Week 1 Flashcards
How do we define an older adult by chronological age?
• Gerontologists focus on those 60+ years of age
• Federal government uses 65 as determinant
for Social Security & Medicare eligibility
• Researchers use subgroups
- “Younger old” = 65-75
- “Older old” = 75-85
- “Oldest old” = 85+
What are the older definitions of aging?
- Societal determinants (“50 is the new 40”, etc)
* Health status determinants
What are the truths about aging?
• Aging takes place over time
- Grow older developmentally, not chronologically
- Chronological age is not biologically uniform
• Old age is a new concept
• Aging is different from disease
- Functional decline not necessarily due to aging
- Aging changes are distinguished from changes attributable to disease
- Many diseases and co-morbidities associated with the older adult actually have their beginnings during the decade of the 40’s. and 50’s.
What is ageism?
Prejudice or discrimination against a particular age-group and especially the elderly.
What is the life expectancy of the 65+ population?
Close to 20% of the total US population.
What are the factors that contribute to the demographics and life expectancy of the aging adult population?
- Current declining birth rate
- Decreased mortality rates
- Increased life expectancy/better overall health
- Large numbers in the “baby boomer” generation
What is a generation?
Cohort born in specific time period (18-22 year increments)
What are the characteristics of a generation?
• Each generation develops a collective world view based on the prevailing cultural influences in their first 18 years
• Each generation has tendency to reject/rebel against the world view of
previous generation
• Has specific attitudes toward work ethics, behavioral expectations, role norms, language, value and outlook
• Generation gaps affects what our patients want/need and presents societal challenges to health
What are the existing categories of generation gaps?
• GIs: 1901-1921 • Veterans (“Greatest Generation”, Traditionals): 1922-1945 • Boomers: 1946-1960 • Gen X (“Baby Bust”): 1961-1981 • Gen Y (“Millennials”): 1982-2004 • Gen Z: 2004-
What are the generational themes seen in generation “traditionals”?
- Hard work
- Duty
- Sacrifice
- Thriftiness
- Work fast
What are the generational themes seen in generation “boomers”?
- Personal fulfillment
- Optimism
- Crusading
- Buy now, pay later
- Work efficiently
What are the generational themes seen in generation “gen Xers”?
- Uncertainty
- Personal focus
- Live for today
- Save
- Eliminate task
What are the generational themes seen in generation “millenials”?
- What’s next?
- On my terms
- Just show up
- Earn to spend
- Do what’s asked
According to Rowe and Kahn, a person has successfully aged when they have done what…?
- Avoiding disease and disability
- Maintaining high physical and cognitive function
- Sustained engagement in social and productive activities
According to Lewis, what is successful aging?
The changes due solely to the aging process, uncomplicated by damage from the environment, lifestyle or disease
__ is a modified version of “successful aging”
Optimal aging is a modified version of “successful aging”
What is optimal aging?
Capacity to function across many domains– physical, functional, cognitive, emotional, social, spiritual– to one’s satisfaction and in spite of medical conditions
What can a PT do to impact optimal aging?
Physical therapists reduce disabling effects and can
stop the cycle of “disease > disability > new incident disease” in order to facilitate maintenance of quality of life
What are the 5 most common causes of death in the aging adult?
- Heart Disease
- Malignant Neoplasms
- Cerebrovascular Disease
- Chronic Lower Respiratory
Diseases - Pneumonia/Influenza
What are the 5 most common chronic health conditions in the aging adult?
- Arthritis/MSK Issues
- Heart/Circulatory Issues
- Vision/Hearing Issues
- Fractures/Joint Injuries
- Diabetes
- Mental Illness
Aging has contributions from…?
- General whole body inflammatory response (Woods, et al)
- Genetics
- Consequences of lifestyle, primarily decline in physical activity
What is sarcopenia?
Age related loss of skeletal muscle mass and strength
• Not completely age related
• Decreased physical activity
• Co-morbidities
What does sarcopenia result in?
Results in decreased protein reserves
• Challenge to meet protein synthesis demands with injury or disease
• Thus even worse sarcopenia
What happens to muscle as a result of normal aging?
• Whole muscle and fiber atrophy
- Muscle is 50% total body weight in young adults, reduced to 25% by age 75-80
- Replaced by increased body fat
- Type II atrophy > Type I
• Denervation and reinnervation of alpha motor neurons
• Decreased muscle activation – Less agonist, more co-activation of antagonist
• Decreased muscle strength and power
What are the metabolic changes that occurs as a result of normal aging?
• Decreased resting metabolic rate
- Less lean muscle mass
• Insulin resistance (common in older adults)
- Increased body fat further contributes
- Regulator of protein metabolism and important for protein gain and muscle growth
• Decreased growth hormone
• Decreased estrogen and testosterone
• Vitamin D deficiency
What are the skeletal changes that occurs as a result of normal aging?
• Decline in bone mineral
• Increased osteoclast activity, decreased osteoblast
activity
• Osteopenia…leads to increased risk of osteoporosis
- Load absorption decreased
- Decreased load dispersion to other parts of the joint
- Results in increased bone loading, results in increased risk for fracture
What are the effects that occurs in the connective tissue (ligaments, capsule, cartilage) of the joint as a result of normal aging?
• Decreased activity of osteoblasts and chonrdroblasts
• Increased activity of osteoclasts and chondroclasts
• Decreased response to growth factors (hormones, cytokines)
- Alters repair of tissues
• Altered response to tissue loading
• Decreased ability to retain water
- Decreased glycoconjugates that maintain fluid content
• Fragmenting of collagen strands and decreased rate of turnover
• Increased crosslinking between collagen molecules
- Increased stiffness and decreased ability to absorb energy
• Calcification of articular cartilage
- Intervertebral discs: nucleus becomes more fibrous, annulus less organized
- Decreased water content in discs
What are the most common changes that occurs in the joint during normal aging?
- Decreased joint space
- Increased laxity
- Altered load dispersion
- Altered joint forces
- Decreased joint ROM (not uniformly)
What happens to the cervical spine ROM as a result of aging?
- All motions decrease
* Greatest reduction in extension and lateral flexion
What happens to the thoracic and lumbar spine ROM as a result of aging?
- Extension becomes most limited
* No or very little change in rotation
What happens to the hip ROM as a result of aging?
Extension decreases – decreased walking speed
What happens to the ankle ROM as a result of aging?
Dorsiflexion decreases
What happens to the knee ROM as a result of aging?
Without pathology, knee ROM remains fairly stable
What happens to the shoulder ROM as a result of aging?
- Flexion and External rotation
* Thoracic kyphosis may also impact
What does habitual postures often lead to?
- Forward head posture (FHP)
- Thoracic kyphosis
- Lumbar flattening (reduction of lordosis)
What are the characteristics of thoracic kyphosis as it relates to aging?
- Increases > 40 years of age- women > men
- Correlated with increased fall risk
- Associated with osteoporosis and vertebral fractures
What are the characteristics of lumbar flattening (reduction of lordosis) as it relates to aging?
Decreased intervertebral space = decreased diameter of intervertebral foramen: impact nerve root integrity
What are the altered functions associated with forward head posture (FHP)?
Challenges with swallowing, breathing, supine/prone positioning
What are the altered functions associated with hyperkyphosis?
Spine extensors lengthened – weakened : Lifting difficulty
What are the altered functions associated with decreased lumbar lordosis?
Pain, nerve root impingement symptoms, spinal stenosis: Standing, walking painful – limits activity
What are the causes of postural changes in an adult?
- Decreased intervertebral and bone height
* Decreased elastin in ligaments of the spine
What are the effects of decreased intervertebral and bone height on posture?
• 2’ loss over a lifetime
• Decreased ability to withstand compression, tension, and shear, thus more load bearing on the neural arch-osteoarthritis and osteophyte
formation
• Thinning trabeculae of bone- increased risk for spinal deformities and fractures
What are the effects of decreased elastin in ligaments of the spine on posture?
Converts into cartilaginous tissue from scarring, thus become thickened- Spinal Stenosis
What are the MSK conditions that impacts the aging adult?
• Osteoporosis - Fractures • Osteoarthritis - Joint Arthroplasty • Spinal Stenosis • Frailty
What is osteoporosis?
A systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture
What are the types of fractures that is common in the aging adult?
Anterior vertebral body
• Symptomatic or asymptomatic
What position should an older adult take caution in?
ADLS in trunk flexed positions
In what type of joints in OA most common?
Load bearing joints • UE- Hands • LE- Hips, knees, feet • Spine- cervical and lumbar - Can compromise diameter of spinal canal- Spinal Stenosis
What may joint destruction ultimately lead to?
May lead to need for total joint arthroplasty
What are the CNS changes with aging?
- Neuron loss – decreased gray matter
- Myelin loss- decreased white matter (decreased brain weight)
- Nerve cell shrinking
- Delayed impulse conduction and conduction velocity
- Reduction and altered balance of neurotransmitters
- Decreased size of cerebellar hemispheres
- Vestibular changes- decreased hair cells and receptor ganglion cells
- Decreased cerebral blood flow
- Decreased glucose metabolism
What are the functional implications seen with CNS changes?
- Delayed recall- If given time, then able
- Rote memory decreases
- Altered gait, balance, and fine motor control
- Diminished motor learning
- Decreasing activity level
What are the common pathology of the CNS?
- CVA
- TBI
- Parkinson’s Disease
- Dementia
What are the PNS Motor (Somatic &ANS) changes with
aging?
- Axonal degeneration
- Greater internodal length
- Slower conduction velocity
- Decreased ability to adapt to environmental or visceral changes
- Decreased neurons per muscle fiber (fiber grouping)
- Decrease in Ruffini’s, Pacinian, and golgi tendon-like receptors
- Increased sympathetic activity
- Decreased cerebral blood flow
What are the functional implications see with PNS changes?
- Increased recruitment of motor units- more work required to do a task
- Increased co-contraction at the ankle
- Altered motor control and postural stability
- Decreased LE proprioception, vibration, discriminative touch, and balance
- Increased risk of falls
- Resting blood pressure rises with age
- Delayed response to pain
What are the PNS- peripheral sensory innervation changes
with aging?
- Decreased number and density of myelinated peripheral nerve fibers
- Decreased thickness of remaining fibers
- Decreased nerve conduction velocity and action potentials
- Increased H-reflex latency
What are the vision sensory changes seen with aging?
Begins to decrease in the 3rd decade • Neuron loss in the visual cortex • Presbyopia- decreased flexibility of the lens to accommodate from far to near • Decreased elasticity of the lens • Decreased recovery from glare • Decrease tear production • Decreased acuity • Decreased visual fields
What is the functional impact of sensory loss on balance
and function?
- Errors in proprioception have a bigger effect on balance then errors in vision in older adults
- With vision available, oldest older adults need accurate proprioception to maintain balance
- Impairment associated with increased fall risk and functional decline
- PTs need to provide older adults with sensory strategies to increase sensory information
What are the hearing sensory changes with aging?
- Presbycusis- hearing declines with age
* Difficulty tuning out background music
What are the characteristics of presbycusis?
- Effects both genders
* Men especially lose hearing for higher frequencies
What are some suggestions to treating a patient with hearing changes?
- Ask what works best for the patient
- Use a lower tone
- Face the person when possible
- Slow rate of speech appropriately
- Keep background noise to a minimum
- Avoid “elderspeak”
- Avoid jumping from one idea/topic to another quickly
What are the smell and taste sensory changes with aging?
• Ability to detect smells and identify odors decreases
with age
- Has been linked to the three types of dementia
• High prevalence of hyposmia (decreased smell) and anosmia (loss of smell)
• Can create a safety risk
• Impairs ability to taste food
• Thirst sensation declines
Gait changes due to aging, disease, or disability can become a big problem when the individual has ____
Gait changes due to aging, disease, or disability can become a big problem when
the individual has pain, difficulty maintaining balance, lacks sufficient endurance or has insufficient ability to ambulate to meet ADLS
Inability to ambulate safely results in loss of ____
Inability to ambulate safely results in loss of independence and can result in need for
higher level of assistance, even placement in a facility
What are the physiological factors that contribute to aging gait changes?
System changes • Musculoskeletal changes • Higher level neural processes • Sensory and perceptual changes • Individual sensory systems Others • Specific & individual pathologies • Adaptive & anticipatory mechanisms • Intricately related to balance responses
What are the psychological factors that contribute to aging gait changes?
- Depression
- Self-efficacy/confidence
- Appearance
- Older adult’s perception of his or her mobility
- Anxiety or fear
- Perceived risks of community mobility
- Access to or barriers in community
What is the speed of gait like in normal aging gait?
- Decreased self-selected speed & fast speed;
- Ability remains to voluntarily increase speed from self-selected to fast speed;
- Increased gait variability
What is the step/stride length of gait like in normal aging gait?
Smaller step & stride lengths, but symmetrical
What is the step width of gait like in normal aging gait?
Ave. 1-4 inches
What is the toe clearance of gait like in normal aging gait?
Small toe clearance
What is the single limb
support of gait like in normal aging gait?
↑ double limb support, but generally equal stance time B LE
What is the speed of gait like in pathological gait?
Signif. ↓ in free velocity (<0.85
m/s) w/loss of ability to
voluntarily ↑ speed from self selected
What is the step/stride length of gait like in pathological gait?
Signif. ↓ in step & stride length
and/or non-symmetric steps
What is the step width of gait like in pathological gait?
Step width > 4 in. or < 1 in.; or
too much/too little step width
variability
What is the toe clearance of gait like in pathological gait?
Either large toe clearance or
tripping or both
What is the single limb
support of gait like in pathological gait?
Short, shuffling steps; Unequal
stance time; antalgic pattern
What are the effects of normal aging gait at the ankle-foot?
Mild ↓ in force at push-off &/or
slight ↓ in PF and DF ROM
What are the effects of normal aging gait at the knee?
ROM from 5 deg flex during weight acceptance to 60 deg of flex during swing limb advancement
What are the effects of normal aging gait at the hip?
15-20 deg flexion during weight
acceptance and 15-20 deg of
apparent hyperext at terminal
stance
What are the effects of pathological gait at the ankle-foot?
- Large toe clearance or tripping or both
- Forefoot or foot-flat contact during initial contact
- Excess PF or DF
What are the effects of pathological gait at the knee?
- Limited or excessive flexion, wobbling, extension thrust;
- Weight bearing increases
valgus or varus moments
What are the effects of pathological gait at the hip?
- Limited flex or ext; “past retract”, meaning visible fwd then bwd mvmt of thigh during terminal swing
- Excessive abd or add
- Excessive or limited IR or ER
What are the effects of normal aging gait at the pelvis?
5 deg fwd rotation during weight
acceptance; and 5 deg of bwd
rotation at terminal stance/preswing; iliac crest on reference limb is ≥ iliac crest on opposite side during mid-stance
What are the effects of normal aging gait at the trunk?
Erect
What are the effects of pathological gait at the pelvis?
Limited or excess rotation fwd or bwd;
pelvic drop or hiking
What are the effects of pathological gait at the trunk?
Fwd, bwd or sideways lean
What is the average width of a street?
332 m
What is the critical speed for crossing a street?
1.14 m/s, broken down to:
• Crossing 2 lane road in 10 seconds (5 sec/lane)
• And 3 sec to get up and down off either curb (1.5 sec/curb)
• The critical speed is 8 m/7 seconds = 1.14 m/sec
What is the speed requirement for the rural area?
30m/min (0.5 m/s)
What is the speed requirement for the urban area?
82.5 m/min (1.375 m/s)
What are the task and environmental demands of gait?
- Minimum walking distance
- Time constraints
- Lighting changes
- Terrain
- External physical load
- Attentional demands
- Postural transitions
- Starts and stops
- Acceleration/deceleration
- Changing directions/turning around
- Obstacles
- Weather changes
- Managing displacement forces
- Traffic level
When does immune system changes with age usually start?
In the 6th decade of life– “Immunosenescence”
• Can begin prematurely in some clinical conditions such as rheumatoid arthritis and
w/chronic organ diseases (i.e., COPD, CKD)
What are the cardinal features of immune system aging?
• Weakened antimicrobial immunity
- Susceptibility to respiratory infections
- Reactivation of chronic viral infections (shingles)
• Impaired anti vaccine responses
• Insufficient protection against malignancies
• Predisposition for unopposed tissue inflammation (i.e., atherosclerotic disease, OA,
neurodegenerative disease)
• Failing wound repair mechanisms
What are the increased systemic inflammation due to immune system changes?
- ↑ proinflammatory cytokines (i.e., interleukin 1 & 10)
- ↑ C-reactive protein (CRF)
- ↑ tumor necrosis factor
What may cause an increased systemic inflammation due to immune system changes?
• Shift in fat mass from periphery → abdomen along w/ general ↑ in overall intraabdominal fat with age
- Abdominal fat metabolically active & serves as inflammatory organ
• ↑ inflammatory cytokines assoc. w/ metabolic syndrome & ↓ organ system function
What does the increased systemic inflammation due to immune system changes result in?
• Muscle wasting
• Loss of physical function
• Underlying factor in development of age-related diseases like Alzheimer’s,
atherosclerosis, cancer, diabetes
What are the reduction in lymphocyte development?
- ↓ T- and B- cell development
- ↓ quality and composition of lymphocyte pool
- ↓ thymic epithelial cells
What does the reduction in lymphocyte development result in?
• ↓ efficiency of response to novel or previously encountered antigens (i.e., ↑
vulnerability to influenza in those > 70 yrs old)
• ↓ responsiveness to vaccines (except for the shingles vaccine)
What are the approaches to address total-body inflammation?
- Anti-inflammatory drugs
- Antioxidants
- Caloric restriction
- EXERCISE!!!!!!! Therapy implications
What are the therapy implications of exercise to address total body inflammation?
- Just one exercise bout results in significant ↓ in inflammatory markers
- Cumulative exercise sessions further ↓ inflammation which can enable regular exercisers to resist fatal infections & aggressive pathogens
- Results in wider window of homeostasis
- Enhances systemic “reserve”
- Decreases risk for disease
- Delays functional decline
What are the characteristics of infectious disease in aging adults?
• Accounts for 1/3 of all deaths in 65+
• Early detection difficult due to absence of typical signs and symptoms
- Lack of fever
- Lack of leukocytosis
- In case of UTI, absent or masked clinical manifestations as dysuria, frequency, suprapubic tenderness)
What is the 1st sign of illness during infectious disease in aging adults?
- Change in mental status or cognitive impairment
- Decline in function
- Falls
- Weight loss/anorexia
- Slight increase in respiratory rate
- Vague symptoms such as nausea, vomiting, decreased urinary output
What are the most common types of infectious disease in the aging adult?
- Bacterial pneumonia
* Urinary tract infections (UTI)
What are the other conditions that may present atypically in an older adult?
- Heart failure: confusion, agitation, anorexia, insomnia, fatigue
- Acute bowel obstruction: acute confusion, minimal or absent abdominal pain and tenderness
- Biliary or liver disorders: nonspecific mental and physical deterioration, no jaundice or abdominal pain
What is a common thread in all aging adults?
Cognitive dysfunction or confusion
What are the therapy implications for infectious disease in the aging adult?
- Be sensitive to descriptions of unusual changes and observant of subtle changes with older adult patients in every setting, but esp OP setting
- Be prepared to treat older patients in the hospital with medical dx of infectious disease for the effects of deconditioning
- Realize that although you may not be able to challenge pts acutely ill in the hospital setting, but return to basic function and prevention of functional decline remain high priority goals
- Prepare for functional setbacks after your older adults in OP sustain acute illness
- Prepare for some exacerbation of previously compensated system deficits after an acute illness
