CARE PROTOCOL FOR WELL ELDERLY

DefinitionWell elderly is a person that had gone through ageing process without any medical illness or medication, accomplish ADL independently but some may have arthritis, diabetes but the disease won’t limit them from involved in activities.

PREPARED BYADLIN HANI BINTI MAZLAN HANAFI

NUR AIMI BINTI ISMONUiTM kampus Puncak Alam

OverviewChanges experience due to ageing• Endocrine, Gastrointestinal and Metabolic Systems

- decrease amount of total body water and total body fat- reduce in sense of taste and smell (decrease food enjoyment)

• Integumentary system- change in skin d/t dry, wrinkled- uneven discoloration, loss elasticity, delay in wound healing- capillaries can be fragile and easily bruise

• Cardiovascular system- cardiac output drops, heart rate slows, heart rate should exceed 60 b/min- degenerative process affect the ability heart to pump the blood- wall of heart become hypertrophy and lead to HPT, arteriosclerosis

• CNS (central nervous system)- elderly experience 45% loss of cells in certain areas in brain- average of 6-7 % reduce weight of brain- elderly may have slower reflexes, decreased equilibrium, decreased perception of

touch and temperature

• Sense- deterioration of hearing and vision- pupils show a decrease in ability to accommodate to light- diminish hearing capability for high-pitched sounds

• Respiratory System - result of alteration in respiratory muscle, normal elasticity, recoil of thorax- the lung tissue loses its elasticity- respiratory muscle lose their strength and coordination

• Musculoskeletal system- bones become brittle, susceptible to fracture- joint lose flexibility, loss skeletal muscle mass- elderly become easy to fall d/t decrease joint mobility and muscle weakness

Scope• Guideline for physiotherapist to

provide appropriate, safe and effective management for well elderly

Objective• General

- to assist physiotherapist in planning and implementing activities for well-elderly to enhance their quality of life

• Specific - provide knowledge and understanding to manage the well-elderly- maintain independence in ADL and their social life- prevention of accidents and injuries- use of assistive and supportive devices to suit the needs in specific environment- integrate into community

Assessment A. History taking

- general health- mental status- medical and surgical history- medication- occupation- social history – living independently/ with family- past history

B. Current history- quality of life at present moment (activity and life style)

C. Observation - getting up from chair- posture in standing- gait- limping, waddling, circumduction- ambulation w or w/o aids- balance in sitting and standing- joint swelling and joint deformity - wearing spectacles or hearing aids

D. Palpation - skin temperature- skin texture- tenderness- any bony deformity

E. Joint movement- AROM of limbs- PROM of limbs

F. Muscle power/ coordination/ balance- oxford’s muscle strength grading system- finger-nose test- modified/sharpen Romberg Test- timed up and go test- functional reach test- berg’s balance test- steps test- chair rise test- arm curl test- 4 square test

G. Functional activities- self care activities : ADL- locomotion : walking, stairs climbing

H. Neurological - reflexes- sensation- motor- proprioception- coordination

I. Short & long term goal- setting up STG and LTG based on the findings, capabilities of patients and their psychosocial needs

NB generally the ultimate goals to be achieved :-maintain and enhance the functional independence in ADL- improve and maintain psychological well-being

KEMENTERIAN KESIHATAN MALAYSIA PHYSIOTHERAPY DEPARTMENTGERIATRIC ASSESSMENT FORM

DR’S DIAGNOSIS ANTOMY CHART

DOCTOR MANAGEMENT

PROBLEMPAIN SCALE : 1 2 3 4 5 6 7 8 9 10COMMENTS :

SPECIAL QUESTION GENERAL HEALTH :MENTAL STATUS :PMHX/ SURGERY :IX/ MRI/ XRAY :OCCUPATION :MEDICATION/ STEROIDS :1. Are you taking more than 4 meds Y/N2. New med within last 2weeks Y/N3. Are you on tranquilizer sleeping Y/Npills, anti depressant?4. While walking, did you experience any of

the following? a. dizziness/ headache Y/N b. vertigo Y/N c. loss of consciousness Y/N

CURRENT HISTORY

PAST HISTORY

OBSERVATION

NAME : AGE : SEX : M/F R/N: DATE :

SPECIAL QUESTIONS (cont…)5. Environmental problem e.gLighting, flooring probs. Y/N6. Any falls within last 12 months If yes, how many times?______ Y/N7. Injuries within last 12 monthsIf yes, how many times?______ Y/N8. Continence - urinary Y/N - bowel Y/N

PALPATION

NEUROLOGICAL REFLEXES :MOTOR : SENSATION :

CLEARING TESTS / OTHER JOINTS

PHYSICAL EXAMINATIONMovementJoint active passive PHYSIOTHERAPIST IMPRESSIONS

MUSCLE POWER SHORT TERM GOAL

FUNCTIONAL ACTIVITIESSPECIAL TESTS1. GET UP AND GO TEST2. MODIFIED RHOMBERG TEST3. TIME UP AND GO TEST4. FUNCTIONAL REACH TEST5. BERG’S BALANCE TEST6. STEP TEST7. CHAIR RISE TEST.

LONG TERM GOAL

PLAN OF TREATMENT

ATTENDING PHYSIOTHERAPIST

FALL RISK SCREENING FORMDATE : NAME : AGE : I/C NO : GENDER : ADDRESS :RACE :FILL IN THE YES/NO FOR THE QUESTIONS BELOW YES NO

1. Do you take any medication (including herbal)

2. Do you take more than 4 medications daily?

3. Have you taken any new medications in the past 2 weeks?

4. Do you sometimes feels dizzy when you stand up?

5. Are you sometimes unsteady when you stand or walk?

6. Do you use a cane or a walker?

7. Do you sometimes have to rush to the bathroom?

8. Have you fallen down in the past 3 months?

9. Do you have poor vision?

10 Do you have poor hearing?

* If one or more of the above answers is yes, patient is considered to have risk of fall.

PHYSICAL ABILITY EVALUATION FORM

TIME UP AND GO TEST

MODIFIED RHOMBERG TEST

Functional Strength Arm Curl Test (ACT)-analysis of the patient’s upper extremity strength-

1. Equipment- straight backed chair (height 17”), dumbbell (5lbs for women, 8lbs for men), stopwatch

2. Starting position- pt sitting in the middle of chair with back straight and feet on floor. - the weight is held on dominant. (elb in extension by the side of pt’s torso, perpendicular with the floor, wrist in neutral)

3. Protocol- the pt is requested to turn the palm outward(supinate) while curling the arm thru the full ROM and return to full extension.- in down ward position, the hand should returned to the original position (neutral wrist)- therapist demonstrate the test and allow twice practice from pt to ensure the correct form. - a 30 secs trial is performed and recorded. - therapist can help to keep the pt’s upper arm still against their body during the trial. - pt can squeeze the therapist’s fingers to stabilize the upper arm from moving to ensure FROM is achieved.

4. Scoring- the total numbers of curls executed correctly within 30mins.

5. Adaptations of hand use is required- unable to hold the dumbbell d/t medical condition, a Velcro wrist weight may be used.- unable to perform 1 repetitions, use the lighter weight and state on assessment form

Functional Reach Test ( FRT)- Analysis of the patient’s postural control-

1. Equipment- a yardstick mounted on the wall at the sh. height.

2. Starting position- position the yardstick at the level of pt’s acromion process. - pt stand with feet shoulder width apart and arm raised to 90degree (parallel to floor)

3. Protocol- the pt is instructed to reach as far forward as possible w/out letting the feet raise from the floor. - location the middle finger is recorded.- trial distance : final number – start number. - perform 1 practice trial for patient understanding and 1 test trial for record.

4. Instruction to the patient- please reach as far as you can without losing your balance.- keep your feet on the floor.

5. Criteria to stop the test- patient’s feet lifted up or they feel forward. - therapist stands at the front because mostly patients fall forward with this test.

5. Prediction- older adults who score < 6,7 inches indicate limited functional balance.- healthy people able to score > 10inches.

STEP TEST

Intervention• The main treatment will be :

i) Exercise Therapyii) Pain Managementiii) Patient Educationiv) General Fitness

1. Exercise Therapy- Improves overall physical capacity and cardiovascular function in the elderly. - influences both life span and quality of life- offers way to maintain physical and mental healthTypes of exercise :

i) mobilising exsii) strengthening exsiii) balance exsiv) relaxation exsv) breathing exsvi) proprioceptive exsvii) aerobic exsvii) stretching exs

2. Pain managementHelp to reduce pain for patients with neuro and musculoskeletal problemsType of modalities :i) Cold therapyii) Hot packiii) TENS/ EMS

3. Patient Educationeducation programme sholud be include :i) Explanation on the conditionii) Advice on home exs programmeiii) Advice on prevention from getting worse iv) Prescription on exs

4. FitnessEncourage patient to do regular exs 20-30 minutes per session, 3 x per weekexp : brisk walking and sport activities

EXERCISEPURPOSE :-1. CARDIOVASCULAR ENDURANCE- Improve circulation and heart muscle works effectively- Efficient lungs, muscles and other systems functions2. MUSCULAR ENDURANCE- Ability of muscle to perform action for longer period of time3. MUSCULAR STRENGTH- Strengthen the muscle and bones- Improve posture, prevent osteoporosis.4. FLEXIBILITY- Level of elasticity of muscles, tendons, joints and ligaments

BENEFITS 1. Physical and psychological – reduce anxiety, improve appetite, alleviates minor

aches/pain, increase muscle endurance, improve postural control, improve balance

AEROBIC EXERCISE PERIOD1. Involved rytmic , repetitive , dynamic exercise of large group muscles from 20-30mins2. Must within individual tolerance.Progression should be done to the individual capacity. (heart rate monitored according Target

Heart Rate)

TARGET HEART RATE (KARVONEN FORMULA)THR : Target Heart RateMHR : Maximum Heart Rate (220 – age) RHR: Resting Heart Rate

% Fitness Level 50-60% - Never exercise before56-60% - Sometimes only61-70% - Exercise 3x per week71-85% - Regular exercise more than 3x perweek, under training program.

e.g : 70 years old elderly with RHR 80bpm never exercise before

THR : RHR + %fitness level(MHR – RHR): 80 + 50%(220-70)-80: 80 + 35 : 115b.p.m

3. Aerobic Exs : walking, brisk walking, treadmill walking, cycling, dancing running, sowing, stair climbing, and swimming

4. Frequency 3-5 times per weekintensity : Heart rate should reach 115bpm (refer prev exmple)time : 20-30mins

COOLING DOWN PERIOD Purpose :1. prevent blood pooling in extremities2. Prevent light headedness or fainting3. Prevent arrhythmias/ CR CxCharacteristic4. Repeating a warm p routine (assist venous return)5. Muscle recovery6. Period : 5-8mins

GUIDELINES ON CHOOSING AN EXERCISE PROGRAM

1. Exs is according to one’s physical capability and pt’s needs.2. Exs should be enjoyable3. Consult a doctor beforehand. Patient with medical problem should

adjust exs activity4. Alert with unusual symptoms ( chest pain, SOB, muscle cramps)5. Movt should be smooth and lively. (avoid jerky movt)6. Breathing Exs should be carried out within exs.7. Do not stop Exs suddenly (slow down)8. Move as much as possible (more complex movt)9. Fix a daily exs for yourself.

SAFETY1. Aerobic exs should be conducted after warm up and ends

with cooling down to avoid muscle cramp, pain and injury2. Wear proper attire and shock absorbing shoes3. Exercise is safe (good ventilated room and no slippery floor)4. Avoid exs 2hours after heavy meals5. Avoid dehydration (drink a lot)6. Avoid exs when you are sick.7. Avoid exs on bad wheather (too hot, too cold, highly

polluted air, too dark)8. Avoid taking warm bath because it may interrupts

physiological cooling down mechanism.9. Stop exs when you have chest pain or breathlessness

DRUG USED AND EXERCISE (PRECAUTIONS)

DIABETES MELLITUS• no exs when blood glucose above 20mmol/L and less than 3.5mmol/L (exs range between 4-20mmol/L• if FBG > 20mmol/L, monitor the blood glucose level before commencing the exs.• exs should commence at least after half an hour after medications•Complications of acute DM - hyperglycemia : thirsty, polyuria, lethargy, nausea, vomit and semi consciousness - hypoglycemia : hungry, headache, tremors, sweating and behavioral changes. (provides any sweets)

HYPERTENSION• ensure blood pressure is stable before exs• Severe HPT or poorly controlled pressure should avoid

isometric/ callisthenic exs (they should be monitored closely).• exs should commence at least after half an hour after

medications

MUSCULOSKELETAL PROBLEMS• Exs should be performed within pain-free ranges• Severe arthritis, joint problems should be supervised.

PRECAUTION1. Pt with DM, HPT, HD and MS problems should follow the criteria

before they join the exs program.2. Screening (DM, HPT, HD and MS problems) should be done earlier3. Pt on regular medical check up4. Compliance to medication5. Evaluation should be carried out regularly

TIPS TO PREVENT FALLSPoor balance Balance training (taichi, gym ball exs)

Muscle weakness of the legs Strengthening exs ( climbing stairs, walking and static climbing)

Poor coordination Coordination training (taichi)

Cluttered walkway Keep the walkway clear

Oil and water spills on floor Wipe all the spills immediately

Loose rugs Replace with non slip rugs

Poor lighting Maintain adequate lighting

High Bed Height Select the suitable bed height (feet can reach the floor while sitting)

Unstable chairs with wheels Use stable chairs with suitable seat heightNo mobile chair without brake

Slippery floor Walk close with wall for supportTake special care when walking outdoor

Poor vision Wear appropriate glassesHold handrail when climbing stairs

Inappropriate use of walking aids Use it correctly and seek professional advice if in doubt.

AlgorithmReferral Assessment Any

dysfunction/ disability

Yes

No

Well with risk?

Yes

No

Refer to care protocol elderly

with illness

Advice on maintain healthy

lifestyle

Well elderly prog and activitiesTreatment Re-evaluationimproved

yes

No

Discharged

Balance and coordination

- exs to improve balance- advice- pt education- recreational activities

Musculoskeletal- exs to increase /maintain ROM, flexibility, muscle

strength- pain mx- advice - pt education- recreational activities

Cardiorespiratory - exs to improve cardiopulmonary endurance with emphasis within limit- advice- patient education- recreational activity

Psychosocial status- exs for physical

function- relaxation- functional self management- stress reduction prog- advice

THANK YOU