OAT Geriatrics Flashcards
The aging MSK system from a biomechanical perspective, including changes in muscle mass, bone density, height, lean body mass, body water, and body fat
Loss of muscle mass (decreased strength)
Loss of bone mineral density (osteoporosis, fractures)
Osteoarthritis
Decreased height, decreased lean body mass, decreased body water, increased body fat (changes in pharmacokinetics)
Common mechanical and inflammatory MSK complaints in geriatric pts
Mechanical: cervical stenosis, OA, osteoporosis, postural imbalance, gait changes, low back pain, CTS
Inflammatory: RA, PMR, psoriatic arthritis
Important considerations regarding MSK physical exam in geriatric pts
Evaluate gait
Assess posture
ROM for upper and lower extremities
Evaluate feet for ulcers/nail care
OSE of mm. and joints for somatic eval
Neck pain is related to anatomy in that the intervertebral discs are ______ anteriorly than posteriorly. Greatest pressure in the neck occurs with ______ of the C-spine. After the age of 50, the nucleus pulposus becomes more _______ and has characteristics similar to the annulus fibrosis
Thicker; extension; fibrocartilaginous
Neck pain comorbidities
CV disease Dizziness Low back pain OA osteoarthritis Orthostatic hypotension Shoulder pain
[others include autonomic failure, concentration problems, digestive system disease, headaches, TMJ, trapezius mm. ischemia]
The most common form of arthritis, often affecting hands, feet, knees, and hips, and is the leading cause of LE disability in older adults; severe dz can interfere with ADLs
Osteoarthritis
The incidence of osteoarthritis is higher in women, and there is a rapid increase in incidence at age ______ that levels off around age 80. Risk factors include older age, obesity, genetics, occupation, and prior injury
50
Common complaints with osteoarthritis in geriatric pts
Initial symptoms = pain in one joint; can progress over time to multiple joints
Deep ache, usually with use
Joint stiffness after periods of inactivity, just after waking, and sitting
Night pain may interfere with sleep
Medical treatment options for OA include weight management, walking aids, braces, NSAIDs, duloxetine, topical capsaicin, intraarticular injections, and orthopedic intervention as a last resort. Prevention is also of high importance. What are some research findings regarding benefits of OMT in geriatric pts with osteoarthritis?
During and after treatment, subjects who had received OMT demonstrated continued improvement in their ROM, while ROM in the placebo group decreased
Manual therapy group had significant and clinically important sustained improvements at 1 year; exercise therapy had similar result
Case study of female with knee OA had resolution of effusion within a couple days post-treatment with articulatory, CS, MET, and MFR
What are some considerations regarding the aging nervous system in geriatric pts?
Decrease in brain weight (drug toxicities, delirium)
Alterations in CNS NT’s
Decrease in memory
Decreased reaction time
Altered sleep with decreased deep sleep and increased wakefulness
Decreased vibratory sense (altered gait)
Decreased righting reflex, increased postural instability, altered gait all lead to increased accidents and falls
Common neurologic complaints in elderly populations
MS Parkinson disease Stroke Dementia Sciatica Vertigo
Important neurologic PE considerations in elderly pts
Evaluate vibration — may be normal
Reflexes
Observe for asymmetrical test results — could suggest stroke
Mini mental status exam to evaluate cognition
What reflex may be absent in older adults?
Ankle reflex
Fastest-growing source of disability due to neurologic disorder in elderly pts; risk factors include older age and family hx, evidence may show that smoking is protective
Parkinson disease
PE findings of Parkinson may include tremor, bradykinesia, rigidity, postural instability, and gait changes. Nonmotor sxs include cognitive dysfunction, dementia, mood d/o, sleep d/o, fatigue, autonomic dysfunction, olfactory dysfunction, and pain. Symptomatic tx may include levodopa, amantadine, MAO-B inhibitors and/or anticholinergics. What are some important non-pharmacologic treatment considerations?
Education
Emotional/psychological support
Exercise
PT/OT/speech therapy
Meditation
Nutrition
Parkinson disease OMT research findings
Those treated with OMT had significant increases in stride length, cadence, and max velocities of upper and lower extremities
Tremors, balance, mobility improved post-treatment
Pts with PD may be more susceptible to SD in head/cranial and cervical regions
Pulmonary changes seen in aging population
Decreased chest wall compliance (increased work of breathing)
Loss of lung parenchymal support
Decreased resp muscle strength (decreased effective cough)
Increased alveolar dead space
Increased perception of SOB —> anxiety!
Calcification of costal cartilages
Decreased PaO2
[overall result is decreased secretion clearance, effects of hypoxemia, and increased risk of pulmonary complications]
Cardiovascular changes seen in aging population
Calcification and sclerosis
Increased sympathetic tone
Decreased hemodynamic response to inotropic agents —> fatigue, decreased endurance, depression
[clinical predisposition to HTN, LVH, orthostatic hypotension, valvular stenosis, endocarditis, conduction abnormalities, decreased hemodynamic response to stress, decreased response to stress]
4 major complications/comorbidities of HTN
Heart attack
Stroke
Chronic heart failure
Kidney disease
HTN prevalence is higher in _____ until age 45, then it is similar in both sexes until age 64, and in 65+ the prevalence is higher in ____
Men; women
Diagnostic criteria for HTN stage 1 vs stage 2
Stage 1 = 140-159/90-99
Stage 2 = 160+/100+
[pre-HTN is 120-139/80-89]
Exacerbating factors for HTN
Obesity Sleep apnea Increased salt intake Excess alcohol Cigarette smoking Polycythemia NSAIDs Low K+ intake Metabolic syndrome
[also note secondary causes of HTN — genetic syndromes, kidney dz, renal vascular dz, primary hyperaldosteronism, cushing, pheochromocytoma, coarctation of aorta, hypercalcemia, medications]
S/s of HTN
Signs — elevated BP, retinal changes, LVH, radial-femoral delay (coarct of aorta)
Symptoms — headache, somnolence, confusion, visual disturbance, n/v
Non-pharmacologic HTN tx include DASH diet, weight reduction, reduced alcohol intake, reduced sodium intake, increased exercise, relaxation techniques, and biofeedback (with DASH, weight loss, and exercise being most effective).
One study showed that OMT decreased BP by at least ____ mmHg; _____ hemoconcentration, ______ fibrinolytic activity, and _____ fibrinogen concentrations
3; decreased; increased; decreased
Research has shown that somatic dysfunctions at ___, ___, and ____ are much more common in pts with hypertension
C6, T2, T6
In a 1983 study, authors concluded that there was a high correlation of changes in ____ in pts with significant cardiac disease in men and women
T4
5th leading cause of death >65 y/o and most common infectious cause of death; evidenced by fever (+/-), cough, malaise, chest pain, mental status change, and/or renal dysfunction
Pneumonia
Risk factors for PNA in elderly
COPD Immunosuppression Smoking CHF Diabetes Malignancy Previous hospitalization for CAP
Studies have shown that __________ (OMT finding) have a sensitivity and specificity of 69% for acute PNA. _______ in the elderly is associated with a 9x increased risk of death in PNA pts, and OMT is capable of reversing the effects of this risk factor. There is also evidence that OMT reduces the mean length of hospital stay as well as overall risk of _______ in PNA.
Chapman’s points; immobility; mortality
3 considerations regarding aging immune system in elderly pts
Decreased T cell function
Decreased Ab production
Increased autoantibodies
[predisposes to infections, malignancies, and autoimmune d/o]
Considerations regarding the aging GI system in elderly pts
Decreased gastric HCl production
Colonic motility diminished
Decreased calcium absorption
Decreased hepatic biotransformation
Decreased hepatic albumin synthesis
[leads to altered drug absorption, constipation, osteoporosis, altered pharmacokinetics]
Considerations regarding aging GU system in elderly pts
Decreased bladder capacity
Alterations in pelvic support
Enlarged prostate gland
Diminished vaginal/cervical secretion
Decrease in sexual response
Infection is the primary cause of death for 1/3 of individuals aged 65 years and older. What are factors contributing to increased risk of infection in elderly?
Immune senescence (decline in T cell function, decline in Ab responses, decreased B cells)
Increased disease burden
Breakdown of barriers to pathogens (skin, mucosal linings)
Communal living/institutionalization
Indwelling devices
Physical exam considerations in elderly pts with infection
Symptoms may be absent or atypical
Altered febrile response in some frail older adults — for healthy, community dwelling older adults: >38 C (100.4 F); for frail older adults: >37.8 C (100 F) oral or >1.1 C (2F) above baseline temp
Constitutional sxs may necessitate further testing (changes in functional status)
Research findings regarding preventative OMT in nursing home residents
OMT significantly reduced number of hospitalizations and decreased medication usage in elderly nursing home residents
Short-term effect of a lymphatic pump protocol on blood cell counts in nursing home residents
With thoracic inlet MFR, splenic pump, and pedal pump utilized one time for 6 minutes, there were statistically significant decreases in platelet counts
Effects of adjuvant lymphatic OMT in pts with LE ulcers
Thoracic inlet MFR, doming the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump resulted in: decreased wound surface area and mean leg volume during intervention phase
Adjunctive OMT may have reduced edema and reversed trend of wound growth in pts with venous stasis ulcers
T/F: 74% of nursing home residents report constipation
True
[risk factors include female gender, physical inactivity, low education and income, concurrent med use, depression, malnutrition]
History taking in geriatric pts with constipation should include _____ criteria to check for IBS, as well as alarm symptoms including ____________; other considerations include abdominal exam, rectal exam, and/or colonoscopy
Rome; hematochezia, +FOBT, weight loss, FHx colon cancer, or IBS
Viscerosomatic changes and Chapman’s reflexes associated with constipation
Sympathetics to colon = T10-L2
Chapman’s =
Anterior: antero-lateral thigh along IT band
Posterior: L2-L4 TP extending laterally to iliac crests
OMT considerations for constipation include colonic release and normalization of autonomics. OMT is considered a less-invasive, less costly treatment option for pts with colonic inertia based on a JAOA study in 2013. What was the effect of OMT on chronic constipation in a 2009 study assessing 3 domains — severity (cleveland criteria), transit time (bristol stool scale), and pt assessment and quality of life?
Statistically significant improvement in all 3 domains
Behavioral changes with aging in elderly populations
Decreased activity/mobility (falls, accidents)
Decrease in memory
Decrease in brain weight
Bereavement, disability, loss of independence/impairment of ADLs — may lead to depression, alcohol abuse, tobacco abuse, malnutrition
Cognitive changes
Leading cause of injury among older adults in US
Falls
Test utilized in fall risk assessment in all older persons who report a single fall
Get up and Go test — assesses balance and ambulation
[from a sitting position, stand without using arms for support, walk several paces, turn, and return to chair. Sit back in chair without using arms for support]
Fall-related risk factors
Vitamin D deficiency
Decreased strength or balance control
Somatic dysfunction
Medication
Depression
Environmental hazards
What type of exercise was proven in a research study to be the most cost-effective prevention of falls for community dwelling seniors?
Tai chi
Effect of OMM on gait dysfunction and balance in elderly population
58% decrease in steps taken, improved step/stride length, increased velocity
A/P sway was significantly reduced in OMT group
T/F: suicide rates are 2x lower in the older adult compared to general population
False; they are 2x higher
[note atypical presentation — increased somatic complaints, cognitive changes, sleep problems, fatigue, low energy]
How high does one have to score on the geriatric depression scale to be considered as “probable depression”?
> 5/15
Scoring the mini mental state exam
Maximum score is 30
Mild impairment = 21-29
Moderate = 10-20
Severe = <9
Treatment for depression in the elderly may include psychotherapy, monotherapy with SSRIs, ECT, and/or OMT.
What did research show regarding adjunctive OMT in women with depression?
All pts in OMT group reverted back to normal range on Zung depression scale by week 8
OMT considerations for geriatric pt with depression
Treat SDs that are part of atypical presentation — i.e., chronic pain, LBP
Balance autonomics — eval and treat OA/AA and sacrum
Some evidence for efficacy of cranial manipulation in depression and anxiety
