Test2 Flashcards
1
Q
Signs of elder abuse
A
Physical: injuries/trauma, bruises, emaciation
Behavioral: anger, helplessness, suicidal actions
Psychological: fear, anxiety, depression
Social: limited contacts, withdrawal
Others: trouble sleeping, messy look or unwashed hair or dirty clothes, develops preventable conditions
2
Q
PD- Late Middle Characteristics
A
All symptoms worse, but independent with ADLs
3
Q
Intrinsic -
Motivation
A
Achieve goals (function, participation, etc)
To have control of their circumstances
4
Q
TSA: technique indications and implications
A
- Anatomic TSA
Must have intact rotator cuff
For all forms of degenerative or inflammatory glenohumeral damage
2. Reverse TSA In presence of complete tear of rotator cuff Must have intact deltoid More common for proximal humerus fx Revision TSA
5
Q
PD of >15 years are ___ to fall
A
5x more likely
6
Q
Extrinsic -
Motivation
A
Please someone else
Praise, attention
Punishment (negativity)
7
Q
Hypoglycemia
A
Blood glucose <70 mg/dL
Causes: OD insulin, late or skipped meals, or overexertion in exercise
S/S: headache, weakness, irritability, poor muscular coordination, inability to respond to verbal commands
Need to ingest carbs
8
Q
PD - general goals of therapy
A
Maintain/Increase activity level
Decreasing rigidity or bradykinesia
Optimizing gait
Improving balance and motor coordination
9
Q
PD - Late
Interventions
A
Physical:
Compensatory exercise; Dietar; Skin care/Hygiene; Pulmonary function
Pharmacological:
Levodopa/carbidopa (Sinemet); Dopamine agonists; Antidepressants
Psychosocial:
Dementia; Depression
10
Q
TJA (total joint arthroplasty)
Therapy continuum
A
Phase I: Pre-Hab
Phase 2: TJA acute care
Phase 3: Post-Acute rehab
Phase 4: Post-rehab
11
Q
People-first language
A
Emphasizes the person first, not the disability by starting the phrase…
“Person who..” or “Person with…”
12
Q
Type 1 DM Age of onset? Proportion? Type of onset? Etiologic factors? Body weight at onset?
A
Age of onset: Usually < 20 y/o
Proportion: < 10%
Type of onset: Abrupt
Etiologic factors : possibly viral/autoimmune, resulting in destruction of Islet cells
Body weight at onset: Normal or thin
13
Q
Nursing home
Reimbursement
A
Insurance
Private pay
Medicaid
Note: rehab services covered under Part B Medicare if patient has it
14
Q
TJA- total joint arthroplasties
Who?
A
2018 - mean age 66.8 (primary and revision)
- 5 years THA
- 8 years TKA
- 9% F
- 1% M
Projected growth of 171% THA and 185% TKA by 2030
Typically elective w/ older adults (patients healthy enough for a major surgical procedure)
15
Q
Key aspects of Patient Centered Care
A
- Patient’s values and preferences guide POC
- Focus on the PERSON not the illness
- Quality and value defined by respect for personal choices
- Goals driven by the patient and their functional desires
- Patient empowerment to take an active role in care plan
16
Q
Medicare Part A
A
Automatic- pay into system while working
Hospital, SNF, Hospice, some HHC
17
Q
Prevents the body from properly using energy from food
A
DM
18
Q
PD- Late Characteristics
A
Severely disabled, impaired
Dependent with ADLs
19
Q
DM diagnosis
A
Classic symptoms + plasma glucose =>200 mg/dL
Fasting plasma glucose =>126 mg/dL
A1c > 6.5%
20
Q
Rehabilitation in Reverse
A
Hospice PT
Assisting a patient and caregivers as their mobility declines
May include equipment recommendations, Ned mobility for positioning and comfort
PRN visits may be indicated
21
Q
PD- external cues
Auditory
A
Metronome
Music
Step to the count
22
Q
PD- Early Middle Characteristics
A
Symptoms bilateral Bradykinesia, Rigidity Mild speech Axial rigidity Stooped posture Stiffness Gait impairments
23
Q
Pharmacodynamic changes
A
How drugs affect the body.
Physiologic system changes
Cellular level changes (Increased/decreased receptor sensitivity)
Biochemical response changes
24
Q
Older adults consume more drugs compared to younger counterparts.
Because…
A
More illness
More adverse drug reactions (ADRs) - altered response to drug therapy
Physician reliance on drug therapy over non-pharmacologic options
Multiple Rx from multiple providers
OTC and self-help remedies
Sharing of medications
25
PD- Bradykinesia
| Impact on mobility
Slow, small movements
Narrow BOS
Lack of arm swings
26
DM
| Long term consequence - Kidneys
Leading cause of end-stage renal disease
27
ALF: assisted living facility
Patients that need housing, supports and health care
Not to be confused with senior independent living apartment communities
Some offer a continuum of care
28
9 physiological signs of death
1. Confusion, delirium, disorientation
2. Increased time sleeping
3. Anxiety, restlessness
4. Weakness, functional loss, fatigue
5. Reduction in BP, variable irregular HR
6. Rapid breathing w/ periods of apnea
7. Cool distal extremities
8. No interest in food
9. Constipation, diarrhea, incontinence, reduced urine output
29
```
Nursing home (long-term care)
2 avenues of entrance
```
1. Pt may need 24 hour care, but has no primary need or does not qualify for skilled nursing therapy
Nursing staff available around the clock.
Rehab services available as OP
Services billed under part B
2. Pt may initially have Part A services either by being admitted to facility:
As a prior non-resident under skilled nursing status and then transition to residency
As a resident w/ a qualifying hospital stay that requires follow-up skilled nursing services and/or rehab with eventual transfer back to LTC status
30
PD- Freezing
| Impact on mobility
Decreased anticipatory postural adjustment
Abnormal mapping of body and movement
Abnormal visual-spatial maps
Divided attention affects mobility
31
Post-acute setting?
| More complicated dx and ability to tolerate at least 3 hours a day therapy
IPR
32
Prediabetes
Body can’t use glucose correctly
Body cells don’t recognize all insulin
Or
Cells stop responding to action of insulin
Rise in blood glucose
May have trifecta of prediabetes, HTN and dyslipidemia- increases risk of Type 2 DM and heart disease
33
VA healthcare
Free for veterans with service-connected conditions
Must apply and qualify
Must receive services at a VA facility
Co-pays for veterans with non-service connected conditions and based on income
34
PD- Bradykinesia
| Exercise principles
Fast, large steps
Large arm swings
During ambulation, in semi-tandem...
35
LADA
Latent autoimmune diabetes in adults
Slow progressing form of autoimmune diabetes
Similar etiology to Type 1, but onset usually >30 y/o
Don’t need insulin for several months to years after diagnosis
36
Pre-fracture factors indicating poor functional recovery
| Hip fractures
```
Decreased pre-fracture functional independence
Greater co-morbid disease burden
Cognitive impairment
Affective status/depression
Poor nutritional status
Poor social support
Presence of frailty
```
37
Medicare Part D
Premium
Prescription drug coverage
38
```
Type 2 DM
Age of onset?
Proportion?
Type of onset?
Etiologic factors?
Body weight at onset?
```
Age of onset: usually >40 y/o, but increasing number in all ages, including kids
Proportion: >90%
Type of onset: gradual
Etiologic factors: obesity-associated insulin resistance
Body weight at onset: majority (80%) obese
39
Type 2 DM
| Cardinal s/s
May have polyuria and polydypsia
Visual blurring
Neuropathic complications
Infections
Significant blood lipid abnormalities
Often asymptomatic
40
Rock Steady Boxing
Founded in 2006
Classes offered at affiliates (gym, T, Sr centers..)
Usually 2x week
Small fee per class
Improvements in balance, gait speed, and perceived QOL, and maintained it.
41
Characteristics of polypharmacy
Use of meds for no apparent reason
Use of duplicate meds
Concurrent use of interacting meds
Use of contraindicated meds
Use of inappropriate dosage of meds
Use of drugs to treat ADRs (adverse drug reactions)
Patient improves w/ discontinuation of meds
42
Balance in PD
Balance exercises should begin in early stages of disease
Equilibrium reactions in all planes of movement
Rhythmical stabilization to increase static balance
As long as resistance doesn’t increase truncal rigidity
Timing of resistance must be gradual
Dynamic balance techniques
43
```
Hypoglycemia
Onset?
Mood?
Mental status?
Skin?
Pulse?
Respiration?
Breath?
```
```
Onset: rapid
Mood : labile, irritable, nervous, weepy
Mental status: difficulty concentrating, speaking, focusing, coordinating
Skin: pale, sweating
Pulse: tachycardic
Respiration: shallow
Breath: normal
```
44
PD- functional assessment
1. Sit to stand
2. Bed mobility
Rolling
Supine <> Sit (Key is in Knees- Knee flexion rotations for everyone.)
3. Gait
Different environments and challenges
45
Skilled Maintenance
Hospice PT
Maintenance of QOL unable to be performed safely by other caregivers
Ex: ambulation and transfers that a caregiver can’t manage 2ndary to severe weakness and balance limitations in conjunction w/ caregiver limitations
46
DM
| Long term consequence - skin
Neuropathic Ulcers
47
DM
| Exercise education
Glucose before and after to determine needed levels of intake
48
PF- Middle Stage
| PT focus
Treat ADLs, gait, balance, and postural deficits that are being impacted
Optimize postural alignment
Maintain postural stability
Reduce multi-tasking to prevent falls
Increasing movement speed/amplitude
Focus on cognitive and motor movement strategies, cueing strategies
Teach compensatory strategies to maintain QOL
Suggest support group for patient and caregiver
49
PD- Freezing
| Occurs when...
```
Approaching doorways, obstacles, or chairs
When turning or changing direction
When distracted while walking
Crowded or cluttered places
Medication isn’t working well
```
50
DM
| Long term consequence - Eyes
Retinopathy: damage to retina did to abnormal blood flow
51
Blood glucose cautions with exercise
250-300 mg/dL = Caution
Do NOT exercise with => 250 mg/dL with evidence of ketoacidosis
Do NOT exercise >300 mg/dL
< 100mg/dL consider snack and retest or make decision based on symptoms
52
Home health
| Reimbursement
Medicare Part A
PPS
60 day national episode payment (certification period)
OASIS (outcome and assessment information set) - assessment tool
Health condition and care needs
In past therapy has impacted payment for HHC, however this is changing (2020)
53
Patient-centered goal setting
Primary way to enhance patient centeredness
Improved outcomes and satisfaction
Can be critical for motivation
Highly personal
54
PD-Late Middle
| Interventions
Physical:
Corrective and compensatory exercise
(Speech and Occupational therapy)
Pharmacological:
Levodopa/carbidopa (Sinemet) ; Dopamine agonists; Selegiline; Antidepressants
```
Psychosocial:
Caregiver issues (medications, mobility); Monitor for dementia
```
55
PD- balance
| Functional
Specific practice
```
Compliant surfaces
Uneven surfaces
Incline/Decline
Stairs/Curbs
Obstacles
Dynamic BOS
Visual modification
Dual task
```
56
PD- Late Stage
| Non-motor
```
Dementia
Incontinence
Skin changes
Sexual dysfunction
Pain
```
57
PD- external cues
| Attention
Visualize movements
Focus on each step of the task
Counting 1,2,3...
“Look through the doorway”
58
What influences motivation?
Self-efficacy expectations
Belief in capabilities
Outcome expectations
Belief personal action will produce certain consequence
```
Enhanced by:
Successful performance
Verbal encouragement- “you are capable of this”
Vicarious experience
Physiologic and affective states
```
59
TJA Pre-operative educational classes
Multidisciplinary format w/ goals of:
Prepare for surgery and recovery related issues, including surgery procedure, therapy expectations and post-op routine
Decrease post-op complications
Increase likelihood of d/c home vs facility and decrease LOS/hospital costs
Help identify post-op support system and decrease anxiety
Encourage patient’s active role in recovery
60
6 things
| Individualized care
1. Recognizing individual needs and differences
2. Using kindness and humor
3. Empowering to take active part
4. Gentle verbal persuasion
5. Positive reinforcement
6. Be genuinely interested
61
OA in the older athlete
Common in aging adult
Equally common in the older athlete
Strong flexible muscles act as shock absorbers
Treatment should focus progressive resistance exercise, education on functional activities that minimize compression and shear:
Cycling, rowing, swimming, walking, cross training
Increase in total joint arthroplasties w/ expectation of return to sport
62
Aging and motivation
Greater self-regulatory
Focus on positive
Immediate benefits of behavior
Stronger adherence
Positive self-concept
Social supports
Information-seeking behavior
63
Modifiable risk factors for Type 2 DM
Physical inactivity
High body fat or body weight
High BP
High cholesterol
64
PD- balance exercises
| Dynamic
Bosu ball
Lunges
Step-ups
Wii balance board
65
Hip fractures-
FNF (femoral neck fractures)
Typical repairs
< 65 years old : internal fixation
THA: older individuals or those with already limited mobility
66
Festination and Propulsion (PD)
COG too far forward over BOS
Slow velocity of gait
If doing this...
STOP -
Use cue to start again: “BIG” step, reach for your heel
(U-Step walker: brake to stop)
Add weight posteriorly to walker or belt - trying to move COG posteriorly- if needed
67
OP therapy
| Reimbursement
Medicare Part B
80% covered
Cap has been removed
PT bills for services for reimbursement
Reimbursement based on Medicare fee schedule
68
8 considerations when teaching new information or skills to older adults
1. Accommodate for slower speed of mental processing
2. Present one new item at a time, if possible, before moving to the next item
3. Encourage “errorless” learning
4. Incorporate compensatory strategies as needed
5. Incorporate multimodal sensory inputs
6. Encourage formation of a “habit”
7. Have older adult verbalize new habit to encourage formation of intentions to be completed in the future (prospective memory)
8. Have older adult paraphrase the info or demo the new skill
69
Social support
Need to investigate and understand what their social support is
Teach those involved in supporting patient
Use social support in goal setting
70
5 reasons why many aging adults have difficulty understanding verbal and written health communication
Sensory deficits
High stress and/or anxiety
Language barrier
Communication at TOO HIGH LEVEL
Lower health literacy
71
Injuries in older athletes
| Macrotrauma (Acute, Traumatic)
Trauma occurs less frequently
Participation in less contact sports
Exceptions: cycling, hiking, climbing, skiing (falls and accidents common with these sports)
More likely to sustain a fracture than rupture ligament (2ndary to decreases in bmd)
More likely to tear or avulse muscle than strain muscle - bc increased collagenous stiffness
Increased recovery time needed- deconditioning occurs faster 2ndary to normal age related changes (can be frustrating)
72
Exercise and DM- evidence
Improved skeletal muscle glucose transport
Improved whole body glucose homeostasis
Increase insulin sensitivity 12-72 hours post exercise
Increases carbohydrate metabolism
Reduced risk of CV mortality
73
DM stats
14.6 million Americans diagnosed
Appx 6.2 million undiagnosed
25% adults in US have prediabetes
Nearly 50% with DM are older than 60
Nearly 25% over 65 have DM
Projected to be 1 in 3 with DM by 2050
Most common endocrine disorder
A leading cause of death
Leading cause of blindness and renal failure in adults
74
The pancreas has 2 functions:
1. Endocrine gland secreting hormones: insulin and glucagon
| 2. Exocrine gland producing digestive enzymes
75
Hip fractures- therapy considerations
| Acute stage
Goal: resort mobility asap
Pt likely has pre-existing lower function, fall-risk
High likelihood of limited WB
PWB requires 30-50% > energy than normal ambulation
Higher stakes for bed rest, immobility complications
Consider other areas of osteoporosis risk when planning mobility
76
PT in hospice care - types
Rehabilitation Light
Rehabilitation in Reverse
Skilled Maintenance
77
PD- Rigidity
| Impact on mobility
Loss of spinal flexibility is seen in early stages and correlated w/ functional performance tasks
Reaching, supine to sit, balance control
Agonist/Antagonist Co-Contraction
Flexed trunk
Decreased trunk rotation
Decreased joint ROM
High axial tone
78
Hyperglycemia
Causes: infection, missed insulin doses, surgery, pregnancy, renal failure, uncontrolled DM
Can occur in those w/ or w/o DM
High intensity aerobic exercise
79
PD- external cues
| Visual
Visual:
Laser
Tape lines or Xs on the floor
80
Both of these serve as a bridge between living at home and being hospitalized, especially those with functional decline (sometimes serve as a “testing ground” for whether home even an option eventually)
SNF and IPR
81
Ketoacidosis
Typically occurs from
Prolonged hyperglycemia
(More common in Type 1)
Fruity breath (acetone), dehydration, weak and rapid pulse, Kussumal respirations
82
Hip fracture surgery is considered...
Urgent
To significantly lower risk of death
Followed by early mobilization-
Up in chair w/in 24 hrs, walking in 48 hrs
83
PD- gait training
```
LSVT “BIG” theory
Locomotor training
Split belt treadmill
Obstacle courses
Inside vs Outside
Environment (quiet vs crowded)
Attention (focus vs divided; add dual tasking)
```
84
DM
| Long term consequence - CV
CVD leading cause of M/M in DM
1.5-4 fold increased risk of CAD, stroke, or MI
Diabetic cardiomyopathy
Atherosclerosis begins earlier and is more extensive in Type 1
Higher risk of CAD, stroke and PVD in Type 2
85
Geragogy recognizes older adulthood as a developmental stage with key elements concerning...
Age-related
Sensory, Physical, Psychological, Cognitive, and Psychosocial
Changes
86
Acute care
| Reimbursements
IP PPS (inpatient perspective payment system)
```
DRG method (diagnostic related group)
Medicare Part A
Lump sum based on diag
Severity of illness considered
Co-morbidities considered
```
Consideration- must be cost effective, productivity matters
PT does not impact payment
87
Rehabilitation Light
Hospice PT
PT once a week or biweekly
Slow, easy strengthening exercises and functional activities
Issue an HEP...very light, but essential to slow progression
88
DM
| Long term consequence - MSK
Distal joints/segments
Syndrome of limited joint mobility and stiff hand syndrome
Dupuytren contracture
Adhesive capsulitis
DISH: diffuse idiopathic skeletal hyperostosis
Arthritis
Osteoporosis
89
LTAC
| Reimbursements
Medicare Part A
PPS based on length of stay >25 days
Number of days based on dx and co-morbidities
Full payment received at 5/6th of Stay
Money made this way
Money list if patient stays past assigned length of stay
Consideration- must be cost effective, productivity matters
PT does not impact payment
90
PD- external cues
| Proprioceptive
Weight shifting/Rocking
Side step
Backward step
Tapping your leg
91
Hospice care
Covered by Medicare Part A
Terminal condition w/ 6 or less months to live
No longer seeking cure
92
Limitation in the ability to obtain, process, and understand basic health information and services necessary to make appropriate health decisions and follow treatment instructions
Health literacy
93
Two-hour oral glucose tolerance test
Normal?
Prediabetes?
Diabetes?
Normal
< 140 mg/dL
Prediabetes
140-199 mg/dL
Diabetes
> 200 mg/dL
94
3 physical settings of subacute care
LTAC
IPR
SNF
95
Assisted Living
| Reimbursement
Insurance
Private pay
Note: rehab services covered under Part B if patient has it
96
PD- Sensorimotor Agility Exercise
| Early stage
Boxing: anticipatory postural adjustments/corrections, fast arm/foot motions, backward walking, timing/sequencing actions
Lunges: big steps, limits of stability, quick direction changes
Kayaking: trunk rotation, segmental coordination, speed, reciprocal UE movements
Tango, Video games, Zumba
Challenge mind and body simultaneously: Multitasking (physically, cognitively, alter environment)
97
Post-acute setting?
Single joint replacement, conditions requiring much longer recovery period, or pt who can’t tolerate 3 hours therapy per day
SNF
98
Polypharmacy
Administration of many drugs together
Administration of excessive medication
Excessive or inappropriate use of medications
99
TJA Pre-operative PT
High-intensity strength training
Patient training on walking devices
Planning for recovery
Managing patient expectations
Value NOT from:
Multiple intensive training sessions for strength and ROM
May or may not decrease hospital LOS or d/c disposition
May or may not affect post-op function
100
Acute care PT
| THA/TKA
Early intensive rehab (decreases physiological disturbances)
As early as POD zero
May be at a day surgery facility
Associated w/ decreased DVT/PE, chest infections, urinary retention, HAI risks
Results in accelerated functional recovery and earlier hospital d/c
Within first 24 hours of surgery- optimally POD zero
Emphasize function for optimal d/c - home
Early strengthening
Education very important
101
IRF
| Reimbursements
Medicare Part A
PPS- predetermined fixed amount
Payment based on inpatient rehab facility patient assessment instrument (IRF-PAI)- FIN Scores
Distinct groups based on clinical characteristics and expected needs
Consideration- if patient unable to be seen 3 hours say on average 5-7 days a week, payment will be impacted
Patient will need to d/c to another location
Therapy impacts payment
102
To control DM, exercise must be done with ___ between sessions
Exercise best ___.
Avoid exercise....
No more than 2-3 days between sessions
Exercise best about 1 hour after a meal
Avoid exercise at night and alone
103
LSVT “BIG”
Training program designed to promote high amplitude/BIG movements of limbs and body
Designed to improve speed, balance, and QOL
4x week for 4 weeks
Intense program with many repetitions
Must be certified as a “BIG” therapist to document “BIG” treatment
“High amplitude training” when not certified
104
Medicaid
Low income coverage for those over age 65
< $1025 month
Provides coverage for premiums, out of pocket expenses, nursing home care, prescription drugs
Medicare pays first then Medicaid pays
Administered by federal and state governments
May have different names
Must check eligibility often
105
“Carpe Diem” HEP
```
Cervical rotations
Chin tucks
Shoulder ABD/ER and FLEX
Knee FLEX rotations
Bridges and/or pelvic tilts
Hip ABD/ADD (knees flexed)
Knee to chest stretch
Hamstring stretch
Ankle pumps (10-20x each)
Deep breaths
```
106
Hip fractures- therapy considerations
| Post-Acute stage
Likely will require post-acute IP stay
(Many hip fx >85 qualify for IPR)
Focus on precipitating factors to the causative agent for hip fx. (Fall, osteoporosis, cognitive deficits, home environment, support...)
AND how normal aging changes/augments
Fear of falling
107
Injuries in older adults-
| Microtrauma (Overuse injuries)
Muscle strains, bursitis, tendinopathies
May be more prone to these injuries when compared to younger athletes
Stiffer, less flexible
Arthritic changes
Less shock absorption and protection
Joint pain and edema more common in older athletes as compared to their younger counterparts (structural changes)
108
7 Common ADRs
| adverse drug responses
1. GI symptoms (Opioids, non-opioids, NSAIDS)
2. Sedation (Opioids, analgesics, antipsychotics)
3. Confusion (Antidepressants, narcotics, anticholinergic)
4. Depression (Barbiturates, antipsychotics, antihypertensive)
5. Orthostatic hypotension (HTN drugs)
6. Fatigue/Weakness (diuretics and muscle relaxers)
7. Dizziness/Falls (sedatives, antipsychotics, opioids, antihistamines)
109
PD- Early stage
| Characteristics
Fully functional
May have unilateral tremor (resting), unilateral rigidity, bradykinesia
Non-motor: constipation, depression, apathy
110
Hip fractures-
Intertrochanteric fractures
Typical repairs
Sliding hip screws
Intermedullary nails (done Percutaneously w/ less surgery time and less blood loss)
Often PWB
111
Aging adults may require a ___ assessment to determine specific needs.
Usually __ in nature
Essential the older adult receive ___
Comprehensive assessment
Interdisciplinary in nature
Essential to receive the level and types of services required to address needs
112
PD - Late Stage
| Motor
```
Falls
Retropulsion
Freezing
Choking
Aspiration
Axial rigidity
Drooling
Decreased breath support
```
113
Hip fractures- types
1. Intracapsular (45%)
Involving femoral head and neck
2. Intertrochanteric (45%)
3. Other : (10%) subtrochanteric
114
Non-modifiable risk factors for Type 2 DM
Family hy of DM
>45 y/o
Race/ethnicity
Hy of gestational diabetes
115
Post-Acute PT THA/TKA
Largest proportion of therapy time
Optimal d/c home and start HH or OP PT
May need dispo other than home first - be aware of other issues (family, insurance, home environment etc)
Sometimes older adults have complicated and longer recovery. Co-morbidities.
Slow recovery TKA > THA but more lingering gait abnormalities THA
116
Assessment of senior athletes
Norm referenced tests:
Senior fitness test
YMCA fitness test
ACSM fitness test
Sport or movement specific exam:
Selective Functional Movement Assessment
whole body functional approach
117
PD- Early
| Interventions
Physical:
Preventative exercise program
Pharmacological:
Anticholinergics (tremor)
Selegiline (neuro-protection)
Psychosocial:
Education; Information
118
SNF
| Reimbursements
Medicare Part A
100 days of coverage
Days 1-20 paid in full
Days 21-100 copay up to $164.50 day
Per diem PPS
Covers all costs (routine, ancillary, capital)
Resource utilization groups III (RUGs)
Based on resident assessment and classification using MDS 3.0
Number of therapy minutes and day’s impacts reimbursement
119
Motivating the older adult-
| Challenges
Overcoming fear
Graded exposure
Building on baseline tolerance
Apathy
Medication may be necessary first step
Focus on activities that can be done successfully
120
```
Hyperglycemia
Onset?
Mood?
Mental status?
Skin?
Pulse?
Respiration?
Breath?
```
```
Onset: gradual
Mood: lethargic
Mental status: dulled sensorium, confused
Skin: flushed, dehydrated
Pulse: less rapid, weak
Respiration: deep, rapid (Kussmaul)
Breath: fruity
```
121
PD- Early Middle
| Interventions
Physical:
Corrective exercise program
Pharmacological:
Levodopa/carbidopa (Sinemet)
Selegiline (neuro-protection)
Psychosocial:
Counseling; Support groups; Monitor for depression
122
Hip fracture- facts
Initial mortality following hip fx is high
In-hospital mortality 2.3-13.9%
For women, 5-fold increase for all cause mortality first 3 months after fx
For men, 8-fold
1/3 of elderly patients dead 1 year after hip fx
123
```
PD- gait training
Dynamic exercises (8)
```
```
Tandem
Backwards
Side steps
Grapevine
Stopping
Starting
Turning
Changing directions
```
124
TSA: therapy considerations
No extensive pre-op education pathways like THA/TKA
Patient in sling- what can do:
Gait disturbances primary issue w/ aging adult
(Pt can’t swing arm...balance? Need for AD?)
Joint mobility at other shoulder
Functional reach using alternate strategies
Core strengthening
One-armed ADL strategies
Functional mobility and bed mobility strategies
May need OT referral
125
PD- 7 Rigidity treatment examples
```
1. Manual therapy
Stretching/PROM/AROM
Joint compression/approximation/traction
2. Deep breathing/relaxation
3. PNF
4. Core strengthening
5. Tai Chi
6. Kayaking
7. Large amplitude steps w/ directional changes
```
126
PD- Freezing
| What to do...
Stop,
take a deep breath,
weight shift side to side,
try a side or backwards step before trying to take a “BIG” step forward
Try different cues
Frustration or stress = worse
127
8 communication tips
1. Slow down, allow extra time
2. Use plain, nonmedical language
3. Show or draw pictures
4. Limit amount of info and repeat it
5. Use the teach-back technique
6. Create a shame-free environment; Encourage questions
7. Sit face to face, use eye contact
8. Listen w/o interrupting
128
MODY
Maturity onset diabetes of the young
More likely to be inherited, stronger genetic risk factor
Shares Type 2 symptoms
NOT linked to obesity
Develops before age 25
129
Fasting plasma glucose test
Normal?
Prediabetes?
Diabetes?
Normal
< 100 mg/dL
Prediabetes
100-125 mg/dL
Diabetes
> 125 mg/dL
130
Fundamentals of LSVT “BIG”
1. Target
BIG- large amplitude whole body movements
2. Mode
High intensity: modulated by LSVT specialist
Requires consistency over 4 week period
3. Calibration
Calibration of perception of movement
Mismatch between patient perception of output and how others perceive it
4. 7 BIG exercises for HEP
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Rehab considerations
Proximal stability will facilitate distal mobility- Don’t forget the core
Generalized strengthening is important -
Don’t forget appropriate exercise prescription
Stretching:
Warm up imperative and may include some stretching
Cool down stretching is better
60 seconds is better than 30 in the older adult
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PD- balance exercises
| Static
```
Wobble board
Air-ex/Foam pads
EO/EC
Head turns/nods
Reaching outside BOS
Perturbations + protective step response
Seated on physioball
```
133
Self efficacy beliefs
Verbal encouragement of capability
Expose to role models
Decrease unpleasant sensations associated w/ activity
Encourage actual PRACTICE
Educate on benefits and reinforce those benefits
134
PD- Middle stage
| Motor
```
Bilateral features
Wearing off meds
Dyskinesias
Increased rigidity
Hunched posture
Shuffling gait
More assistance needed w/ ADLs such as fine motor tasks, increased slowness (more difficulty w/ transfers)
```
135
PD- How does cueing work?
Basal ganglia acts as an internal cue to enable movement sequences to be carried out implicitly, automatically and w/o attn
Cues replace these lost internal cues w/ an external cue
Bypass BG dysfunction path
Learning shifts from implicit to explicit
Cueing = motor learning tool
136
Defective ___ function in pancreas results in DM
Endocrine
137
Goals should be...
Related to specific behavior
Challenging but realistic and attainable
Achievable in the near future
138
TSA (total shoulder arthroplasty)
3rd most common after THA and TKA
300% increase in past 15 years
Mean age 68.9
56% men
Higher rates of complications w/ advancing age and female gender
Men with first procedure <59 more likely to new revision procedures
139
Elder abuse %
Estimates as high as 10%
Most frequently verbal 9%
Financial 3.5%,
Physical <1%
140
Sit to stand
| PD Functional training example
Break task into parts:
1. Bend forward
2. Lift pelvis up
3. Extend knees and hip
4. Maintain standing
Repeated practice of impaired “parts”
Neuroplasticity - correct the impaired “part”
Encourage repetition
141
Pharmacokinetic changes
How body handles the drug. Drugs and metabolites remain active for longer periods of time- increasing risk for toxic side effects
Absorption- altered GI function
Distribution- changes in total body water, lean body mass, % body fat, plasma protein concentrations
Metabolism- reduced liver mass, decreased hepatic flow, decreased activity of drug metabolizing enzymes
Excretion - Decreased renal blood flow and mass, decreased function of renal tubules
142
Anticholinergic effects
Alters tissue response to ACh
Common w/ antihistamines, antidepressants, antipsychotics
CNS effects: confusion, nervousness, drowsiness, dizziness
Peripheral effects: dry mouth, constipation, urinary retention, tachycardia, blurred vision
Extrapyramidal symptoms: dystonias, tar dive dyskinesia, pseudo-parkinsonian (antipsychotics)
143
PD - Middle Stage
| Non-Motor
Cognitive decline evident with executive and visuospatial
Orthostatic hypotension
Mood disorders
Hallucinations are rare
144
PD- symptom based treatments
Rigidity
Exercise principles
```
Trunk rotation
Reciprocal movements
Rhythmic movements
Erect alignment
Large movements
```
Loss of spinal flexibility is seen in early stages and correlated w/ functional performance tasks
Reaching, supine to sit, balance control
145
Simplified metabolism
Food broken down into glucose
Glucose provides energy body needs
Pancreas releases insulin- signals cells to absorb glucose from bloodstream
W/O insulin, glucose can’t be utilized by cells for energy and glucose remains in blood (hyperglycemia)
146
PD- Late Stage
| PT focus
Appropriate equipment
Simplify tasks: breakdown movements; repetition, repetition
Sensory stimulation and movements
Educate caregiver: body mechanics w/ transfers; floor transfers (falls will happen)
Home evaluation
147
Hip fractures-
Subtrochanteric
Typical repairs
Hemiarthroplasty
148
Non-operative mgmt - hip fractures
For those who may gain only minimal function from stabilization because they were either...
Not ambulatory to begin with OR
Have severe dementia OR
Contraindications to anesthesia or medical conditions prohibiting surgery
149
Type 1 DM
| Cardinal s/s
Polyuria (excessive urination)
Polydipsia (excessive thirst)
Weight loss with polyphagia (excessive hunger)
Blurred vision
150
Geragogy
Teaching approach recognizing special needs of older adults related to learning
Need to fine-tune adult teaching and instructional styles for olde adults who:
Are post-career
No longer raising families
Are often frail
151
Medicare
> 65 years old and some disabled
Has 4 parts A, B, C, D
152
Medicare Part C
Medicare advantage plans
Provide both A and B and other services
Provided through private insurance companies
Locked in for certain periods of time, not able to use original Medicare
153
DM
| Long term consequence - Nerves
Sensory, motor and autonomic neuropathy
154
Aging in place
Allowing an older adult to live in their residence of choice for as long as they are able
Living in a community with some level of independence instead of residential care
155
PD- Freezing
| Exercise principles
Improve weight shifting m
Understand role of external cues
Exercise in small spaces
Practice dual tasks
156
The __ are cells of the pancreas involved in endocrine function
Islets of langerhans
Alpha: release glucagon- raises blood glucose
Beta: releases insulin- lowers blood glucose
157
Medicare Part B
Premium, deductible, co-insurance, co-pay
Doctor’s services, OP care, some HHC, labs, X-rays, DME
158
PWR: Parkinson’s Wellness Recovery
Founded by a founder of LSVT BIG
Basic4 PWR!Moves- targets skills impaired in PD w/ mobility
1. Antigravity extension (PWR!up)
2. Weight shifting (PWR!rock)
3. Axial mobility (PWR!twist)
4. Transitions (PWR!step)
Moves performed differently to target different symptoms. (Rigidity, bradykinesia, incoordination and automaticity.)
159
Hip fracture- statistics
Typically low trauma/low energy occur at mean age 80
75% older than 70
3 in 4 hip fx assoc deaths may be causally related to pre-existing medical conditions rather than fx itself
