Treating the geriatric patient

Question 1

How much more likely our geriatric patients to be hospitalized than middle-age adults?

Answer 1

Twice as

Question 2

How do PTs save the hospital money?

Answer 2

Shortening LOS
Reducing re-admission rates
Reducing falls and fall-related injuries
Reducing complications caused by immobility

Question 3

When can Medicare take back money from hospitals?

Answer 3

Medicare can effectively take back money from hospitals if patients are re-admitted for the same problem within 30-days of discharge for (HRRP) diagnosis

Question 4

What are the individual health remission reduction program diagnosis?

Answer 4

Question 5

What are the main aspects of the acute-care PT?

Answer 5

Assess patient’s current functional mobility and risk for falls
Plan of care should maximize patient’s mobility and ability to discharge to the next level of care
Make recommendations for DME and discharge location
Communication of recommendations to the rest of the care team
Most often RN, SW, CM

Question 6

What does geriatric acute-care require of the PT?

Answer 6

Management of patients receiving mechanical support
Recognition & management of pharmacology effects
Physiological effects of medical and surgical interventions
Monitoring patient’s responses to activity in a potentially critically ill state
Being able to anticipate and respond to patients who may begin to decompensate

Question 7

How often do patients 65+ require postacute care?

Answer 7

70% of the time

Question 8

What are the requirements for being admitted to inpatient rehab facility?

Answer 8

Must be able to tolerate 3 hours of therapy for 5/7 days each week or 15 hours in 7 days
Must require at least 2 therapy disciplines, with 1 being PT or OT
Qualifying medical condition
Required therapy must begin within 36 hours from midnight of the day of admission

Question 9

What are the qualifying diagnosis is for IRF?

Answer 9

Question 10

Were the main aspects of the inpatient rehab PT

Answer 10

Maximize functional independence to prepare for dc to home
Determine DME needs
Family training, if needed

Question 11

How is skilled nursing facilities different from IPR’s?

Answer 11

Typically lower amount of therapy compared to IPR but can still be considered intense

Question 12

When can a patient enter a SNF?

Answer 12

Within 30 days of the qualifying hospital stay

Question 13

When is the baseline care plan set within admission to SNF?

Answer 13

48 hours of admission

Question 14

Where the main aspects of the SNF PT

Answer 14

Maximize functional independence to prepare for dc to home
Determine DME needs
Family training, if needed

Question 15

When do patients become residents of long-term care settings?

Answer 15

Decreased cognition
Frequent falls
Social issues
Unable to care for self at home
Family unable to provided necessary care

Question 16

We are the risk factors for permanent residency in a long-term care facility?

Answer 16

Hospitalization
Advanced age
Dementia
Female gender
Frailty/pre-frailty
Discharge from hospital to SNF

Question 17

What is considered homebound? I.e. covered under Medicaid part A for home else services

Answer 17

Question 18

What are the main goals for the home health PT?

Answer 18

Promote independence in activities of daily living (ADLs)
Reintegrate the patient into the community
Minimize the risk for recurrent hospitalization and/or nursing home admission
Educate caregivers
HH PTs are in a unique position to monitor patient medication compliance and potential ADRs

Question 19

What are outpatient services billed under?

Answer 19

Can be billed under Medicare Part B, Medicaid, self-pay, private insurance

Question 20

What are the various goals of the outpatient physical therapist?

Answer 20

Maximize functional capacity & prevent loss of function
Optimize human movement
Bridge into wellness
Recover from planned or unplanned surgery
The list goes on

Question 21

What is leading gas in the tank?

Answer 21

Getting as much benefit from session as possible, but leaving enough “gas in the tank” to make sure your patients can do what they need to do when they go home or after you leave
You don’t want them so fatigued that they can’t function, especially if they are 1RM living

Monitoring blood pressure
220/140 – In ICU for a week
Monitoring medication compliance

Question 22

What is primary aging order the preventions?

Answer 22

Question 23

What is secondary aging and what are the preventions?

Answer 23

Question 24

What is tertiary aging and what are the preventions for?

Answer 24

Question 25

What are the possible related concerns on the caregiver is also an older adult?

Answer 25

Is the caregiver able-bodied? Is the caregiver cognitively able? Is this a safe situation for the patient to potentially discharge to?

Question 26

What is considered a fall?

Answer 26

An event that results in a person coming to rest unintentionally on the ground, floor, or other lower level 6 Not as a result of a major intrinsic event (syncope, MI, stroke, etc.) or overwhelming hazard An unintentional loss of balance that leads to failure of postural stability

Question 27

What are factors that contribute to risk for falls in geriatric patients?

Answer 27

Sensory deficits Urinary incontinence Depression Dementia/cognition Musculoskeletal impairments Fear of falls Pain Foot problems Vision impairment Hearing impairment Cardiovascular Medications Neurological impairments Sensory issues Vestibular impairment

Question 28

When should you screen for falls and balance impairment?

Answer 28

Any time they come to you for treatment Any time you notice a potential impairment Annually, on a screening basis

Question 29

What you should you screen for in terms of falls and balance impairment?

Answer 29

Number of falls in the past 12 months: frequency, context, fall characteristics, injuries associated with falls Balance impairment & postural instability

Question 30

What are some self reporting function performance measures?

Answer 30

Activities-Specific Balance Confidence Scale (ABC) Falls Efficacy Scale-International (FES-I)

Question 31

What are some single test mobility measures?

Answer 31

Gait speed SSWS Fast-pace 30 sec sit-to-stand (STS) Floor transfer Stair climb test Timed Up & Go (TUG) 6- & 2-Minute Walk Test (6MWT & 2MWT)

Question 32

What are some of the multi-activity mobility measures?

Answer 32

Short Physical Performance Battery (SPPB) Static standing balance SSWS 5x STS Physical Performance Test and Modified PPT

Question 33

What are some of the balance measures?

Answer 33

Single Leg Stance (SLS) Romberg Test Sharpened Romberg 4-step Square Test

Question 34

What are some of the performance test batteries for functional performance?

Answer 34

Berg Balance Score Tinetti Performance Oriented Mobility Assessment (POMA) BESTest, Mini-BEST, Brief-BEST Dynamic Gait Index (DGI) Functional Gait Assessment (FGA) Fullerton Advanced Balance Scale (FAB) Community Balance & Mobility Scale (CBM) Postural Assessment Scale for Stroke (PASS)

Question 35

How should you treat a fall patient afterwards?

Answer 35

Physical exercise as an intervention, including balance and postural exercises, to reduce the number of falls for patients 65+ can be effective as both a rehab and a “pre-hab” effort. 18 Exercise programs should be structured, progressed, and must achieve the minimum dose of exercise. Individuals who initiate an exercise program to improve balance, but do not achieve the minimum dose may be at a higher risk of falls. 19 Achieving the minimum dose is a challenge of fall prevention, as evidence supports long duration of intervention is required to have the desired effect: Sun et al., 2021 found a frequency of more than 5x per week and a duration of more than 32 weeks was more effective at reducing risk for falls with an integrated approach of resistance, core, and balance training Sherrington et al., 2008 determined that the greatest effects of exercise on fall rates were seen in programs that included a higher total dose of exercise (>50 hours)

Question 36

True or false walking is a singular balance intervention is not supported by evidence to improve balance/reduce fall risks and may actually increase the risk of falls in high risk individuals?

Answer 36

True

Question 37

How should we screen for falls and balance impairment?

Answer 37

Observational gait analysis Functional outcome measures Self-reported measures

Question 38

How should we screen for frailty?

Answer 38

Frailty phenotype criteria TUG Gait speed

Question 39

What are some screening options for frailty? And what are their uses/cutoffs?

Answer 39

Timed Up and Go (TUG) Cutoff: >10 seconds indicates frailty Gait Speed Cutoff: <0.8 m/s Ninety percent of frail individuals have walking speeds of < 0.8 m/s. 30 sec chair rise Cutoff: <14 Assess lower extremity strength 6 Minute Walk Test (6MWT) Cutoff: <548 meters Assess aerobic capacity and endurance

Question 40

True or false lower extremity exercises should not take priority over upward Shirley exercises to maintain and improve mobility?

Answer 40

False

Question 41

What mechanism 1st strength development is primary in the older population?

Answer 41

Neuromuscular efficiency

Question 42

Where the general exercise recommendations for the older adult?

Answer 42

150 minutes of moderate intensity activity per week OR 75 minutes of vigorous intensity activity per week At least 2 days of activities that strengthen muscles per week About 3 days of activities to improve balance per week

Question 43

What are the guidelines for improving muscle performance/muscle performance prescription in the older adult?

Answer 43

Frequency: 2-3x per week Intensity: 40-80% 1RM for 8-12 reps depending on desired intensity Start at 30-40% 1RM and progress to heavier loads of 70-80% 1RM (15-18 Borg)39 1 set of 10-15 reps (if done to failure, equates to 60-70% 1RM) Progressive resistance training, weightlifting, weight machines, resistance band use, body weight resistance, stair climbing 8-10 exercises targeting major muscle groups Pay attention to form & comfort prior to increasing resistance For power training, add a speed component at 40-60% of 1RM39

Question 44

What modifications should you make to muscle performance prescription and trailing chronic disease patients?

Answer 44

Frail & chronic disease: start with 1-3 sets of 10-15 reps, 30-60% 1RM Older adults with certain diagnoses should exercise at lesser intensities (30-60% 1RM at 12-25 reps per set) Acute musculoskeletal conditions Extremely frail or deconditioned individuals Rheumatoid arthritis Comorbidity-limiting exertion including cardiopulmonary or progressive degenerative neuromuscular disorder Post-surgical healing tissue, especially reconstructive (follow surgical protocols when present)

Question 45

Person considerations for strength training and the older adult?

Answer 45

If you make your patient sore after the very first session, they may not come back Be conscious of DOMS and prepare the patient they may experiences soreness If you prepare them, it will not be as frightening to them Many of the them will assume that if they have ANY pain, something is wrong Allow 48 hours rest between strength/power training sessions Make it functional Monitor vital sign

Question 46

For the general guidelines for aerobic exercise in the older adult?

Answer 46

Frequency: 3-7x per week Walking, dancing, swimming, water aerobics, speed walking or jogging , aerobic exercise classes, bicycle riding (non-recumbent stationary or on a path), elliptical machines, some gardening activities such as raking & pushing a lawnmower, tennis, and golf (without a cart) Healthy Aging: Bouts of at least 10 minutes, working up to 30-60 minutes per day for a total of 150-300 minutes per week for Moderate intensities (40-60% HRR; 5-6/10 RPE) Healthy Aging: Bouts of at least 10 minutes, working up to 20-30 minutes per day for a total of 75-100 minutes per week for Vigorous intensities (60-90% HRR; 7-8/10 RPE)

Question 47

What modifications should be made to aerobic exercise for chronic disease and frailty?

Answer 47

Chronic disease: 40-60% HRR for at least 20-60 min Frail: 40-60% HRR for at least 20 min Borg Scale recommended for these populations initially is 11-14

Question 48

What are considerations for aerobic training in the older adult?

Answer 48

Be aware of any comorbidities that may affect performance, particularly cardiac-, respiratory-, or anxiety-related pathology Use RPE scales to determine intensity, especially for patients on beta blockers or with pacemakers Monitor vital signs

Question 49

How should you approach flexibility training in the older adult?

Answer 49

Frequency: at least 2-7x per week Stretch to the point of feeling tightness or slight discomfort. Avoid ballistic movements. Stretch major muscles groups and targeted areas for 30-60 seconds, 3-4x each

Question 50

How should you approach balance training in the older adult?

Answer 50

Frequency: at least 2-7x per week Minimum Dose: 50 hours over 3-6 months 1-2 sets of 4-10 exercises emphasizing static and dynamic balance & postures Multiplanar walking, obstacle negotiation, head movements with walking, transitioning to different height surfaces, moving in different environments, proprioception challenges with altering surface, taking away visual input, sudden stopping/starting, perturbations, narrowing BOS, reaching to different heights

Question 51

Consideration should you make for valid training in the older adult?

Answer 51

If you don’t challenge your patients, they won’t improve At the same time, you may need to gain trust with your patient prior to increasing challenges Make it functional Static to dynamic, narrowing BOS, remove sensory input, perturbations, dual tasking When balance training, try to end treatment on a positive note for the patient

Question 52

How does high intensity interval training work in the older adult?

Answer 52

Efficient way to deliver exercise in a time-constrained environment Safe and feasible for older adults34 Can prevent or delay the onset of comorbidities34 Improvement in cardiorespiratory fitness in independent older adults35 and octogenarians with disease36 Effective to improve health of obese older adults37 Better improvements than Moderate Intensity Continuous Training on functional capacity, lean mass and various skeletal muscle markers of mitochondria37 “Enhances skeletal muscle mass in octogenarians with disease, with up‐regulation of muscle protein synthesis and mitochondrial capacity” 36

Question 53

When why and how should you use intentional under dosage?

Answer 53

Why: Your patient’s goals and your goals may conflict at times It’s still important to address their wants Sometimes we need to show value to our patient in a way they care about first When: Patient coming from a very sedentary level When the patient is highly irritable (symptom-wise) Consider prior experiences with physical activity, exercise, or physical therapy How: No weight or very light weight Increase ROM with a lower load Use RPE