Week 3 Flashcards
What are the definitions of polypharmacy?
- Administration of many drugs together
- Administration of excessive medication
- Excessive or inappropriate use of medications
Why do older adults consume more drugs as compared to their younger counterparts?
• More illness
• More adverse drug reactions (ADRs)
- Altered response to drug therapy
• Physician reliance on drug therapy over non pharmacologic options
• Multiple prescriptions from multiple providers
• Over the counter and self-help remedies
• Sharing of medications
What is included in the polypharmacy cycle?
- More illness in older adults leads to
- Need/take more drugs leads to
- Increased risk of side effects leads to
- Side effects seen as symptoms leads to
- More drugs administered leads to
- More illness in older adults
What are the characteristics of polypharmacy?
- Use of medications for no apparent reason
- Use of duplicate medications
- Concurrent use of interacting medications
- Use of contraindicated medications
- Use of inappropriate dosage of medications
- Use of drug therapy to treat ADRs
- Patient improves with discontinuation of medications
What are pharmacokinetic changes?
How the body handles the drug
What are the pharmacokinetic changes in response to drugs?
- Absorption- altered gastrointestinal function
- Distribution- changes in total body water, lean body mass, % body fat, plasma protein concentrations
- Metabolism- reduced liver mass, decreased hepatic blood flow, decreased activity of drug metabolizing enzymes
- Excretion- decreased renal blood flow and mass, decreased function of renal tubules
What do pharmacokinetic changes result in?
Drugs and drug metabolites remaining active for longer periods of time and prolonging drug effects thereby increasing risk for toxic side effects.
What are pharmacodynamic changes?
How drugs affect the body
What are the physiologic systemic pharmacodynamic changes seen in the body?
- Homeostatic control of circulation – impacts cardiovascular drugs
- Impaired postural control
- Decreased visceral muscle function
- Changes in thermoregulation
- Declining cognitive ability
What are the cellular level pharmacodynamic changes seen in the body?
Binding receptor changes
• Increased or decreased sensitivity
What are the biochemical response pharmacodynamic changes seen in the body?
Subcellular structural and functional changes
What are the common GI symptoms seen as a result of an adverse reactions to medication in the older adult?
Nausea, vomiting, diarrhea, constipation
In what medications are GI symptoms a common adverse reaction?
Common with opioids, non-opioids, and NSAIDS
In what medications is sedation a common adverse reaction?
Common with opioids, analgesics, antipsychotics
When is excessive sedation seen as a common adverse reaction to medication?
With sedative-hypnotics
In what medications is confusion a common adverse reaction?
Common with antidepressants, narcotic analgesics, drugs with
anticholinergic activity
In what medications is depression a common adverse reaction?
Common with barbiturates, antipsychotics, alcohol, some
antihypertensive drugs
In what medications is orthostatic hypotension a common adverse reaction?
Most common with drugs used to treat hypertension
In what medications is fatigue/weakness a common adverse reaction?
Common with skeletal muscle relaxants and diuretics (altered electrolyte balance)
In what medications is dizziness/falls a common adverse reaction?
Common with sedatives, antipsychotics, opioid analgesics, antihistamines
What do anticholinergic effects do as a common adverse reaction to medications?
Alters response of tissues to
acetylcholine
In what medications is an anticholinergic effect a common adverse reaction?
Common with antihistamines, antidepressants, and
antipsychotics
What are the CNS anticholinergic effects as a result of medication?
Confusion, nervousness, drowsiness, dizziness
What are the PNS anticholinergic effects as a result of medication?
Dry mouth, constipation, urinary retention, tachycardia, blurred vision
What are the extrapyramidal symptoms seen as a result of an adverse reactions to medication in the older adult?
Dsytonias, tardive dyskinesia,
pseudoparkinsonisms
In what medications are extrapyramidal symptoms a common adverse reaction?
Common with antipsychotics
What are the the general strategies for the physical therapist when treating a patient on medication?
• Differentiate between diagnosis/disease sequelae and
ADRs
• Identify polypharmacy and refer for reevaluation of meds
• Schedule according to drug effect and rehab needs
• Encourage adherence to prescribed medication regimen
• Provide education on why prescribed meds may be
beneficial and their potential side effects
• Implement non-pharmacologic options to manage conditions
What are the generalized goals of therapy when working with patients with Parkinson’s?
- Maintaining or increasing activity level
- Decreasing rigidity or bradykinesia
- Optimizing gait
- Improving balance and motor coordination
What are the benefits of exercise in patient with parkinson’s?
- Increase synapses formed
- Increased blood vessels in the brain
- Increased cell survival factors
- Better use of remaining dopamine
- Lowers the risk of PD for those with +genetic & environmental factors
- Protects vs. development of PD
- Improves efficacy of levodopa improves cognitive function
- Improves scores reported on QOL measures
- Decreases depression & apathy
- Improves stress & reported fatigue
- Decreases rigidity and bradykinesia
People with PD CAN learn new tasks and improve functional performance through __ during therapy.
People with PD CAN learn new tasks and improve functional performance through FOCUSED PRACTICE OF
TASKS during therapy.”
What are the education points to address with patients with parkinson’s?
• Timing of meds • Hydration • Diet • Exercise • Fall Prevention - Home Modifications - Behavior Modifications • Proper Footwear • Compensatory techniques
What does the choice of intervention for a parkinson’s patient depend on?
The stage of parkinson’s
What are the motor complications seen in patient with early stage parkinson’s?
Mild motor complications
• Resting tremor, bradykinesia, unilateral rigidity, falls are rare, ADL’s OK
What are the non-motor complications seen in patient with early stage parkinson’s?
Constipation, depression, apathy
Because early stage parkinson’s patients are high level functioning patients, what should be features of their PT sessions?
Creative PT sessions
• Vary your exercises regularly
• Work to preserve hobbies
What are the treatment interventions for early stage parkinson’s patients?
- Decrease inactivity, fear, educate, improve aerobic capacity, strength,
balance, promote active lifestyle
What are some examples of sensorimotor agility exercise that we want patients with early stage parkinson’s to partake in?
• 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 the mind and the body simultaneously
• Multi-tasking
• Physically
• Cognitively
• Alter environment
What are the motor complications seen in patient with middle stage parkinson’s?
• Bilateral features
• Wearing off meds
• Dyskinesias
• Increased rigidity
• Hunched posture, shuffling gait
• More assistance needed with ADL’s such as fine motor tasks,
increased slowness (more difficulty with transfers)
What are the non-motor complications seen in patient with middle stage parkinson’s?
- Cognitive decline evident with executive & visuospatial
- Orthostatic hypotension
- Mood disorders
- Hallucinations are rare
What is the PT’s focus during the treatment of a person with middle stage parkinson’s?
- Treat the ADL’s, gait, balance, & postural deficits that are being impacted
- Assist in increasing movement speed/amplitude
- Focus on cognitive and motor movement strategies, cueing strategies
- Teach compensatory strategies to maintain QOL
- Suggest a support group for the patient & caregiver
While treating the ADLs, gait, balance, and postural deficits that are being impacted in a middle stage parkinson’s patient, what are key things for the therapist to keep in mind?
- Optimize postural alignment
- Maintain postural stability
- Reduce multi-tasking to prevent falls
What are the motor complications seen in patient with late stage parkinson’s?
Falls, retropulsion, freezing, choking, aspiration, axial rigidity, drooling, decreased breath support
What are the non-motor complications seen in patient with late stage parkinson’s?
Dementia, incontinence, skin changes, sexual dysfunction,
pain
What is a feature in patients that have had a parkinson’s diagnosis for over 15 years?
5x more likely to fall
What is the PT’s focus during the treatment of a person with late stage parkinson’s?
• Provide appropriate equipment • Simplify tasks - Break down movements - Repetition, repetition, repetition • Sensory stimulation and movements • Educate caregiver - Body mechanics with transfers - Floor transfers (falls will happen) • Home evaluation
What impact does rigidity have on mobility as seen in a patient with parkinsons?
- Agonist/ antagonist co-contraction
- Flexed trunk
- Dec trunk rotation
- Dec joint range of movement
- High axial tone
What are the exercise principles implemented when treating rigidity as seen in a patient with parkinsons?
- Trunk rotation
- Reciprocal movements
- Rhythmic movements
- Erect alignment
- Large movements
What impact does bradykinesia have on mobility as seen in a patient with parkinsons?
- Slow small movements
- Narrow BoS
- Lack of arm swings
What are the exercise principles implemented when treating bradykinesia as seen in a patient with parkinsons?
- Fast, large steps
- Large arm swings
What impact does freezing have on mobility as seen in a patient with parkinsons?
- Dec anticipatory postural adjustments
- Abnormal mapping of body movement
- Abnormal visual-spatial maps
- Divided attention affects mobility
What are the exercise principles implemented when treating freezing as seen in a patient with parkinsons?
- Improve weight shifting
- Understand role of external cues
- Exercise in small spaces
- Practice dual tasks
When does rigidity really become a problem in patients with parkinsons?
Loss of spinal flexibility is seen in early stages and correlates
with functional performance tasks
• Reaching, supine to sit, balance control
What are the rigidity treatment examples in patients with parkinsons?
• Manual therapy
- Stretching/PROM/AROM
- Joint compression/ approximation/traction
• Deep breathing/relaxation: counteract impact of rigidity
• PNF techniques
• Core strengthening
• Tai Chi (rhythmical diagonal movements)
• Kayaking exercise (reciprocal limb and trunk activity)
• Large amplitude steps with directional changes
What are some HEP exercises to address rigidity for patient with parkinsons?
• Cervical Rotations • Chin Tucks • Shoulder Abd/ER • Shoulder Flexion • Knee Flexions Rotations • Bridges &/Or Pelvic Tilts • Hib Abd/Add (knees flexed) • Knee to Chest Stretch • Hamstring Stretch • Ankle Pumps - 10-20x each • Deep Breaths
According to research, what happens if you give more than 2 HEP for a patient with parkinsons?
Compliance severely decreases
What is bradykinesia?
Slow, small movements which impact quality and efficiency of
movement, and affecting quality of life
What are the presentations of bradykinesia in patients with parkinsons?
• Narrow BOS • Lack of arm swing • Exercise Principles - Fast, large steps - Large arm swings: during ambulation, in semi tandem,, etc
When does freezing occur in patients with parkinsons?
- Approaching doorways, obstacles, or chairs
- When turning or changing direction
- When distracted while walking
- Crowded or cluttered places
- Medication is not working well
What should a patients with parkinsons do when they experience freezing?
• 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
How does cueing work?
- Basal ganglia acts as an internal cue to enable movement sequences to be carried out implicitly, automatically, and without attention
- Cues replace lost internal cues with an external cue
- Bypass the BG dysfunction path
- Learning shifts from implicit to explicit
- Cueing = motor learning tool
What are some attention cues we can give our patients with parkisons?
- Visualize movements
- Focus on each step of the task
- Counting “1, 2, 3…”
- “Look through the doorway”
What are some visual cues we can give our patients with parkisons?
- Laser
* Tape lines or X’s on the floor
What are some auditory cues we can give our patients with parkisons?
- Metronome
- Music
- Step to the count
What are some proprioceptive cues we can give our patients with parkisons?
• Weight shifting/Rocking
- Side Steps
- Backwards Step
• Tapping your leg
Festination and propulsion is as a result of what?
COG too far forward over BOS in people with slow velocity of gait
What should a patient do when they notice they are going into festination or propulsion?
• STOP • Use cue to start again - “BIG” step - Reach for your heel • If they have a U-step walker: brake to stop • Add weight posteriorly
What are the functional assessments to do in a patient with parkinsons?
• Sit to stand
• Bed Mobility: rolling, supine <> sit
• Gait
- Different environments and challenges
The key to supine to sit transfers is in the ___
The key to supine to sit transfers is in the KNEES, knee flexion rotations for everyone!
What are some specific practice that we can implement to make exercise functional for our patients with parkinsons?
- Compliant surfaces
- Uneven surfaces
- Inclines/declines
- Stairs/curbs
- Obstacles
- Dynamic BOS
- Visual modification
- Dual tasks
What are some static balance exercise we can do for our patients with parkinsons?
- Wobble board
- Air-ex/Foam Pad
- EO/EC
- Head turns/head nods
- Reaching outside BOS
- Perturbations + Protective Step Response
- Seated on Physioball
What are some dynamic balance exercise we can do for our patients with parkinsons?
- Bosu ball
- Lunges
- Step-ups
- Wii balance board
What are the characteristics of balance in a patient with parkinsons?
- Balance exercise should begin in early stages of the disease
- Equilibrium reactions in all planes of movement
- Rhythmical stabilization to increase static balance, as long as resistance does not increase truncal rigidity
- Timing of resistance must be gradual
- Dynamic balance techniques
What are some types of gait training exercises we can do for our patients with parkinsons?
LSVT “BIG” Theory • Locomotor Training • Split Belt Treadmill • Obstacle Courses • Inside vs. Outside • Environment - Quiet vs. Crowded • Attention - Focus vs. divided - Add dual-tasking!
What are some types of dynamic gait training exercises we can do for our patients with parkinsons?
- Tandem
- Backwards
- Side Steps
- Grapevine
- Stopping
- Starting
- Turning
- Changing Directions
What is an example of functional training exercise that we can do for our patients with parkinsons?
Sit to stand • Break the task into parts 1. Bend forward 2. Lift pelvis up 3. Extend knees and hip 4. Maintain standing • Repeated practice of the impaired “parts” • Neuroplasticity – correct the impaired “part”. Encourage repetition
What are some examples of core strengthening exercises that we can do for our patients with parkinsons?
- Bridges
- Pelvic Tilts
- Prone Press Ups
- Posture/extensors
What are some examples of UE strengthening exercises that we can do for our patients with parkinsons?
- Wall Push-ups
- Rows
- RTC IR/ER
- PNF D1/D2 UE
What are some examples of LE strengthening exercises that we can do for our patients with parkinsons?
• Squats • Lunges • Clamshells • Side Steps vs Band • Standing Leg Raises • Heel Raises • Toe Raises • Leg Press
What is LSVT “BIG”?
Training program designed to promote high amplitude/BIG
movements of the limbs and body
• Designed to improve speed, balance, and QOL
• Program: 4 times per week x 4 weeks
• Intense program with many repetitions
• “Must be certified as a “BIG” therapist to document “BIG”
treatment
- “High amplitude training” when not certified
What are the fundamentals of LSVT “BIG”?
• Target: BIG – large amplitude whole body movement
• Mode
- High intensity: modulated by LSVT specialist
- Requires consistency over 4 week period
• Calibration
- Calibration of perception of movement
- Mismatch between patient perception of output and how
others perceive it.
• 7 BIG exercises for HEP
What are the characteristics of rock steady boxing as it relates to parkinsons?
• Boxers condition for optimal agility, speed, muscular
endurance, accuracy, hand-eye coordination, footwork and
overall strength
• Improvements in balance, gait speed, and perceived quality
of life, and they maintained it
What are the basic 4 Parkinson’s Wellness Recovery (PWR) moves and what do they target?
Targets skills impaired in PD with mobility • Antigravity extension – PWR!UP • Weightshifting – PWR!ROCK • Axial Mobility – PWR!TWIST • Transitions – PWR!STEP
What are the components for later in life planning that should be done by patients with parkinsons?
- Insurance
- Senior living communities
- Advanced directives
- Address the topic BEFORE it is too late!
- HELP the family PLAN for progression
What are the characteristics of pre-operative PT for a total hip/knee arthroplasty in an aging adult?
• 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
What are the goals of pre-operative educational classes for a total hip/knee arthroplasty in an aging adult?
Conducted prior to surgical date in multidisciplinary format w/goals of:
• Prepare patients for surgery and recovery related issues, including surgery procedure, therapy expectations and
post-operative routine
• ↓post-operative complications
• ↑ likelihood of discharge to home vs a facility & ↓ LOS/hospital costs
• Help patient identify post-op support system & ↓ anxiety
• Encourage pt’s active role in recovery process
What are the general benefits of pre-op PT and education for a total hip/knee arthroplasty in an aging adult?
• Shorter LOS!!
• EARLY mobilization
• Shorter overall therapy time
frame
What are the characteristics of early intensive rehab for the acute care of a total hip/knee arthroplasty in an aging adult?
Decreases physiological disturbances
• As early as POD zero
• May even be at a day surgery facility or a short-stay hospitalization
• Associated w/↓ DVT/PE risk, chest infections, urinary retention, HAI
• Results in accelerated functional recovery & earlier hospital d/c
When should acute care PT for a total hip/knee arthroplasty in an aging adult be done and what type of PT should be done?
- At least within 1st 24 hours of surgery, but optimally POD zero
- Emphasize function for optimal d/c dispo of home
- Education very important (and remember, not all THA’s have posterior prec)
- Early strengthening (possible e-stim TKA)
When is the largest proportion of therapy time help for a total hip/knee arthroplasty in an aging adult?
Post-Acute
What are the characteristics of post-operative PT for a total hip/knee arthroplasty in an aging adult?
Optimal d/c dispo to home and commence home health or OP PT
• May need dispo other than home at first
• Be the advocate in acute care
• Be aware of other issues (family, insurance, post-acute qualifications, home
environment)
• D/C dispo planning starts on admission and even before!
Why may an older adult have a complicated and longer recovery following a total hip/knee arthroplasty?
- B TKA (sometimes B THA depending on approach, health status)
- Co-morbidities affecting recovery
- Slow post-surgical recovery (TKA > THA, BUT more lingering gait abn s/p THA)
What are the indications and implications of an anatomic total shoulder arthroplasty?
- Must have intact rotator cuff
* For all forms of degenerative or inflammatory glenohumeral damage
What are the indications and implications of a reverse total shoulder arthroplasty?
- In presence of complete tear of rotator cuff
- Must have intact deltoid
- More common for proximal humerus fx
- Revision TSA
What are the therapy considerations for a total shoulder arthroplasty?
• No extensive pre-op education pathway exists like THA/TKA
• Don’t get caught up in “I can’t do anything while the patient is in a sling!”
- Gait disturbances primary issue w/aging adult
• Remember the patient does not have the ability to perform contralateral UE swing— Balance? Need for AD?
• Before they leave the hospital!! Many times, MD may not order PT!
• Joint mobility at other shoulder complex components– AC joint, SC joint??– and “good” shoulder
• Functional reach using alternate strategies
• Core strengthening
• One-armed ADL strategies
• Functional mobility and bed mobility strategies
• May need OT referral
Which type of fracture surgery is considered urgent and why?
Hip fx surgery is considered urgent (not elective like TJA) to
significantly lower the risk of death
What are the complicating issues seen in an aging adult post orthopedic surgery?
• Have a longer hospital LOS
• Slight increased risk of falls while hospitalized, particularly in bathroom
• Have a larger number of pre-existing co-morbidities (DM, CHF, COPD, renal failure) or
social disadvantages (live alone, require additional social support)
• Have a prior TJA or debilitating OA in the contralateral joint or other joints
• Have pre-existing cognitive and sensory impairments
• Have reduced functional aerobic capacity
• Have marked reductions in muscle mass and strength (particularly those who are frail or experienced a fall)
• Require adaptation to usual movement patterns
• Experience post-op complications (MI, DVT/PE, surgical site infection, sepsis,
hemorrhage, mortality), and medical complications (UTI, pressure ulcers, nutritional
deficiencies)
• Experience more side effects from medications and general hospitalization (particularly
anesthetics, opioid pain meds)
- Delirium/cognitive impairment
- Perioperative acute pain
- Pulmonary complications
- Fall risk
• Be admitted to the ICU
• Discharge to a skilled care facility
What are the pre-fracture factors indicating poor functional recovery in the therapy considerations of a hip fracture in an aging adult?
- Decreased pre-fracture functional independence
- Greater co-morbid disease burden
- Cognitive impairment
- Affective status/depression
- Poor nutritional status
- Poor social support
- Presence of frailty
What are the major types of hp fractures in an aging adult?
- Intracapsular, involving the femoral head and neck (approx. 45%)
- Intertrochanteric (approx. 45%)
- [Others (approx. 10%): subtrochanteric]
What does the surgical management of a hip fracture in an aging adult depend on?
- Type and severity of fx
- Preference of ortho MD
- Pt age
- Co-morbid conditions
- Prognosis
What type of patients are non-operative management used for after sustaining a hip fracture?
For those who may gain only min function from stabilization because they were either not ambulatory to begin w/ or have severe dementia, those with contraindications to anesthesia or medical conditions prohibiting surgery
What are the types of surgery done for a femoral neck fracture in an aging adult?
- <65 years of age: internal fixation
* Older individuals or those with already limited mobility: THA
What are the types of surgery done for an intertrochanteric fracture in an aging adult?
- Sliding hip screws
- Intermedullary nails (done percutaneously w/less surgery time needed, less blood loss)
- Often PWB
What are the types of surgery done for a subtrochanteric fracture in an aging adult?
Hemiarthroplasty
What are the therapy considerations for a hip fracture repair in the acute stage?
- Goal: restore mobility ASAP!
- Pt likely has pre-existing lower function, fall-risk
- High likelihood of limited WB (PWB req. 30-50% > energy than normal ambulation)
- Higher stakes for bed rest, immobility complications
- Consider other areas with risk of osteoporotic changes when planning mobility
What are the therapy considerations for a hip fracture repair in the post- acute stage?
- Likely will require post-acute inpatient stay (many hip fx >85 yrs old qualify for IPR)
- Focus on precipitating factors to the causative agent for hip fx (Fall? Osteoporosis? Cognitive deficits? Dangerous home environment? Frailty? Social support?) AND how normal aging changes have augmented these factors
- Fear of falling!
