Principles of Geriatric

Rehabilition

Wanarani Aries Sp.RM

26-03-2007
 • With the aging of population

It’s important to maximize & maintain

functional capacity

To maintain QOL & decrease health care

cost
• With timely intervention, the rehabilitation
team can help restore the functional
capacity

Help reduce the nation’s & the individual

total health care cost
• US : one-third of the total US expenditure on
personal health care is accounted for by the 65+
years.
• 1990 : 30 M (12,7 % of population) were 65+
years

Increase to 17,3% in 2020

2050 : 18%

Note : the greatest increase will be the oldest-age group of 85 years more
than double from 3,3 M to 7,0 M in the 30 years from 1990 to 2020.
• Grouping of age by WHO :
1. Young-old = 65-74 years
2. Old-old = 75-85 years
3. Oldest-old = 85+ years
• As the population ages

There is an increase :
1. The prevelance of chronic conditions
2. The activity limitation
• The physiatric history & physical examination should
identify an individual’s : IMPAIRMENTS, DISABILITIES &
HANDICAPS as defined by the WHO. (ICDH,1980)
• Although an individual can have multiple impairments

Might not cause a disabilty or handicap unless they affect

function in the home or community.
For example :
 An impairment such as a 20° degrees flexion contraction
of the right arm might cause no disability or handycap in
an individual with the ability to walk
 This same impairment can cause considerable disability
in an individual with complete paraplegia who must fully
± extend the elbow to accomplish a wheelchair transfer.
• In 1997 the WHO revised it’s definition of disablement & functioning.
In the future, may look for IMPAIRMENTS, ACTIVITIES,
PARTICIPATION during the history and examination. These new
definitions are not commonly used in clinically at present.
• Gerald Felsenthal
• Jeffrey Lehmann
• Geriatric Rehabilition : can be defined as medical treatment plus
prevention, restoration plus accomodation and education.
 the accomodation is to the irreversible effects of normal and
pathological aging and requires an ascociated education of the
patient and family
 To teach the new ways to accomlish the functional tasks that can
no longer be done as the patient previously were because the
effects of aging
 Teach the new techniques to the patient or education the family,
depending on the patient ability to learn
 Many impairments include irreversible & reversible components.
Exercise can be used to prevent or reverse shoulder immobilization
(disuse) during treatment. This preventive concept should be
broadened to include all geriatric patients by remembering the USE
IT OR LOSE IT concept.
• Biology & physiology of aging :
1. Body composition
2. Postural changes
3. Neurological changes
4. Skin
5. Cardiopulmonary changes
6. Urological
7. Hydration
8. Temperature
1. BODY COMPOSITION
A. MUSKULOSKELETAL CHANGES WITH AGE :

STRUCTURAL CHANGES WITH AGE, GENERAL MODEL

Atrophy

Distrophy

Edema

Elasticity

Demyelinization

Neoplasm

Mutation
STRUCTURAL CHANGES WITH AGE, MUSKULOSKELETAL
SYSTEM
Decrease in muscle mass

Decrease in type II muscle fibres

Decrease in boint joints

Decrease in bone density

Decrease in proteoglycan content IVD and end-plate

Decrease in nutrion to IVD and end-plate

Decrease in lumbar lordosis

Decrease in lumbar structure

Increase in size midportion IVD

Increase in thoracic kyphosis

 FUNCTIONAL CONSEQUENCES
FUNCTIONAL CONSEQUENCES
OF AGE, MUSKULOSKELETAL
OF AGE, GENERAL MODEL
SYSTEM
Accuracy Loss of muscle strength

Decrease in bone strength

Speed
Altered thermoregulation
Range
Altered BMR
Coordination Decreased in spinal ROM

Stability Decreased in end-plate strength

Altered diss matrix

Strength
Decrease in endurance
B. NEUROLOGIC CHANGES WITH AGE
ANATOMIC CHANGES AT THE CELLULAR LEVEL

Loss of neurons

Loss of dendrites and dendrite spines

Intra- and intercelluler accumulation of abnormal substances (lipofuscin,

melanin, neurofibrillary tangles, amyloid proteins)

Decrease in number of synapsis

Demyelination and swelling of axons

Decrease number of neurofilaments and neurotubules

ANATOMIC CHANGES IN CNS

Decrease brain weight by 6-11%

Cortical atrophy area frontal and temporal cortex (cell loss and cortical thinning)

Reduction in brain volume

Significant increase in CSF spaces

Gray matter changes

White matter atrophy

Accumulation of iron in the corpus striatum

Decrease number of motor neurons in the cord

Increase number of glial cells in the cord

FUNCTION CHANGE
Memory Loss of short-term
declarative memory for FUNCTION CHANGE
names, current events Vibratory sense Impaired, especially in
lower extremity
Verbal processing Progressive slowing after
3rd decade Two-point Impaired, especially in
Verbal intelligence Unimpaired until at least discrimination lower extremity
7th decade Topognosis Extinction seen,
Personality Unchanged face/hand dominant

Sleep Delayed onset, increased Sensory nerve Slowed both peripheral

wakenings, easy arousal, conduction and spinal
increased apnea, velocity
decreased deep sleep, SEP Latency delayed
more naps
Prorioception Unchanged
Alertness Moderately impaired
Myotactic reflexes Achilles’ reflex affected
Autonomic Orthostatic hypotension,
function impotence, Thermoregulation Impaired ability to
thermoregulatory, GI, discriminate changes
lacrimal, and urinary
changes
COMMON MOTOR CHANGES IN HEALTHY ELDERLY
FUNCTION CHANGE
Appearance Some wasting, particularly thenar and intrinsic
hand muscle and extensor digitorum brevis; loss of
muscle mass
Reflexes Loss of Achilles’; all others typically preserved
Pathologic reflexes Snout and grasp may be present
Accesory motions Nodding and intention tremors may be seen
electrodiagnostic Increased F-wave latency; decreased amplitude

COMMON AUDITORIUM CHANGES IN HEALTHY ELDERLY

FUNCTION CHANGE
Tone Loss most significant in higher frequencies, may
need to use lower frequency tuning fork
Localization Some difficulty with localizing sound source,
especially higher frequencies
Perception Increased difficulty in conversation Vowes and
lower tones heard better Dependency on lip reading
may be noted
Evoked potentials Increased latency; decreased amplitude
 C. THE AGE RELATED CHALLENGES OF POSTURE AND BALANCE
Posture is complex neuromuscular function that it is the action of aligning body segments.
The functions that maintain alignment are called equilibrium or balance.
D. CARDIOPULMONARY CHANGES
Normal changes noted Key point : All volumes are decreased Key point : Air trapping occurs
with aging
• Decreases in Increased stiffness of chest wall Limitation in expiration before air
VC Ankylosing spondytilis is fully expired
MVV Cervical SCI Emphysema
FEV Neuromuscular disease including : Chystic fibrosis
PO DMD, ALS, MG, GBS, Kyphoscoliosis Asthma
• FEV decreased at a Increased stiffness of lung Chronic bronchitis
rate of 30cc/year Pulmonary edema Flattening of the diaphragm
• No changes in Interstitial lung disease Increased:
TLC Airway resistance
PCO2 •Decreases in Expiratory effort
• Increases in VC Respiratory muscle fatigue
RV TLC Impaired gas exchange as a result
FRC RV of air trapping leads to resp. muscle
fatigue.
FVC
•Decreases in : VC, FEV, MVV,
MVV (decreases in severity) FVC
All volumes are decrease, this is distinctive •FEV decreases 45 to 75 cc/year in
for restrective lung disease COPD patients
•FEV is normal •Increases in: RV, FRC, TLC
Note: RV increases in C-spine injury