Gerontology

Chapter 7 Gerontology



General principles




• Assessment should be based around the functional ability of the older person and their ability to maintain an independent lifestyle.


• Movement is context-dependent and therefore it is essential to understand the individual’s physical and social circumstances and the external environment that indirectly affects the individual.


• Older people are more likely to have a long-term condition, and are also more likely to have impairments resulting from two or more concurrent conditions. The impact of multi-pathology must be taken into account during the assessment process.


• It is important for the physiotherapist to assess whether the presenting problem is due to age-related change, underlying impairments, deconditioning, deskilling or a combination of these. The physiotherapist should also assess the individual’s values and beliefs about their health and identify any psychological barriers that may impact on rehabilitation.


• The physiotherapist should include specific assessment of the musculoskeletal, cardiorespiratory and neurological systems depending on the older person’s presenting problems. The assessment process may need to accommodate for changes in the older person’s ability to participate in a lengthy assessment.


• It may take a number of sessions to complete the assessment.


• Physiotherapy is often part of a multidisciplinary assessment of an older person.


• Teamwork is essential in order to build a comprehensive picture of the older person’s abilities and establish an effective treatment plan.



Knowledge specific to gerontology



Systemic ‘normal’ age changes




• The development of age-related changes tends to follow a pattern that is unique to the individual.


• Normal biological ageing progressively lowers the amount of available reserve.


• The rate and extent of decline varies across physiological systems and individuals.


• Physiotherapists should expect greater variability among their older patients.



Central nervous system: special senses



Vision




• Visual acuity, accommodation and depth perception decline with age.


• Adaptation to darkness and light occurs more slowly.


• Contrast sensitivity decreases with ageing (Hampton et al 1997).



Practical points




• Check that glasses are clean and that the person is wearing the correct pair.


• Ensure that the treatment area is well lit.


• Exercise sheets and information leaflets should be large, bold type.


• Assess the person’s ability to distinguish objects in his/her immediate environment.



Hearing and vestibular system




• Hearing loss especially at higher frequencies is common (Hampton et al 1997).


• The vestibular system shows progressive loss of hair cells, vestibular ganglion cells and nerve fibres which contribute to decline in the ability to detect orientation in space and uncertainty to move around in the dark (Ghosh 1985).



Practical points




• Even mild hearing loss makes understanding speech difficult, particularly when there is background noise or more than one person talking.


• Try to reduce background noise as much as possible.


• Face the person to facilitate lip reading.


• Check that hearing aids are switched on.


• If one ear is better, speak on that side.


• Don’t shout as this distorts the speech sounds.


• Speak clearly, more slowly and at a slightly lower frequency.


• Sometimes it may be necessary to use written communication (carry some paper with you) or basic sign language.


• Be aware that an older person may come across as confused when in fact they have not heard the question or instruction.



Skin and somatosensory system




• Older people are less sensitive to:


– Vibration especially in the lower limbs (Kenshalo 1986, Shaffer and Harrison 2007)

– Touch pressure (Wickremaratchi et al 2006)

– Two point discrimination (Shimokata and Kuzuya 1995)

– Cutaneous pain (Lautenbacher et al 2005)

– Smell and taste (Boyce and Shone 2006).

• These changes are due to a reduction in the number and structure of specialised nerve-ending receptors and peripheral nerve degeneration.


• Thinning of the subcutaneous tissue leads to wrinkling of the skin. The skin capillaries bleed more easily.



Practical points




• Care should be taken when handling and positioning the older person if they have thin, delicate skin.


• Watch for sensitivity to interventions, e.g. ice, massage.



Central nervous system: brain and spinal cord




• Ageing is associated with:


– A slow accelerating reduction in brain size with a 10% or greater loss in total brain weight over a normal long life. Both grey and white matter is lost, the former to a greater degree.

– Shrinking of the branches of the dendritic arbour.

– Reductions in the enzymes that help produce neurotransmitters.

– An accumulation of lipofuscin, neurofibrillary tangles and plaques in neurones but not to such a degree as in dementia (Hampton et al 1997).

– A small decline in maximal nerve conduction velocity (Rivner et al 2001).



Practical points




• The ability to remember new memories of events or facts, working memory and episodic memory declines in normal ageing (Hedden and Gabrieli, 2004).


• The physiotherapist should supplement instructions with an exercise sheet or visual prompts and instructions.


• The number of exercises may have to be limited and more time given to learn them.


• Changes in nerve conduction velocity do not impact on function.



Muscles




• Ageing is associated with:


– Loss of muscle mass and a corresponding reduction in maximal muscle strength (Skelton and Beyer 2003, Deschenes 2004).

– Not all muscle groups atrophy at the same rate with weight-bearing muscles showing the most change.

– Loss of motor units and a decreased number of Type II muscle fibres (Proctor et al 1995).

– Slower contraction and more susceptibility to fatigue (Connelly et al 1999).

– Decreased excitability (Porter et al 1994).

– The marked decrease in skeletal muscle strength is due to a combination of biological changes, the accumulation of acute and chronic diseases, reduced physical activity and nutritional deficiencies (Fiatarone and Evans 1993, Doherty 2003).



Practical points




• Performing a task such as rising from a chair may require the frail older person to function near their maximum functional reserve capacity.


• An additional small deficit in muscle function, such as prolonged rest or acute illness, can tip an older person into dependency.


• Appell (1990) found a 3–4% daily reduction in muscle strength during the first week of immobilisation and up to a 40% decrease in isokinetic muscle strength after 3 weeks.


• Muscle atrophy also plays a role in the development of contractures.


• The physiotherapist should encourage the older person to keep as active as possible unless contra-indicated.



Bones and joints




• Ageing is associated with:


– Universal loss of bone density from about the mid-30s onwards, accelerating after the menopause in women and in the mid-50s in men.

– As we age, the balance between bone formation and re-absorption is upset, leading to a loss over the lifetime (Chan and Duque 2002).

– Excessive cross-linkages makes cartilage less able to handle mechanical stress (Loeser 2004).



Practical points




• Increased stiffness of the connective tissues and degenerative changes in the joints contribute to a decrease in flexibility and range of motion (very small age-related loss) which may affect the ability to execute volitional or compensatory postural responses.



Gait and posture




• Ageing is associated with:


– Reduced gait speed due to shorter step length and increased time in double stance (Ferrandez et al 1990)

– Reduced hip, knee and ankle movement (Judge et al 1996)

– Increased anterior pelvic tilt (Winter et al 1990)

– Larger degree of out-toeing

– No difference in step width

– No difference in foot clearance

– Increased postural sway (College et al 1994)

– Reduction in height and stooped posture although there are marked variations in older individuals.



Practical points




• The speed an individual chooses for daily ambulation is the most fundamental measure of gait performance.


• Some gait changes are related to subtle physiological changes in the sensorimotor system, but others are best explained as functional adaptations.


• Older people may unconsciously choose to walk in a manner that increases the proportion of time spent in stance and double support to increase stability.



Respiratory system




• Age-related changes begin slowly after the third decade but progress more rapidly after the sixth decade. Changes over time are a combination of biological factors (age-related), environmental factors (pollution) and personal/social factors (smoking).


• Ageing is associated with:


– Increased stiffness of the chest wall

– Decreased strength of intercostals and accessory muscles of respiration

– Enlarged alveolar ducts/alveoli

– Decreased elasticity and increased cross-linked collagen

– Increased functional reserve and closing capacity

– Decreased local pulmonary vascular regulation

– Reduced chemoreceptor and muscle response

– Reduced effectiveness of cilia (Hampton et al 1997).



Practical points




• Despite these changes, the respiratory system is capable of maintaining adequate oxygenation and ventilation during the entire lifespan.


• However, the respiratory system reserve reduces with age, and diminished ventilatory response to hypoxia and hypercapnia makes older people more vulnerable to respiratory failure during high demand states, e.g. heart failure, pneumonia.



Cardiovascular system




• Ageing is associated with:


– An increase in heart weight

– Thickening of the endocardium and the semilunar and atriaoventricular valves

– Stiffening of the artery walls

– Increased peripheral vascular resistance

– A decrease in cardiac output

– A decrease in heart rate and maximal heart rate (Hampton et al 1997).



Practical points




• The ageing heart can significantly increase its maximum output and allows older people to perform vigorous exercise, although not up to the same intensity as a younger individual.



Autonomic nervous system




• Ageing is associated with:


– Abnormal central and peripheral thermoregulatory responses leading to reduced ability to regulate body temperature (Kenney and Munce 2003).



Practical points




• Extra precautions should be taken during strenuous exercise and hot conditions.



Genitourinary system




• Ageing is associated with:


– A decrease in weight and volume of the kidney (20–30% by age 90)

– Reduction in glomeruli by up to 50% over the lifespan

– A decrease in proximal tubule volume and length

– Reduction in bladder capacity

– Loss of muscle tone resulting in difficulty in emptying the bladder or in some cases involuntary loss of urine (Hampton et al 1997)

– The ageing kidney has a lowered reserve. Kidney disease or acute illness can have serious effects on renal function.


Gastrointestinal system




• Ageing is associated with:


– Reduction in the intestinal mucosa blood flow

– Atrophy of the musculature of the intestinal wall

– Reduction in vitamin and iron absorption (Hampton et al 1997)

– The gastrointestinal system functions well in healthy older people

– However dietary neglect, disease and medication may lead to an altered nutritional status.


Recognising delirium




• Delirium (acute confusional state) is a common condition in older people affecting up to 30% of medical (Siddiqi et al 2006) and up to 50% post fractured neck of femur patients (Marcantonio 2000).


• Delirium is characterised by an acute (hours to days), fluctuating change in mental status with inattention and altered levels of consciousness.


• There are two main types:


– Hyperactive delirium: agitation and visual hallucinations

– Hypoactive delirium: lethargy and withdrawal.

• There are many precipitating factors including immobility, malnutrition, intercurrent illness, dehydration and stress of admission to hospital or other unfamiliar settings (Elie et al 1998).


• It is important that the physiotherapist is able to recognise the signs of delirium and feedback to the MDT.


• Symptoms generally resolve when the underlying cause is treated.



Adapting assessment of older people with cognitive impairment




• Poor memory means that history taking is often difficult and to obtain a clear idea of the presenting problem may take time.


• Older people with cognitive impairment may not be able to recall how long they have had a physical problem or pain.


• The physiotherapist needs to recognise confabulation – filling in gaps in their memory with false memories.


• Information may have to be supplemented by a family member or a person that knows them well.


• Initial approach:


– Approach the person slowly from the front

– Respect personal space

– Address the person by name and make eye contact

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Nov 5, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Gerontology

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