Geriatric RehabilitationGeriatric Rehabilitation

What would be the most appropriate assistive device?

78 y/o F S/P (L) TKA w/ severe RA of hands, shoulders, knees

A. Large based quad cane B. Crutches C. Two-wheel walker D. Forearm supports attached to a two-wheel

walkerE. Wheelchair

Hoenig H. JAGS, 1997 & GRS.

Rehabilitation: Rehabilitation: ConceptsConcepts

ImpairmentDisability Handicap

Geriatric RehabilitationGeriatric Rehabilitation

General Aspects• Identify the correct diagnosis !• Assess for comorbidities• Involve the patient (& family) • Team approach to care• Prevent complications(A,B,C,…)

Geriatric RehabilitationGeriatric Rehabilitation

MD

Therapists

RN

Other

Patient

SW, Dietary, PT, OT, SpT, RecT

Rehabilitation TechniquesRehabilitation Techniques

ExerciseAssistive Devices• Mobility aids• Orthotics• Adaptive methods/equipment.

Assistive Devices- Mobility AidsAssistive Devices- Mobility Aids

Device Supports• Canes 15-20 % of body weight

• Crutches 100% of body weight • Walker ~ 50 % (not 100) of body weight

Geriatric RehabilitationGeriatric Rehabilitation

Prevent complications A B C sA. Aspiration, Anorexia, inActivityB. Bedsores,C. Constipation, Contractures, CognitionD. DVTs, Depression, DUsE. Else: infections (UTI, Pneumonia), pain,

incontinence

Geriatric RehabilitationGeriatric Rehabilitation

Specifics• Joints

– Elective replacements– Fractures

• Stroke• General Medical Problems

Hip Fractures 250,000/yearAmputations 50,000/year

Spinal/Compression FractureSpinal/Compression FractureMortality unclear

Age-adjusted mortality 2.15 (FIT) (a)

RR 1.66 F, 2.38 M (b)

Life expectancy (c)

Men: 6.1 y (60-69y) 1.4 y (>80)Women: 1.9 y 0.4 y

(a) Osteoporos Int 2000;111:556-561.(b) Lancet 1999;353:878-882.(c) Arch Intern Med 1999;159:1215-20

Am J Med 1997; 103:12S-19S & Lancet 1999;353:878-882

Hip FractureHip FractureMortalityMortality

Acute: 3% F 8% M die1 year: 20% F 30-40 % M (<80 y)

>50 % M (>80y)

2 year: Returns to rate of general population

Hip FracturesHip Fractures Outcome at 1 yearOutcome at 1 year

40% cannot walk independently60% require assistance with ADL80% need help with IADL.

Functional Recovery S/P Hip FxFunctional Recovery S/P Hip Fx

Independent Function Before 6 months after

•Dress 86 49

•Transfer 90 32

•Walk across a room 75 15

•Walk half a mile 41 6

Percentage Able toPerfrom

JAGS 1992;40(9):863.

Joints/FracturesJoints/Fractures

Dx: fracture type determines surgical intervention– Pins/Screws/Plates– THA

Go to pictures

Intertrochanteric Fracture

Gardner’s 4

Lateral View

AP View

Joints / FracturesJoints / FracturesComorbidities:

OsteoporosisCalcium & Vitamin DHormone status: Estrogen, TestosteroneMedications: Steroids, thiazides,“too late” for DEXA ? use for f/uOther complications . . .

Joints/FracturesJoints/FracturesComplications

AA – Activity (asap), BB – Look at skin! (NURSING!)

CC – Laxatives (see pain below)D D – DVT prevention, DislocationMultiple regimens—LMWH, Warfarin, FondaparinaxEE- Else

Infections – Make sure foley out ASAPPain– Not moving so it doesn’t hurt is NOT good pain control!

(Use routine + PRN meds)

AmputationAmputation

Common 50,000/ yearLevel of amputation:

BKA- - work by 40-60%AKA- - work by 90-120%

Stump healingContracturesRisk of contralateral amputation - 20% @ 2 years

700,000 strokes/ yearRecurrence rate 7-10% annually

StrokeStroke Diagnosis:Diagnosis:

Etiology (hemorrhage, thrombotic, embolic)Developing interventions in acute phase

Location (frontal, posterior, left vs right)May be factor in deficits and treatments needed

Coordinated care improves outcomes.

Recovery: Proximal to distalRecovery: Proximal to distalFlaccid to spastic to recoveryFlaccid to spastic to recovery

StrokeStroke

Rehabilitation is complex due to the variety of causes and residual deficits

Recovery and time needed to reach maximal recovery affected by the number of deficits.– Hemiparesis, hemianopsia & sensory deficits

are less likely to ambulate (I) and will require a longer time than those with hemiparesis only

StrokeStroke

Comorbidities are often multiple: DM, Alcohol and Tobacco (withdrawal),Hypertension, Hyperlipidemia

StrokeStroke

Complications:AA AspirationSpeech, LRI / ActivityBB Watch skin, (NURSING!)

CC Laxatives, prevent contractures, DD DVT prev, low threshhold for depression, E E Reflex sympathetic dystrophy (pain),

infection, subluxation…

General Medical/ DeconditioningGeneral Medical/ Deconditioning

Dx:Comorbidities:Complications: