Geriatrics

Osteopathic Care of the Older Patient

Adaptations• Collagen and Elastin• Musculo-skeletal• Neurological• Cardio-casular and lymphatic• Respiratory• Gastro-intestinal• Urinary• Reproductive• Integumentary• Endocrine

Case Study

• 80yoa, male• Fall 3/7 ago, tripped over cat• Knee pain as fell on it

• Discuss:– Systemic adaptations that lead to fall– Examination– Management ideas

Regional changes• Always remember: Change to bone, cartilage, discs, joints, ligaments, muscles

• CSp: Spondylosis, uncenate processes touch and may form jts of Lushka. If not: decrease in mobility esp. S/B (C3/4), Rot (A/A)Change in ligamentous elasticity

• TSp: Rib cortex thickens & prolongs at expense of cartilage -> lower ribs more affected as more cartilage. Problem: Lower lungs perfuse better as upper.

• LSp: discs, vertebrae, jointsLigamentous stocking eg thoracolumbar fascia

• Pelvis: SIJs may fuse• Hip & Knee: Changes to joints, ligaments, muscles.

FFD -> hyperext LSp, ant. pelvic tilt and effect on organs• Ankle & Foot: 65-85yoa: Talocrural ROM decreases by 50% Foot & subtalar similar

Think about function of those areas to decide on management strategy.

Walking• Spinal engine- don’t need Lex to achieve fwd mvmt but:• Increase stride lenth, time with ground contact, propulsion effect• Need to keep COG change to a minimum• Preferred walking speed! (with minimal enegry expenditure)

Gait Changes with Ageing: Usual

• Gait velocity – decreases from around 70yoa -> increased energy expenditure• Cadence – Number of steps in certain time usually stays the same but smaller

stride length• Double stance time – Increases to around 50% of time. Balance is an issue• Walking posture – usually not changing that much but can due to eg. FFD

Gait Changes with Ageing: Non-Usual

•Loss of symmetry L/R, motion and timing•Difficulty initiating/ maintaining gait (higher centres, cerebellu,, CNS)•Retropulsion (fall backwards)•Footdrop (L5 nerve root or fibular nerve)•Short step length•Wide-based gait•Circumduction•Forward lean•Festination•Sidebending lean•Irregular instability (Cerebellum)•Arm swing reduction (eg. Parkinson)

Gait Assessment• 10m Walk if possible

• “Get up and go” without Uex helping incl. turning and sitting down again

• Balance test: Increasingly challenging– 1. Wide stance. Eyes open, Eyes closed.– 2. Close stance. Eyes open, Eyes closed.– 3. One foot slightly forward. Eyes open, Eyes closed.

– 4. One foot in front of the other. Eyes open, Eyes closed.

• Reach – look for forward lean not twist. Want to see 6in.

• Stand up, turn around and sit down: <10 steps is ok. >10steps: think balance etc.

Falls• Common• Females > Males

– Why? Eg. Mm changes• Multi-factorial• NICE Guidelines CG21 Falls

Causes: DAME• Drugs (Pxx, Alcohol)• Age• Medical Conditions (CVS, Dizziness, Postural Hypotension, Dementia)• Environment (Inside often worse than outside)

Causes - Internal Factors• Ageing• Impaired sensory input (eg. Balance)• Dizziness/ unsteadiness• Drug related• Gait abnormalities• Reduced cerebral perfusion• Epilepsy• Psychiatric problems• CVS Health

Causes - External Factors

• Poor lighting• Clutter• Footwear (not fitting, not supportive, slippers!!!)• Incorrect use of aids• Pets• Cables• Unfamiliar environment

Balance

• Three inputs to cerebellum• Need two for balance to be functional

• Sight• Proprioception• Vestibular apparatus

• Osteopathy can address: Balance, mm tone, stability, etc.

Effects of Falls• Physical Injury (50% of reported falls): S/T injury, skin breaks, #, friction burns, falls

onto object, cord lesion, hypothermia

• Psychological injury: fear, loss of confidence, anxiety/depression/reflection

• Social Injury: Anxiety in carers, extra burden on carers, separation from family/friends

• Death: Directly from fall, up to 25% of frequent fallers will be dead within 1 yr

• “Long lie down”: Remaining on the floor for >1hrPressure ulcers, Hypothermia, hypostatic pneumonia, 50% will be dead within 6mths (even without injury)

Questions to ask

• SPLATT:

• Symptoms at the time• Prev Hxx• Location• Activity at the time• Time of the day• Trauma caused

Rehabilitation & Prevention• Address underlying causes• Use of walking aids• Improve gait with TTT & Exx• Individually tailored exx, Other: Brisk walking (>2mph)

and swimming are great ;)• Identify & remove hazards (eg. Handy Van from AGE

UK, carer with pt consent)• Check Meds• Advice on footwear• Teach how to get up from floor.

http://www.bhps.org.uk/falls/hadafall.htm

Dementia & Neurological Change

• Dementia: Syndrome not disease, i.e. a set of signs and symptoms

• Affected area of cognition may be memory, attention, language, problem solving

• >6mths to be diagnosed• Generally post 65yoa• 2 main types: vascular dementia, Alzheimer’s

disease• Issue with gaining consent. Discussion!

Loneliness

• Losses of– Own capacity– Socialisation– People

• Depression, raised BP, heard disease, stroke, alcoholism

• 1 in 4 >65yoa diagnosed with depression• 1 in 2 of care home residents• Coping strategies: Pets, Religion, Group exx, etc.

Tremors• Essential Tremor: cause unknown• Parkinsonian Tremor

(Hand, Feet, Jaw resting tremor, Bradykinesia, Micrographia etc. Osteopath can work with Bradykinesia, stiffness, mvmts as address MSk system that acts out)

• MS• Stress• Hyperthyroidism• Stroke• Fragile X syndrome (genetic syndrome – mental

retardation, autism)• Drugs (incl. alcohol abuse/withdrawal)

Specific Conditions

• Oedema– Can treat: mm pump, lymphatic system- channels, diaphragms

• Incontinence (faecal and/or urinary)– Train pelvic floor & work with posture

• Pressure Ulcers– Take jewellery, watch, etc. off when treating to not cause skin tears

• TIA & Stroke• Dehydration – see next slide

Dehydration• Difficult to detect. Main symptom is thirst but this sensation has changed in older

people.• Other signs: dry mouth, tongue, thick saliva, urine changes, dizziness, sleepiness,

UTI, irritability, malaise, constipation, poor skin elasticity, low BP with rapid paint pulse, rapid breathing

• Tea and Coffee- Diuretics?

Ways to combat:• 6-8 glasses of water per day, keep water handy• Suggest little but often?• Check body weight• Avoid prolonged hot sun• Soups, fruit juices, vegetables