- Alternative is a 6 min step test (6MST), 20cm high single step w/o hand rails: correlates with VO2max results from an exercise test
Assessment of muscular strength
- 1 RM
- 10-1 RM: more appropriate for older adults with CVD, pulmonary, metabolic disease
- Functional tests for older adults: 2 components of senior fitness test includes - 30 sec chair stand (LE) and single arm curl (UE)
Assessment of muscular endurance
- Ability too execute repeated muscle actions at a specific intensity for a prolonged period of time
- Normative values for push-ups and curl-ups available
Other functional tests for assessing cardiorespiratory fitness, strength, endurance, flexibility, balance in older adults
- Senior fitness test (SFT)
- Short physical performance battery (SPPB)
- Continuous scale physical performance test
- SF 36 (RAND)
- Duke activity status index: rough estimate of pt’s peak O2 uptake, applicable for older adults with known CVDs where there might be additional risks of stressing pt’s CV system with exercise tests
Exercise interventions to improve CRF, strength, & functional mobility
- Aerobic endurance ex
- Resistance training ex
- Functional training
- Assistive devices
Principles of exercise training
- Overload principle
- Reversibility principle
- Specificity principle
- Adaptation principle
- Variation principle
Components of exercise training (FITT)
- Mode
- Intensity
- Duration
- Frequency
- Progression
Recommendations for aerobic ex training for the older adult or geriatric patient (having conditions like arthritis, DM, HTN, etc)
- Moderate intensity ex for ≥ 150 min per week (30min for 5 days)
- Vigorous intensity ex for ≥75 min per week (25min for 3 days)
- In terms of METs: > 500-1000 MET-min/week recommended
- Light ex (<40% HRR/VO2R) or <20 mins may be beneficial for deconditioned individuals int eh beginning (can perform multiple sessions of ≥10 min per day)
- Can progress using any component, may need longer for older/deconditioned individuals
Recommendations for resistance ex training for older adult
- General recommendations: for each muscle group, 2-4 sets with 2-3min rest, 60-80% 1RM (8-12 reps per set) for 2-3 days/wk (separated by at least 48 hours). All major muscle groups in one session or ‘split’ session
- 40-50% 1RM (10-15 reps-light intensity) for older/sedentary adults
- For improving endurance, <50% 1RM (15-20 reps per set), < 2sets
- Progression by increasing number of sets, resistance
- No ‘duration’ recommendations
- For oldest adults (>80 years), high intensity (70-80% 1RM) once per week may be beneficial
For older adults with obstructive/restrictive diseases, to improve respiratory muscle strength and endurance
- Respiratory muscle training (max inspiratory pressure <60cm H2O): use inspiratory/expiratory threshold trainer; 30-60% of MIP for 15-30min 1-2x/day
- Breathing strategies: pursed lip breathing
- Airway clearance techniques: postural drainage, percussion, vibration, oscillating positive expiratory pressure device (Acapella flutter)
What is the goal of functional mobility training
- Improve functional activity level
Describe task specific training for function mobility training for older adults
- Pedometer for goal of walking longer
- Increase gait speed for goal of crossing street safely
- Correct Ad for optimal energy conservation for goal of staying active throughout the day
- If aerobic improvement is less likely, educate pt about energy conservation techniques: break up large tasks, pace yourself, & breathe out during hardest pat of task
