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The Health of The Elderly in The Health of The Elderly in Rehabilitation For Health Promotion Rehabilitation For Health Promotion
and Preventive Medicineand Preventive Medicine
The Health of The Elderly in The Health of The Elderly in Rehabilitation For Health Promotion Rehabilitation For Health Promotion
and Preventive Medicineand Preventive Medicine
Assoc. Prof. S.Ufuk Yurdalan, Ph.D. ,PTAssoc. Prof. S.Ufuk Yurdalan, Ph.D. ,PT9 Eylul University,9 Eylul University,
School of Physical Therapy and RehabilitationSchool of Physical Therapy and Rehabilitationİzmir-TRİzmir-TR
Assoc. Prof. S.Ufuk Yurdalan, Ph.D. ,PTAssoc. Prof. S.Ufuk Yurdalan, Ph.D. ,PT9 Eylul University,9 Eylul University,
School of Physical Therapy and RehabilitationSchool of Physical Therapy and Rehabilitationİzmir-TRİzmir-TR
TerminologyTerminologyTerminologyTerminology
older , elderly , geriatric , gerontology older , elderly , geriatric , gerontology
adult , individuals , people ..men &womenadult , individuals , people ..men &women
aged over 65 & octogenarians aged over 65 & octogenarians
What is geriatric ???What is geriatric ???
Geriatric is the medical branch Geriatric is the medical branch dealing with the care of the aged.dealing with the care of the aged.
When When do do we old ???we old ???
“ “ Forty is the old age of youth; fifty is the youth of Forty is the old age of youth; fifty is the youth of old age.old age.““
young olds young olds 65 -7465 -74
old olds old olds 7575 - - 8484
oldest olds oldest olds 85 +85 +
DemographyDemography
During the first 50 yrs of the 21st century, theDuring the first 50 yrs of the 21st century, theworld population 65 and over is expectedworld population 65 and over is expected to triple.to triple.The number of people 80 yrs and older grew at anThe number of people 80 yrs and older grew at anaverage rate at 159% between 1960-90, and is expectedaverage rate at 159% between 1960-90, and is expectedto continue growing at 70% until 2020 among countriesto continue growing at 70% until 2020 among countriesbelong to OECD.belong to OECD.
Family Community HealthFamily Community HealthVol.26,No:4,pp.338-349,Aug 2003Vol.26,No:4,pp.338-349,Aug 2003
Survival curves in humanSurvival curves in human
How big is the increase in years of How big is the increase in years of active life?active life?
WHAT IS THE WHAT IS THE ELDERLYELDERLY
POPULATION IN EUROPE ???POPULATION IN EUROPE ???
WHAT IS THE WHAT IS THE ELDERLYELDERLY
POPULATION IN EUROPE ???POPULATION IN EUROPE ???
Population PyramidsPopulation Pyramids
Asia (1995 and 2025) Latin America (1995 and 2025)
Europe (1995 and 2025)
Where Where do we meet the elderly ???do we meet the elderly ???
family family
elderly communitieselderly communities
hospitalshospitals
dispensary dispensary
hospices …hospices …
Who are interested in the elderly ???Who are interested in the elderly ???
Multi-professional teamMulti-professional team
geriatrics, PT’s & OT’s, nurses geriatrics, PT’s & OT’s, nurses
psychologists, social workers…psychologists, social workers…
families, friends, neighbors, etc.families, friends, neighbors, etc.
PT - Elderly InteractionPT - Elderly Interaction
GERIATRIC REHABILITATIONGERIATRIC REHABILITATION
What does geriatric rehabilitation do ???What does geriatric rehabilitation do ???
……. Focuses on restoring functional independence to older adults, in terms . Focuses on restoring functional independence to older adults, in terms
of mobility, of mobility, activity of daily living activity of daily living (ADL’s), and quality of life (QoL).(ADL’s), and quality of life (QoL).
J of Gerontological Nur.J of Gerontological Nur.Vol.27, Iss.10, pp.7,Oct 2001Vol.27, Iss.10, pp.7,Oct 2001
What are the expectations ???What are the expectations ???
Small gains in function can mean large gains Small gains in function can mean large gains
in elder patient’s QoL. in elder patient’s QoL.
Disease Management and Health Disease Management and Health OutcomesOutcomes
11(6): 363-374, 200311(6): 363-374, 2003
The Seneca study
dietary, QoL, lifestyle, and healthydietary, QoL, lifestyle, and healthy
ageing in Europe ??? ageing in Europe ???
1,091men / 1,109 women 1,091men / 1,109 women
aged 70 – 75 yrsaged 70 – 75 yrs
Be., Fr., It., NL, Port., Sp., Switz., Pl.Be., Fr., It., NL, Port., Sp., Switz., Pl.
1988 - 19991988 - 1999
Mortality riskMortality risk
smokingsmoking
having a low-quality diethaving a low-quality diet
being physically inactive being physically inactive
The net effect of a healthy lifestyle on the process of The net effect of a healthy lifestyle on the process of healthyhealthy ageingageing is likely to go together with is likely to go together with decreased decreased
morbidity.morbidity.
Healthy ageingHealthy ageing
……is provided by “health promotion” is provided by “health promotion”
Age & AgeingAge & Ageing
32(4): 427 - 434, July.200332(4): 427 - 434, July.2003
Public health policies are designed to create an Public health policies are designed to create an infrastructure to infrastructure to promote healthy ageingpromote healthy ageing and and
offer support to the growing elderly offer support to the growing elderly population.population.
Disease and Management & Health Disease and Management & Health OutcomesOutcomes
11( 5 ): 299 – 309, 200311( 5 ): 299 – 309, 2003
DEFINITION OF DEFINITION OF
HEALTHY / SUCCESSFUL HEALTHY / SUCCESSFUL
AGEINGAGEING
Definition of healthy / successful ageingDefinition of healthy / successful ageing
… … includes the maintenance of physical and includes the maintenance of physical and mental function, as well as continued social mental function, as well as continued social
engagement.engagement.
Health Screening and Health Health Screening and Health Promotion for ElderlyPromotion for Elderly
Succesful ageing factorsSuccesful ageing factors
racerace
ethnicityethnicity
educationeducation
economic & social resourceseconomic & social resources
Disease and Management & Health Disease and Management & Health OutcomesOutcomes
11 ( 5 ) : 299 – 309, 200311 ( 5 ) : 299 – 309, 2003
AGEING PROCESSAGEING PROCESS
Begins before birth but the effects onlyBegins before birth but the effects only
become apparent around the age of 30.become apparent around the age of 30.
With ageing there is a With ageing there is a lossloss in size and in size and functionalfunctional unitsunits within every bodily system and a within every bodily system and a
decrease in the proficiency of the remaining decrease in the proficiency of the remaining functionsfunctions
Ageing is characterized by a Ageing is characterized by a decreased abilitydecreased ability to adapt to and recover from physiological to adapt to and recover from physiological
displacing displacing stimuli.stimuli.
ExerciseExercise is a form of physiological is a form of physiological stimulationstimulation requiring complex requiring complex interactioninteraction among among systemssystems..
PT’sPT’s who test and prescribe exercise for middle-who test and prescribe exercise for middle-aged and older persons should be aware of the aged and older persons should be aware of the affects of aging on the various systems and on affects of aging on the various systems and on thethe abilityability to exercise and train, as well as the to exercise and train, as well as the generalgeneral characteristicscharacteristics and specificand specific needs of needs of
olderolder people.people.
Effects of ageing on systemsEffects of ageing on systems
cardiovascular systemcardiovascular system
left ventricular hypertrophyleft ventricular hypertrophy
limited left ventricular fillinglimited left ventricular filling
decreased beta-adrenoceptor med. CV responsesdecreased beta-adrenoceptor med. CV responses
cardiac dysrhytmias with exercisecardiac dysrhytmias with exercise
Pulmonary systemPulmonary system
decreased & impaired pulmonary functionsdecreased & impaired pulmonary functions
effects of smoking , chronic illnesses effects of smoking , chronic illnesses
Musculoskeletal system/ bone massMusculoskeletal system/ bone mass
gradual loss of bone massgradual loss of bone mass
begins at age 30 to 35begins at age 30 to 35
-In women, it accelerates after menopause-In women, it accelerates after menopause
-In men, it accelerates at age 50 to 55-In men, it accelerates at age 50 to 55
spontaneous fractures & fractures after mild traumaspontaneous fractures & fractures after mild trauma
OsteoporosisOsteoporosis
-Genetic factors-Genetic factors
-Nutrition -Nutrition and life style factorsand life style factors
-Hormonal and reproductive factors-Hormonal and reproductive factors
-Medications-Medications
-Comorbid factors-Comorbid factors
MJAVol.180, pp.18-22, March.2004
Musculoskeletal system / muscle massMusculoskeletal system / muscle mass
reduces in the number and size of fast-twitch reduces in the number and size of fast-twitch glycolglycolyytic muscle fiberstic muscle fibers
diminishes muscle massdiminishes muscle mass
stiffening of cartilage, tendons, and ligamentsstiffening of cartilage, tendons, and ligaments
Musculoskeletal systemMusculoskeletal system
Distribution of body fatDistribution of body fat
More fat is deposited internally and on the torsoMore fat is deposited internally and on the torso
Relation between muscle mass & body Relation between muscle mass & body fatfat
Diminished muscle mass is masked by an Diminished muscle mass is masked by an increased amount of body fat.increased amount of body fat.
LIFESTYLE !!! LIFESTYLE !!!
Neurological systemNeurological system
decreases in the number and size of neuronsdecreases in the number and size of neurons
decreases nerve conduction velocitydecreases nerve conduction velocity
decreased righting reflexesdecreased righting reflexes
increased reaction timeincreased reaction time
loss of ankle jerks and vibratory senseloss of ankle jerks and vibratory sense
Neurological systemNeurological system
increased postural swayincreased postural sway
Due to changes of posture, older people’s center of Due to changes of posture, older people’s center of gravity shifts to behind the hips.gravity shifts to behind the hips.
ASSISTIVE DEVICES!!!ASSISTIVE DEVICES!!!
Neurological systemNeurological system
Control of the movement is: Control of the movement is:
--less coordinationless coordination
--more hesitantmore hesitant
--require more attentionrequire more attention
Elderly’s common problemsElderly’s common problems
Muscle weakness, falls, fractures Muscle weakness, falls, fractures Arthritis, foot problems Arthritis, foot problems Cardiovascular diseasesCardiovascular diseases
Alzheimer, Parkinson, CVAsAlzheimer, Parkinson, CVAsPainPain
CancersCancersVision & hearing lossesVision & hearing lossesCognitive impairmentsCognitive impairments
Depression disorders & dementiaDepression disorders & dementia
RELEVANT RESEARCH ON THE RELEVANT RESEARCH ON THE ELDERLYELDERLY
Medline / Cinahl 1985 - 2002Medline / Cinahl 1985 - 2002
Muscle strengthMuscle strength should be one of the factors that is should be one of the factors that is assessed and treated in elderly at risk for falls.assessed and treated in elderly at risk for falls.
More clinical trials are needed to determine ifMore clinical trials are needed to determine if
muscle strengthening exercises are affective in muscle strengthening exercises are affective in preventing preventing falls.falls.
J of American Geriatric SocietyJ of American Geriatric Society
52 ( 7 ) :1121 – 9, July. 200452 ( 7 ) :1121 – 9, July. 2004
Medline, cochrane , embasse Medline, cochrane , embasse 1991-20041991-2004
Vitamin DVitamin D supplements appears to reduce supplements appears to reduce risk risk of fallsof falls among ambulatory or institutionalized among ambulatory or institutionalized healthy older individuals by healthy older individuals by more than 20 %.more than 20 %.
JAMAJAMA
291(16):1999 – 2006, Apr. 2004291(16):1999 – 2006, Apr. 2004
Strength trainingStrength training in rehabilitation isin rehabilitation is helpfulhelpful and and safe insafe in managing physical dysfunction, managing physical dysfunction, weight control, osteoporosis, and low back weight control, osteoporosis, and low back
painpain
Muscle strengthMuscle strength is reliably enhanced by is reliably enhanced by resistance exercises (once a wk) and may aid in resistance exercises (once a wk) and may aid in reducing reducing hip fracturehip fracture as well as improving the as well as improving the
ability to undertake daily activities and maintain ability to undertake daily activities and maintain independence.independence.
J of Reh Research & DevelopmentJ of Reh Research & Development
Vol. 37, No: 2, pp. 245 – 254 , Vol. 37, No: 2, pp. 245 – 254 , March/April 2000March/April 2000
The Epidos prospective studyThe Epidos prospective study
In ambulatory elderly women the effect of fracture is stronger in In ambulatory elderly women the effect of fracture is stronger in the first 6 months and persists for several yrs thereafter.the first 6 months and persists for several yrs thereafter.
Prevention of hip fracture and improved care may contribute to Prevention of hip fracture and improved care may contribute to increase life expectancy in addition to preserving QOL.increase life expectancy in addition to preserving QOL.
J of The Ame Ger SocJ of The Ame Ger Soc52 ( 5 ) : 685 – 690, May 2004.52 ( 5 ) : 685 – 690, May 2004.
FallsFalls remain a major cause of morbidity & remain a major cause of morbidity & mortality for the elderly, despite considerable mortality for the elderly, despite considerable growth in fallgrowth in fall preventionprevention programs in recent programs in recent
years.years.
Health promotion consist ofHealth promotion consist of group exercisegroup exercise programs through multidisciplinary, programs through multidisciplinary,
multifactor interventions for high-risk multifactor interventions for high-risk populations.populations.
Participation in a weekly group exerciseParticipation in a weekly group exercise
program with moderate intensity can improve program with moderate intensity can improve balance and reduce falls.balance and reduce falls.
Age & AgeingAge & Ageing
32 ( 4 ) : 407 - 414, July 200332 ( 4 ) : 407 - 414, July 2003
Gymnastics once a week didn’t provide benefits in Gymnastics once a week didn’t provide benefits in HRQOL and functional status after 10 wks.HRQOL and functional status after 10 wks.
To improve the health of the general public, To improve the health of the general public, sedentary older adults should be recruited and sedentary older adults should be recruited and encouraged to combine gymnastics with health encouraged to combine gymnastics with health
enhancing physical activities.enhancing physical activities.
JJ of Epidemiology & Community of Epidemiology & Community HealthHealth
58 ( 2 ) : 83 – 8 , Feb 200458 ( 2 ) : 83 – 8 , Feb 2004
ExerciseExercise programs significantly improveprograms significantly improve balance and mobilitybalance and mobility in patients with balance in patients with balance problems. Enhanced balance training may , in problems. Enhanced balance training may , in addition, improveaddition, improve confidence and QOLconfidence and QOL but but
needs further research.needs further research.
J of Ame Ger Soc.J of Ame Ger Soc.
51( 6 ): 847–52 , June 200251( 6 ): 847–52 , June 2002
AA new methodnew method of exercise prescription is of exercise prescription is based onbased on walking velocitywalking velocity of the elderly.of the elderly.
Moderate intensityModerate intensity physical activity is physical activity is recommended for healthrecommended for health promotion,promotion, disease disease
preventionprevention, and especially as a means of , and especially as a means of delaying functional loss in the elderly.delaying functional loss in the elderly.
Aeyegi, YukitoshiAeyegi, Yukitoshi
App 60 % of the max walking velocityApp 60 % of the max walking velocity
represents represents
moderate exercise.moderate exercise.
SIMPLY, SAFELY, EFFECTIVELY !!!SIMPLY, SAFELY, EFFECTIVELY !!!
Wearing shoes withWearing shoes with low heels and large contact low heels and large contact areaarea may help older adults may help older adults reduce the risk of reduce the risk of
fallfall
in everyday settings and activities.in everyday settings and activities.
J of the Amer. Ger Soc.J of the Amer. Ger Soc.
52 ( 11 ): 1840 – 6, Nov 200452 ( 11 ): 1840 – 6, Nov 2004
Contrary to findings from gait-laboratory studies,Contrary to findings from gait-laboratory studies,athletic shoes are not associated with relatively athletic shoes are not associated with relatively
low risk of fall in older adults during everyday low risk of fall in older adults during everyday activities.activities.
Fall risk was markedly increased when Fall risk was markedly increased when participants were not wearing participants were not wearing shoes.shoes.
J of The Amer. Ger Soc.J of The Amer. Ger Soc.52 ( 9 ): 1495 – 1501, Sep 200452 ( 9 ): 1495 – 1501, Sep 2004
““In In blood pressure monitoringblood pressure monitoring as older adult’s as older adult’s
perceptionsperceptions can serve as guidelines forcan serve as guidelines for
gerontologists and others in gerontologists and others in hypertensionhypertension
management effectively management effectively with olderwith older
adults.”adults.”
J of Gerontological NursingJ of Gerontological Nursing
30 ( 1 ): 44-52, Jan 200430 ( 1 ): 44-52, Jan 2004
Managing smoking, obesity, sedentary lifestyle, Managing smoking, obesity, sedentary lifestyle, homocysteinemia are equally important in reducing homocysteinemia are equally important in reducing
coronary risks in the elderly.coronary risks in the elderly.
By promoting and monitoring a healthy lifestyle, By promoting and monitoring a healthy lifestyle, healthcare providers can help older adults improve healthcare providers can help older adults improve
their CV health.their CV health.
J of Gerontological NursingJ of Gerontological Nursing29( 6 ): 18-23, June 200329( 6 ): 18-23, June 2003
Future research Future research
--needs to address compliance issues, and interventions for people needs to address compliance issues, and interventions for people with cognitive impairment, dizziness and vision loss.with cognitive impairment, dizziness and vision loss.
--is also required in residential care and hospital settings, where is also required in residential care and hospital settings, where there is relatively little research evidence to guide us.there is relatively little research evidence to guide us.
Internal Medicine JournalInternal Medicine Journal34 ( 9-10): 557-564, Se34 ( 9-10): 557-564, Sepp/Oct 2004/Oct 2004
Self-rated verbal communication is significantly related Self-rated verbal communication is significantly related to age, IADLs, intellectual activity, social activity, to age, IADLs, intellectual activity, social activity,
cognitive function, max phonation time, the number cognitive function, max phonation time, the number of teeth, the wearing of dentures, self-rated general of teeth, the wearing of dentures, self-rated general
health and oral function.health and oral function.
……hearing ability and wearing of hearing aids..hearing ability and wearing of hearing aids..
Geriatrics & Gerontology Int.Geriatrics & Gerontology Int.4 ( 2 ): 100 – 4, June 20044 ( 2 ): 100 – 4, June 2004
epidemiological follow-up study over 5 epidemiological follow-up study over 5 yrsyrs
Depressed older people are at high risk for physical Depressed older people are at high risk for physical disability.disability.
An individualized program to maintain their ADLs and An individualized program to maintain their ADLs and IADLs and physical exercise IADLs and physical exercise
should be included in their treatmentshould be included in their treatment..
J of the Amer. Ger Soc.J of the Amer. Ger Soc.
49( 3 ): 290-6, March 200149( 3 ): 290-6, March 2001
Client and family centered care, along with the provision of Client and family centered care, along with the provision of enhanced QOL and well-being through appropriate mobility enhanced QOL and well-being through appropriate mobility
activities and pain management are the corner stones to a activities and pain management are the corner stones to a positive hospice approach for the elderly with terminal cancer positive hospice approach for the elderly with terminal cancer
and other life-threatening illnesses.and other life-threatening illnesses.
Throughout the dying process,Throughout the dying process,it is essential for it is essential for PT’s & OT’sPT’s & OT’s to focuses on assessments and to focuses on assessments and
interventions for clients to adaptation.interventions for clients to adaptation.
Topics in Geriatric Reh.Topics in Geriatric Reh.Vol.20, No:2, pp.120-30, 2004Vol.20, No:2, pp.120-30, 2004
There is a need to establishThere is a need to establish ethical guidelines,ethical guidelines, which take into consideration differences inwhich take into consideration differences in religion, culture, ethnicityreligion, culture, ethnicity and race in the and race in the
elderlyelderly..
Clinical MedicineClinical Medicine
3(3): 232 – 4, May/June 20033(3): 232 – 4, May/June 2003
Community Health Care For Older Adults
“Family,and Community Based Care : The Supports For Care Plan
Implementation” Comhrensive Geriatric Assessment., 2002
ComplemComplemaantaryntary,,and Alternative Therapand Alternative Therapyy
-Mind-Mind -body therap-body therapyy
-Manual-Manual,,and body-and body- work therapwork therapyy
-Ac-Acaapuncturepuncture
-- Alternative Alternative dietary therapdietary therapyy
-- Herbal Herbal medicinemedicine
-- AromatherapyAromatherapy
-- HomeopathyHomeopathy
-- Magnetic Magnetic therapytherapy
-- Spiritual Spiritual healinghealing
Topic in Geriatric Reh.18(2): 63 – 79, 2002
ApplicationApplicationss of CAM Therap of CAM Therapyy in in GeriatricGeriatricalal RehabilitationRehabilitation
Strok Strok AcAcaapuncturepuncture
FallFall Tai-ChiTai-Chi
ArthritArthrit Yoga,relaxation techniqueYoga,relaxation technique
PaPaıınn MindMind -Body therap-Body therapyy
AlzheimerAlzheimer IMIAIMIA
ParkinsonParkinson Alexander Alexander techniquetechnique
Benefit of IntegratBenefit of Integratee CAM Therap CAM Therapyy intointo Geriatric Geriatric RehabilitationRehabilitation
-- Enhancing Enhancing communicationcommunication
-- Increasing Increasing therapeutic therapeutic optionsoptions
-- Promoting Promoting empowermentempowerment
ConsiderationConsiderationss in Prescri in Prescribebe Exerci Exercisses es FFor or ElderlyElderly
-- Medical – Medical – physiological physiological factorsfactors
-- Psychological Psychological f factorsactors
The The Physiotherapy Physiotherapy Evaluation Evaluation FFor or ElderlyElderly
-- Age / Age / gendergender
-- Primary Primary diagnosisdiagnosis
-- Secondary Secondary diagnosisdiagnosis
-- VisualVisual,,and and sensory sensory impairmentsimpairments
-- MedicationsMedications
-- Cognitive Cognitive statusstatus
-..........-..........J Geront. NurVol.27, Iss.10, pp.19, Octob., 2001
The The Objectives of Objectives of Exercise ProgramExercise Program
-- Improve Improve self-care self-care capabilities capabilities and and well-beingwell-being-- Improve CV Improve CV capacity capacity and and enduranceendurance-- Increase Increase muscular muscular strength strength and and enduranceendurance- - Improve Improve or or maintain maintain flexibility, flexibility, coordination coordination and and
balancebalance-- Weight Weight controlcontrol-- Promote Promote relaxationrelaxation-- Relieve Relieve anxiety, anxiety, insomnia insomnia and and depressiondepression-- Maximize Maximize social social contact contact and and enjoyment enjoyment all all the lifethe life
An An ExampleExample
-- Habitual vs. Habitual vs. physical physical activityactivity
-- Intensity: Intensity: LowLow
30 –40 VO30 –40 VO2Max 2Max 50-70 VO 50-70 VO2Max 2Max %%
2-3 2-3 METs (METs ( walking on 2-3 walking on 2-3 mphmph ))
-- Duration:Duration: Warm-up/ Warm-up/ exercise / exercise / cool-downcool-down
Avoid Avoid rapid rapid or or major major changes in changes in intensityintensity
The The Research Research Agenda on Agenda on Geriatric Geriatric RehabilitationRehabilitation
-Structure of -Structure of carecare : : Different Different settingssettings
-Process of -Process of carecare :: ExercisesExercises
-Process of -Process of carecare :: Assistive technologyAssistive technology
Am. J Phys. Med. Reh.Vol.83, pp.858-866, 2004
