Activity & Mobility Handout

8/13/2019 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

Documents

Activity & Mobility Handout