Being oldie ..…..Being oldie ..…..

Don’t criticize the coffee; you Don’t criticize the coffee; you too may be old and weak too may be old and weak yourself somedayyourself someday

The cascade ofThe cascade ofFalls, Osteoporosis, Fractures, Falls, Osteoporosis, Fractures,

RehabilitationRehabilitation

Geriatric syndromesGeriatric syndromes

ImmobilityImmobility

InstabilityInstability

IncontinenceIncontinence

Intellectual declineIntellectual decline

IsolationIsolation

Inanition (malnutrition)Inanition (malnutrition)

CONCEPTUAL MODELS: HEALTH & ILLNESSCONCEPTUAL MODELS: HEALTH & ILLNESS

1. BIOMEDICAL: 1. BIOMEDICAL: Focuses on disease .Focuses on disease .

2. BIOPSYCHOSOCIAL: 2. BIOPSYCHOSOCIAL: Focuses on function and well- Focuses on function and well- being being

. ב.א., הסבתא האישית שלי. ב.א., הסבתא האישית שלי11סיפורי סבתא: סיפורי סבתא:

, אלמנה, מתפקדת עם מעט עזרה מהמשפחה , אלמנה, מתפקדת עם מעט עזרה מהמשפחה 8181בת בת הקרובה, לא לחלוטין צלולה, משתמשת במקל הליכה הקרובה, לא לחלוטין צלולה, משתמשת במקל הליכה "בגלל רגליים חלשות", שולטת חלקית על סוגר השתן"בגלל רגליים חלשות", שולטת חלקית על סוגר השתן

ברקע: סוכרת, יתר לחץ דם, מחלת לב איסקמית, אי ברקע: סוכרת, יתר לחץ דם, מחלת לב איסקמית, אי ספיקת לב, כאבי עצמות ומפרקים שסוכמו ספיקת לב, כאבי עצמות ומפרקים שסוכמו

כאוסתיאוארתריטיס ואוסטיאופורוזיס, ירידה בראיה כאוסתיאוארתריטיס ואוסטיאופורוזיס, ירידה בראיה וסיפור רצנטי של שתי נפילות וסיפור רצנטי של שתי נפילות

תרופות: נוגדי כאבים, משלשלים, כדורי שינה, תרופות: נוגדי כאבים, משלשלים, כדורי שינה, סולפונילאוריאה, חוסמי האנזים המהפך, חוסמי סידן, סולפונילאוריאה, חוסמי האנזים המהפך, חוסמי סידן,

משתנים, תכשירי סידן, ויטמיניםמשתנים, תכשירי סידן, ויטמינים

הקטסטרופה: נפלה בלילה בדרכה לשירותים, פונתה הקטסטרופה: נפלה בלילה בדרכה לשירותים, פונתה בבוקרבבוקר

Diagnostic work-upDiagnostic work-up : :

Physical examinationPhysical examination Lab testsLab tests Holter - ECGHolter - ECG EchocardiographyEchocardiography Duplex carotidsDuplex carotids CT brainCT brain EEGEEG

NORMALNORMAL

איך קרה שסבתא שוב נפלה?איך קרה שסבתא שוב נפלה?

מהמשפחה הקרובה, מהמשפחה הקרובה, עזרהעזרה אלמנה, מתפקדת עם מעט אלמנה, מתפקדת עם מעט ,,8181בת בת כללית:כללית:

חולשהחולשה קלה-מתונה, משתמשת במקל הליכה בגלל קלה-מתונה, משתמשת במקל הליכה בגלל קוגניטיביתקוגניטיביתירידה ירידה

השתן השתןסוגרסוגרברגליים, שולטת חלקית על ברגליים, שולטת חלקית על

אירוע אירוע איסקמית, אי ספיקת לב, איסקמית, אי ספיקת לב, מחלת לבמחלת לב, , לחץ דםלחץ דם, יתר , יתר סוכרתסוכרתרפואית: רפואית:

, וסיפור רצנטי של שתי , וסיפור רצנטי של שתי ראיהראיה עצמות ומפרקים, ירידת עצמות ומפרקים, ירידת כאביכאבי חולף, חולף, מוחימוחי

נפילותנפילות

נוגדי כאבים, משלשלים, כדורי שינה, סולפונילאוריאה, חוסמי נוגדי כאבים, משלשלים, כדורי שינה, סולפונילאוריאה, חוסמי תרופתית: תרופתית:

, תכשירי סידן+די, ויטמינים, תכשירי סידן+די, ויטמיניםהאנזים המהפך, חוסמי סידן, משתניםהאנזים המהפך, חוסמי סידן, משתנים

לשירותיםלשירותים, בזמן נסיון להגיע , בזמן נסיון להגיע ליילהליילהנסיבתית: נפילה בנסיבתית: נפילה ב

CausesCauses of falls: of falls:

Intrinsic Intrinsic (cns, pns, vision, proprioception, (cns, pns, vision, proprioception, musculoskeletal etc.) musculoskeletal etc.)

Extrinsic Extrinsic (environmental, medications) (environmental, medications)

Circumstantial Circumstantial

Falls are markers of general health conditionFalls are markers of general health condition

Incidence: 33% of ≥75y / yearIncidence: 33% of ≥75y / year

FrailtyFrailty

Loss of physiologic reserve that Loss of physiologic reserve that makes a person susceptible to makes a person susceptible to disability from minor stresses.disability from minor stresses.

Formalized phenotype: definition Formalized phenotype: definition and validation of the clinical and validation of the clinical

syndrome of frailty syndrome of frailty Multiple (3-5/5) criteria presentMultiple (3-5/5) criteria present::

Weight lossWeight loss WeaknessWeaknessExhaustionExhaustionSlowed walking speedSlowed walking speedLow activityLow activity

Premises of Frailty ConferencePremises of Frailty Conference

Frailty is a biologic and physiologic Frailty is a biologic and physiologic syndrome associated with agingsyndrome associated with aging

Frailty is a result of multisystem Frailty is a result of multisystem dysregulationdysregulation

The hallmark of frailty is enhanced The hallmark of frailty is enhanced vulnerability to stressorsvulnerability to stressors

The clinical presentation of frailty is The clinical presentation of frailty is definable and may appear subsequent to definable and may appear subsequent to the development of physiologic the development of physiologic vulnerability.vulnerability.

SarcopeniaSarcopenia

A process of gradual loss of muscle A process of gradual loss of muscle mass and strength mass and strength

Reduced force production 25-30%, more rapid Reduced force production 25-30%, more rapid after 70, Lower extremities > upperafter 70, Lower extremities > upper

(2SD)(2SD)

A fall is a A fall is a major eventmajor event in the life in the life of an older personof an older person

Aging Clin Exp Res. 2002 Feb;14(1):18-27.Aging Clin Exp Res. 2002 Feb;14(1):18-27.Falls: a comparison of trends in community, Falls: a comparison of trends in community,

hospital and mortality data in older Australians.hospital and mortality data in older Australians.

There is a clear age-related effect, with There is a clear age-related effect, with those in the 85-year and older age group those in the 85-year and older age group having a having a falls-related mortality ratefalls-related mortality rate approximately 40 timesapproximately 40 times that of those aged that of those aged 65-69 years, and a 65-69 years, and a hospitalization rate 9 hospitalization rate 9 timestimes that of those in the 65-69 age group that of those in the 65-69 age group..

Complications:Complications:Trauma: fractures, soft tissue injury, Trauma: fractures, soft tissue injury, subdural hematoma subdural hematoma

Long lying: dehydration, pneumonia, Long lying: dehydration, pneumonia, pressure ulcers, rhabdomyolysis pressure ulcers, rhabdomyolysis

Confidence: fallphobia, depression, immobility Confidence: fallphobia, depression, immobility

Other: disability, hospitalization Other: disability, hospitalization

Institutionalization Institutionalization

FracturesFractures4-6% of falls result in fracture, of which 4-6% of falls result in fracture, of which 25% are hip 25% are hip fractures.fractures.

Other common fractures are:Other common fractures are: humerus humerus wrist wrist vertebrae vertebrae ramus pubis ramus pubis ribs ribs

Cumulative risk of fracture

50 55 60 65 70 75 80 85 90

Age (years)

0

10

20

30

40

Cu

mu

lati

ve r

isk

(%)

Fracture SiteHip (women)

Vertebral (women)

Wrist (women)

Hip (men)

Vertebral (men)

Wrist (men)

Impaired balance represents a Impaired balance represents a major cause of fallsmajor cause of falls

simple testssimple tests (unipedal stance, (unipedal stance, tandem walk, get-up-and-go test)tandem walk, get-up-and-go test) are good predictors of impaired are good predictors of impaired

balance and propensity to fallbalance and propensity to fall . .

Treatment & PreventionTreatment & Prevention Always try to establish the metabolic Always try to establish the metabolic

bone disorder underlying the bone disorder underlying the fracture. Look for:fracture. Look for:OsteoporosisOsteoporosisOsteomalaciaOsteomalaciaHyperparathyroidism (1Hyperparathyroidism (100, 2, 200))Paget's diseasePaget's diseaseMalignancyMalignancyInfectionInfection

Hot topicsHot topics in osteoporosis treatment in osteoporosis treatment

BiphosphonatesBiphosphonates: Duration, efficacy and safety: Duration, efficacy and safety

TeriparatideTeriparatide: human parathyroid hormone, (anabolic): human parathyroid hormone, (anabolic)

Vitamin DVitamin D:: may improve neuromuscular function in may improve neuromuscular function in elderly who fall, however, there is no evidence that this elderly who fall, however, there is no evidence that this prevents falls or fractures in the elderlyprevents falls or fractures in the elderly

Interventions which may reduce hip fracture risk in

individualsKeep older people activeRegular review of medicationsSkilled assessment of environmentAdvice on smoking and alcoholDietary review - calcium, total nutrientsEye tests

Small changes can result in major functional gains!

MedicationsFoot wearWalking aidesSurface heightsChairs/bedWall barsLightingFlooring/mats

Fields of Geriatric MedicineFields of Geriatric Medicine

גריאטריה חריפהגריאטריה חריפהגריאטריה סיעוד-מורכבגריאטריה סיעוד-מורכבגריאטריה סיעודגריאטריה סיעודפסיכוגריאטריהפסיכוגריאטריה

שיקום גריאטרישיקום גריאטריPOST-ACUTE CAREPOST-ACUTE CARE

20032003מיטות אשפוז בישראל, מיטות אשפוז בישראל,

1434914349 כללי כללי 54595459 ברה"נ ברה"נ 706706 שיקום שיקום

598598חריפה חריפה ::2056020560 גריאטריהגריאטריה10471047 שיקומית שיקומית 1467614676 סיעודית סיעודית

32223222פסיכוגריא' פסיכוגריא'

Major indications for geriatric rehab:Major indications for geriatric rehab:

strokestrokehip fracturehip fracturedeconditioningdeconditioning

REHABILITATION: process & the attitudeREHABILITATION: process & the attitudeThe restoration of The restoration of form and functionform and function, to the maximal , to the maximal possible level, considering underlying co-possible level, considering underlying co-morbiditiesmorbidities

Rehabilitation should be:Rehabilitation should be: Comprehensive Comprehensive Multidisciplinary Multidisciplinary Continuous Continuous Focusing on function Focusing on function

Geriatric rehabilitation:Geriatric rehabilitation: ComorbiditiesComorbidities Multicausal disability Multicausal disability Pre-status function Pre-status function

CONCEPTUAL MODELS: HEALTH & ILLNESSCONCEPTUAL MODELS: HEALTH & ILLNESS

1. BIOMEDICAL: 1. BIOMEDICAL: Focuses on etiological and pathologyFocuses on etiological and pathology

2. BIOPSYCHOSOCIAL: 2. BIOPSYCHOSOCIAL: Focuses on function and well- Focuses on function and well- being being

Assessment:Assessment:Disease:Disease: diabetic retinopathy diabetic retinopathyImpairment:Impairment: visual decline visual decline Disability:Disability: low level ADLlow level ADLHandicap:Handicap: probably, not necessarily probably, not necessarily

Disease Disease Impairment Impairment Disability Disability Handicap Handicap

:basic termsMeasuring rehabilitation

  pADL (personal activities of daily living)  iADL (instrumental ADL)   FMA (functional movement activities)      

FIM : Functional Independence MeasureFIM : Functional Independence Measure Motor FIMMotor FIM (13 items) (13 items) Self-care : feedingSelf-care : feeding grooming grooming bathing bathing dressing (upper body) dressing (upper body) dressing (lower body) dressing (lower body) toileting toiletingsphincter control: bladder managementsphincter control: bladder management bowel management bowel managementmobility : transfers, toilet, tubmobility : transfers, toilet, tublocomotion ; walk, wheelchair, stairslocomotion ; walk, wheelchair, stairsCognitive FIMCognitive FIM (5 items) (5 items)communication : comprehension, expressioncommunication : comprehension, expressionsocial cognition : social interactionsocial cognition : social interaction problem solving problem solving memory memory

Total: 18 items, each score 1-7, range 18-126 Total: 18 items, each score 1-7, range 18-126 Efficacy (delta FIM), Efficiency (delta FIM / length of stayEfficacy (delta FIM), Efficiency (delta FIM / length of stay) )

Handicap, Disability, Impairment and Disease. Case 1.Handicap, Disability, Impairment and Disease. Case 1.

A.L., 70 year old maleA.L., 70 year old male

2-year difficulty walking, falls2-year difficulty walking, falls

Review of systems and medical history: negativeReview of systems and medical history: negative

Physical exam: Romberg + pansensory distal loss of sensation, Physical exam: Romberg + pansensory distal loss of sensation,

symmetric, flat foot gait with foot slappingsymmetric, flat foot gait with foot slapping

AssessmentAssessment:: Handicap Handicap

disability disability

Impairment Impairment

Disease Disease

Plan:Plan:

AssessmentAssessment::HandicapHandicap = none, = none, disabilitydisability = difficulty walking and driving. = difficulty walking and driving. ImpairmentImpairment = lower extremity sensory loss, = lower extremity sensory loss, DiseaseDisease = peripheral neuropathy, type unknown= peripheral neuropathy, type unknown

Plan:Plan: PT for gait training, diagnostic work-up of PT for gait training, diagnostic work-up of neuropathyneuropathy

Handicap, Disability, Impairment and Disease, Case 2Handicap, Disability, Impairment and Disease, Case 2

P.K. a 93 year old male. No longer able to walk, dress or feed P.K. a 93 year old male. No longer able to walk, dress or feed

himself. Wife says he is passive, thinks he is unable to do things himself. Wife says he is passive, thinks he is unable to do things

by himself. Attendant admits to perform all self care tasks for the by himself. Attendant admits to perform all self care tasks for the

patient because he feels sorry for him.patient because he feels sorry for him.

Assessment: patient is generally apathetic, but began crying Assessment: patient is generally apathetic, but began crying

stating" I am old; it's just a downhill battle, what's the use?stating" I am old; it's just a downhill battle, what's the use?

Physical exam: patient is frail, but is able to stand up and walk Physical exam: patient is frail, but is able to stand up and walk

independently with a walker in the clinicindependently with a walker in the clinic

AssessmentAssessment:: Handicap, Disability, Impairment, Disease Handicap, Disability, Impairment, Disease

PlanPlan

AssessmentAssessment:: Handicap = severely impaired social role function, Handicap = severely impaired social role function, Disability = difficulty walking, dressing, self-feeding. Disability = difficulty walking, dressing, self-feeding. Impairment = psychomotor retardation,Impairment = psychomotor retardation, Disease = depression Disease = depression

Plan:Plan: start antidepressant therapy, start PT and OT start antidepressant therapy, start PT and OT guidanceguidance