activity & mobility handout
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ACTIVITY & MOBILITY
Objectives
Differentiate common aging changes from
abnormal or pathological changes Recognize the clinical implications of
common aging changes
Recognize the atypical presentation ofconditions in older adults
Develop a plan of care for conditions
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Common Aging Changes -
Neurological System Slowed reaction time
Intellect the same
Conduction of nerve impulses slowed
Sensory input decreased Need more time to process
Slower deep tendon reflexes
Amount of neurotransmitters decreaselessable to respond to stresses in an effective &efficient manner
Less effective thermoregulation by
hypothalamus-risk heat stroke
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PARKINSONS DISEASE
Nerve cells in substantia nigra of the midbraindecrease in number
Causes a decrease in the amount of availabledopamine
Chemical in the synapses that breaks downdopamine (MAO-B) continues to deplete whatlittle dopamine is left
Since acetylcholine levels remain normal, thisresults in a imbalance
End result - Less dopamine, more acetylcholine
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Parkinsons Disease (PD)
Dopamine is essential for normal &smooth functioning of the extrapyramidal
motor system, including posture, balance,
coordination, support, & voluntary motion Increased actylcholine causes rigidity &
akinesia
Causessome, but often unknown
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PDClinical Manifestations
Resting tremor, often unilateral in early
stages
Bradykinesia or profound slowness Oculogyric crisis, blepharospasm
Rigidity or cogwheeling rigidity
Postural instability
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PDOther Manifestations
Micrographia
Freezing
Hypominia (decreased facial expression)
Dysarthria & dysphagia
Anxiety & fatigue
Depression (30%- 60%)
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PDOther Manifestations
Decreased autonomic reflexes
Seborrhea, increased perspiration
Constipation & urinary retention
Sleep disturbances (88%)
Cognitive impairment (25% - 35%)
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PD - Medications
Goalregulate symptoms while minimizingundesirable side effects
Dopamine agonistsimproves dyskinesias Levodopa (L-dopa)
Levodopa-carbidopa (Sinemet)
Bromocriptine mesylate (Parlodel)
Pergolide (Permax)
Pramipexole (Mirapex)
Ropinirole (Requip)
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PD - Medications
Optimal Levodopa Absorption Take 30 minutes prior to meals with 46 oz. of
water
Can take light non-protein snack with med ifneeded
Smaller dosing, more frequently get betterresponse
Do not crush medication if sustained release Do not stop meds abruptly
Keep on consistent schedule
Time activities to when medications most effective
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PD - Medications
Monoamine Oxidase (MAO-B) Inhibitor
Selegiline (Eldepryl, CarbeX)
Anticholinergicreduces tremors & rigidity Trihexyphenidyl (Artane)
Cycrimine (Pagitane)
Procyclidine (Kemadrin)
Benztropoine (Cogentin)
Biperiden (Akineton)
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PD - Medications
Antihistaminessimilar to anticholinergics
Catechol-O-Methyl Transferase (COMT)
Inhibitorsslows down breakdown oflevodopa & prolongs action, minimizes on/off
phenomenon (Useless without Sinemet)
Entacapone (Comtan)
Tolcapone (Tasmar)
Amantadine (Symmetrel) - antiviral
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PDOther Treatments
Meditation Biofeedback
Massage
Acupuncture Tai chi exercises-helps balance
Ginger for nausea
St. Johns Wort for depression
Ginkgo biloba, milk thistle
Coenzyme Q10
Antioxidants
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PDOther Treatments
Deep brain stimulation
Replacing earlier ablation, thalamotomy, &
pallidotomy procedures
Transplantation of fetal tissue
Unified Parkinson Disease Rating Scale
(UPDRS) - Standardized rating scale used to
follow PD symptoms See client education guide in Black, p.2174
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ESSENTIAL TREMORS
Asymmetrical tremor with action, made
worse by stress and fatigue
Can see at rest & can have some rigidity No other signs of PD
Unknown cause, familial
Usually effects hands, head, or voice
Katharine Hepburn
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ESSENTAIL TREMORS
Need to differentiate from PD, effects 5 timesmore people than PD
Does not progress to PD
Does not respond to PD medications
Treatment Alcohol
Beta-blockers (limited help) Primidone (Mysoline) (limited help)
Benzodiazaeines (limited help)
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Parkinsonism
Parkinson-like symptoms, but due to
other causes (ex. Dementia)
PD medications usually of little to nouse
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MUSCULARSKELETAL
SYSTEM-Aging Changes
MS system has a major impact on function
Age v. inactivity
Decreased lean body mass Decreased spine length
Longer muscle response time
Less flexible joints Decreased bone mass
See Table 12-4 in Ebersole, p. 229
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OSTEOPOROSIS
Means porous bone (not to be confused
with osteoarthritis)
Chronic, progressive metabolic bonedisease
Osteopeniaprecursor to osteoporosis
Osteoclastic activity more
Osteoblastic activity less
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Osteoporosis (OP)-Risk Factors
Female
Increasing age
Caucasian & Asian race
Thin, small framed Diet low in calcium
Alcoholism & cigarette smoking
Inactive lifestyle
Long-term use of corticosteroids, thyroidreplacements, anticonvulsants, thiazide diuretics
Postmenopausal-women, low testosterone-men
History of dietary, liver, or malabsorption problems
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OP-Clinical Manifestations
Called a silent killer or silent disease
Symptoms not present until fractures
occur or disease is advanced Initial complaint often back pain, loss of
height (usually 2 inches or more), orspinal deformities
Most common fracture sites are hip,vertebral, or wrist
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OP-Why is this a problem?
1 in 2 women age 50+, have OP
1 in 8 men age 50+, have OP
Number expected to grow as people live longer
Results in 1.5 million fractures annually Significantly under diagnosed and treated
Vertebral fractures lead to chronic pain &disability (doubles risk of death)
Hip fractures50% unable to walkindependently again, 1/3 require NH care,mortality rate is about 24% within 612 months
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OP-Diagnosis
Conventional x-ray detects OP only after
about 30% of bone mass has been lost
Bone mineral density measurements(BMD) with a dual energy x-ray
absorptiometry (DEXA or DXA) scan
T-score
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OP-Prevention
Balanced diet rich in calcium & vitamin D (400
800 units per day)
Adults need 1,200 mg. Calcium per day
Older adults need 1,500 mg. Calcium per day Weight-bearing exercises
Healthy lifestyle
Bone density testing
Sources of calcium
Hip protectors
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OP-Medications
Supplemental calcium with vitamin D Best absorbed calcium gluconate & citrate
Biophosphonates (alendronate/Fosomax,risendronate/Actonel)
Calitonin
Selective estrogen receptor modulators
(Raloxifene/Evista) Parathyroid hormone (teriparatide, Forteo)
Estrogen replacement (not recommended asmuch)
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ARTHRITIS
Osteoarthritis (Degenerative joint
disease/DJD)
Rheumatoid arthritis
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Osteoarthritis (DJD)
Most common form of joint disease
Not a normal part of aging
Usually caused by trauma, mechanical stress,
joint instability (Lewis Table 63-1) Often in weight bearing joints, spine &hands (often asymmetrical)
Destruction of articular cartilage & narrowing of
joint space, inflammation & thickening of jointcapsule & synovium, boney growths at jointmargins
Not considered an inflammatory disease
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Osteoarthritis (OA)
Clinical manifestations Pain (worsens with use & when barometric
pressure falls, early on better after rest)
Restriction on movement Early morning stiffness or after rest,
generally resolves with stretching
Swollen, not red or hot Crepitation
Loss of function
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OA-Care
Manage pain & inflammation glucosamine/chondroitin
Capsaicin
Heat & cold
Acetaminophen NSAIDS (ibuprofen, COX 2 inhibitors)take on
regular basis, not prn
Opioid narcotics
Corticosteroids (intraarticular & systemic) Synthetic synovial fluid (intraarticular)
Surgery
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Rheumatoid Arthritis (RA)
Chronic, systemic, inflammatory
disease of connective tissue & joints
Periods of remission & exacerbation
Can occur at any age, but peaks at 20
50 years
Women affected 23 times more
frequently than men, smoking linked to
disease development & severity
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RA-Clinical Manifestations
Commonly affects wrist, upper hand joints,
elbows, shoulders, neck, but not the back
Late onset RA in older adultspresents with
less inflammation & is not as symmetrical(mistaken for OA)
Etiology probably autoimmune, with a genetic
factor
Synovium is inflamed, eventually cartilage &
bone destruction
Bone deformities and soft tissue swelling
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RA-Complications & Tests
Extraarticular manifestations Can effect nearly every body system
Often related to Sjorgren syndrome &Felty syndrome
Get deformities, flexion contractures,nodules, skin breakdown, cardiopulmonaryeffects
TestsRF factor, ESR, C-reactive protein,ANA titers (see Black, Table 79-3). Many ofthese factors are elevated in older adultsdue to other conditions
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RA - Care
Manage pain & inflammation
Same meds as for OA
See Black, pages 2342-2344
Disease modifying antirheumatic drugs Start early
Ex. Antimalarials or methotrexate
Immunosuppressants
Gold therapy Biologic therapy (ex. Etanercept, sq injection)
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RA - Care
Other treatmentsAntibiotics (minocycline)
Apheresis
Careful use of all of these treatments inolder adults
Nutritionbalanced diet, may be problem
due to medications or depression & fatigue
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RA - Care
Limit disabilities & maintain function
Similar to OA, stress rest, joint protection,
proper exercise More lifestyle adjustments due to
psychosocial aspects of the disease
Manage stress, body image issues
More difficult with older adults due to
aging changes and other conditions
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Hazards of Immobility
If you dont use it, you loose it
Many causes for mobility/activity
problems in older adults Staying mobile and active reduces the
impact of many conditions and improves
psychosocial functioning
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General Principles Review
General principles the same Maintain strength and endurance (aerobic activity)
Maintain flexibilityROM, tai chi
Maintain ventilationincentive spirometer, deepbreath, cough
Maintain circulationTED hose, compressiondevices, adequate fluids, active movement
Maintain bowel & bladder functionfluids, diet,environment, routines to facilitate
Maintain safetyprevent falls, injury
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Falls
Complete module on website in syllabus Do quizzes at the end for your learning
1 -2 questions from the quizzes will be on theexam
Falls are not a normal consequence of aging
1/3 of community older adults fall each year, to 2/3 of institutionalized older adults fall
5%-10% result in serious injury, often startsdownward trajectory
Always need to ask about this in anassessment, may not volunteer information on
falls
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Dizziness
Common reason to fall, identify cause soyou can target interventions to the cause
Ask person to describe feelings or whathappens when feel dizzy
Vertigo
false sense that one is moving or the
environment is moving
Usually neurological cause
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Dizziness
Disequilibrium Inability to maintain balance
Causesaging changes, new glasses, fatigue,
arthritis, foot problems, Parkinsons Disease, more Presyncopal/syncopal episode
Feel light-headed or faint, falling out
Causesoften CV (orthostatic B/P, decreased
cardiac output, arrhythmias), hyperventilation,vasovagal response with defecation or micturition,anemia
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Fall Prevention
Identify high risk times or activities
If cognitively impaired, need to assess
judgment and ability to remembersafety interventions on a continuousbasis (ex. use call light before gettingout of bed)
Cognitive ability can change day to day,hour to hour (ex. delirium)
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Foot Disorders
Greatly effect mobility, gait & balance
Many amputations begin with footproblems
LOOK AT THE FEETEVERY DAY get functional information
identify problems (ex. Pressure ulcers)
Causesdiabetes, PVD, peripheralneuropathy, arthritis, poor footwear, highheels, aging
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Feet Disorders
Aging changes
Fungal & bacterial conditions
Symptoms Treatment
Corns (on toes) & calluses (on bottom offeet)
Causes
Treatment
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Feet Disorders
Warts Cause
Treatment
Hammer toes (second to fifth toes), claw toes,mallet toes, bunions (great toe) Cause
Treatment
Ingrown toenails Cause Treatment
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Cardiovascular System
Aging changes Valves & ventricles thicken
Decreased # of pacemaker cells
Arteries stiffer, venous valves less effective Elevated systolic B/P to 130
Clinical implications Increased demand can lead to some distress
Heart does not elevate as quickly & takes longer toreturn to baseline
Regular exercise can reduce effects of aging
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Orthostatic Blood Pressure
Why do it?
What is orthostatic hypotension?
How to do it?
Lie supine for 10 minutes & obtain B/Pand heart rate (HR)
Have pt. Stand and immediately take B/Pand HR, ask about dizziness
After upright for 2-3 minutes, obtain B/Pand HR again
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CV - Disease Presentation
Diseases that present differently in older
adults
Angina and MI CHF
Arrhythmias
PVD Heart murmur
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Respiratory System
Aging changes Chest wall stiffness
Pulmonary capillary network & alveolar surface
decreased
Cough & laryngeal reflexes reduced
Residual volume increased
Clinical implications
Increased risk of pneumonia Increased risk from anesthesia
Increased aspiration risk
R i t Di
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RespiratoryDisease
Presentation Asthma
Pulmonary emboli
Pneumonia
TB
SOB at rest
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