A Functional Testing Approach To Geriatric Rehab T. Daniel Walters - - PowerPoint PPT Presentation
A Functional Testing Approach To Geriatric Rehab T. Daniel Walters PT, DPT, GCS 1 Introduction Prevalence of the older adult population 50% case load are patients age 65 years and older More than 37 million American adults are age 65
1
baby boomers, declining birth/death rates.
85
2
year
cause of death from injury in people age 65 and
25%
fractures in older adults
3
Do what you want, when you want, for as long as you want Some degree of mobility disability Requiring help with ADLs Complete dependence 4
females, <32 lbs. for men
majority of the day
functional markers and goals
5
node cells and contractility of vascular walls.
abstract thought, mild decline in executive function
systems decline at a similar rate, 20‐30% per decade
vertebral bodies effected first
Failure
mask symptoms
6
and need for medications, with possible multiple prescribers and drug interactions
prescription drugs
a medication screening on all patients in every setting
7
(sedative‐hypnotics)
8
9
pain rated 6/10 on numeric scale located in mid‐thoracic region that started 2 weeks ago and the pain pattern appears
Metoprolol, and Fosamax. Client recently had an increase in housekeeping duties due to her husband being hospitalized for pneumonia however her ability to participate in these ADLs effectively and safely is decreasing due to pain and fatigue. History of osteoarthritis in bilateral hips, HTN and
distances to essential places such as the grocery store without an AD, pain or reports of fatigue. Currently the patient reports increased pain with household ambulation and intermittent use of 4 WW.
10
university of Otago in New Zealand discovered that low cost ($300‐600) home modifications reduced injury rates caused by falls at home per year by 26%.
11
(VCF)
and the wall can accurately rule in thoracic VCF
with distances less than 7 cm
margin of ribs and superior surface of mid axillary pelvic line indicates further evaluation required.
further testing (DEXA scan)
12
regularly
OVCF with sensitivity of 95%
OVCF with specificity of 96%
asymptomatic or have inconsistent pain patterns
limit future morbidity
13
when the test is negative
the better the test is at identifying true positives and limiting false negatives
when the test is positive
the more certainty you have that a positive result confirms disease presence, limiting false positives
14
disease"
disease
fall risk (low, medium, high)
15
lowest score is unable to assess a patient’s level of ability.
assesses fall risk may not be sensitive enough to assess low levels of fall risk among
difficult to rule out risk of falls
highest score is unable to assess a patient’s level of ability.
risk score may initially be in range to rule in, but the patient’s ability exceeds the measure's highest score
difficult to determine whether or not the patient continues to be at risk
16
detectable change
score that ensures the change isn't the result
clinically important difference
statistically significant
change required for the patient to feel a difference
17
18
fast walking speed. Perform 3 trials and take the average
and function.
falls
adverse events
19
community residents without neurological deficits
test
accuracy for falls
20
plantarflexion strength
propulsion, use as an adjunct with gait speed test
muscle testing secondary to the short moment arm
shoulders or hands and should not push down. Test is stopped if ROM is < 50%, knee flexed or balance is lost
21
validate the chair stand test as an objective measure of strength
from a chair without UE support was 40‐47% of a person’s body weight
compare with norms)
30 sec chair stand age related norms:
Age 60‐69: women 11‐17, men 12‐19 Age 70‐79: women 10‐15, men 11‐17 Age 80‐89: women 8‐14, men 8‐15 Age > 90: women 4‐11, men 7‐12 < 8 repetitions indicates risk for mobility disability and frailty
5x chair stand age related norm’s for males and females
Age 60‐69: 11.4 sec Age 70‐79: 12.6 sec Age 80‐89: 14.8 sec > 15 sec is associated with fall risk and frailty
22
approximately 10 ft.
adults
fall prediction rate of 90%
predictive of requiring ambulation device
23
identified as the most important predictor of subsequent institutionalization, more than disease and physiological indicators
as opposed to strength may be a better indicator of ADL dependence.
predictor of performance of physical tasks than knee ext. strength in OA.
24
functional
realistic goals
activity to do whatever one wants
requiring patient to make choices on activity participation
climb of 1.3 steps per second, considered normal for healthy older adults
living environments 25
if >30 sec
each task
to get back in shape! 26
27
May serve as an important measure of safety and a reliable indicator of one's ability to age in place.
28
not touching other leg.
fallers vs. non fallers, suggesting older adults that can SLS for at least 30 sec are low risk (rule out), however SLS < 30 sec cannot adequately provide risk of falling info (cannot rule in)
29
30
predictive of having a fall within the next 6 months
31
decade after age 50 without factoring in chronic diseases.
with lower scores on Barthel Index (BI)
items: feeding, transferring, grooming, toileting, bathing, ambulation, stair climbing, dressing, bowel control, and bladder control
32
1 Chronic Disease (CD) Male Left Kg Male Right Kg Female Left Kg Female Right Kg 50‐59y 41.3 45.7 25.0 27.5 60‐69y 38.9 42.1 22.6 25.2 70‐79y 34.0 37.2 19.9 22.1 >80y 29.2 31.4 16.2 18.2 2 CD 50‐59y 40.0 44.3 24.3 26.9 60‐69y 38.1 41.5 22.9 25.4 70‐79y 33.6 36.5 20.0 22.1 >80y 27.3 29.7 15.2 16.8 >3 CD 50‐59y 39.0 41.8 22.5 25.5 60‐69y 36.5 38.6 21.2 23.9 70‐79y 32.2 34.8 18.4 20.7 >80y 25.3 28.1 15.7 17.6
33
days ago with no resulting serious injury or fractures. Client fell while getting out of the tub after taking a standing shower. PMH includes generalized OA effecting multiple joints, lumbar spinal stenosis with loss of protective sensation on plantar aspect bilateral feet, HTN and cigarette smoker for 50 years ½ pack per day, COPD. Patient reports driving to the bank yesterday and ambulates with a straight cane when outside the home. 1 flight of stairs in the home, currently no report of pain but does complain of intermittent radicular pain in lower extremities after prolonged periods of standing. Medications include aspirin 81mg, Tylenol arthritis as needed for pain, multi‐ vitamin, Spiriva.
34
ambulation and correlates well with other performance measures such as gait speed
35
time, which may prove more beneficial for certain patients to help pace themselves
perform 400 MWT
test
36
effects on HR
Number Description % Threshold Nothing at all 50‐60% 1 Very light, Gentle walk 2 Fairly light 60‐70% (aerobic) 3 Moderate, steady pace 4 Somewhat hard, brisk walk with conversation 70‐80% (aerobic) 5 Starting to breath hard 80‐90% (anaerobic) 6 getting uncomfortable 7 Very hard breathing, unable to talk and keep pace 90‐100% (VO2max) 8 uncomfortable 9 Extremely hard 10 Maximum exertion, can’t continue
37
38
recent hospital stay for pneumonia. Previously ambulating community distances to essential places without AD, currently the patient is able to ambulate 400m during 6 min walk with mRPE ranging from 3‐5 but presents with observed lateropulsion, staggering with direction changes using a reaching strategy to
Flomax, furosemide, potassium chloride, Advair
the client reports only drinking 1 bottle of water daily.
39
balance
effective at measuring change over time
feet nor the footwear influence score on mCTSIB
sensitivity to help rule out
40
dysarthria, dysphagia
smooth pursuit, persistent ocular tilt reaction
visual acuity, sensory integration and response to COG perturbation
41
disorders
interventions
dwelling older adults
42
chest
43
balance and multidirectional movements
arranged at 90 degree angles, forward/backward and sideways facing forward the entire time
2 or more falls
44
chair stand
balance conditions
score Rhomberg Semi tandem Tandem Gait speed 5x sit to stand 0‐9 sec unable unable 1 <10 sec < 0.43 m/sec >16.7 sec 2 0‐2 sec 0.44‐ 0.60 m/sec 13.7‐16.6 sec 3 3‐9 sec 0.61‐ 0.76 m/sec 11.2‐ 13.6 sec 4 10 sec > 0.76 m/sec <11.1 sec
45
respectively with cutoff of 21
respectively with cutoff of 11
46
ambulatory patients
risk for falling
47
prediction value of 84%
Balance Scale (r = 0.752, p < 0.01) and between ABC score and TUG (r = 0.698, p < 0.01)
ability
48
scale from not at all concerned(1) to very concerned(4) with regard to falling while performing that daily activity item
with a cutoff score of >16 for risk of falling
49
in assuring
50
application in acute care stroke
51
especially when considering strength requirements for functional mobility tasks
more objective and practical measures
52
53
for muscle adaptation and also applies to cardiovascular training, equating to 3‐4 mRPE scale
sufficient to reach threshold stimulus, enabling combination of motor learning and strengthening
exercise and vice versa
6 weeks
strength response 12‐16 weeks
gains 6 months
conditions
54
allowing 24‐48 hours rest for each muscle group worked
60‐80% 1 rep max
ability to move through full ROM
are seen at training intensities of 80% in the very old and frail population
80% or 10 reps is as effective as 3 sets in achieving
55
Can be adjusted based on intensity
3‐4
with 5‐10 min periods of warm up and cool down
56
between hard= 2‐3 days, moderate= 2‐3 days, low= 1‐2 days to prevent overtraining
practice daily
level
at 1 min. hold is most beneficial for older adults 57
58
59
1, 2, 4, and 8) and visited again for a booster session at 6
during the months when no visits were scheduled.
took about half an hour
walk outside the home at least 2 times a week.
60
adults
epidemiology in September 2014, men over the age of 70 who participate in swimming were 33 % less likely to have a fall compared to other types of physical activity such as walking, stationary bikes and calisthenics.
types of exercise with likelihood of having a fall, nearly 2700 falls occurred.
that men with good leg strength and postural control are more likely to participate in swimming?
61
reduced by 30%
protectors
moving safely in the community
strategies; assist with home adaptations and modifications, if needed
motivation
vision expert, and a nurse or community pharmacist who can discuss medications
62
practitioners who treat older adults at risk for falls or who have fallen
recommended exercise programs such as tai chi
stage balance test, orthostatic hypotension test
63
modifiers in your assessment to reflect a wider scope of need, for example:
example:
and appropriate for household ambulation only
deficits and dependence with ADLs
and unilateral left vestibular weakness as evidenced by left line
64
m/sec in 4 weeks to reduce risk of hospitalization and to 1.0 m/sec in 8 weeks for community ambulation readiness to attend weekly church
weeks and to 9 reps in 8 weeks for greater BLE functional strength and ADL independence
8 weeks to improve sensory integration and reduce risk of falls
for community ambulation
ambulation distance within context of a 6MWT or 2MWT; along with essential places or activities 65
related to patient centered goals)
ADL participation
activation
gait speed and stair climbing ability
reduce line of progression deviation during gait training
alleviation or exacerbation of symptoms and for how long.
functional activities requiring more strength, postural control to complete. 66
Outpatient ($) to Wellness
providers, patients and caregivers especially with changes in condition
67
68