PT for Geriatrics
神經物理治療學及實習
胡名霞
1
contents
• Introduction
– Aging definition, epidemiology
– Aging theories, age-related changes
• Commonly seen clients
– Is there age-related diseases?
– dementia
• Assessment Principles
• Treatment Principles
2
Definitions
• Geriatric (老人病學的)
– The branch of general medicine concerned with
the clinical, social, preventive and remedial
aspects of illness in the elderly
• Geriatrics (老人病學)
– Medical care of elderly; health and social care
of the elderly
• Gerontology (老人科學)
– The application of fundamental science to the
process of aging
3
Aging in Taiwan
• Aging population > 7% in 1993
• Estimated >14% in 20??
• Life expectancy in 2010
–76.15 years
–82.66 years
(內政部統計處 100年1月12日
http://sowf.moi.gov.tw/stat/Life/T04-analysis.html )
4
人口老化速率比較
老年人口比率到達年次
國名
7﹪
14﹪
台灣
1993
2021
日本
1970
1993
英國
1930
1975
西德
1930
1975
美國
1945
2015
瑞典
1890
1975
法國
1865
1995
所需時間
（年）
28
25
45
45
70
85
130
行政院衛生署
(From 蔡誾誾，物理治療與長期照護研討會, 91.8.17.)
5
被證實的人瑞報導
• 在1997年過世的法國婦女柯莫特（Jeanne
Calment），以122.45歲的高齡成為文獻記載
活得最久的人瑞(centenarian)。
6
Morbidity
Active Life Expectancy
7
(From Guccione, Geriatric Physical Therapy, 2000)
Aging theory
Normal aging
Biological function
Biological function
Normal aging
diseases
Mature
death
• Haflick 大限說(生物
鐘)
diseases
Mature
death
• 後天損害
– Celullar
– Genetic
– systems
8
Age-related physiological decline
• Skin
– 汗腺退化以致調溫能力減退
– 油脂減少、皮膚乾燥
• Adipose tissue
– Weight gain starts > 30 y/o
– Body composition change, caloric
consumption ↓
• Musculoskeletal system
– Osteoporosis, back pain↑, strength ↓
9
Age-related physiological changes
• Sensory systems
– Vision: presbyopia (老花)、cataract (3/4
over 60 y/o)
– Hearing loss
– Taste bud↓
– Proprioception↓
– Touch sensation ↓
10
Age-related physiological changes
• Brain and mentality
–
–
–
–
Reaction time slow down 20%
Less able to concentrate
Depression may ↓creativity and memory
Dementia may occur
• Cardiopulmonary function
• Posture and balance
• Gait and mobility
11
12
13
14
Age-related decline in balance
(Sheldon, 1963)
15
Functional Impairment in
Community-Dwelling Elders
• Sequence of disability(Dunlop et al., 1997)
Walking
Bathing
Transferring
Dressing
Toileting
Feeding
16
Physical Stress Theory
Mueller, Maluf.
Physical Therapy, Volume 82, Number 4,
April 2002
http://www.ptjournal.org/cgi/
reprint/82/4/383
17
Summary of Fundamental Principles for Physical Stress Theory.
Mueller M J , Maluf K S PHYS THER 2002;82:383-403
18
©2002 by American Physical Therapy Association
Effect of physical stress on tissue adaptation.
Mueller M J , Maluf K S PHYS THER 2002;82:383-403
19
©2002 by American Physical Therapy Association
Effect of prolonged low stress lowers thresholds for subsequent adaptation and injury.
Mueller M J , Maluf K S PHYS THER 2002;82:383-403
20
©2002 by American Physical Therapy Association
Effects of immobilization
•
•
•
•
•
•
•
•
musculoskeletal: osteoporosis, stiff joints,
contracture, muscle atrophy (up to 20% after 6 weeks
of bed rest)
circulatory: deep vein thrombosis→pulmonary
embolism
skin: pressure sore due to loss of tissue, shearing
stress, ↓blood supply, and uncleaned sweat, urine and
faeces.
postural hypotension
respiratory: hypostatic pneumonia
urinary and bowel problems: kidney calculi (結石),
incontinence
apathy and depression
psychiatry in the elderly: depression, hypomania,
paranoid psychoses, neuroses, dementia, confusion
21
Effect of “overload” stress raises thresholds for subsequent adaptation and injury.
Mueller M J , Maluf K S PHYS THER 2002;82:383-403
22
©2002 by American Physical Therapy Association
Life cycle/ development after 40
http://www.vitalnation.org/html/vital_guide/vital_guide.html
23
contents
• Introduction
– Aging definition, epidemiology
– Aging theories, age-related changes
• Commonly seen clients
– Is there age-related diseases?
– dementia
• Assessment Principles
• Treatment Principles
24
Commonly seen clients
• Arthritis
•
Osteoporosis
•
Cerebral Vascular
Accident (Stroke)
•
Cancer
•
Parkinson's Disease
•
Urinary and Fecal
Incontinence
•
Amputations
•
Cardiac and
Pulmonary Diseases
•
Dementias
•
•
•
•
•
•
Alzheimer's Disease
Coordination and
Balance Disorders
Functional
Limitations related to
mobility
Sports/Orthopedic
Injuries
Joint Replacements
Hip Fractures
25
Dementia
• An impairment in some or all aspects of
intellectual functioning in a person who is
fully alert.
• Cognitive impairment affecting
–
–
–
–
–
–
Memory
Orientation
Abstract thinking
Judgment and problem solving
Language
personality
26
失智症十大警訊
•
•
•
•
•
•
•
•
•
•
記憶力減退，甚至影響到工作
無法勝任原本熟悉的事物
言語表達出現問題
喪失對時間、地點的概念
判斷力變差、警覺性降低
抽象思考出現困難
東西擺放錯亂
簡易心智狀態問卷調查表
行為與情緒出現改變
(SPMSQ)
個性改變
活動力及開創力喪失
27
失智症分類
• 退化性(40%)
– Alzheimer disease
– 8.1 years from diagnose to death
• 血管性, multi-infarct dementia (30%)
– 腦中風
– 6.7 years
• 其他病因
– 甲狀腺功能低下、腦瘤、憂鬱症(depression)、藥物
中毒等
– 5.6 years for Pick disease
• Medical and nursing care can extend life
expectancy to beyond 20 years
28
失智症狀分期
輕度/初期 (健忘期)
中度/中期(癡呆期)
重度/晚期(殘障期)
個性改變
↓活動內容能力
↓個人衛生
害怕及憂鬱
↑對人、時、地的定向
感喪失
↑語言障礙
↑ADL障礙
↑情感障礙:
憂鬱、焦慮、退縮
↑精神症狀:
幻覺、妄想
↑身體脆弱度:
臥床、失禁
↑認知障礙
維持正常活動
提供結構性環境
提供身體照顧
29
Alzheimer staging
(Umphred, p. 806)
1st stage (2-4
years)
2nd stage
3rd stage
Loss of
functional skills
(unable to handle
finance, drive car,
tell time) or
orientation
Memory loss
Lack of
spontaneity
May need to give
up job, unable to
live safely alone
Memory loss
Neurological symptoms:
Aphasia, apraxia,
wandering, repetitive
movements, stereotypical
behavior, changed
appetite, constant
movement, wide-based
gait
Psychotic symptoms:
paranoid delusions,
hallucinations, agitation,
violent behaviors,
uncontrollable screaming
Vegetative
symptoms: mute,
stop eating,
incontinent, muscle
twitches, diaphragm
spasms, unable to
walk, seizures
dies
30
Delirium and reversible dementia
• Usually treatable
• Caused by alcohol/drug, heart/lung
function, metabolic/endocrine, infection,
neurological, pharmacological, and
miscellaneous (sensory deprivation, sensory
overstimulation, pain, constipation, urinary
retention…) (Reading: Umphred pp. 802-4)
• 31% dementic patients actually has
depression
31
contents
• Introduction
– Aging definition, epidemiology
– Aging theories, age-related changes
• Commonly seen clients
– Is there age-related diseases?
– dementia
• Assessment Principles
• Treatment Principles
32
Ultimate goal
• To restore or maintain the highest
level of function possible for the
individual, particularly function
associated with movement.
• Management versus treatment
33
(From: doctor2008.wordpress.com)
34
(From: actuary-info.blogspot.com)
35
Class activity
• Which tests will you pick?
• (Fig 1 decision tree, HAS, 2005)
36
Assessment
•
•
•
•
•
•
•
•
•
•
•
說明簡單清楚、實際
口令音量要大，但應避免高頻率的尖銳聲音
BP, HR, RR
Lifestyle and environment
MMSE (Mini-mental status examination)
CDR (clinical dementia rating scale)
跌倒危險評估
系統檢查，尤其是感覺與肌力評估
Balance tests: 如 Berg Balance Scale等
Barthel Index
Physical fitness
37
MMSE (簡易心智量表)
• Cut off score for cognitive
dysfunction: 24
• Category
–
–
–
–
–
(Umphred, p. 806)
>=26: minimal
21-25: mild
15-20: moderate
10-14: severe
<= 9: profound
38
Mentality- SLUMS
• Saint Louis University Mental State
exam (中文介紹: 胡名霞，2010)
39
Depression
• Geriatric Depression Scale
– Cutoff 15 or 8 points
• Post stroke depression more likely to
occur in patients with lesions in the left
hemisphere, towards frontal pole
• Management by team:
– Pharmacotherapy, psychotherapy
– Environmental manipulation, including
• Therapeutic techniques (massage, heat,
Feldenkrais FI, aerobic exercise) can ↑
relaxation response and ↓anxiety
40
跌倒史評估 (Tideiksaar, 1989)
S-ymptoms
P-revious falls
L-ocation
A-ctivity
T-ime
41
Task-oriented Systems theory
task
individual environment
42
(Shumway-Cook, Woollacott, 2001)
43
Physical stress level is a composite value.
Mueller M J , Maluf K S PHYS THER 2002;82:383-403
44
©2002 by American Physical Therapy Association
Arndt-Schultz Principle
• The elderly require a higher level or a longer period of
stimulation before the threshold for initial
physiological response is reached.
• The physiological response in the aged is rarely as
large, as visible, or as consistent as noted in younger
age group.
• The only similarity between the response of the young
and the elderly to stimuli is that once the threshold is
reached, the more stimuli that are provided, the
greater the response.
• On average, the range of safe therapeutic stimulation
is narrower for the elderly than for the young.
45
Guidelines – for older adults and frail
older adults
• ACSM 2007
(http://www.cdc.gov/physicalactivity/
everyone/guidelines/index.html)
• Guidelines for frail older adults at
home, 2005 (http://www.has-
sante.fr/portail/upload/docs/application/p
df/physiotherapy_guidelines.pdf )
46
Strategies for treatment and care
• Starts during diagnostic process
• Goal: safe, independent, perform ADL
and IADL
• Involve significant others, understand
family reactions (Reading: Umphred, p. 807-8)
• Monthly team conference to identify
safe physical activities for recreation,
relaxation and overall fitness of the
patient
47
促進老人學習能力的要領
• 減少同時之干擾，如噪音、同時處理多項事務、
環境干擾
• 進行之速度由老年人自行決定，勿催促
• 學習內容安排有條理且實際
• 想辦法增加動機：增加與老人本身之相關性
• 感官之選擇：聽覺有利於短期記憶，視覺訊息有
利於長期記憶
• 回饋獎勵方面：盡量給正向的回饋，安排會成功
的練習
48
Test of emotional capacity to
participate in a learning task
• First obtain patient’s cooperation
• Then ask patient to
– Close eyes
– Close eyes and keep them closed for 30 sec; then
1 min
– Close eyes; move only the eyes to the right and
left slowly (goal: slow movement with control)
– Close eyes: move eyes in diagonals, right and up,
then left and down; then left and up, right and
down
• If patient requires effort to complete, then
high tension is present
– Start with passive therapeutic procedures
49
Crisis moment solution
• Staff should learn to use nonverbal skills of
communications
• During a crisis moment:
– Distraction by the carer, eg. Bump into a chair
– Distraction by others, eg, started clapping hands,
singing
– Restart with comfort or nurturing or predictable
sense of well-being, eg. Holding a favorite item,
hugging…
• Feldenkrais approach to learning: learning
must be pleasurable
50
Feldenkrais method
• 1950-1980 developed by Moshe Feldenkrais,
physicist, engineer and jodo master
• Key principle
– People can change and all people can learn
– All movement is in relation to the environment
• Key components
– Awareness Through Movement (ATM)
– Functional Integration (FI)
51
Tips for therapeutic exercise
• type: endurance, strength, flexibility,
coordination, balance, etc
• strengthening: consider distal mm
• endurance: bicycle, swimming, walking...
• for osteoporosis: weight bearing exercises
• goal setting: realistic
• fit with the lifestyle and is interesting to the
subject, performed regularly
• safe
• sufficient intensity
• remember warm-up and cool-down
52
PT programs
• Preventive: To
↑fitness
– Flexibility
– Strength
– Edurance
• Cardiac
• muscular
– Body composition
• Therapeutic: To
↓impairments and
↑function
–
–
–
–
Fall prevention
Osteoposis management
Dementia
…..
• The best 5 ex
– 慢跑、游泳、自行車、
有氧舞蹈、步行
Management vs. Treatment
53
體適能
• 教育部體適能網
(http://140.135.82.106/)
• 國立成功大學醫學院家庭醫學科 楊宜青
醫師體能活動與健康
http://stud.adm.ncku.edu.tw/hea/4wo
rk/wmain/work2.htm
54
Walking
• HR ↑較慢，但步行一公里所消耗的能量約
與比跑步一公里相當
• 主要運動到的是臀部與下肢肌群
• 三種步行方式：
– 快速步行：4.8~5.6km/hr
– 跨步行走：5.6~8km/hr
– 競走： 8~16 km/hr
• 漸進式，目標45分鐘內走完8公里，每週
至少3次，每次15~30分鐘
55
Walking注意事項
•
•
•
•
準備一雙好鞋、穿著寬鬆衣物
以自己覺得舒服為原則。
持之以恆勿一曝十寒反增危險
運動中若能達到最大心跳率之70~85﹪則有訓
練心肺耐力的效果(最大心跳率＝220－age)
• 爬山、加快步伐、背重物走路等均可增加心跳
速率
• 步行時要保持身體自然挺直，抬頭挺胸，上肢
擺動，雙手輕握拳、兩眼平視，呼吸自如。
56
Functional Benchmarks for
Pedestrians
Parameter
Benchmark
Walking speed
1.22m/s
Walking distance
300 m
Curb height
20.32 cm
57
Environmental considerationshypothermia
• Accidental hypothermia (core temp ↓35°C)
can occur at room temp 15.5-18.3 °C
• Symptoms
– Bloated face, pale and waxy or pinkish skin color,
trembling on one side of the body without
shivering, irregular and slowed heartbeat, slurred
speech, shallow and very slow breathing, low blood
pressure, drowsiness, delirium
• Prevention
– Room temp set ↑21 °C
– Long underwear, undershirt
58
Patients at high risk for hypothermia
• > 65 y/o
• Shows no signs of shivering or pale skin in
response to cold
• Taking phenothiazine (psychosis or nausea
medicine)
• Hormone system disorders, hypothyroidism
• Head injury, strokes, Alzheimer’s or other
dementia, Parkinson’s… neurological
conditions
• Severe arthritis
• Arteriosclerotic peripheral vascular disease,
chronic ulceration, amputation
59
Environmental considerationsTransplantation Shock
• Elderly who become severely disoriented and
unable to function ADL in a new environment
• Typically occurs in patients with very mild
dementia
• Management
–
–
–
–
–
Return to previous familiar environment
Patient consent before a move
Repeated reminding of expected change
2 or 3 trial visits before permanent move
Minimize institutional length of stay to ↓ learned
dependency and learned helplessness (Solomon, 1982;
1990)
60
公共環境-德國法蘭克福機場
61
連續性的照護觀- Setting of management
照護地點
家庭
輕微關節
炎、無症
狀之心臟
病
參加長青
社的活動
依賴程度
賴
心臟衰弱、
持家、購
物困難
需餐飲服
務、日間
托老等
社區
機構
記不得吃
藥、無法
自炊、穿
衣
居家照護、
日間托老、
日間醫院、
安養院
臥床或椅、
無法自己
進食、清
潔等
護理之家、
長期照護
機構
獨立 需提醒、偶爾照顧 需定期照顧 完全依
（independence
threatened)
（independence
delegated)
（Levenson, 62
1993)
Evidences and Summary
63
1966-2001
Meta Analysis
on effects of
exercise on
cognitive
function (Colcombe
& Kramer, 2003)
18 studies
64
Exercise affects cognition:
hypothesis (Colcombe & Kramer, 2003)
• Speed hypothesis: RT, tapping speed
• Visuospatial hypothesis
• Controlled-processing hypothesis
– Tasks requiring effort, rather than
automatic
• Executive-control hypothesis
– Tasks requiring coordination, inhibition,
scheduling, planning and working memory
65
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