GERIATRIC REHABILITATION

Vijayan Gopalakrishna Kurup

Chief Physiotherapist
Rajagiri Hospital
 TRADITION SPEAK…

One who always serves and respects elderly is blessed

with four things : Long Life, Wisdom, Fame and Power”
-- Manusmriti Chapter 2:121
Stages and Age of Man
 Geriatric Rehabilitation
 Defined as Medical treatment plus Prevention, Restoration
plus Accommodation and Education

 The declared objective of Geriatric services is to help old

people to remain
 as independent as possible

 for as long as possible and

 to offer them as much control over their lives as possible.

 Need

Increase in life expectancy

Advances in Medicine
Increase in standard of living
Greying of world population
Increase in the dependency ratio (6:1)
“AS MODERN MEDICINE ADDS YEARS
TO LIFE, REHABILITATION BECOMES
INCREASINGLY NECESSARY
TO ADD LIFE TO THESE YEARS”
- HOWARD A RUSK
HEALTH PROBLEMS OF AGED

Problems due to aging process

Problems associated with long term Illness

Psycho-social problems
 GIANTS OF GERIATRICS
Intellectual impairment
Immobility
Incontinence
Impaired homeostasis/Instability
Insomnia & Sleep disorders
Iatrogenic
FACTORS AFFECTING GERIATRIC
REHABILITATION

I.BIOLOGIC
 ATYPICAL PRESENTATIONS
 MULTIPLE DISEASES
 DECONDITIONING
 DISEASE – DISEASE INTERACTIONS
 POLY PHARMACY
 HOMEOSTENOSIS
II.PSYCHOLOGIC
 COGNITIVE DEFICITS
 DEPRESSION
 POOR MOTIVATION
 BELIEFS ABOUT RECOVERY
 BELIEFS ABOUT REHABILITATION
 BELIEFS ABOUT SELF
III.SOCIAL
SOCIETAL PREJUDICE
SELF AGEISM
LACK OF SERVICES
INACCESSIBLE BUILDINGS
LESS FREQUENT REFERRALS
FINANCIAL BARRIERS
 Multiple Concurrent Losses
Loss of physical health
Loss social contacts: friends / family die
Loss of familiar roles: mother, wife, employed person
Loss of financial security: retirement, widowhood
Loss of independence and power
Loss of mental stability
HIERARCHY OF PHYSICAL FUNCTION OF THE OLD
 Characteristics of Aging

 Reserve capacity of organ systems

 Internal homeostatic control

 Ability to adapt

 Capacity to respond to stress

 Vulnerability to Disease/ Injury

 Process of Rehabilitation

Many barriers for older people in

rehabilitation process

Nevertheless, the steps of

rehabilitation are same for people
of all ages, even though the process
may differ slightly
 Process of Rehabilitation

1. Stabilization of primary problem

2. Prevent secondary complications

3. Restore lost function

4. Adaptation of person to new disability

5. Adaptation of the living facility

6. Working with family

1.Stabilization of the primary problem

- Rehab. cannot proceed until the primary illness is

stabilized
- In older adults, homeostenosis, comorbidity,
polypharmacy and deconditioning – complicate the
management of acute illness
- Maintenance of function must be part of the
management of acute illness.
2. Prevent secondary complications
- Much more common in older patients than in
younger patients
- Common complications & hazards of hospitalization
- Delirium
- Deconditioning
- Depression
- Malnutrition
- Pressure sores
- Incontinence
3. Restore lost function
- Basic principle of rehab
- Recovering the ability to walk, dress, bathe, etc. –
very important
- Attempts to restore function to optimum even at
irreversible medical conditions
- Have realistic goals and work in small increments
4. Adaptation of person to new disability
- Helping a person adapt to a new disability may mean
helping him to make changes in his belief system
- eg. while many elders are reluctant to use assistive
devices, acceptance and use of a walker or cane
for ambulation allow the person continued
independence.
5. Adaptation of the living facility
- Environmental modification to maintain function
eg. difficulties in using the Indian style toilet
due to proximal muscle weakness, arthritis and
deconditioning can be overcome by installation
of grab bars.
6. Working with family
- Educating the family – important – to understand –
Rehabilitation is possible at any age – will lead to
better function and QOL for both patient and
caregivers
- Caregivers – need to know – the patients should be
encouraged to do most of their ADLs by themselves
- Make sure – family expectations are
realistic based on patient’s condition
Goal setting
Reasonable goal-setting – the other most significant
determinant
The goal of each patient must be
 Functionally significant
 Achievable
• within a reasonable period of time
• with reasonable patient effort

•SMART GOALS
 Reasons For Admissions In Geriatric Ward

1.Therapeutic optimism
2.Medical urgency
3.Basic care
4.Relief of strain (on relatives)
 Goals of Geriatric Assessment

Improve diagnostic accuracy

Define functional impairment
Limit iatrogenesis
Prevent cascade of disasters
Recommend optimal living situation
Predict outcomes
Monitor clinical change over time
 Areas of Assessment
Functional assessment
Mobility, gait and balance
Sensory and Language impairments
Continence
Nutrition
Cognitive / Behavior problems
Depression
Caregivers
Components of assessment for Rehabilitation Potential

Medical assessment
Assessment of nursing needs
Assessment of impairments
Assessment of disabilities
Assessment of cognitive function
Assessment of the patient’s strengths / resources
Assessment of the patient’s and family’s priorities
 Hidden Illness:
You Must Ask, They Won’t Tell!

Sexual dysfunction
Depression
Incontinence
Musculoskeletal stiffness
Alcoholism
Hearing loss
Memory loss
 ILL EFFECTS OF INSTITUTIONALIZATION
L Familiar surroundings SENSORY
O Intimate family relationships AND
S Personal belongings SOCIAL
E Privacy ISOLATION

Relationships, Brief & Superficial with strangers

Atypical schedules & routines/unusual noises
Authoritarian & rigid attitudes
frequency of Diagnostic & Therapeutic misadventures
Anxiety Apathy/Withdrawal
Helplessness/Depression
Chronic Living Death
 HOSTILE ENVIRONMENT

Cascade of dependency
Functional loss
Iatrogenic disease
Adverse drug reactions
Nosocomial infections
Delirium
Malnutrition
Hazards of Hospitalization in Older Persons
THE REMEDY
 Give great attention
 Treat as responsible & respected persons
 Approach with optimism & enthusiasm
 Simulate home environment
 Stimulating environment
 Comfortable furniture & facilities, physical aids
 Complete list of drugs
 Avoid Psychotropic drugs
 Counseling & Gentle encouragement
 Early discharge
 Day Hospital
 FALLS
Most feared problem in elderly
Second only to fear of loss of independence
1/3 of elderly have falls or near-falls
10-20% result in injuries
3-5% fracture
Fall Fear of falling “Shut-in” Attitude
Social isolation, immobility, weakness,
deconditioning another Fall
 CAUSES OF FALLS

Illness Drugs Environmental Aging Social/Life

Style
Stroke Benzodiazepines Poor lighting Vision Isolation
Syncope TCAs Uneven surface Hearing Bed rest
Parkinson’s Anticholinergics Slippery surface Strength Exercise
Dementia Antipsychotics Obstacles Balance Nutrition
Delirium Antivertigo drugs Bad weather Reaction time Alcoholism
Depression Barbiturates Crime Motor control Drug abuse
Arthritis Shoe style
Paraparesis
Home visit from an PT / OT and an ergonomist to
assess homes for environmental hazards and
recommend modifications
Falls and hospitalization for falling decreased;
death decreased

 Trial study. Am J Phys Med Rehabil2002; 81:247-252.Home visits for

patients with fall.
Exercise

The best remedy

 Effects of exercise training

 muscle strength, endurance and maximal

aerobic capacity
 flexibility, coordination and balance
 risk for falling & enhance mobility
 socialization & self-esteem
 Helps in maintaining or promoting independence in
ADLs
 Health Benefits of Exercise

• Reduced risk of coronary heart disease

• Help to control hypertension
• Increased functional capacity
• Prevention of osteoporosis
• Weight management
• Reduced stress
• Mood enhancement
• Increased sensitivity to insulin in diabetics
 General guidelines
Be safe
Design to improve muscle strength, flexibility,
endurance, coordination, balance, and functional
capabilities
Start at low level and progress slowly
Include a warm-up and cool-down period of
at least 5 - 10 mins
Monitor signs of overtraining eg. HR, perceived
exertion
 General guidelines

 Give the elderly an understanding of the

purpose of the exercise
 Perform regularly, at least 3-5 times/wk
 Perform for at least 30 mins and preferably
1 hour each time
 Fit within the life-style
 Exercise prescription

 Frequency
 Intensity
Type
Time
 Exercise prescription

Frequency:
 Minimum 3 time/weeks but no
more than five days per week.
 Exercise prescription

Intensity:
 Should be a perceived exertion
between light to hard, an RPE 10-16
 70% of maximum HR
 Exercise prescription

Type:
 Walking is the preferred method

 Stationary or active bike riding

 Swimming
 Exercise prescription

Time:
Begin with a comfortable time e.g.. initially 10
mins.

Gradually increase by 2-4 mins each week until

reaching 20-60 minutes
 Exercise prescription

 Strengthening exercise at least two times/week

(preferably immediately after aerobic exercise)
use free weights

10 RM through the full ROM

 Aerobic exercise prescription for elderly

Prescription Active Elderly Sedentary Elderly

HRmax
60-80% 40-60%
Duration
20 min 10 min
Frequency 3x / week 5x / week

Period 14 weeks 14 weeks

 Start with low intensity

 Intervalize-shorter exercise duration
 Keep total session time at > 30 min
 ROLE OF REHABILITATION
Highest priority
for most elderly people for a satisfying QOL is to
maintain independence
INCREASE SELF CONFIDENCE – believing
that a task can be done.

INCREASE FORTITUDE – strength, courage

& endurance to do it.

INCREASE MOTIVATION – desire to do it

 THE CONCEPT OF LONG–TERM CARE FACILITIES AND
OLD AGE HOMES
IS NEITHER ACCEPTABLE CULTURALLY NOR
SUSTAINABLE ECONOMICALLY
In SummARY…
Disability and dependency need not be an inevitable
part of old age
Much of disease, disability, dependence,
preventable, treatable, manageable
Geriatric rehabilitation
 Helps to prevent development of disability and maintain function
 Help to regain lost functions when disability is already present

Maintenance of independence – major goal of

Geriatric Rehabilitation
GERIATRIC REHABILITATION

may mean different things to different people, but it

is of growing importance anyway..

We don’t know enough about geriatric

rehabilitation, nor how it best work, but we do know
quite a bit how it can work well, and quite a lot how
it may work better..
 WHAT WOULD PROBABLY MAKE IT WORK

Focus on good assessment of function

Pay attention to frailty, drugs and co-morbidities
Motivate, encourage independence, set goals
Prevent disuse, do not immobilize (as far as
possible)
Prescribe exercise with initially supervised training
Bring knowledge from different disciplines to work
together
Evaluate outcome
 STAY GREY OUTSIDE
BUT REMAIN GREEN INSIDE
Thank you for your attention