Geriatrics Sir Zahid

GERIATRICS
PHYSICAL THERAPY
BY
ZAHID MEHMOOD BHATTI

Assistant Professor of Physiotherapy
Lahore College of Physiotherapy
LM&DC
General Concepts & definitions of Aging
• Aging:
• The process of growing old; describes a wide array of physiological changes in the
body systems; complex and variable.
• Features:
1. Common to all members of a given species.
2. Progressive with time.
3. Evidenced by a:
a) Decline in homeostatic efficiency.
b) Increasing probability that reaction to injury will not be
successful.
4. Varies among and within individuals.
Features of aging – Cont.
5. Not a disease
6. Characterized by increased vulnerability to environmental changes
7. As chronological age increases, probability of death increases.
8. Reflects accumulated results of reduced cellular function, cell injury,
and cell death.
9. Some dimensions of aging grow and expand over time, while others
decline. Reaction time, for example, may slow with age, while
knowledge of world events and wisdom may expand
Categories of elderly.
A. Young elderly: ages 65-74

(60% of elderly population).
B. Old elderly: ages 75-84.
C. Old & frail elderly: ages> 85.
Definitions
Gerontology: the scientific study of the factors impacting the normal
aging process and the effects of aging.
Geriatrics: the branch of medicine concerned with the illnesses of old
age and their care.
Life span: maximum survival potential, the inherent natural life of the
species; in humans 110-120 years.
Life expectancy: the number of years of life expectation from year of
birth, 75.8 years in U.S.; women live 6.6 years longer than men.
Senescence: Last stages of adulthood through death.
The old age is defined as the age of retirement. In our country it is
fixed at 60 years and above and in USA it is 65 years.
Geriatric physical therapy
• It covers a wide area of issues concerning people as they go
through normal adult aging, but is usually focused on the older
adult.
• There are many conditions that affect many people as they grow
older and include but are not limited to: arthritis, osteoporosis,
cancer, alzheimer's disease, hip and joint replacement, balance
disorders, incontinence and more.
• Geriatric physical therapy helps those affected by such problems in
developing a specialized program to help restore mobility, reduce
pain, increase fitness levels and more.
Objectives
• Students will:
• Gain knowledge of theories of aging
• Understand incidences of mortality and morbidity for pathological

manifestations of aging including CV, pulmonary, MSK,
neurological/sensory, GI and metabolic dysfunctions
• Use this background info to formulate the bases for assessment

and treatment of clients within this age group
• Gain an understanding of prevention as a treatment modality

Demographics, Mortality & Morbidity
US population Statistics
1. Persons over 65: represents a rapidly growing segment with lengthening
of life expectancy;
a) 13% of US population in year 2000 is older than 65 years.
b) By year 2030, expected over 65 population will be 22% of US population.
c) Older women outnumber older men; 145 women for every 100 men.
d) White represents about 90% of persons over 65: only 10% are nonwhite
(8% black)
2. Increase Life expectancy: Two concurrent factors that have affected the
increase Life expectancy in the proportion of aged in US society are:
3. A declining birthrate and a declining death rate due to:
a) Advances in health care, improved infectious disease control.
b) Advances in infant/child care, decreased mortality rates.
c) Improvements in nutrition and sanitation.
PAK. Population Statistics
UN estimates
Year Total Population Population Population Population
0 -14 (%) 15 - 64 (%) 65 + (%)
1950 37542 40.3 54.1 5.6
1955 41109 40.3 54.8 4.9
1960 45920 40.4 55.3 4.3
1965 51993 41.6 54.5 3.9
1970 59383 42.6 53.6 3.8
1975 68483 43.2 53.1 3.7
1980 80493 43.4 52.9 3.7
1985 95470 43.4 52.9 3.8
1990 111845 43.7 52.5 3.8
1995 127347 43.3 52.9 3.8
2000 144522 41.4 54.7 3.9
2005 158645 38.1 57.8 4.1
2011 173593 35.4 60.3 4.3
US Population aged 65 +
Year Population
1900 4%
1940 6.9%
1950 8.2%
1970 10%
2010 13% 33.9 million
Living Alone in USA
60
50
40
30 Male
Female
20
10
0
65-74 75+
Older women outnumber older men; 145 women

for every 100 men.
Sex Distribution and Marital Status
• Because women usually live longer than men, the problems of
America's elders are largely the problems of women.
• In 1996, there were just over 2 men for every 3 women older than 65;
this ratio widened to about 1 man for every 3 women among individuals
older than 85.
• Older women have a significant probability of living longer than their
mates. In contrast to the 46% of women aged 65 years or older who
were widows, only 15% of their male counterparts had lost their
spouses.
Mortality
• Leading causes of death (mortality) in persons over 65, in order of
frequency.
• Coronary heart disease (CHD), accounts for 31% of deaths.
• Cancer, accounts for 20% of deaths.
• Cerebrovascular disease (stroke).
• Chronic obstructive pulmonary disease (COPD).
• Pneumonia/flu.
MORTALITY - Life Expectancy
• Life expectancy can be calculated from two points:
• at birth and
• a time closer to death.
• Taking the first approach, a child born in 1900 would have been expected to live only
49 years on the average, and only 41% of the children born that year would have
been expected to reach age 65.
• By 1974 the average life expectancy of a child born that year had grown to 71.9 years,
and 74% of that birth cohort is expected to reach age 65.
• An American male born in 1995 is expected to live 72.6 years on the average and a
female 6.3 years longer.
Morbidity
• Leading causes of disability/chronic conditions (morbidity) in persons over 65, in
order of frequency.
a) Arthritis, 49%.
b) Hypertension, 37%.
c) Hearing impairments, 32%.
d) Heart impairments, 30%.
e) Cataracts and chronic sinusitis, 17% each.
f) Orthopedic impairments, 16%.
g) Diabetes and visual impairments, 9% each.
h) Most older persons (60-80%) report having one or more chronic conditions.
Morbidity - Active Life Expectancy
Prevalent Chronic Conditions
• The proportion of elderly at any age without any chronic
conditions is small.
• More than one half of male elders older than 80 years and 70%
of female elders of similar age have two or more chronic
conditions.
Functional Limitations
• Limitations in functional activities increase with age.
• In 1985 the total number of disabled elderly living in the community
with any degree of chronic limitations in any basic or instrumental
ADL was 5.5 million persons.
• Elders in the 65-to 74-year-old group are thought to be healthier and
generally better off than their counterparts aged 75 years or older,
who are often termed the "frail elderly."
Disease and disability
• There were so many studies conducted who developed relationship
between disease and disability. The leading causes of disability with age
would be:
• Arthritis
• Heart disease
• Stroke
• Fractures of Hip
morbidity and Function
• Guralnik and colleagues have provided ample evidence that an increase in
the number of activities with which an elder has difficulty increases
linearly with co-morbidity, that is, coexistent medical conditions
• Thus, it is not unusual for physical therapists to find that the most disabled
patients are also likely to have a number of medical conditions that
complicate not only understanding of the genesis of functional deficit but
treatment as well.
Utilization of Services
65 years and older persons utilization of different services.

Utilization of Services
Socioeconomic factors.
a. Half of all older women are widows; older men twice a likely to be married as
older women.
b. Most live on fixed incomes: social security is the major source of income;
poverty rate for persons over 65 is 11.4%; another 8% live near the poverty rate.
c. About half of older persons have completed high school.
d. Non-institutionalized elderly: most live in family setting.
e. Institutionalized elderly: about 5% of persons over 65 reside in nursing homes;
percentage increases dramatically with age (22% of person over 85).
Health care costs
• Older persons account for 12% of population and 36% of total
health care expenditures.
• Older persons account for 33% of all hospital stays, 44% of all
hospital days of care.
Heterogeneity
• As people age, they become more dissimilar than similar in terms of
individual physiology. For example:
• A group of 30 year olds has similar cardiovascular endurance, lung
capacity, cognitive ability
• A group of 80 year olds may differ much more in basic physiology
• With this heterogeneity in function, we must know what’s normal to
recognize disease
Effects of Aging
• Some degree of decrease in biological, physiological, anatomical and
functional capabilities occur with age
• Incidences of many diseases are influenced by age advances
• Death rate for atherosclerosis, myocardial degeneration, HTN, and CA all

increase in elderly than the overall death rate
• Age predisposes an individual to develop condition or to a fatal outcome

Effects of Aging
• There is a general decline in structure, function and number of many
kinds of cells with age – predisposition to disease
• Collagen/elastin cells of skin - crystalline
• Articular hyaline cartilage – fragmented
• Lens of eye – brittle
• Loss of structure and function w/in all organs
Role of Physical Therapy
• Geriatric physical therapy is a rapidly growing specialty area
focused on optimizing aging.
• Physical therapists who work in this area treat a broad range of
individuals, including:
• healthy adults who want to continue to safely pursue recreational activities
as they age
• individuals who are at risk for injuries from falls or other adverse events
• persons with medical conditions that limit their mobility or ability to
perform activities independently
• critically ill or injured older individuals requiring acute hospital care
• older persons who need rehabilitation after surgery
• frail individuals requiring short-term skilled nursing or long-term care
• older persons in hospice care who want to remain as independent as
possible
Role of Physical Therapy
Health conditions commonly treated by geriatric physical therapists include:

• Cancer-related • Neurological conditions (e.g.,
complications stroke, Parkinson disease, multiple
• Complications from sclerosis, vestibular disorders)
hypertension • Osteoarthritis & rheumatoid
• Fall risk arthritis
• Fractures • Osteopenia & osteoporosis
• Heart & lung disorders • Overweight & obesity
• Joint replacement surgery • Pre-diabetes & diabetes
• Sports related injuries
• Wounds & amputations
Manifestations of Aging
Thank you
Comprehensive Geriatric Assessment
(CGA).

Assistant Professor
Lahore College of Physical Therapy
LMDC
Definition
Comprehensive geriatric assessment (CGA) is defined as a

multidisciplinary diagnostic and treatment process that identifies
medical, psychosocial, and functional limitations of a frail older
person in order to develop a coordinated plan to maximize overall
health with aging
Multidimentional Assessment (MDA)
➢The domains of multidimensional assessment, in the field of geriatric
medicine can extend up to the level of:
➢Mental health,
➢physical health,
➢functioning, and
➢social situation
➢The Use of Standardized Assessment tools in aforementioned areas

become the common practice in geriatric care.
Mental Status Assessment
➢Te use of standardized questions to assess mental function may be
particularly important for older patients who are experiencing difficulty
in performing certain daily Functional tasks which includes:
➢Depression,
➢Substance abuse,
➢Adverse effects of prescribed and over-the-counter medications,
➢Medical conditions
Components of the Mental Status
Examination
• Level of consciousness
• Attention
• Language
• Fluency Source: Adapted with permission
• Comprehension from RL Strub and FW Black. The
• Repetition Mental Status Examination in
• Memory Neurology, pp 163–172, © 1980 FA
• Short-term memory Davis Company.
• Remote memory
• Proverb interpretation
• Similarities
• Calculations
• Writing
• Constructional ability
Attention and Level of Consciousness
• Before an examiner can test and comment on the higher intellectual functions
of the brain, including memory, some assessment, must be made of the
patient’s level of consciousness and attention.
• Conciousness can be assessed by GCS:
• A score of 13-15 referred as Normal
• A score of 8-12 referred as disoriented
• A score of 7-3 referred as comatose.
• Attention can be assessed by “A” test of vigilance”:
 The examiner presents random letters at a rate of one letter per second.
The examiner observes for errors of commission and omission.
• Neglect is a form of inattention in which the individual does not attend stimuli
presented from a particular side, and it occurs most commonly with non-
dominant hemisphere lesions (usually the right).
Higher Integrative Functions
Location Assessment
• Frontal Lob • Points finger each time the examiner

makes a fist and makes a fist when
the examiner points.
• Dominant: standard aphasia testing
• Temporal Lob (spontaneous speech, repetition,
comprehension, writing, and naming)
• Nondominant: interprets affect
(names affects shown in photos of
faces or conveyed in examiner’s voice)
Higher Integrative Functions
Location Assessment
• Parietal Lob • Dominant: names fingers, knows
left and right, performs
calculations on paper, reading
• Nondominant: constructs copy of
matchstick figure made by the
examiner
• Matches colors and objects if
• Occipital Lob unable to name them
Memory
• Memory can be thought of as comprising three components.
• First and most fleeting is immediate recall.
• This can be assessed with digit repetition. Normal older persons can correctly recall five
to seven digits.
• The second component of memory is short-term memory, ranging over a
period of minutes to days.
• This is usually tested by asking the person to remember three to four objects or abstract
terms and then requesting him or her to recall them 5 or 10 minutes later after
• A third component of memory is remote or long-term memory.
• In one study, older adults were able to recall 80% of a catechism that had been learned
some 36 years
Language
• Language should be observed and tested in a comprehensive mental
status examination’
• Spontaneous speech is observed during the initial interview.
• A simplified approach to aphasia divides the spoken language
functions to be tested into three areas:
• comprehension,
• fluency, and
• repetition
Language
• Comprehension can be tested by asking the patient yes or no
questions. If there is doubt about the responses, the patient may be
asked to point to objects in the room. The task may be made more
difficult by having him or her try to point to objects in a particular
sequence or after the examiner has provided a description of the item
rather than the item’s name.
Language
• Fluency is a characteristic of speech that describes the rate and
rhythm of speech production and the ease in initiating speech.
• Patients may be asked to name objects and their parts, such as a wristwatch
and its band, buckle, and face.
• Repetition is tested with easy expressions (e.g., “ball” or “airplane”)
progressing to more difficult ones
Common Laguage Disorders
• Dysarthria
• Persons with dysarthria, who have difficulty in the
mechanical production of language, use normal grammar.
• Aphasia
• Broca’s Aphasia
• All three language parameters are impaired in such a case. After a
period of recovery, some language function may return.
• Wernick’s Aphasia
• Wernicke’s aphasia is characterized by impaired comprehension and
repetition. Speech is fluent but marked by paraphasia (i.e., words or
sounds that are replaced by other sounds, such as “wife” or “car” for
“knife”) and neologisms (i.e., nonsense words).
Writing and Construction Ability
• At this point in the examination, the patient may be
presented with a blank sheet of paper for subsequent tests.
• The patient is asked to write his or her name at the top of
the page.
• Below the signature, the patient is asked to write a complete
sentence, perhaps about the weather.
• The ability to reproduce the line drawings of the examiner
represents construction ability.
• The testing begins with simple figures such as a triangle or
square and progresses to more complex drawings such as a
cube, house, or flowerpot.
• Mattis reminds us that testing the ability to copy figures is
not specific to dementia because trouble with this test may
reflect motor incoordination or apraxia
Writing and Construction Ability
• Asking the patient to draw a clock showing the numerals and time (e.g.,
“10 minutes past 11 o’clock”) can act as a single item screen for
cognitive impairment.
• The examiner draws a large circle on a blank sheet of paper and asks
the patient to fill in the numbers as on a clock.
• This task is thought to be a sensitive test of parietal lobe dysfunction.
• Persons with primarily right or nondominant hemisphere dysfunction,
write the numbers correctly but plan poorly.
• Those with primarily left or dominant hemisphere dysfunction have
trouble writing the numbers but execute the general plan of the clock
correctly, perhaps placing lines where the numbers should be.
• Clock drawing has been used to screen for cognitive impairment as well
as to follow progression of diagnosed Alzheimer’s disease.
Mental Status Assessment
➢The specific Standardized assessment tools used for assessment of
mental status are:
➢Minimental state Examination (MMSE)
➢Cognitive Capacity Screen
➢The Kokmen Short Test of Mental Status
➢Orientation-Memory-Concentration Test
➢Geriatrics Depression Scale (GDS) for depression.
➢Dementia and Delirium
➢ Blessed Dementia Scale
➢Blessed Dementia information –memory- concentration Scale
➢Short oriented Memory Concentration Test
➢ Clock Drawing Test (CDT).
➢ Confusion Assessment Method (CAM).
➢ Time and Change Test (TCT).
➢ Short Portable Mental Status Questionnaire (SPMSQ).
Functional Assessment
• Quality of life assessment is directly related to functional assessment

includes:
• The ability to perform various tasks of daily life, such as dressing and
housework. (ADLs)
• The more cognitively complex and physically demanding tasks, such as
grocery shopping.(IADLs)
• Aside from specific medical diagnoses, functional status is
independently associated with the care the patient needs, the risk for
institutionalization, and mortality.
Functional Assessment
• Different scales used for Functional assessment Includes;

• Barthal Index (ADLs)
• Katz ADLs
• Lawton IADLs
• Palliative Performance Scale (PPS).
• Geriatric Health Questionnaire (GHQ).
• Kurtzke Expanded Disability Status Scale
• Rikli – Jones 2 minute Step Test
• Rikli – Jones 30 second Chair Stand Test
Social Assessment
• Most long-term care is provided by caregivers who often need physical and
emotional support in order to maintain the older person at home.
• Frequently, the caregiver is a woman, especially daughters and daughters-
in-law.
• Evaluation of the older person cannot be complete without some
assessment of the social support system.
• Therefore, a special attention in assessing older adults for abuse as well as
for the functioning of their social support situation is needed.
• Personal finances may have an impact on health, nutrition, and residence.
Social Assessment
• Burden Interview:
• The Burden Interview has been specially designed to reflect the stresses
experienced by caregivers of dementia patients.
• It can be completed by caregivers themselves or as part of an interview.
• Caregivers are asked to respond to a series of 22 questions about the impact
of the patient’s disabilities on their life.
• For each item, caregivers are to indicate how often they felt that way (never,
rarely, sometimes, quite frequently, or nearly always).
Social Assessment
• Scoring system of Burden Interview:
0 -20 Little or no burden
21 – 40 Mild to moderate burden
41 – 60 Moderate to severe burden
61 – 88 Severe burden
• Higher scores indicate greater caregiver distress.

• Clinical observations and other instruments, such as
measures of depression, should be used to
supplement this measure.
Pain Assessment
• Knowing how to assess pain in older persons in clinical settings is
essential to avoid unnecessary suffering and functional impairment,
to monitor the response to therapy, and to achieve freedom from
significant pain, which is an important component of quality of life.
• The adequate assessment of pain is pertinent to the care of

ambulatory older persons as well as older adults in specialized
settings, such as the nursing home or hospice.
Pain Assessment
• Different Pain scales used for geriatric population includes:
• Brief Pain Inventory (Short Form).
• Faces Pain Scale
• Functional Pain Scale
• Checklist of Nonverbal Pain Indicators (CNPI)
• Numeric Rating Scale
• Pain Assessment in Advanced Dementia Scale (PAINAD)
• Pain Thermometer
• Verbal Descriptor Scale
• Verbal Numeric Scale
Nutrition & Weight Loss
• Determine Your Nutritional Health is a screening tool act as guide for both
a patient education tool and a quick, convenient means to identify patients
who have risk factors for poor nutritional status.
• The assessment is a brief, 10-statement form that is completed.

•
• The form also includes a description of warning signs for poor nutritional
health.
• Determine Your Nutritional Health (Scale)

Balance & Fall Risk Assessment
• The Activities-specific Balance Confidence (ABC) Scale.
• Berg Balance Scale.
• Functional Reach Arm Test
• TineittiPerformance-Oriented Assessment of Balance
• Falls Efficacy / Confidence in Mobility Test
• Fugal Myer – sensation and LE function
• Prorioception.
• Postural Sway assessment scale.
Gait & immoblity
• The Get-up and Go Test (GUG)
• 10 meter Walk Test (10 MWT)
• Timed up & go Test (TUG)
• Tinetti Performance-Oriented Assessment of Gait (POAG)
• Gait Speed (self selected)
• Gait Abnormality Rating Scale - modified (GARS-M)
• Dynamic Gait Index
• Hess Figure of 8 Gait Test
Pressure Ulcers, DVT and Sensory Perception and
Urinary Incontinenance
• Fugal Myer – sensation and LE function
• Braden Scale for Predicting Pressure Sore Risk
• Autar_DVT_Risk_Assessment_Scale
• Wells’ Clinical Decision Rule for DVT
• Snellen Eye Chart
• Whispered VoiceTest
• Two Point Discrimination
• Lower Extremity Vascular Tests & Measures
• Steriogonosis
• Bladder Dairy
Cardio-pulmonary, Fatigue & edema
assessment
• Vital sign status
• 6 minute Walk Test
• Borg Rate of Percieve Exertion (PRE)
• Cardiac Endurance Tests
• Piper Fatigue scale
• Fatigue severity Scale
• Pitting Edema – measurement
Health Promotion and Disease Prevention
• The aspects of mental status, functional status, social situation, values

history, and medical considerations act as a focus of preventive activities.
• An individualized plan for health promotion and disability prevention

grounded in evidence based guidelines should be based on a
multidimensional assessment because older persons vary greatly in their
medical and functional status.
• Although age-related changes are frequently associated with physical and

physiologic decline, health care professionals who treat older adults must
avoid the temptation of thinking that older persons are beyond efforts at
improving wellness or preventing illness.
Indications For Referral
• Specific criteria used by CGA programs to identify patients include:
• All patients above a certain age (eg, 85 years).
• Medical comorbidities such as heart failure or cancer
• Psychosocial disorders such as depression or isolation
• Specific geriatric conditions such as dementia, falls, or functional disability
• Previous or predicted high health care utilization
• Consideration of change in living situation (eg, from independent living to
assisted living, nursing home, or in-home caregivers)
• One outpatient approach would be to refer patients for CGA may develop
major illnesses requiring hospitalizations or to improve functional status and
to prevent from fall.
• An inpatient approach would be to refer older patients admitted for a
specific medical or surgical reason (eg, fractures, failure to thrive, recurrent
pneumonia, pressure sores).
Exclusion Criteria
• Most outpatient CGA programs exclude patients who are unlikely to
benefit because of terminal illness, severe dementia, complete
functional dependence, and inevitable nursing home placement.
• Exclusionary criteria have also included identifying older persons who

are "too healthy" to benefit, such as those who are completely
functional without any medical comorbidities.
Conducting The Assessment
• comprehensive geriatric assessment (CGA) involves several processes
of care that are shared over several providers in the assessment team.
• The overall care rendered by CGA teams can be divided into six steps:
• Data gathering
• Discussion among the team
• Development of a treatment plan
• Implementation of the treatment plan
• Monitoring response to the treatment plan
• Revising the treatment plan
Assessment tools
• A pre-visit questionnaire sent to the patient or caregiver prior to the
initial assessment to gather a large amount of information regarding:
• Ability to perform functional tasks and need for assistance
• Fall history
• Sources of social support, particularly family or friends
• Depressive symptoms
• Vision or hearing difficulties
• Office staff can be trained to administer screening instruments to
both save time.
MAJOR COMPONENTS
• Core components of comprehensive geriatric assessment (CGA) that
should be evaluated during the assessment process are as follows:
• Functional capacity
• Fall risk
• Cognition
• Mood
• Polypharmacy
• Social support
• Financial concerns
• Goals of care
• Advanced care preferences
Additional Component
• Additional components may also include evaluation of the following:
• Nutrition/weight change
• Urinary continence
• Sexual function
• Vision/hearing
• Dentition
• Living situation
• Spirituality
Models of CGA
• Several meta-analyses of randomized trials have evaluated five
models of CGA
• Home geriatric assessment
• Acute geriatric care units
• Post-hospital discharge
• Outpatient consultation
• Inpatient consultation
THANKS
Anatomical & Physiological changes
in Aged
Musculoskeletal System
ZAHID MEHMOODF BHATTI
Assistant Professor
Learning Objectives
• At the end of this lecture the students will be able to;
• Identify the structural and functional changes in the skeletal

muscles.
• Understand the causes of decreased muscle performance.
• Understand aerobic performance of skeletal muscle.
• Develop a strengthening and endurance training program
INTRODUCTION
• The evidenced of prominent feature of Impairments of neuromuscular
performance in old age are:
• Muscle weakness,
• slowing of movement,
• loss of muscle power and
• early muscle fatigue
• These impairment is often accompanied by inactivity or chronic
diseases that will further impair neuromuscular performance.
• As a result, many elderly men and women have functional limitations
on walking, lifting and maintaining postural balance and on recovering
from impending falls, leading to disability.
INTRODUCTION
• The mechanisms underlying these limitations are complex, but

alterations in the components of the motor units play an
important role.
• By the age of 80, 40-50% of muscle strength, muscle mass,
alpha motor neurons and muscle cells are lost.
• The independence associated with mobility is critical in
achieving a longer lifespan and, especially, a high quality of life.
Structural Changes
in
skeletal Muscle
Structural Changes with age in Muscles
• Reduction in Muscle Mass.

• Reduction in Muscle Fiber Number and Size.
• Reductions in Motor Units number and size.
• Age related changes in Motor Unit components.
• Age-Related Changes in Motor Neurons
• Muscle Fat Infiltration
Reduction in Muscle Mass
Aging is associated with decreases in total muscle cross-sectional
area, amounting to approximately 40% between the ages of 20 and
80 years.
• Lower muscle mass has been correlated with poor physical
function and may contribute to the changes in contractile
behavior.
• Age-related reductions in muscle mass are a direct cause of
declines in muscle strength with aging.
• This results major functional deficit and that is physical inactivity
(Disability)
Reduction in Muscle Mass
• (Melton et al 2000). demonstrated that the physical disability (measured as ability
to perform activities of daily living) was increased when the skeletal muscle index
(SMI), determined by estimating whole body muscle mass and dividing by height
in meters squared) values were lower than 5.75kg/m2 in women and 8.50kg / m2
in men
• According to the authors, these cut-off points could be used to determine the
degree of sarcopenia.
• The factors contributing to the loss of muscle mass with age seem to be:
• A reduction in the numbers of both type I and type II muscle fibers.
• A decline in cross-sectional area, predominantly of type II fibers.
• The cross-sectional area of type I fibers seems to be well maintained.
• Thus, the relative area (percentage of type II fibers x mean fiber area of type II
fibers) occupied by type II fibers is significantly reduced with age.
Reduction in Muscle Fiber Number and Size
• Reduction in Muscle Fiber Number
• The total number of muscle fibers is significantly reduced with age,
beginning at about 25 years and progressing at an .accelerated
rate thereafter
• Changes in Muscle Fiber Size
• The size of the individual fast-twitch type II fibers decreases with
age, whereas the slow-twitch type I fiber size does not change.
Reductions in Motor Units number and size
• There is a decrease in the number of functional motor units

associated with a concomitant enlargement of the cross-sectional
area of the remaining units.
• The average motor neuron loss from the second to tenth decade is
approximately 25% and is common in:
• Largest and fastest motor units, i.e., type II motor units of both proximal
and distal muscles.
• Muscles of the lower limb and more in distal than in proximal muscles.
Mechanisms of changes in
Motor Unit Changes
1. Changes in Axons.
2. Changes in Neuromuscular Junction
3. Altered Motor Unit Remodeling.
4. Sarcopenia
Motor Unit Changes- Axon.
• The loss of motor neurons is accompanied by a reduction in both
the numbers and diameters of motor axons.
• Loss is estimated to be approximately 5% from young age to old
age.
• EMG has shown changes in both duration and amplitude of motor
unit action potentials.
• Axonal nerve conduction velocities of all motor nerve fibers are
uniformly reduced.
Motor Unit Changes –Neuromuscular Junction.
• The number of pre-terminal axons entering an end plate
increases.
• There is increased incidence of branches.
• Sarcolemma becomes smoother
• The length of end plates increases and is composed of a greater
number of acetylcholine receptors.
• These changes may alter the surface area of the postsynaptic
terminal, resulting in a diminished ability of the muscle cells to be
activated by the motor neuron.
Motor Unit Changes –Altered Motor Unit Remodeling
• In response to reduced activity of the type II fibers (Strengthening):

• Motor unit remodeling occurs in such a way that type II fibers are
selectively de-nervated and re-innervated by collateral sprouting of
axons from fibers of the slow motor units (Type I Fibers).
• The fast motor unit axons degenerate when they no longer innervate
muscle fibers.
Motor Unit Changes – Sarcopenia
Sarcopenia (defined as the loss of muscle mass associated
with aging) such as:
• A decrease in the number of nerve terminals;

• A fragmentation of the neuromuscular junction;
• A decrease in neurotransmitter release; and
• A decreased number of acetylcholine receptors.
Age-Related Changes in Motor Neurons
• Aging beyond 60 years is associated with a reduction in number of
lumbosacral spinal cord motor neurons e.g
• Loss of the largest alpha motor neurons and their myelinated axons in lumbar
ventral roots. and
• Preservation of smaller motor neurons with age
• The size of slow motor units increases.
• The number of fibers and the total fiber area in a given motor unit also increase.
Age-Related Changes in Motor Neurons
• The collected evidence strongly suggests, muscle undergoes continuous
denervation and reinnervation, due to an accelerating reduction of functioning
motor units.
• Initially, reinnervation can compensate for this denervation. However, as this
neurogenic process progresses, more and more muscle fibers become
permanently denervated and subsequently replaced by fat and fibrous tissue.
• The surviving segmental neurons Increase in branching complexity and exhibit
additional collateral growth due to:
• Perhaps as a compensatory mechanisms for the loss of motor neurons. Or
• An increased load due to increased innervation ratios to the muscle fibers
they innervate.
MUSCLE FAT INFILTRATION
• Fat infiltration of skeletal muscle is common among the elderly and
has been associated with a greater incidence of mobility limitations.
• In a recent study, muscle attenuation (indicative of fat infiltration)
remained an independent determinant of incident mobility
limitations.
• People with muscle attenuation were 50-80% more likely to develop
mobility limitations during follow-up, which was independent of
muscle area, muscle strength or total body fat mass.
Physiological or Functional Changes in
Skeletal Muscle i.e Muscle Performance
• Strength (Muscle weakness)
• Power
• Endurance
• Velocity
• fatigue
• Metabolic Pathways: Glucose Uptake
• Enzyme Activity
• Blood Flow and Capillarity
Age-Related Changes in Muscle Performance
Strength
• Gradual reduction in Isometric and dynamic voluntary strength
takes place by the seventh decade of life and may accelerate
thereafter.
• Arm, leg, and back strength decline at an overall rate of 8% per
decade, starting in the third decade of life. (Schiller et al 2000).
• Healthy men and women in their seventh and eighth decades of
life demonstrate average reductions of 20% to 40% in maximal
isometric strength in various muscles.
• Reduction of quadriceps muscle strength is such that the average
80-year-old is at or near the minimum level of strength required to
rise from a chair.
• Reduction in Leg muscle strength appears to be related to
reduction in walking speeds
MUSCLE Weakness
• Muscle weakness is the most important determinant in old age which may lead to
reduce functional performance threshold and results in the decrease activity level
to perform first IADLs, then ADLs and finally a bed ridden patient.
• In addition, impairments in muscle function associated with acute or
chronic diseases, hospitalization resulting from trauma or surgery,
and inactivity may accelerate the decline in strength.
• Thus, during the course of daily living, older people may be working
at relatively close to their maximal capacity/Functional performance
Threshold.
• This concept of 'close to maximal capacity' is important during
rehabilitation when the aim is not only to regain muscle strength but
also to enhance functional reserve.
PHYSIOLOGY OF MUSCLE WEAKNESS
• Physiologically, muscle weakness may be either because
any single factor or a combination of multiple factors
including in the following areas:
1. Skeletal Muscle Changes itself.
2. Changes in neural mechanisms.
3. Other Misc. changes.
4. Commulative effect of Multiple Factors.
1. Skeletal Muscle Changes:
• A reduction in the quantity of muscle tissue (Muscle Mass)
resulting in reduced Cross bridges.
• A decrease in the force developed by each cross bridge.
• Muscle atrophy and loss of myo-fibrillar protein, caused by
a reduction in the number of motor neurons in the spinal
cord.
• Incomplete re-innervation of de-nervated muscle cells,
results in a decrease in the number and size of muscle
fibers.
2. Changes in neural mechanisms
• A decrease in the ability to activate or delay in activation of the
existing muscle mass may be the effect of Changes in neural
mechanisms include:
• Undefined changes in the central nervous system.
• A delay in the conduction velocity of motor nerve fibers
• A delayed transmission at the neuromuscular junction.
• Alterations in the proportions of motor units and myofibers
of different types, particularly a decrease in the number or
the relative cross-sectional area of type II fast fibers.
3. Other Miscellanous Changes;
• Loss in the ability of the sarcoplasmic reticulum to handle
calcium within the fibers.
• Changes in the myosin molecule.
• An increased passive resistance of the connective tissue
structures,
4. A combination of afore mentioned factors may contribute
to altered contractile behavior.
Age-Related Changes in Muscle Performance -
Endurance
• A decline in muscular endurance is a feature of old age that contributes to
functional loss and disability.
• Human aging is accompanied by a number of changes in the neuromuscular
system (Stackhouse et al2001) that might affect endurance, including:
• Motor unit remodeling.
• Reduced maximal motor unit discharge rates
• A general shift toward a greater type I fiber composition.
• Reduced blood supply and capillary density,
• Impairment of glucose transport .
• Lower mitochondrial density.
• Decreased activity of oxidative enzymes.
• Decreased rate of phosphocreatine repletion.
• The extent of these age-related alterations appears to vary by muscle group
and level of habitual physical activity.
Age-Related Changes in Muscle
Performance - Fatigue
• Muscle fatigability is another important component of performance.
• The effect of old age on the magnitude of fatigue and the potential mechanisms
that contribute to fatigue is less clearer.
• Fatigue is typically measured as a loss of force during repeated or continuous
activation.
• The results of some investigations suggest that older men and women fatigue
more than younger subjects, which is consistent with studies in animal models.
• Human aging is accompanied by a number of changes in the neuromuscular
system (Stackhouse et al2001) that might affect fatigue also including:
• Motor unit remodeling.
• Reduced maximal motor unit discharge rates
• A general shift toward a greater type I fiber composition.
Power
• The power output is governed by
• The velocity of shortening and The force-generating capacity of the muscle.
• Human studies have shown that , to produce the absolute and relative forces during
voluntary contractions is lengthened in the elderly and, therefore, the ability to generate
explosive force (power) and to accelerate a limb is reduced (Foldvari et al 2000, Frontera
et al 2000).
• These alterations have a negative effect on the protective reactions used before or
during a fall.
• Several studies have shown that, in the elderly, differences in skeletal muscle power
could explain more of the variability in function and disability, particularly during lower
intensity tasks such as walking compared with higher intensity activities such as climbing
stairs or rising from a chair.
• The decrease in power output partially results from motor unit remodeling, which
reduces the fast to-slow-fiber ratio.
• Reduced capacity for rapid-force generation also limits the functional capacity required
for walking speed and stair climbing.
Age-Related Changes in Muscle Performance-
Velocity
• An important characteristic of neuromuscular performance is the time-course
of muscle actions.
• The maximal speed of muscle contraction decreases with age.
• This decrease is reflected in a decrease in the actin-myosin ATPase activity
and may explain the slowing of movement with age.
• This property is important because the velocity of movement can have
greater relevance than absolute muscle strength on the ability to perform a
number of the activities of daily living, independence and functional capacity
(Foldvari et al2000).
• With age, also lengthens the time for muscle relaxation, thus impairing the
ability to perform rapid alternating movements.
Age-Related Changes in Muscle Performance-
Metabolic Pathways: Glucose Uptake
• Aging is associated with decreased glucose tolerance and a greatly increased
incidence of noninsulin-dependent diabetes mellitus (NIDDM) due to:
• Reduced levels of Glut-4 protein. in skeletal muscle
• Decline in the insulin-receptor signaling system due to reduction in tyrosine
kinase activity
• Reduction in the translocation of transporters from the intracellular
compartment to the sarcolemma membrane.
• This change in the insulin-receptor signaling system at the cellular level has a
significant impact on function.
Age-Related Changes in Muscle Performance - Enzyme
Activity
• The glycolytic enzymes (phosphorylase, phosphofructokinase, and lactate
dehydrogenase) do not show age-associated changes.
• The aerobic enzymes (succinate dehydrogenase, citrate synthase, and B-
hydroxyacyl-CoA-dehydrogenase) decline with age.
• In addition mitochondrial decay occurs which includes:
• Decreased mitochondrial content,
• Decreased oxidative capacity,
• Decreased enzyme activities, and increased mitochondrial DNA deletions or
mutations.
Enzyme Activity
• Functionally, these changes decrease oxygen uptake by muscle during
exercise and contribute to the decline in Vo2max in older people by
reducing the a-v 02 difference maximum.
• In addition, the decline in mitochondrial content and function impairs
muscle oxidative and endurance capacity and is, therefore, likely to
contribute to the increase in muscle fatigability that occurs with aging.
Age-Related Changes in Muscle Performance
Blood Flow and Capillarity
• Sustained muscular performance requires a proper balance between energy
supply and demand.
• There is actual reduction in the total number of blood capillaries, both capillary-
to-fiber ratio and the number of capillaries in contact with each muscle cell
• This causes reduction in blood flow to muscles causes decreased endurance
capacity of muscle with age.
• This causes decreased oxidative capacity, possibly impairing energy balance and
ability of muscle to sustain power output over time.
Age and Exercise
Introduction
• Skeletal and cardiac muscle adaptations occur because of
changes in intensity, duration, and frequency of physical
activity (increase or decrease).
• The adaptations include alterations in morphological,
biochemical, and molecular properties which ultimately lead to
altered functional characteristics from the cellular to the whole
tissue and functional performance levels.
• The principle of specificity refers to adaptations in the
metabolic and physiological systems, depending on the type of
overload imposed.
Adaptations in the metabolic and physiological systems, depending
on the type of overload imposed.
Specificity Principle
Endurance
Strength Training
Training
Specific strength Endurance training

adaptations adaptations
Maximal power after

Improved Maximal endurance
strength training,
Benefits of Strength Training
• Strength training, or resistance exercise, is generally defined as
training in which the resistance against which a muscle generates
force is progressively increased over time.
• Strength training increases muscle size, defined as hypertrophy.
• Hypertrophy means an increase in contractile protein content (synthesis rates of
myosin)
• This results in parallel increase in the total volume of mitochondria within the
cell
• This adaptation improves capability of the muscle to sustain power output.
• Before training you need to calculate one repetition maximum (1 RM)..
• Training stimulus is to training between 60% and 100% of the 1 RM.
• The fast-twitch type II fibers show greater hypertrophy than slow-twitch type I
fibers with strength training.
Changes with Resistance Exercise
• Skeletal Muscle
• Increases in resting levels of anaerobic substrates (ATP, glycogen)
• Increase in fiber size (fast-twitch type II fibers)
• Increase in activity of anaerobic enzyme function (glycolysis)
• Increased capacity for levels of blood lactic acid
• Improved motivation
• Improved pain tolerance
Strength Training and the Older Adult
• Studies demonstrate that frail elderly men and women,
• Retain the capacity to adapt to resistance exercise training.
• Significant and clinically relevant muscle hypertrophy
• Increases in muscle strength.
• When the intensity of the exercise is low,
• Only modest increases in strength are achieved by older persons.
• Whereas, if given an adequate training stimulus (>60% of 1 RM),
• Older men and women show similar or greater strength gains compared with
young individuals as a result of resistance training.
Benefits of Progressive resistance exercise
• Progressive resistance exercise, defined as periodically
increasing the exercise intensity, Strength Increased at the rate
of approximately 5% per training session.
• Hypertrophy of Muscles.
• Protection from Injury
• Protection from Poor balance
• Protection from Postural sway.
• Prevent disability and institutionalization
• Increase energy requirements,
• Decrease body fat mass, and maintain metabolically active tissue
mass in older people.
• Improves insulin action bone density, energy metabolism, and
functional status, in older adults.
Aerobic Exercise
• Aerobic exercise takes place in the presence of oxygen and involves aerobic
metabolism of glucose.
• The exercise is relatively comfortable and can be sustained for 20 minutes to
many hours.
• Regularly performed aerobic exercise increases VO2max,
• The extent of change is dependent on
• The baseline fitness level of the individual and
• The intensity of the aerobic training.
• A moderate intensity aerobic exercise program at 50% maximal heart rate
(HR) reserve, 55 min/day, 4 days/week for 12 weeks without weight loss
results in improved glucose tolerance.
Fundamental Adaptations
• The fundamental adaptations of the heart to aerobic training
include:
• A resting and sub-maximal exercise bradycardia.
• Increased stroke volume,
• An increase in left ventricular end-diastolic volume.
• Improved myocardial contractile function.
• Moderate increases in myocardial mass.
Mechanism underlying Aerobic Training
• The absolute gains in aerobic capacity after aerobic exercise training are similar
between young and older individuals.
• The mechanism for adaptation to regular sub-maximal exercise appears to
be different between old and young people.
• Older individuals show a greater increase in oxidative capacity of the skeletal
muscles after training.
• These skeletal muscle adaptations contribute to the rise in VO2max with
training by increasing the a-v O2 difference , a major determinant
ofVO2max.
• The other major determinant of VO2max is increase cardiac output.
Changes with Aerobic Training
• Skeletal Muscle
• Increases in capacity to generate ATP aerobically
• Increase in the number of mitochondria
• Increase in the size of mitochondria
• Increase in activity of aerobic enzyme function
• Increase in skeletal muscle myoglobin content (increase quantity of
oxygen available)
• Increase in blood flow within the muscle
• Selective skeletal fiber hypertrophy (slow-twitch type I fibers)
• Increase in muscle's capacity to mobilize fat, oxidize carbohydrate
Changes with Aerobic Training
• Cardiac Muscle
• Increase in weight and volume (increase in the size of the left
ventricle wall and cavity)
• Increase in total hemoglobin and plasma volume
• Decrease in resting and submaximal exercise heart rate
• Increase in stroke volume at rest and during exercise
• Increase in diastolic filling
• Increase in maximal cardiac output
• Increase in capacity to extract oxygen from the circulating blood
• Decrease in systolic and diastolic blood pressure at rest and
submaximal exercise
Gender Discrimination
• Although both older men and women respond to endurance training
with an increase in Vo2max, However, the mechanism of adaptation is
different.
• In older men, two thirds of the increase in VO2 max is due to an augmented
cardiac output and one third is due to a wider a-v 02 content difference.
• However, in older women the changes in left ventricular systolic performance
and diastolic-filling dynamics do not occur.
• Thus, the increase in VO2 max in older women is due to peripheral
adaptations that lead to the enhanced a-v 02 content difference.
• Peripheral adaptations include:
• An increases in skeletal muscle capillarization
• Activity of mitochondrial marker enzymes, e.g., citrate synthase.
• The underlying reasons for this gender-specific adaptation are unclear but
most likely reflect the difference in hormonal patterns.
Reversing Decline
• Although both aerobic and resistance training are recommended to improve
muscular function in the elderly, only resistance training can reverse or delay
the decline in muscle mass and strength with aging.
• The incorporation of aerobic and resistance exercise training into the life-
style of older individuals can have a considerable impact on the:
• functional capacity,
• physiological reserve, and
• independence.
• Exercise enhances the functional capacity, bringing the older adult
physically well above the threshold of performance.
Developing Exercise Interventions For The Older
Adult
• In a program of exercise for the older adult, it is important to include:
• Aerobic exercise,
• Strengthening, and
• Flexibility components.
• In evaluating the older adult for exercise, several factors need to be considered.
• First, it is unrealistic to totally depend on an exercise tolerance test to develop
the exercise program or prescription.
• Second, a good history, systems review, and appropriate use of tests and
measures are essential to determine risk factors and associated medical
conditions.
• Third, it is critical to establish goals jointly with the older adult and to obtain
commitment of participation.
• Both physiological changes and psychosocial problems impact the older adult's
exercise prescription and how the program is conducted.
Exercise Program
• The exercise prescription or program should contain aerobic
exercise and resistance training.
• The exercise prescription, describes the type, frequency,
duration, and intensity of the proposed activity.
• It includes information on the warm-up, conditioning, and
cool-down components of each exercise session.
• Risks of Exercise
• Compliance
SUMMARY
• Lack of functional capacity leads to a more dependent lifestyle and
earlier entry into nursing homes.
• Decreased functional capacity also contributes to the risk of falls
and a decline in the physiological organ system.
• From a health care point of view, the increased risk of
hospitalization is a costly health problem.
Pathological Conditions
Associated with the Elderly

Assistant Professor
123
A. Musculoskeletal disorders and diseases
B. Neurological disorders and diseases
C. Cognitive Disorders
D. Cardiovascular disorders and diseases
E. Pulmonary disorders and diseases
F. Integumentary disorders
G. Metabolic pathologies
Format / Outlines of Presentation

124
1. Osteoporosis
2. Fractures
3. Degenerative Arthritis
Musculoskeletal disorders and diseases

125
A. 1. Osteoporosis
Disease process that results in reduction of bone mass due to:
in Osteoblastic activity
in Osteoclastic activity
126
1. Hormonal deficiency: ➢ Liver disease
➢ estrogens and androgens ➢ Paget’s disease
➢ Certain types of cancer
2. Nutritional Deficiency: 4. Medication that affects Bone Loss
➢ Inadequate calcium ➢ Corticosteroids
➢ Impaired absorption of Calcium ➢ Thyroid Hormones
➢ Excessive alcohol ➢ Anticonvulsants
➢ Caffeine consumption ➢ Catabolic drugs
➢ Some estrogen antagonists
3. Decreased Physical Activity ➢ Chemotherapy
➢ Inadequate mechanical loading
6. Additional Risk Factors
4. Disease that affect bone loss ➢ Family history
➢ Hyperthyroidism ➢ Asian race
➢ Diabetes ➢ Early menopause
➢ Hyperparathyroidism ➢ Thin and small build
➢ Rheumatoid arthritis
➢ Smoking
A. 1. Osteoporosis - Etiological Factors

127
1. Affects about 20 million in US
➢ One in every 3rd women suffer from osteoporosis.
➢ 1/3rd will experience major orthopedic problems related to osteoporosis
2. Bone Loss
➢ 1% per year (Starting for women at ages 30-35, for men 50-55 years)
➢ Accelerating loss in post menopausal women, approximately 5% per year
for 3 to 5 years
3. Structural weakening of bone
4. High risk of fractures
5. Trabecular bones more involved than cortical bone (biomechanical
architectural difference). Commonly affected areas are
➢ Vertebral column
➢ Femoral neck
➢ Distal radius / wrist, Humerus
A. 1. Osteoporosis - Characteristics 128

1. Osteoporosis - Examination
1. Medical Record Review 5. Motor Functions
➢ History, Physical examination, ➢ Strength
Nutritional history ➢ Endurance
➢ Bone density tests ➢ Motor control
➢ X-rays for known or suspected fracture 6. ROM / Flexibility
2. Physical activity and fall history 7. Postural Deformity
3. Assess dizziness ➢ Feet: Hammer toes, Bunion lead to
antalgic gait
4. Sensory integrity: ➢ Postural kyphosis, forward head
➢ Vision position
➢ Hearing ➢ Hip and knee flexion contracture
➢ Somato-sensory 8. Postural hypotension
➢ Vestibular 9. Gait and balance assessment
1. Osteoporosis
Goals, Outcomes, and Interventions
1. Medication 2. Promote health, provide counseling
1. Medication
3. Daily Vitamin D intake
➢ Evista
➢ 200 IU premenopause
➢ Fosamax (alendronate)
➢ 400 IU after menopause
➢ Calcitonin
➢ 600 IU after age 75
2. Daily calcium intake 4. Diet
➢ 1000 mg premenopause ➢ Low in salt
➢ 1500 mg after age of 50 ➢ Avoid excessive protein
years ➢ Inhibits body’s ability to
absorb calcium
1. Osteoporosis
Goals, Outcomes, and Interventions
3.Maintain bone mass: exercise 4. Postural / Balance training
➢ Weight bearing (gravity ➢ Postural re-education
loading) exercises ➢ To reduce kyphosis
➢ Walking (30 min/day) ➢ Forward head position
➢ Stair climbing ➢ Flexibility exercises
➢ Use of weight belts to ➢ Functional balance exercises
increase loading ➢ Chair exercises
➢ Resistance exercises ➢ Standing / kitchen sink
➢ Hip knee extensors exercises
➢ Triceps ➢ Hip extension
➢ Hip abduction
➢ Partial squats
➢ Gait Training
1. Osteoporosis
Goals, Outcomes, and Interventions.
5. Safety Education and Fall prevention
➢ Proper shoes ➢ Fracture prevention
➢ Thin soles ➢ Counseling on safe activities
➢ Flat shoes ➢ Making environmental
➢ Enhance balance abilities (No adjustments
heels) ➢ Making more spacious
➢ Assistive devices
place for the ambulation
➢ Avoid sudden forceful
➢ Cane movements
➢ Walkers ➢ Twisting
➢ Standing
➢ Bending
➢ Over lifting
132
Musculoskeletal Disorders and Diseases
2. Fractures
133
A. 2. Fractures
a) High fracture risk associations
a) High risk of fracture in the elderly associated with:
➢ Low bone density
➢ Multiple risk factors
➢ Age
➢ Co-morbid disease
➢ Dementia
➢ Psychotropic medications
➢ Reduced Balance & Coordination
b) Hip fracture
➢ Common orthopedic problems of older adults
➢ More than 270,000 hip fractures annually in US
➢ Rate doubles each decade after 50 years:
➢ Age 90 years affects 32% of women
➢ Age 90 years affects 17% of men
134
A. 2. Fractures – (b) Hip Fractures
1. Mortality rate
➢ 20% associated with complications
2. Incidence:
➢ 347000/yr by 2020
➢ 512000/yr by 2040
➢ 2:1 white women : men
3. About 50% will resume their premorbid level of function
➢ Walking independently
4. Results in dependency
➢ 1/3rd of patients
5. Majority are treated surgically
➢ 95% are femoral neck or intertrochanteric fractures
➢ Remaining 5% are subtraochentric
135
A. 2. Fractures - (b) Hip Fractures Cont. . .
5. Improvement of Outcomes
➢ Intensive interdisciplinary rehabilitation program
➢ Early mobility
➢ Psychological counseling
➢ Encouragement of patients
➢ Education of patient and attendants
6. Basis of Physiotherapy treatment protocols
➢ Type of fracture
➢ Type and approach of surgical procedure
136
Most Common Cause - Falls
➢30% of individuals > 65 experience a fall (in US)
➢Interaction between falls and bone strength
➢Falls that result in hip FX low 1 to 14%, but 90% of hip FX occur from
falls
➢Osteoporosis: predisposes individually for FXs
➢Affects trabecular bone more rapidly than cortical bone
Anatomy
➢Force at hip trochanteric region in single limb stance is 2.5 to 2.75 times
body weight.
➢Trabecular bone in femoral head assists transmission of forces into
dense cortical bone of femoral neck and proximal femur.
➢Trabeculae here are thin and susceptible to FX by excessive forces
Most Common Sites of Hip FX
➢ Inter-trochanteric Region:
➢ With femoral neck = 90% of hip FXs
➢ Women with OP suffer more intertroch. FX than femoral neck
➢ Most often from trauma, fall or twisting leg
➢ Stable – posteromedial cortex intact
➢ Unstable – posteromedial cortex is comminuted or if FX extends into
subtrochanteric region.
Most Common Sites of Hip FX
2. Femoral Neck:
• Also results from falls, but more related to position of limb during fall
3. Subtrochanteric
• 10% incidence
Fixation
1. Intertrochanteric FX:
➢ Most often fixated with sliding hip screw
➢ Provides fixation of FX and impaction of proximal and distal bone fragments.
➢ If comminuted/displaced, wiring added to ensure hip abductor muscle
strength and stability, or use newer IM hip screw
2. Femoral Neck:
➢ Also results from falls, but more related to position of limb during fall
3. Subtrochanteric
➢ 10% incidence
Fixation
1. Femoral Neck:
➢ Non-displaced - screws and pins parallel to long axis of neck (DHS)
➢ Displaced – ORIF or prosthetic (hemiarthroplasty)
➢ 15-33% rate of AVN so best choice may be prosthetic
2. Subtrochanteric:
➢ IM nails more common than sliding screws
Post-op Course
➢Early immobilization – post-op day 1
➢Prevent DVT, Pna
➢WB restrictions vary from NWB to FWB
➢Arthroplasty – posterolateral = THR precautions
➢Anterolateral = avoid extreme extension and adduction
➢No ROM restrictions with ORIF
Pathological Hip Fractures
➢Hyperparathyroidism (femoral neck)
➢Metastatic disease (use THR or hemiarth. Check acetabulum for
disease)
➢Parkinsons – if adductor tone, anterior approach used + tendon
release)
➢60% mortality with femoral neck FX after 6 mos.
Pathological Hip Fractures
➢Paget’s Disease:
➢Chronic progressive disease of excessive osteoclast resorption activity
➢Bone marrow replaced by fibrous tissue and disorganized trabeculae
➢Can be asymptomatic, and localized to one or several bones
➢Can have localized pain and tenderness and night pain unrelated to limb
position
➢Most often at pelvis, femur, tibia, skull (least often vertebrae)
➢ CV complications: may have high output failure and increased HR d/t
increased blood flow thru bone
➢Non-displaced FX ORIF can have excessive bleeding; displaced –
THR/hemiarthriplasty depending on condition of acetabulum
A. 2. Fractures
c) Vertebral Compression Fracture
1. Usually occur in
➢ Lower thoracic and Upper lumbar region (T8- L3)
2. Typically results from routine activity
➢ Bending
➢ Lifting
➢ Raising from chair
3. Chief Complaints
➢ Immediate: Severe local spinal pain
➢ Later On: Pain increased with trunk flexion
➢ Pain aggravated during SLR and over head abduction activities
4. Spinal fracture leads to
➢ Shortening of spine
➢ Progressive loss of height
➢ Spinal deformity (Kyphosis) can progress to respiratory complication
➢ Restricted mobility and bed ridden complications
146
A. 2. Fractures
c) Vertebral Compression Fracture Cont. . .
5. Goals, outcomes and Interventions

(Early Phase Rehabilitation Plan)
➢ Patients education and counseling

➢ Horizontal bed rest, out of bed 10 mins every hour
➢ Emphasis on proper posture
➢ Isometric extension exercises in bed
147
A. 2. Fractures
c) Vertebral Compression Fracture Cont. . .
6. Goals, Outcomes and Interventions

(Late Phase Rehabilitation Plan)
➢ Teach patient extension exercises: avoid flexion activities

➢ Postural training
➢ Extension Brace
➢ Modalities for relief of pain
➢ Safety education and modify environment
➢ Decreased vertebral loading: use soft sole shoes
148
A. 2. Fractures
d) Stress Fracture
Fine, hairline fractures (insufficiency fracture)

1. Common sites
➢ Pelvis, Distil tibia, distal fibula, metatarsal shaft (2nd), foot
2. Unsuspected source of pain
3. Signs of local tenderness and swelling
4. Goals, Outcomes and Interventions
➢ Rest
➢ Correction of exercise excess or faulty exercise program
➢ Reduction of vertical loading e.g; soft sole shoes
149
A. 2. Fractures
e) Clinical Complications
There are more clinical complications of the fractures in the elderly
➢Fracture heal more slowly
➢Older adults are prone to common complications following fracture are
➢ Pneumonia
➢ Pressure sores
➢ Psychological complications due to hospitalization
➢ Psychosocial complications due to reduced mobility
➢Rehabilitation is prolonged due to
➢ Lack of support system
➢ Co-morbid conditions
➢ Decreased vision
➢ Poor balance
150
Musculoskeletal Disorders and Diseases
3. Degenerative Arthritis
151
A. 3. Degenerative Arthritis (Osteoarthritis)
Introduction
A Non inflammatory progressive disorder of joints, typically affects hips, knees,

fingers and spine
1. Affects more than 16 million in US
➢ Incidence: Increases with age
➢ At 55 years of age 57% population affected
➢ At 75 years of age 70% population affected
➢ Female : Male, 5:1
2. Moderate limitation in ADL’s seen in 24% individuals
152
Characteristics
1. Pain, swelling, stiffness

➢ Knee pain, Hip pain
2. Muscle spasm
3. Loss of ROM / Mobility
4. Crepitations on movement
5. Bony deformity
6. Muscle weakness secondary to disuse
153
Goals, Outcomes and Interventions
1. Medical and Surgical Management
➢ Nonsteroidal anti-inflammatory drugs (NSAIDs)
➢ Corticosteroids injections
➢ Topical analgesics
➢ Joint resurfacing
➢ Joint replacements
2. Physiotherapeutic interventions for reduction of pain
➢ Relaxation procedures
➢ Use of electrotherapeutic modalities
➢ Use of manual therapy techniques (Role of traction and distraction)
154
Goals, Outcomes and Interventions Cont. . .
3. Exercise Rehabilitation
➢ Maintain or Improve ROM
➢ Correct muscular imbalance:
➢ strengthening exercises to support joints, improve balance and ambulation
➢ Aerobic conditioning
➢ Walking programs:
➢ To decrease joint symptoms
➢ To improve function
➢ Sense of well being
➢ Aquatic programs
➢ Pool walking
➢ Enhances ease of movement
155
Goals, Outcomes and Interventions Cont. . .
4. Patient education and empowerment
➢ Education of the patient about the condition
➢ Patients active participation in self care
➢ Education of joint protection strategies
➢ Energy conservation strategies
5. Provide assistive devices for ambulation and activities of daily living
➢ Canes
➢ Walkers
➢ Shoes inserters
6. Promotes healthy lifestyle
➢ Weight reduction to release stress on joints
156
B. Neurological Disorders and Diseases
1. Stroke
2. Parkinsonism
3. Cognitive Disorders
157
Stroke
Stroke (Cerebrovascular accident, CVA)

➢Sudden, focal neurological deficit resulting from ischemic or hemorrhagic lesion
in the brain
➢Approx. 500,000 new victims every year in US
➢Approx. 30% die during acute phase
➢Approx. 30 to 40% lives with severe disability
158
Stroke
Clinical Signs and Symptoms
➢Impaired sensory and motor function hemiside:
➢ Alteration in sensation
➢ Tone
➢ Reflexes
➢ Incoordination
➢ Balance
➢Speech and language disorders
➢Perceptual disorders
➢Cognitive and behavioral changes
➢Bladder and bowl dysfunction
159
Parkinsonism
➢Affect about 20% of patients above 65 years

Clinical Signs and Symptoms
➢Rigidity
➢Bradykinesia
➢Resting tremors
➢Impaired Postural Reflexes
160
Parkinsonism
Functional Impairments
➢ Impaired functional mobility
➢ Problems with initiating movements
➢ Freezing episodes
➢ Slowed movements
➢ Impaired gait
➢ Festenating gait ( abnormal and involuntary increase in speed of walking)
➢ Impaired Postural control
➢ Stooped posture
➢ Loss of balance control
➢ Impaired balance reactions
➢ Impaired speech and oro-motor control
➢ Bradykinesia of hands
➢ Impaired hand writing
➢ Dressing
➢ Self care
161
Clinical implications and Neurological Rehabilitation in the Elderly
➢Common complications are

➢Contractures
➢Deformities
➢Bed sores
➢Cognitive complications
➢Rehabilitation is usually prolonged due to
➢Co-morbid diseases
➢Decreases sensory-motor function
➢Poor balance
162
C. Cognitive Disorders
1. Delirium
2. Dementia
3. Depression
163
1. Delirium
Fluctuating attention state causing temporary confusion and loss of mental

function, an acute disorder, usually reversible
Etiology:
➢Oxygen deprivation to brain due to:
➢ Drug toxicity
➢ Systemic illness
➢Environmental changes / Sensory deprivation due to:
➢ Recent hospitalization
164
1. Delirium
Sign & Symptoms:
1. Acute onset, often at night
2. Duration: hours to weeks
3. May be hypo or hyper alert, distractible; fluctuates over the course of the
day
4. Orientation usually impaired
5. Illusions / Hallucinations,
6. Periods of agitation
7. Memory deficits: Immediate and recent
8. Disorganized thinking
9. Incoherent speech
10. Sleep / wake cycles always disrupted
165
2. Dementia
Loss of intellectual functions and memory causing dysfunction in daily living.

1. Deterioration in daily function
➢ Impoverished thinking
➢ Impaired judgments
➢ Disorientation
➢ Confusion
➢ Impaired social functioning
2. Disturbance in higher cortical functions
➢ Aphasia (language disturbances)
➢ Apraxia (Motor skills dysfunction)
➢ Agnosia (Impaired Perception)
166
2. Dementia
3. Memory impairments
➢ Both recent and remote
4. Personality changes
➢ Alteration and accentuation of premorbid traits
➢ Behavioral changes
5. Alertness (Consciouness) usually normal
6. Sleep often fragmented
167
2. Dementia Types
1. Reversible dementia
10% to 20% of dementia
Causes:
a) Drugs side effects
b)Nutritional Disorders
a) Sedatives
a) B-6 deficiency
b) Anti-anxiety agents b) B-12 deficiency
c) Anti-depressants c) Pernicious anemia
d) Antiarrhythmics d) Folate deficiency
e) Antihypertensives
f) Anticonvulsants
g) Antipsychotics
h) Anticholinergics
168
2. Dementia - b) Reversible dementia Cont. . .
3. Metabolic disorders
➢ Hypo/Hyperthyroidism 4. Psychiatric
➢ Hypercalcemia disorder
➢ Hypo/Hypernatremia ➢ Depression
➢ Hypoglycemia ➢ Anxiety
➢ Kidney, Liver failure ➢ Psychosis

5. Toxins
➢ Cushing syndrome
➢ Air Pollution
➢ Addison’s disease
➢ Alcohol
➢ Hypopituitraism
➢ Carcinoma
169
2. Dementia
2. Primary degenerative dementia (Alzheimer’s Disease)
50% to 70% of dementia
1. Affects estimated 1.6 million individuals

➢ 10 to 20% of over 65 years population
➢ 4th leading cause of the disease
➢ Affects upto 50% of nursing home population
2. Etiology
➢ Unknown
➢ Evidence of chromosomal abnormality
➢ Predisposing factors
➢ Family history
➢ Downs syndrome
➢ Traumatic brain injury
➢ Aluminum toxicity
170
2. Dementia
2. Primary degenerative dementia (Alzheimer’s Disease)
3. Pathophysiology
➢ Generalized atrophy of the brain
➢ Decreased sensitivity of neurotransmitters
➢ Diffuse ventricular dilation
➢ Histopathological changes
➢ Neurofibrillary tangles
➢ Neuritic senile plaques
➢ Build up of beta-amyloid protein
4. Types
➢ Senile dementia (after the age of 60 Years)
➢ Presentile dementia (Between 40 to 60 Years)
171
2. Dementia
c) Primary degenerative dementia (Alzheimer’s Disease)
5. Sign & Symtoms:

➢ Dementia:
➢ Insidious onset with generally progressive deteriorating course
➢ Irreversible
➢ Mean survival time post diagnosis is 4 years
➢ Many have
➢ Periods of agitation
➢ Restlessness
➢ wandering
➢ Sundowning syndrome
➢ Confusion and agitation increases in late afternoon
172
C. 2. Dementia
3) Multiple Infarct dementia (MID)
20 to 25 % of dementia
1. Etiology
➢ Large and small vascular infarcts in both gray and white matter of brain, producing loss of
brain function
2. Sign & Symptoms:
➢ Sudden onset
➢ Spotty and patchy distribution of deficit
➢ Areas of preserved ability along with impairments
➢ Focal neurological signs and symptoms
➢ Gait and balance abnormalities
➢ Weakness
➢ Exaggerated DTR’s
➢ Emotional liability common
➢ Associated with history of stroke, cardiovascular disease, Hypertension
173
2. Dementia - Examination
1. History
➢ Determine onset of symptoms
➢ Progression
➢ Triggering events
➢ Common problems
➢ Social history
2. Examine cognitive function
➢ Orientation
➢ Attention
➢ Calculation
➢ Recall
➢ Language
➢ Standardized test:
➢ Mini-Mental state exam; score less than 24 out of 30 is suggestive of mental decline
174
2. Dementia Examination Cont. . .
3. Examination for impairments in higher cortical functions

➢ Inability to communicate
➢ Perceptual dysfunction
4. Examine for behavioral changes
➢ Restless
➢ Agitated
➢ Distracted
➢ Wandering
➢ Inappropriate social behavior
➢ Repetitive behaviors
175
2. Dementia - Examination Cont. . .
5. Examine self care

➢ Ability to carryout activities of daily living
➢ Limitation in grooming and hygiene, continence
➢ Standatd Test (Barthal Index)
6. Examine motor function
➢ Dyspraxia
➢ Gait abnormalities (Dynamic gait Index)
➢ Balance instability (BBS)
7. Environmental safety, optimal functioning
176
2. Dementia Goals, Outcomes and Interventions
1. Environment
➢ Provide safe environment
➢ Prevent falls
➢ Prevent injury or further dysfunction
➢ Utilize safety monitoring devices e,g; alarm devices
➢ Provide soothing environment with
➢ Reduced environmental distractions
➢ Reduce agitation
➢ Increase attention
177
2. Dementia - Goals, Outcomes and Interventions Cont. . .
2. Support individuals remaining functions

➢ Approach to the patient – friendly. supportive and calm
➢ Use consistent, simple commands and speak slowly
➢ Use non verbal communications: sensory cues, gestures
➢ Avoid stressful tasks: emphasize familiar well learned skills
➢ Approach learning in a simple, repetitive way, proceed slowly and provide
adequate rest time
➢ Provide mental stimulation: utilize simple well linked activities, games
178
3. Depression - Incidence
A disorder characterized by depressed mood and lack of interest or

pleasure in all activities, and associated symptoms for a period of at
least two weeks
Incidence:
➢Community dwelling elderly
➢5% clinically diagnosed major depression
➢10 to 15% have depressive symptoms
179
3. Depression - Predisposing factors
1. Family history, prior episodes of depression

2. Illness, drug side effects, hormonal
3. Chronic conditions: loss of physical functions, pain e.g; stroke
4. Sensory deprivation (Loss of vision or hearing)
5. History of Losses: death of family member or friend, job, income.
Independence
6. Social isolation: lack of family support
7. Psychological losses: memory, intellectual functions
180
3. Depression – Examine depressive symptoms
1. Nutritional problems
➢ Significant weight loss or weight gain
➢ dehydration
2. Sleep disturbance
➢ Insomnia or hypersomnia
3. Psychomotor changes
➢ Inactivity with resultant functional impairments
➢ Weakness or agitation
4. Fatigue or loss of energy
5. Feeling of worthlessness, low self esteem, guilt
181
3. Depression - Examine for depressive symptoms
6. Inability to concentrate
➢ Slow thinking, impaired memory, indecisiveness
7. Withdrawal from family and friends, self neglect
8. Recurrent thoughts of death
➢ Suicidal ideation
9. Decline in cognitive function
10. Standardized test
➢ Geriatric Depression scale
➢ 30 items yes / No scale
➢ Less than 8 indicative of depression
182
3. Depression Goals, Outcomes and Interventions
1. Medical Treatment
➢ Pharmacotherapy: tricyclic antidepressants (e.g; Chlopromazine, Prozac)
➢ Psychotherapy
➢ Electroconvulsive shock therapy (ECT)
➢ If drug treatment is unsuccessful or contraindicated
183
3. Depression Goals, Outcomes and Interventions
2. Avoid excessive cheerfulness

➢ Provide support and encouragement
3. Assist patient in adjustment process to losses, coping strategies
4. Encourage activities
➢ Exercise program
➢ Aerobic training associated with increased feeling of well being
5. Assist in improving / maintaining independence
➢ Emphsize mastery by patient
➢ Achievement of short term goals rather than long term goals
184
D. Cardiovascular disorders and diseases
1. Coronary Artery Disease (CAD)

2. Hypertension
3. Peripheral vascular diseases
185
E. Pulmonary Diseases and Disorders
Common conditions
1. Chronic bronchitis
2. Chronic obstructive pulmonary diseases (COPD)
3. Asthma
4. Pneumonia
5. Lung Cancer
186
F. Integumentary Disorders and Diseases
Pressure Sores (Decubitis Ulcers)
Characteristics
Localized area of tissue ischemia and ulcer formation, the result of
prolonged pressure over an area or damage to the skin by shear
forces
1. Affects 10 to 25% of hospitalized, ill elderly patients
2. Risk factors:
➢ Inactivity
➢ Immobility
➢ Sensory impairments
➢ Cognitive deficit
➢ Decreased circulation
➢ Poor nutritional status
➢ Incontinence
➢ Moisture
187
Characteristics
3. Common sites: bony prominences
➢ Ischial tuberosities
➢ Sacrum
➢ Greater trochanter
➢ Heels
➢ Ankles
➢ Elbows
➢ Scapula
➢ occipit
4. If not treated properly can lead damage deep structures
5. Potentially fatal in frail elderly and chronically ill patients
188
Characteristics
Assessment
1. Sensory deficit
2. Cognitive impairments
3. Hygiene
4. Mobility / activity level of the patient
5. Assess effective use of pressure relieving devices
189
Characteristics
Goals, Outcomes and Interventions
1. Prevention:
➢ Regular change of position
➢ Regular inspection of the suspected areas
2. Provide good skin care
3. Appropriate wound care
4. Provide pressure relief
5. Consistent use of pressure relief devices
6. Encourage circulation and healing
➢ Use of physical agents
➢ Active and Passive ROM exercises
➢ Functional training
7. Provide adequate nutrition
190
G. Metabolic Pathologies
Diabetes Mellitus
➢A disorder of carbohydrate metabolism, characterized by elevated blood sugar
(hyperglycemia) and sugar in urine (glucosuria): results from inadequate
production (type I, insulin dependent or juvenile onset diabetes) or inadequate
utilization of diabetes (type II, Non insulin dependent or maturity onset diabetes)
➢Problems associated with long term elevation of blood glucose:
➢Neuropathy
➢Retinopathy
➢Cardiovascular diseases
➢Peripheral ulceration
➢Renal diseases
191
Diabetes Mellitus
➢Assessment
➢Medical
➢ Fasting plasma glucose test
➢ Urine analysis
➢Symptoms
➢ Frequent urination
➢ Increased thirst
➢ Fatigue
➢ Nausea
➢ Weight loss
➢ Blurred vision
192
Diabetes Mellitus
Goals, Outcome and Interventions
➢Dietary control:
➢Weight reduction and
➢low fat diet
➢Exercise
➢Improves blood glucose control and circulation reduces cardiovascular risk
➢Exercise testing: is recommended prior to exercise prescription due to
increases cardiovascular risk
➢Exercise Prescription: daily A combination of aerobic & strengthening exercise
is recommended, duration and intensity depends upon patients tolerance
➢Exercise induced hypoglycemia is a common problem, so be alert to deal with
it
193
Diabetes Mellitus
Goals, Outcome and Interventions cont…
➢Emphasize proper foot care: good footwear, hygiene
➢Medical management type II: use of oral hypoglycemic agents when diet, exercise and
weight reduction don’t remain effective
➢Promote health: reduction of other risk factors for peripheral vascular disease e.g;
Smoking cessation, control of hypertension
194
195
Arthro-kinesiologic
Changes in Aged Adults
Assistant Professor Physiotherapy
LM&DC
Bone
Review of Tissue Structure and Function
1. Bone contains widely dispersed specialized cells that
manufacture and secrete a dense, fibrous extracellular matrix.
2. Compact bone's characteristic rigidity and stiffness are due to the
presence of the dense collagen network within the extracellular
matrix.
3. This collagen lattice is structurally reinforced by calcium
phosphate-based minerals.
4. Bone would be a very soft and pliable material if it were not for
the mineralization of the calcium salts on the collagen and matrix
material.
5. The collagen fibers within compact bone possess some degree of
elasticity and therefore are well-suited to resist tensile forces.
6. Calcium phosphate, in contrast, is very good at resisting
compression forces.
7. The interaction of these two materials provides bone with a unique
ability to resist forces in multiple directions.
8. The outer cortex shell of bone is very dense to withstand the high
forces produced by muscle pull and weight-bearing activities.
9. The inner, more spongy, cancellous bone is porous, which allows
bone to flex slightly under a load.
10. Despite bone's inert appearance, the tissue is physiologically very dynamic and
hence possesses a rich blood supply.
11. Osteocytes constantly differentiate into active osteoblasts that produce new
bone.
12. Simultaneously, the osteoclasts act as macrophages and reabsorb unneeded or
extra bone.
13. The net result of this constant process of syntheses and re-absorption is to
change the shape, density, and ultimate weight-bearing ability of bone.
14. This dynamic process allows bone to remodel and heal itself in response to
mechanical stress and trauma.
Age-Related Changes in Bone
1. The precise shape and density of bone are maintained through life by a balance
of mechanical and physiological mechanisms.
2. As an individual advances in age and becomes less active, a loss of bone mass
per unit volume usually occurs.
3. If the bone becomes excessively brittle and prone to fracture, the condition
may be classified as osteoporosis.
4. This process is characterized by a progressive loss of both fibrous matrix and
mineral content.
5. New bone is not made at a rate to replace the natural rate of bone absorption.
Age-Related Changes in Bone
6. The decline in physical activity and subsequent diminished stress placed on bone are
often associated with growing old.
7. Therefore, the loss of bone mass and increased susceptibility to fracture should be
considered a normal age-related process.
8. Males lose about 3% of their cortical bone mass each decade after age 40.
9. Women, on average, lose cortical bone at a similar rate but show an accelerated rate
of bone loss after menopause.
10. Diminished physical activity from bedrest may have a more significant demineralizing
effect on bone than does the decrease in estrogen after menopause.
11. Regular moderate physical activity in persons with osteoporosis can reduce the risk
of falls and bone fracture.
ARTHROKINESIOLOGIC IMPLICATIONS
OF AGING
1. Reduction in Joint Angular Velocity
2. A Natural Adaptive Mechanism
3. Reduction in the Extremes of Joint Range of Motion
4. Increased Stiffness in PCT
5. Age-Related Influences in Joint Mechanics
6. Practical and Clinical Significance of Decreased Joint
Mobility
7. Joint Mobility and Influence on Whole Body Posture
Arthrokinesiologic Implications Of Aging
Diminished joint angular velocity
• Reduced Physical Activity. • Physiological changes in the

• Sedentary life-style. sensorimotor systems:
• Excessive medication • Decreased reaction times
• Poor nutrition • Increased rate of loss of
• General over cautiousness brain cells
• Fear of falling • Altered level of
• Major life stresses neurotransmitter
production.
• Stiffness in Periarticular • A decreased acuity of the
Connective Tissue: auditory, vestibular, and
• Increased levels of resistance to visual systems.
joint motion. • Conduction velocity of motor
• Reduced power output nerves.
• Skeletal muscle fibers
atrophy
A Natural Adaptive Mechanism
1. Slowing of extremity motion in the aged may be simply a natural

biological process intended to ensure the safety and well-being of
the individual.
2. Age-related changes in the nervous system may slow extremity
movement, to protect:
• painful joints,
• reduce the likelihood of a fall, or
• protect a skeletal system with osteoporosis from large forces.
Reduction in the Extremes of Joint Range of Motion
• Several factors may impede full active or passive range of motion in
the elderly:
• previous injury,
• occupation,
• poor posturing.
• osteophyte formation and
• incongruities at the articular surfaces.
• These factors could interfere with full joint motion in conjunction
with:
• increased viscosity of the synovium,
• calcification of articular cartilages, and
• increased fatigability of muscle.
ATTENTION
Increased Stiffness in PCT
• Wright and Johns have determined articular capsule and muscle

combine to account for about 90% of the total passive stiffness in a
healthy joint and 10% by tendon and skin.
• Stiffness in PCT certainly needs to be considered as a prime factor
in the reduced range of joint motion in the elderly and may be due
to:
• Alterations in the structure of the collagen.
• Reduction in physical activity
• Lack of natural stretch applied to PCT.
Age-Related Influences in Joint Mechanics
• Increased stiffness in PCT in the aged may have significant

influence on joint arthrokinematics. E.g Shoulder Abduction.
Practical and Clinical Significance of
Decreased Joint Mobility
• The functional impact of limitation of joint motion on aged individuals
depends on:
• which joint is limited,
• the degree of the limitation, and
• the overall health and mobility of the person.
• Life style Modifications
• Home Modification. (e.g Shoulder Abduction)
• Walking Pattern. (gait modification)
• Body Posture (LOG).
• Physical Activity Level. Athlete vs Sedentary)
Kinetic Considerations of the Joints in the Aged
1. Joint posture is determined by the net effect of all internal and

external torques acting about the joint.
2. Internal Joint Torque Considerations
a. Reduced Ability to Generate Muscle Force. Clinically
b. Work vs. Power Considerations
c. Change in Length of Internal Moment Arm
3. External Joint Torque Considerations
1. Pathomechanics of Senile Kyphosis.
Internal Joint Torque Considerations
1. Maximal internal torque about a joint is defined as

the product of the maximal volitional muscle force
multiplied by the length of the associated internal
moment arm.
2. Aging and various changes in structure and function
of connective tissue can alter these variables.
• Reduced Ability to Generate Muscle Force.(Strength).

• Reduced Skeletal muscle due to disuse atrophy secondary to a reduction in
physical activity.
• Other factors that may contribute to the reduced peak muscular force in the
aged are:
• A loss in the number of functioning motor neurons, (atrophy of fast-twitch (type II) muscle
fibers).
• decreased quality of synapses at the neuromuscular junction.
• decreased motivation to produce large forces.
• Sensori-motor changes in the elderly
• Therefore:
• Exercise programs that strive to increase or maintain muscle active force production,
as well as maintain joint flexibility and angular velocity, are as rational for elderly
persons
• Work vs. Power Considerations.

• The work is equal to the product of the average internal torque multiplied
by the degrees of joint rotation.
• both are expected to naturally decline in the elderly.
• This is why both "strengthening" and range-of motion exercises are usually
recommended for the elderly.
• Power is defined as the rate of performing work.
• The average power produced is determined by the product of the average internal
torque multiplied by the average velocity of the joint movement.
• both are expected to naturally decline in the elderly.
• Change in Length of Internal Moment Arm.
• Joint posture may be defined as the habitual position of a joint or series of

joints. The length and orientation of the internal moment arm may
change in the elderly and subsequently alter joint posture.
External Joint Torque Considerations
1. external torque is the product of a force multiplied by the length of the

external moment arm.
2. The force component of an external torque may arise:
a. from gravity,
b. from a weight applied to a limb, or
c. through some other source that is external to the joint.
3. The external moment arm is the distance from the axis of rotation to the
perpendicular intersection with the external force.
Pre-Senescent Normal Age Related
Pathology Factors Changes
in Physiology
Increased Potential for

Factors
Other Changes in Reducing
Factors
Arthrokinesiology Physical
Activity
Altered Posture and Patterns of

Movement
Actual Changes in
Arthrokinesiology
Reduced Functional Status

SUMMARY
• Arthrokinesiology, or the study of the structure, function, and movement of
skeletal joints, is one component of the scientific basis of physical therapy.
• Age-related changes in joint function can occur in the elderly, even in the
absence of disease.
• When the effects of disease are coupled with reduced physical activity, the
elderly may experience substantial decrease in function.
• Successful treatment of joint impairments and abnormal posture in the
elderly is based on a careful analysis of the pathomechanics of the affected
joints.
• An important role of the physical therapist is to understand when or how
physical therapy can diminish the effect of these factors have on an
individual's function and ultimately his/her quality of life.
Age-Related Physiological
Changes of CVS

Assistant Professor
Lahore College of Physical
Therapy
Physiological changes with aging on CVS
Results in Effects on;
• Heart Rate
• Stroke Volume
• Early Diastole
• Late Diastole
• Cardiac Output
• Blood pressure
Heart Rate
• The affect of Age on heart rate can be of two types;
• Affect in Resting Heart rate
• Affect on Maximum Heart Rate
Affect in Resting Heart rate
• Resting heart rate is determined by fitness, so a very fit individual may have a low
resting heart rate with a higher resting stroke volume.
• Resting heart rate is either reduced or there is no change with Age however age-
associated changes occur in mechanisms that regulate heart rate.
• Autonomic Control:
• Parasympathetics reduced HR and Sympathetic Increase HR.
• Since resting heart rate is controlled by the autonomic nervous system, it can be
affected by emotional factors and by changes in posture.
• Reduced number of pacemaker cells in the sinoatrial node:
• This decline in pacemaker cell number may, in part, explain the decreased heart
rate.
Affect on Maximum Heart Rate
• Maximum heart rate, is the heart rate achieved at the point when no further
increase in maximum oxygen consumption is observed despite increases in the
intensity of the work load, shows a linear decrease with age.
• Maximum exercise heart rate is a much more constant parameter.
• The most notable and clinically important change is the decline in maximum heart
rate.
• The typical formula of 220 minus age provides a relative guideline for an expected
change in maximum heart rate.
• The decline in maximum HR is a Directly related with decline in VO2 max.
• Factors responsible for Reduced Max. HR:
• Increased Stiffness of the heart.
• Slower filling of the left ventricle,
• Age-related decrease in the number of cells in the sinoatrial (SA) node.
Heart Rate And Management of Older Adults
• To enhance cardiovascular endurance, exercise programs must challenge older adults.

• 100 feet Walking does not constitute an acceptable aerobic challenge for most people,
unless heart rate is within a training zone of 60% to 80% of the HR max estimated.
• For training effects to influence, elevated HRs have to be sustained for 20 minutes or
more.
• Nonetheless, it is not unreasonable to accumulate 20 minutes of aerobic challenge
throughout the course of a daily treatment.
• Five minutes of exercise bike followed by a rest followed by 5 minutes of alternating
normal/brisk gait is an example of accumulating aerobic exercise.
• The heart, like any other muscle, must be challenged to grow stronger.
Stroke Volume
• There are several age-related changes in the left ventricle, including:
• Increases in afterload,
• A reduction in peak diastolic filling rate, and
• The increase in wall thickness and overall mass.
• These changes with age, causes reduction in the rate of left ventricular filling during
early diastole and diminish ventricular compliance.
• Because of these changes a greater proportion of blood must enter in late diastole.
• These changes do not have an impact at rest, whereas they have a significant impact
during exercise :
• Limiting maximum cardiac output in exercise when diastole will be shortened and
• Limiting coronary blood flow.
• The decreased left ventricular compliance or increased ventricular
stiffness may be due to increased amounts of connective tissue.
Cardiac Output
• Cardiac output at rest is unaffected by age.

• Maximum cardiac output and aerobic capacity are reduced with age.
• There is a linear decline through the adult years, so the average 65-year-
old has 30% to 40% the aerobic capacity of a young adult.
Resting Blood Pressure
• Blood pressure is determined by cardiac output and by total
peripheral resistance.
• Blood Pressure = Cardiac Output X Total Peripheral
Resistance
• Since cardiac output is little altered by age in the healthy older
adults.
• Blood pressure increases with age are likely to reflect mainly
alterations in total peripheral resistance and diminished cardiac
compliance.
Systolic vs. Diastolic Blood Pressure
• Both systolic and mean blood pressures significantly increase

from 20 to 80 years.
• Specifically, systolic blood pressure tends to increase with age
throughout life, whereas diastolic pressure increases until the
age of about 60 years and then stabilizes or even falls.
Effects of increasing age on BP and HR.
Clinical implications.
e. Cardiac output decreases, 1% per year after age 20: due to decreased
heart rate and stroke volume.
f. Orthostatic hypotension: common problem in elderly due to reduced
baroreceptor sensitivity and vascular elasticity.
g. Increased fatigue; anemia common in elderly.
h. Systolic ejection murmur common in elderly.
i. Possible ECG change : loss of normal sinus rhythm; longer PR & QT
intervals; wider QRS; increased arrhythmias.
THANKS
Theories of Aging

Lahore college of Physiotherapy LMDC
What is Aging?
• The term aging is difficult to define because it has

diverse meanings for different professionals.
• Aging is a continuous set of time-dependent processes
that generally mirrors chronological age but is highly
variable and individualized.
• Aged, can best be defined as a "state or condition" that
may or may not correlate with chronological age and
more often reflects the loss of a person's capacity to
maintain independence.
Developmental Changes
• Developmental changes are irreversible normal changes in
a living organism that occur as time passes.
• They are neither accidental nor a result of abuse, inactivity,
or disease.
• They can be divided into three categories:
• Developmental, - refers to changes that occur before birth or
during childhood.
• Maturation, - concerns the changes that result in the
transformation of a child into an adult
• Aging. refers to the group of developmental changes that occur in
the later years
• Unlike development and maturation, changes associated
with aging reduce a person's ability to function, maintain
survival, and have a high quality of life.
Biological Aging
• Age associated changes that involve the physical
structures and functioning of the body and that affect
a person's ability to function or survive are referred to
as biological aging.
• Biological aging reduces the ability of the body to
maintain homeostasis and therefore to survive.
• Biological aging of the different organ systems of the
human body occurs at specific rates and are regulated
by the following two general features:
• A genetic component
• Environment and life-style components
•
Importance of the genetic component
• Longevity, or life span, of each animal species
depends upon the genetic component in the
regulation of biological aging. For example,
• humans live five times longer than cats,
• cats live five times longer than mice, and
• mice live twenty-five times longer than fruit flies.
• For humans and mammals, the genetic
component, is small and influence only 35% in
heritability of life span.
Importance of Environment
and life-style components
• In contrast, the environment and life-style components in regulating
life span is 65%.
• Thus the environmental and life-style choices can modify the
outcome of aging.
Normal vs. Healthy Aging
Normal Aging Healthy Aging
• Diseases & impairments of • Minimize and preserve function
elderly • Influenced by lifestyle choices
• People age differently • One may have a healthy life until
• Diabetes may be a common senescence makes life
disease of adulthood, but is not impossible.
experienced by all aging adults.
Life Expectancy
Some Factors Influencing Your Life Expectancy
• Heredity
• Disease Processes
• Medical Treatment
• Lifestyle Choices
• Nutrition
Theories of Aging
• All aging begins with genetics
• Age effects the biochemical and physiological processes in the body
• Cell and molecular biologists examine and propose theories to
explain the aging process
• What causes aging?
• How can you influence aging …prolong life?
Theories of Aging
• There are several theories of aging and mainly

theories fall into two general categories:
• The programmed model of aging (Programmed
Theories)
• Aging has a biological timetable or internal biological
clock that regulates specific genes
• The stochastic model of aging (Error Theories)
• Aging is a result of internal or external assaults that
damage cells or organs so they can no longer function
properly.
• Many theories are a combination of programmed
and error theories.
Programmed vs. Error Theories
Programmed Theories Error Theories
• Pre-Programmed gene • Collagen Cross-Linking Theory

regulation Theory
• Free Radical Theory
• Master Clock Theory
• Glycosylation Theory
• CatastropheTheory
• Somatic Mutation Theory
Programmed Theories
• Pre-Programmed gene regulation Theory

• Master Clock Theory
Pre-Programmed gene regulation Theory
• This theory states that:

• The aging process is actively programmed by the cell's
genetic machinery.
• There is sequential switching “off” or “on” of specific
genes.
• Aging occurs because of intrinsic timing mechanisms and
signals.
• There is Deliberate programmed cell death called
apoptosis and occurs to remove unwanted or extra cells,
e.g.
• webbing between toes and fingers.
• Fibroblasts removed from umbilical cord when cultured. They
repeatedly divide until 50 divisions, Will not divide past this
point
Telomeric Theory
• Cells fall into three types:
• Continuously replicating,
• Replicating in response to a challenge, and
• Non-replicating.
• Telomeres are specialized DNA sequences at the end of
chromosomes.
• They shorten with each cell division.
• When the telomeres become too short, the cell enters the senescence stage.
Telomeric Theory
• In the normal process of DNA replication, the end of the
chromosome is not copied exactly, which leaves an un-
replicated gap.
• The telomerase is an enzyme that fills the gap by attaching
bases to the end of the chromosomes.
• As long as the cells have enough telomerase, they keep the
DNA strand long enough to prevent any loss of important
information as they go through each replication.
• With time, telomerase levels decrease result in shorter and
shorter DNA strand and ultimately cell death.
Telomeric Theory
Shortened telomeres are found in:

• Atherosclerosis
• Heart disease
• Hepatitis
• Cirrhosis
Telomeric Theory and Cancer
• 90% of cancer cells have been found to possess
telomerase.
• Telomerase prevents the telomere from shortening.
• This allows the cancer cells to reproduce, resulting in
tumor growth.
• Research areas
• Measuring telomerase may help detect cancer.
• Stopping telomerase may fight cancer by causing death
of cancer cells.
• Telomerase may be used to help with wound healing
Master Clock Theory
• This theory states that
“Humans have an organ, cell type, or perhaps an
intracellular molecule that loses function over time”.
• Examples-
• Menopause
• Puberty
Limitations – Cont:
• Limitations:
• The difficulty with this master clock theory is that
• There is no good evidence as to where this master clock or
timing mechanism might lie or how it might control aging in
so many diverse organ systems.
• There are so many age-associated alterations in the diverse
physiological systems.
• It is difficult to determine whether the changes in the
extracellular, intracellular, and multicellular function.
• Weather it tightly linked to some fundamental control system
or the changes occur secondarily as a consequence of other
age-dependent changes.
Error Theories
❑Cross-linking Theory
❑CatastropheTheory
❑Free Radical Theory
❑Somatic Mutation Theory
Collagen Cross-Linking Theory
• This Theory States that:
• Collagen is the most abundant protein in body.
• With age, collagen is less soluble, rigid, and cross-linked.
• Free radicals, glucose, and ultraviolet light are thought to
increase collagen cross-linking.
• Other substances in connective tissue (elastin) as well as
DNA are subject to cross-linking.
• At present, no knowledge how to prevent collagen cross-
linking from occurring.
• Functionally, the age-associated changes in collagen is
observed in skin, loosened teeth, clouded lens, reduced
kidney function, damaged lungs, reduced muscle capacity,
reduced joint mobility, arid altered circulatory effects.
Collagen Cross-Linking Theory
• The accumulation of cross-linked proteins
damages cells and tissue, slowing down bodily
processes.
• Loss of flexibility of connective tissue

• Microvascular changes in arteries
Glycosylation Theory
• The glycosylation theory suggests that :
• Non-enzymatic glycosylation reactions occur when glucose
molecules attach to proteins causing a chain of chemical
reactions resulting in a structural change to the proteins.
• This will create modified forms of proteins and perhaps other
macromolecules that accumulate and cause dysfunction in
aging.
• Glucose joins with certain amino acids in proteins, rendering
an altered amino acid, and ultimately a dysfunctional
protein.
• The faulty proteins continue to accumulate in the cell until
they reach a level that damages the cells, tissues, and organ
• When enough damage accumulates, this may result in cell
malfunctioning ( aging) leading to death.
Free Radical Theory
• Free radicals or other metabolic by-products play a
role in senesce.
• During aging, damage produced by free radicals
cause cells and organs to stop functioning.
• A free radical is a molecule with an unpaired,
highly reactive electron. One type of very reactive
free radical is the oxygen free radical, which may
be produced during metabolism or as a result of
environmental pollution.
Oxygen free radicals are formed in your cells, naturally,
during the oxidation of food to water and carbon
dioxide.
FREE RADICAL Production
Free Radical Theory
The free radical “grabs” an electron from any molecule in its vicinity.
It does this because electrons like to exist in pairs.
When it “grabs” an electron from another molecule, it damages the

other molecule.
Free Radical Theory
• Some of the molecules that may be damaged by free
radicals are fats, proteins, and DNA (both in the
nucleus and in mitochondria).
• If membrane fats are attacked, then you get the
breakdown of the cell membrane. If it is a red blood
cell membrane, you get hemolysis.
• If proteins are attacked, you get the breakdown of
proteins, which may result in the loss of biological
function and the accumulation of “catastrophic”
compounds.
• If DNA is attacked, you will get a mutation that may
cause aging or cancer.
Free Radicals
As the free radical (green) attacks the membrane it

can release another type free radical (blue).
Damaged membrane
mitochondrion
The free radical (blue) attacks the DNA releasing another

free radical (purple).
Free Radical Theory
• Free radicals do not go unchecked. The body has a multi-layed
defense system that reacts and detoxifies the damaging radicals.
• Defenses include:
• Natural antioxidants in the body, such as bilirubin.
• Enzymes such as superoxide dismutase (SOD), catalase, & glutathione
peroxidase.
• Dietary antioxidants such as beta carotene, and the vitamins C and E.
Free Radical Theory
• Under normal conditions, your natural defense mechanisms prevent
most of the oxidative damage from occurring.
• The free radical theory of aging proposes that, little-by-little, small

amounts of damage accumulate and contribute to deterioration of
tissues and organs.
anti-oxidant repaired
molecule membrane
damaged
DNA
The anti-oxidant molecule destroys the damaging free radical. The

membrane repairs itself, but the DNA remains damaged, impairing the
cells function. In addition, the anti-oxidant molecule now has an
unpaired electron and thus becomes a new radical.
Free Radical Theory
For example, when Vitamin E “scavenges” free radicals, it becomes a

free radical and may be more carcinogenic than the original free
radical.
This is the reason why taking high doses of vitamin E SUPPLEMENTS

appears to INCREASE cancer risk in a person, not decrease cancer risk.
Free Radical Theory
• Not all free radicals cause damage.
• You use free radicals as part of your immunological response system.
• Macrophages engulf bacteria
• Free radical reactions produced inside the macrophage oxidize and kill
bacteria.
Question: Does it make any biological sense to try to eliminate all free
radicals in your body by taking supplements?
Can This Stop Aging?
Can you delay or stop aging by taking vitamins and
other free radical scavengers?
• There is no evidence-based proof that dietary supplements
delay or stop aging. This is a big area of nutrition quackery.
BEWARE!
• Remember, there is a lot of evidence-based proof that taking
some supplements INCREASES cancer rate, for example lung
cancer. Smokers who take beta-carotene supplements have
higher lung cancer rates than smokers not taking these
supplements.
• Therefore, the risk/benefit ratio is
in favor of NOT taking SUPPLEMENTS
to retard aging
•
The End
Balance & Fall
RISK AMONG OLDER ADULTS
Assistant Professor
LCPT (LMDC), Lahore.
Introduction
• Falls are one of the greatest threats to the health of older adults, and they can be life threatening.
• Each year, one third of people over 65 suffer a fall, and one third of these falls cause injuries
requiring medical treatment.
• Even low-level falls (e.g., slipping while stepping off a curb or on a tile floor) can be life threatening
in people over 70.
• These people are three times more likely to die from such injuries as younger people.
• Fall-related injuries, particularly those requiring hospitalization, are the most frequent cause of
developing new or worsening disability (Touhy & Jett, 2014).
• Falls are the leading cause of emergency department visits by older adults and the number one
cause of hospital admissions due to trauma.
• The estimated average cost of a hospital admission due to a fall is $20,000. By 2030, it is estimated
that up to $54 billion will be spent on healthcare costs due to falls (Schubert, 2011).
Introduction
• Falls in the older adult are one of the largest public health issues.
• Thirty-five percent of adults over 65 years report falling more than
once in the previous year, and this number increases to 50% in adults
over 75 years (Campbell et al 1990, American Geriatrics Society et aI
2001).
• Falls in the elderly are multifactorial and have been attributed to:
• Medication use,
• Environmental challenges,
• Cardiopulmonary compromise,
• Cognitive changes, and sensory and motor deficits (Tmetti et al 1986).
Introduction
• Once an older adult falls, Certain changes takes place that

further increase the risk of fall and may include:
• Fear of fall
• Decreased
• Mobility,
• Speed, and
• Fluency of movement.
• Therefore, it is essential that the geriatric specialist
performs:
• A thorough multifactorial balance evaluation and
• Initiates treatment as early as possible
Screening and Assessment
• Screening for potential balance impairments and risk of falls is an

important component of the functional screening of an older adult,
particularly if a patient has:
• A prior history of falls,
• Medications,
• Comorbid conditions that may affect balance or equilibrium.
• Older adults should be assessed for any factors that may place them
at greater risk for falls, including:
• Age (>85 years) • Acute illness (influenza,
• Gender (female) infections)
• Race (white, non-Hispanic) • Previous history of falls
• Chronic disease such as: • Gait and mobility impairment
• Osteoarthritis, • Vision and hearing deficits
• Parkinson’s Disease,
• Cardiovascular Disease
Fall Risk Assessment
1. Assessing mobility, strength, and gait is essential in determining the

older patient’s risk for falling and experiencing difficulty in meeting
other physical needs.
2. The speed of walking, stride length , and type of gait are also
indicators of increased fall risk.
3. Slower gait, smaller steps, and irregular gait can signal neurologic
disorders that predispose the patient to falls.
4. Unsteady frontal gait may be a sign of cerebrovascular disease or
normal pressure hydrocephalus.
5. Short steps may be a sign of Parkinson’s disease.
Etiology of Slow Gait
• Slow gait may be caused by:

• Muscle weakness,
• Inactivity,
• Peripheral vascular disease,
• Chronic obstructive pulmonary disease (COPD),
• Or angina.
Instrument Time Required to Administer Equipment Required
Timed sit-to-stand test <10 min Stopwatch, chair
Berg balance scale <20 min Stool, stopwatch, ruler
Functional reach test <5 min Tape measure, platform for foot position
Limits of stability test 20–30 min Computer software
Dynamic gait index 15 min Staircase, shoebox, two cones, tape
measure, tape
Tinetti balance assessment 20 min Armless chair, pencil
Timed up-and-go (TUG)test (see <5 min Chair, measuring tape, stopwatch
below)
Expanded timed up-and-go test <5 min Chair, measuring tape, stopwatch
Four-square step test <5 min Four canes, stopwatch

Prevention and Intervention
• Patients and families need to know how to prevent falls. The four
essentials for prevention:
• Make the home or other environment safer.
• Ask the healthcare provider to review all medications (for side
effects and interactions).
• Vision check.
• Encourage exercises that improve balance and coordination.
Prevention and Intervention
Additional Precautions
• Additional precautions that can make the home safer and prevent falls
include:
• Removing tripping hazards such as remove rugs from stairs and floors
• Placing often-used items within easy reach so that a step stool is not needed
• Installing grab bars next to the toilet and in the tub or shower
• Placing non-stick mats in the bathtub and on the shower floor
• Adding brighter lighting and reducing glare by using lampshades and frosted
bulbs
• Adding handrails and lights on all staircases
• Wearing shoes that offer good support and have thin, non-slip soles
• Avoiding wearing slippers and socks (without shoes) and going barefoot
Washroom Safety
Washroom Safety
EXERCISE INTERVENTION STRATEGIES
• Physical therapists may employ a number of intervention strategies and approaches

in the delivery of therapeutic exercise for the purposes of improving balance and
reducing fall risk in older adults. Some of these strategies include:
• Multifactorial intervention: May be interdisciplinary in nature; any program or
protocol that includes assessment of and interventions for more than one fall risk
factor.
• Single-factor intervention: Focuses primarily on the risk factor associated with
falling (i.e., only balance training activities, strengthening exercises, or home
safety education).
• Multicomponent exercise program: Incorporates multiple components; may
include performance, balance/postural control, walking, and/or cardiovascular
endurance activities.
• Single-component exercise program: Contains one modality of exercise (i.e. balance,

strengthening, or endurance).
• Balance training program: Specifically designed to target and progressively improve
static and dynamic balance.
• Moderate-challenge balance exercise programs: Incorporates two of the three
modes of balance exercises: 1) movement around the individual’s center of mass, 2)
utilizing narrowed base of support, and 3) minimal upper extremity support.
• High-challenge balance program: Incorporates all three modes of balance exercises
(see above).
• Structured exercise intervention/program: Scripted; composed of specific

components (warm-up, balance, gait training, etc.) delivered in a consistent manner
over time; designed to be progressive and challenging.
• Best practice programs: Exercise programs, often offered at senior centers and
wellness facilities, composed of evidence-based activities.
• Evidence-based programs: Have been translated and tested in the community setting
in randomized controlled trials and deemed effective in reducing risk of falling. Highly
scripted, target specific populations, and include specific implementation
instructions.
THANKS
Conservative Pain Management
in
Elderly

Consultant Physical Therapist/
Medical Educationist
Introduction
• Pain has been defined as an unpleasant sensory and emotional
experience associated with -actual or potential tissue damage.
• More simply, pain has been defined as a hurt that we feel.
• Elderly persons often believe that pain is an inevitable consequence of
aging, therefore, the presence of pain may be denied Because of:
• Fear of medical procedures and expenses,
• Loss of autonomy, and
• Possible institutionalization .
• Conversely, pain complaints may be used to deal with other functional
impairments.
• Boredom and loneliness may contribute to increased perception and
complaints of pain.
• Proper pharmacological management of acute post-operative and
chronic pain has recently been described by AGS.
• One goal of conservative treatment for the elderly is the appropriate
reduction of medication usage.
Introduction
• Pain has been recognized to be the most common
symptom for which health care is required by the general
population in the world.
• Today we will discuss the conservative management of pain
experienced by the older patient including:
• Noninvasive,
• nonsurgical, and
• nonpharmacological approaches to patient care are emphasized. *
• Before Discussing the pain management in older adults, number of
factors need to be addressed including predisposing physical and
mental conditions and individual's willingness to report pain and
to seek health care.
Introduction
• Arthritis, is the most common cause of pain.
• Other physical conditions that commonly result in chronic pain
for the elderly include
• Cancer,
• Osteoporosis with compression fracture,
• Degenerative disk disease,
• Diabetic neuropathy,
• Trigeminal neuralgias,
• Residual neurological deficits.66•
• Acute postoperative pain
• Pain associated with athletic injuries will become more common as a
growing number of older persons pursue active recreational interests.
Incidence of Pain in Elderly
• Over 85% of older adults have at least one chronic disease that may
result in a range of discomforts, including pain.
• Between 25% and 50% of community-dwelling elderly have important
pain problems.
• Geriatric nursing home residents have an even higher prevalence of
pain, which is estimated to be between 45% and 80%.
• The elderly are often either untreated or undertreated for pain.
• Consequences of under-treatment for pain can have a negative impact
on the health and quality of life of the elderly, resulting in depression,
anxiety, social isolation, cognitive impairment, immobility, and sleep
disturbances.
• Reasons that physicians often cite for inadequate pain control include
lack of training, inappropriate pain assessment, and reluctance to
prescribe opioids.
Classification of Pain
As with other age groups, the elderly have pain that can be classified patho-
physiologically as either nociceptive or neuropathic in origin. Alternatively, pain
may be mixed, that is, having origins that are both nociceptive and neuropathic.
nociceptive neuropathic
• Nociceptive pain may be either • Neuropathic pain results from a
visceral or somatic and is due to pathophysiologic disturbance of
stimulation of pain receptors. either the peripheral or the
• In the elderly, this stimulation central nervous system.
may be the result of • In the elderly, common examples
inflammation or musculoskeletal include postherpetic neuralgia
or ischemic disorders. and diabetic neuropathy.
• Patients with nociceptive pain • more likely to respond to
are treated pharmacologically adjuvant agents such as anti-
with both opioid and nonopioid convulsants and antidepressants
agents as well as
nonpharmacologic interventions.
EVALUATION OF CLINICAL PAIN
• Evaluation represents a synthesis of information derived from the
patient's history, subjective interview, objective physical examination,
and special tests and investigations like Radiology and Blood chemistry
etc.
• Other references should be consulted for information concerning
comprehensive patient evaluation, including physical,
psychological/psychiatric, and special testing procedures related to pain.
• The evaluation should clarify the underlying basis for the pain and guide
proper therapeutic interventions.
• The evaluation also provides baseline information needed to determine
the effectiveness of treatment.
• Ongoing re-evaluation of pain is necessary to disclose a change in the
patient's physical status and to document response to treatment
• A comprehensive assessment should include a careful history and

physical examination and diagnostic studies aimed at identifying
the precise etiology of pain.
• Characteristics such as intensity, frequency, and location should
be described.
• Standardized geriatric assessment tools to assess function, gait,
affect, and cognition should be used.
• Intensity should be assessed by using one of several pain scales
that have been accepted for use in the elderly
• When possible, use of an interdisciplinary team approach to
assessment and management of pain in the elderly is advantageous.
• These strategies need to be sensitive to cultural and ethnic issues, as
well as to values and beliefs of patients and their families.
• Once etiologic factors are determined and therapy is initiated, a pain
log or diary is appropriate to assess effectiveness of treatment.
• PT should encourage patients to record such documentation on a daily
basis.
• Regular reassessment by use of previously administered assessment
scales is important and serves to modify therapy to assure an optimal
response.
• Reassessment should include an evaluation of compliance and the
presence of adverse effects
Outcomes Used for elderly Pain assessment
• To document patients' subjective pain experiences, a number of pain
assessment tools have been developed.
• Perhaps the simplest unidimensional tool for the measurement of pain
intensity is the Verbal Rating Scale which include description such as: No
Pain, mild, moderate, severe, or unbearable pain.
• Pain Estimated also by Numeric Rating Scale. Patients rate the severity of
their pain on a scale of 0 to 10, or 0 to 100. On this scale, 0 indicates no
pain, and end points of 10 or 100 represent the worst possible pain.
• The Visual Analogue Pain Rating Scale consists of a l0-cm line with
typical verbal anchors of"no pain" at the left and "pain as bad as it could
be" at the right when the scale is oriented horizontally.
• The Graphic Rating Scale consists of a visual analogue pain rating scale
with additional word descriptors, e.g., mild, moderate, and severe.
Outcomes Used for
elderly
Pain assessment
FIG. Simple pain rating scales.

A, Visual Analogue Pain Rating
Scale (horizontal).
B, Visual Analogue Pain Rating
Scale (vertical).
C, Visual Analogue Pain Relief
Rating Scale.
D, Graphic Rating Scale.
Symptoms Recording: Body Chart
• The main problem is usually recorded
on a body chart, all which have similar
features and all are similarly asexual.
The chart on the right is a more or less
standard view of one. It shows an
anterior and posterior view of the
body (some charts have left and right
views as well) and shows it in the
anatomical position. It is the ideal
place to reflect the description and
relationship of symptoms. You could
qualify them as following: nature,
depth, frequency and impact. If the
symptom is pain, you could add the
VAS/NRPS grade. Some departments
will have their own symbols for
describing pain, stiffness, acute,
chronic, whether it radiates, etc.
Outcomes Used for elderly Pain and Functional
assessment
• Patients in pain typically have reduced activity levels, so it is
important to assess physical function, including activities of daily
living (ADL) and physical performance.
• Barthel Index and the Katz Index ofADL, do not include the range
of activities in which community-dwelling elderly individuals are
typically engaged.
• Gibson and colleagues have suggested that the Human Activity
Profile and the Sickness Impact Profile are more useful
• To document patients' subjective pain experiences, a number of
pain assessment tools have been developed.
Characteristics of Pain
• Onset: (Rapid or Insidious)
• Location: (Local-Referred-Radiating)
• Behavior: (Constant – Intermittent)
• Intensity: (Mild-Moderate-Sever)
• Quality: (Sharp, Dull/Aching, Excruciating, Cramping, Shooting,
Throbbing, Stabbing, Burning)
• Aggravating and Relieving factors
• Morning Stiffness/Pain
• Whether the patient able to continue the activity or weight bearing
after acute injury or was forced to cease activity immediately.
THEORETICAL BASIS FOR PAIN
• It has been widely Considered that pain is not simply a direct consequence of
the normal aging process. However, More recent studies supported to age-
related changes contributing to pain in the elderly.
• Nociceptors attached to small diameter afferents are activated by intense
mechanical or thermal stimuli and by various chemical sensitizing or
depolarizing agents liberated with trauma or inflammation, e.g., bradykinin,
prostaglandin, histamine, substance P, lactic acid, and potassium ions.
• Some of these agents may become concentrated in the vicinity of nociceptors
due to circulatory impairment or to muscle spasm.
• Nociceptive excitation of small-diameter afferents (myelinated A delta and
unmyelinated C fibers) results in the release of neurotransmitters that
stimulate second-order neurons, ultimately resulting in the perception of
pain at higher brain centers.
• Sensory input from large-diameter afferents (myelinated A beta fibers)
associated with mechanoreceptors has an inhibitory effect on input from the
smaller afferents conveying nociceptive input.
• Inhibitory descending control from higher centers and the brainstem also can
act to minimize the effects of nociceptive input.
• This descending inhibition is mediated by neurotransmitters such as
norepinephrine (NE; noradrenaline) and serotonin (5-HT).
•
Age- Related Changes PAIN Perception
• There is decreases in responsiveness of nociceptors (Free nerve endings in
the skin) and small unmyelinated fibers to noxious chemical stimulation with
age.
• There is slow response time to Thermal Noxious stimuli due to an age-
related decrease in conduction of small myelinated fibers as seen in
peripheral neuropathies e.g., post-herpetic neuralgia and trigeminal
neuralgia based on age-related loss of dorsal root ganglion cells, increased
ectopic impulse discharge, and increased cross-excitation of adjacent dorsal
root neurons.
• Age-related decreases in sensation of touch and vibration also demonstrated
due to a decreases in the number of mechanoreceptors such as Merkel's
disks, Meissner's corpuscles, and pacinian corpuscles.
• Endogenous opiate play a role in initiating descending inhibition (via
endorphins) and in local inhibition at the spinal cord level (via enkephalins).
STRATEGIES FOR PAIN CONTROL
• Pain management may be either the short-or long-term goal of a
comprehensive treatment plan.
• Whenever possible, conditions underlying a clinical pain problem
should be the focus of treatment.
• Those who care for elderly patients with pain have come to
appreciate the importance of a comprehensive multidisciplinary
approach to evaluation and treatment.
STRATEGIES FOR PAIN CONTROL
Multidisciplinary Combination Treatment
• A multidisciplinary approach is • Interventions have been used
specifically indicated in cases in singly or in various combinations
which the underlying cause of in the attempt to more
pain is not remediated or only completely treat factors
partially treatable. underlying a clinical pain
• Such an approach may integrate problem.
the involvement of numerous
health care professions including
• The value of combined use of
medicine, nursing, occupational conservative interventions for
therapy, orthotics and the management of chronic pain
prosthetics, physical therapy, in the elderly is gaining
psychology, recreational therapy, recognition.
social work, and others.
Conservative Treatment I nterventions used to
manage Pain
1. Decrease activity of nociceptors or their
afferent nerve fibers.
2. Increase activity of mechanoreceptors or their
3. Increase descending control via cortical or
reticular formation inhibition.
• A. Limit mechanical stresses through:
1. Prevention of acute edema formation with ice, compression, elevation, or
electrical stimulation
2. Assistive gait device (e.g., cane, walker, and orthotics)
3. Rest from stressful function
4. Limitation of the effects of gravity via hydrotherapy
5. Immobilization (e.g., orthotics, traction)
6. Resorption of chronic edema via mild heat, massage, elevation and
compression, or electrical stimulation
7. Elongation of restrictive connective tissue using vigorous heat (as with
diathermy or ultrasound) and prolonged stretch
8. Restoration of normal joint arthrokinematics through joint mobilization,
stretching or strengthening exercise, or biofeedback
9. Application of ergonomic principles
B. Limit effects of chemical depolarizing C. Create local anesthetic or anti-
and sensitizing agents through:
inflammatory effects through:
1. Enhanced local circulation 1. Iontophoresis (e.g., with Lidocaine or
produced with mild to moderate Dexamethasone)
heat, massage, exercise, or 2. Phonophoresis (e.g., with
electrical stimulation hydrocortisone)
2. Decreased local metabolic 3. Cryotherapy (e.g., cold pack or ice
activity with cryotherapy (e.g., massage)
cold pack or ice massage)
4. TENS
3. Decreased muscle spasm via
select physical agents, massage, 5. Low-intensity laser
exercise, or biofeedback
2. Increase activity of mechanoreceptors or their
B. Directly stimulate large-diameter
A. Stimulate Mechanoreceptors through: afferents from mechanoreceptors through:
1. Passive and active joint 1. Comfortable low-to
range-of-motion exercise moderate-intensity TENS (e.g.,
2. loint mobilization "conventional;' "pulse-burst;' or
"modulated" TENS modes)
3. Comfortable massage strokes
(i.e., mild to moderate intensity) 2. Comfortable submaximal
intensity NMES
4. Voluntary (e.g., walking,
swimming, bicycling) and
electrically stimulated exercise
3. Increase descending control via cortical or
reticular formation inhibition.
B. Increase physiological and
psychological stress through use of
A. Reduce patient anxiety through: uncomfortable "counterirritants" such
as:
1. Progressive relaxation exercises 1. Intense massage (e.g., strong
2. Inducing relaxation with friction, acupressure, connective
biofeedback (e.g., EMG or thermal tissue massage)
modes) 2. Acupuncture or
3. Patient education concerning basis e1ectroacupuncture
for pain and the plan for its successful 3. Uncomfortable but maximally
treatment tolerated NMES
4. Uncomfortable but maximally
tolerated TENS (e.g., "strong low
rate;' "brief intense," "pulse-burst,"
or "hyperstimulation" modes)
5. Uncomfortable brief ice massage
Review of Select Treatment Interventions
1. Assistive Devices and Orthotics
2. Exercise
3. Thermal Agents
4. Crotherapy
5. Transcutaneous Electrical Nerve Stimulation
6. Psycho educational Interventions
THANKS
Management
of
Urinary Incontinence
in
Women and Men
Assistant Professor
Introduction
• Urinary incontinence (UI), a common health condition among older adults, is defined as
the complaint of any involuntary leakage of urine.
• Although UI affects both genders, women have a greater risk of developing this
condition
• The International Continence Society has defined three types of UI: stress UI, urge UI,
and mixed UI.
1. Stress UI: is the involuntary leakage of urine that occurs on effort or exertion, or on
sneezing or coughing.
2. Urge UI: Involuntary leakage of urine accompanied by or immediately preceded by
urgency (a sudden, strong desire to pass urine, which is difficult to defer) defines urge
UI.
3. Finally, mixed UI is the involuntary loss of urine associated with urgency and also
with exertion, effort, sneezing, and coughing.
Effects Of UI in Older adults
• In older adults, Urinary incontinence (UI) can seriously affect not only physical
function, psychological well-being, and quality of life but also poses a significant
economic burden to the individual and society. UI has been associated with:
1. Depressive symptoms
2. poor life satisfaction
3. social isolation
4. sleep disturbances
5. increased risks of falls, and
6. increased risk of institutionalization.
Treatment Options In older Adults
• Currently, there are many treatment options for persons with UI, including:
1. Pharmacotherapy
2. Surgery,
3. Pelvic floor muscle (PFM) exercise, and
4. Other behavioral interventions.
• In older adults, mental and physical status, comorbidity, medications, and
environment often complicate the etiology of UI.
• Thus, the physical therapy management of older individuals with UI may not be
straightforward.
• The physical therapist will need to carefully reflect on how these contributing factors
affect the patient’s prognosis and the efficacy and feasibility of interventions under
consideration.
CLINICAL DICISION MAKING
• To provide a foundation for clinical decision making, briefly discuss:
1. Anatomy and physiology of normal continence mechanisms.
2. Pathophysiology of UI, and risk factors for developing UI
3. UI-specific tools to determine patient outcomes including:
a. UI symptoms,
b. Symptom-related distress,
c. Quality of life, and
d. Sexual function;
4. Evidence based conservative intervention options for UI are:
a. PFM exercise
b. biofeedback
c. electrical stimulation,
d. bladder training, and
e. lifestyle modification.
Examination – History
Medical Conditions That Affect Bladder Function Directly
1. Congestive heart failure 7. Bladder outlet obstruction

2. Peripheral venous (prostatic or bladder neck
insufficiency in men.
3. Renal disease 8. Pelvic organ prolapse,
bladder neck, or urethra in
4. Urinary tract infection women.
5. Bladder tumor 9. Diabetes
6. Bladder stones 10. Neurologic conditions
11. Radiation therapy.
Conditions that Can Precipitate Urinary Incontinence
(UI) by Increasing Intra-abdominal Pressure
1. Chronic cough (chronic obstructive lung disease, smoking,

asthma, allergies, emphysema)
2. Constipation
3. Obesity
4. Occupation (involving heavy lifting), and/or recreational
activities (weightlifting, jogging)
Obstetric History
1. Number of pregnancies and deliveries

2. Mode of delivery (vaginal versus cesarean delivery; forceps- -
assisted vaginal delivery)
3. Episiotomy and/or anal sphincter laceration during delivery
4. Infant birth weight
5. UI/FI (fecal incontinence) during or following pregnancy.
Gynecologic History
1. Menopausal status
2. Hormone replacement therapy
3. Surgery such as:
a. Hysterectomy
b. Pelvic organ prolapse and
c. Anti-incontinence procedures
Examination- History
Drug History
• Medications should be reviewed, including those that alter cognition, fluid balance,
and bladder and/or sphincter function.
• Medications can directly affect urinary function includes:
• Anti-hypertensives, neuroleptics, and benzodiazepines can reduce urethral
pressure.
• Diuretics are known to increase the production of urine.
• Anticholinergics and b-blockers may affect the ability to empty the bladder
completely.
• Other medications can affect urinary function indirectly via their side effects.
• Constipation, a risk factor for stress UI, is a side effect associated with narcotic
analgesic and iron use.
• Another risk factor for stress UI, cough, is a side effect of ACE inhibitors.
Fluid Intake
• Patients should be asked about their daily fluid intake.
• Restricting fluids is a coping strategy used by some to reduce urinary frequency,
urgency, and incontinence.
• However, reducing fluids may lead to Constipation or urinary tract infection, thus
adversely affecting continence.
• Conversely, a patient may report excessive fluid intake, which may exacerbate bladder
symptoms.
• Time of fluid intake should be discussed, as consumption of fluids during evening hours
may contribute to nocturia (waking one or more times at night to void).
• Caffeine, alcohol, and/or carbonated beverage intake should be reviewed to determine
if they are contributing to the patient’s UI.
Key Bladder Symptom Questions
• A careful bladder symptom history is important to identify onset, type,
frequency, and severity of symptoms, precipitating factors, and need for
further medical evaluation.
1. When did your bladder problem begin?
2. Do you leak urine with laughing, coughing, sneezing, lifting, or exercise?
3. Do you leak urine on the way to the bathroom?
4. Do you have to strain to empty your bladder?
5. Do you feel that your bladder is still not empty after you void?
6. Do you experience pain or burning when you empty your bladder?
7. How often do you empty your bladder during the day?
Key Bladder Symptom Questions
8. How often do you wake up at night to empty your bladder?
9. How often do you feel a strong desire or urge to urinate that you can’t stop?
10. How often do you leak urine during the day?
11. How often do you leak urine when you sleep or wake up to empty your bladder?
12. Do you use any type of absorbent product (pad, adult undergarment)?
• If yes, how many do you use in a 24-hour period?
13. Do you leak urine during sexual intercourse?
14. Are your bladder leaks small (drops), medium (wets underwear), or large (soaks
underwear and outer clothing)?
Key Bowel Symptom Questions
1. How many bowel movements do you usually have per day?

2. Do you experience pain with bowel movements?
3. Do you experience frequent constipation? How often?
4. Do you experience frequent diarrhea? How often?
5. How often do you strain to have a bowel movement?
6. How often do you experience loss of liquid or solid stool?
7. Do you need a laxative or enema to produce a bowel movement?
Bladder Dairy
• A bladder diary can be used to capture and quantify bladder function, including
voiding frequency, volume of each void, number of UI episodes per day, the size or
severity of each UI episode, and daily pad usage.
• The 7-day bladder diary has been shown to have high test– retest reliability for
voiding frequency and number of UI episodes.
• However, some patients may fail to produce a valid bladder diary. In such cases, the
clinician may consider administration of the 3-day bladder diary.
• In addition, the mean number of UI episodes recorded during the first 3 of the 7 days
has been shown to be representative of the mean number of UI episodes averaged
across the entire week
Physical Examination
Components of a Basic Physical Examination for Persons with
Urinary Incontinence
General Examination Specific Examination of

Female Clients
• Observation for lower extremity Perineal Observation
edema
• Perineal skin for inflammation,
• Lower extremity strength and excessive vaginal discharge,
joint mobility lesions, scars
• Lower extremity sensation • Demonstration of pelvic floor
• Lower extremity reflexes muscle contraction
• Functional mobility
• External Examination • Specific Examination of Male Clients
• Sensation around the perineum • Genital Observation
• Palpation to identify painful tissues • Irritation of skin or skin breakdown on
• Sacral reflexes: anal wink, bulbocavernosal penis from urine exposure, genital lesions
reflex • Demonstration of pelvic floor muscle
• Internal Examination contraction
• Sensation within the vagina • External Examination
• Palpation to identify painful tissues • Perineal and perianal sensation
• Pelvic floor muscle bulk • Sacral reflexes: anal wink, bulbocavernosal
• Pelvic floor muscle contraction reflex
• Exam rectally if no contraction palpable • Rectal Examination (After Medical
vaginally Clearance Postsurgery)
• Presence and quantification of pelvic organ • Pelvic floor muscle contraction
prolapse
• Quantifying Pelvic Floor Muscle Function.
• The most clinically practical method of examining PFM function is through vaginal, digital
examination.
• Two scales, theBrink50 and Modified Oxford Grading,have been described for grading
digitally (vaginal) examined PFM function.
• The Brink scale (Pelvic Muscle Rating Scale, Version 2) is based on three muscle contraction
variables:
• Currently, there is no suggested standard method of assessing PFM.
• Intensity of the “squeeze” generated by the muscle contraction,
• Vertical displacement of the examiner’s fingers as the muscles lateral to the vagina contract,
• Muscle contraction duration.
• Each variable is rated separately on a 4-point categorical scale. The three subscale scores are
summed to obtain a composite score
• The Modified Oxford scale uses a 6-point numerical scale to grade PFM contraction:
• 0 = no contraction (nil), 1 = flicker, 2 = weak, 3 = moderate, 4 = good (with lift), and 5 =
strong.
Measurement Tools to Evaluate PFM Function
and Strength
Methods to measure ability to
contract Measures to quantify strength
1. Clinical observation Manual muscle test by:
1. Ultrasound,
1. Vaginal palpation
2. Dynamic MRI
2. Vaginal palpation 2. Manometry
3. Ultrasound 3. dynamometry
4. MRI, 4. cones.
5. Electromyography [EMG]).
These methods measure different aspects of PFM activity, anterior and
cephalad movement, squeeze pressure, and electrical activity.
Ability to Contract
1. Ultrasonography applied supra-pubically. Sagittal midline view of
pelvic floor relaxed
(A) fully contracted
(B) with pelvic-floor displacement marked
2. Apparatus with multiple functions: measurement of pelvic-floor
muscle function with surface electromyography and vaginal and
rectal squeeze pressure
3. Palpation method
Ability to Contract.
ABILITY TO CONTRACT
Ultrasonography applied supra-
pubically. Sagittal midline view of
Most physical therapists use vaginal pelvic floor relaxed
palpation to evaluate and give (A) fully contracted
feedback on ability to contract the (B) with pelvic-floor displacement
pelvic-floor muscles. marked
Quantification of Muscle Strength
• Measurement of squeeze pressure is the most commonly used
method to measure PFM maximum strength and endurance.
• The patient is asked to contract the PFM as hard as possible
(maximum strength), to sustain a contraction (endurance), or to
repeat as many contractions as possible (endurance).
• The measurement can be done in the urethra, vagina, or rectum
using manual muscle testing with vaginal palpation, pressure
manometry, or dynamometry.
One commonly used “perineometer,” Vaginal squeeze pressure measured
the Peritron with vaginal probe with a vaginal balloon connected to a
(NEEN HealthCare, Dereham, Norfolk, microtip pressure transducer (Camtech
United Kingdom). AS, Sandvika, Norway).
Different sizes and shapes of vaginal
Vaginal dynamometer. cones
Clinical Recommendations
• Pelvic-floor muscle palpation is the recommended technique for
use by the physical therapist to understand, teach, and give
feedback to patients about correctness of the contraction.
• Position of the patient, instructions given, and the use of 1 or 2
fingers have to be standardized and reported.
• Ultrasound applied supra-pubically, is a noninvasive method
and is an important tool in the future for physical therapists to
assess correctness of the PFM contraction,
Conclusion
• No single measurement tool gives a full picture of PFM strength or function.
• In addition, to date, there are no measurement tools with demonstrated
responsiveness, reliability, and validity and is capable of measuring the
automatic action of the PFM in real-life situations.
• Future technological developments may provide the possibility of measuring
PFM function during different forms of physical exertion.
• Physical therapists need to be aware of the advantages and disadvantages of
current technology to become less reliant on manual palpation skills alone.
Clinical Recommendations
• Measurement of vaginal squeeze pressure is difficult, and

clinical skills and experience are important factors in achieving
reproducible and valid results.
• The method has to be used with caution. Only contractions with
visible inward movement of the measurement device can be
considered valid measurements of PFM strength.
• The use of dynamometers may be a future valid, reliable, and
responsive method of measuring PFM force.
Outcome Measures
• Symptoms, symptom-related bother or distress, quality of life, and sexual
function can be measured with condition- specific standardized
assessment tools.
• If these tools are administered at examination and at discharge from
physical therapy, they can be used to determine the outcome or efficacy of
the physical therapy interventions for UI.
• Shumaker et al develop two Outcome measures to measure Physical
Activity, Travel, Social Relationships and Emotional Health
• Urogenital Distress Inventory (UDI)
• Incontinence Impact Questionnaire (IIQ).
• Barber et al developed a scale for Incontinent women:
• Pelvic Floor Distress Inventory (PFDI),
THANKS
Assistantt Professor
LMDC, Lahore.
Introduction
• Living at home and interacting with the community can be

challenging for the older adult.
• A delicate balance must exist between functional capability,
adaptation of the environment, and reliance upon support
services.
• The purposes of this Presentation are to present some of the
challenges that confront the older adult living at home and to
offer some strategies for minimizing their impact.
GENERAL CONSIDERATIONS
• Challenges for the Older Adult to Remain in the

Community.
• Independent Living
• Combate Dependency
• Team approach to Challenges
•
Challenges for the Older Adult to Remain in the
Community.
Independent living
• Independent living requires:
1. Activities of daily living (ADLs)
2. Instrumental activities of daily living (IADLs)
1. Activities of daily living (ADLs)

• Assessed by Barthal Index.
• People perform ADLs to manage basic personal hygiene and survival needs.
• Functional activities that may be included in this category are bed mobility,
getting in and out of a bed or chair, bathing, toileting, dressing, grooming,
eating, and ambulating.
• These activities are sometimes called personal activities of daily living.
Community.
Independent living
• Instrumental activities of daily living (IADLs)
• Assessed by lanton’s IADL scale
• These include activities as preparing meals, laundering clothes, doing
housework, using the telephone, traveling (using public transportation
or driving), shopping, taking medications, and managing money.
• The capacity to perform IADLs independently is strongly associated with:
• Velocity of gait.
• Balance,
• Grip strength and Can be Improved by
• Chair rise time. Exercise
• Assistive devices can promote independence for community-dwelling
elders.
Community.
Combating Dependence
• Dependence (requiring the assistance of another person) for ADLs
and IADLs, thus increases the risk of institutionalization and
mortality.
• Assistive devices can promote independence for community-dwelling
elders by the appropriate use of :
• Therapeutic exercise,
• Functional training, and
• Prescription and application of appropriate device.
Team Approach to Challenges
• Challenges are often best dealt with by a team or multidisciplinary
approach. For Example:
• Incorporating the expertise and perspectives of several professionals
facilitates:
1. Differentiation of problems.
2. Enhances holistic care for individual patients.
3. Improves compliance and effectiveness of management strategies.
4. Encourages patients and care-givers to be active participants in
developing and carrying out an overall management plan.
RETURNING TO HOME
• Multiple Service Sites

• Factors That Affect Acute Hospital-Based Interventions
• Factors That Affect Short-Term Rehabilitation Interventions
• Factors That Affect Long-Term Rehabilitation Interventions
Multiple Service Sites
1. Minor Injuries – Emergency Care – Return to Home -
Rehabilitation
2. Serious Injuries or Disease - Emergency Care – Admission –
Skilled Nursing Care/Sub-acute Care - Return to Home -
Rehabilitation
3. Less serious injury/ Chronic Disease – Ambulatory Care –
Return to Home- Rehabilitation.
4. Necessary physical therapy interventions may include:
• Strengthening exercises
• Bed mobility & Transfer training
• Gait training,
• An environmental assessment, or other strategies increases
returning the individual to an independent life-style.
Factors That Affect Acute Hospital-Based
Interventions
• If a person is admitted to a hospital, medical/surgical management may
require that individual to be dependent on others and immobile for a
period of time.
• It is important that physical therapists perform comprehensive
examinations and assist patients to regain their independence and
mobility in preparation for returning home.
• A number of physical therapy interventions may be used to help older
patients return home from a hospital.
• Selecting an appropriate mobility aid
• Practice in ADLs and dressing Skills
• Frequency of physical therapy interventions
Factors That Affect Short-Term Rehabilitation
Interventions
• After a hospital stay, a geriatric individual may require additional time and therapy
before being able to return home.
• Such subacute care may occur at another unit of the hospital, a skilled nursing
facility, or possibly a transitional-care center.
• Varying lengths of time will be required to prepare different patients to return
home.
• The Most appropriate Interventions would be:
• Improving the Endurance Capacity.
• Improving Bed mobility and Transfer
• Improvement in Balance and Gait.
Factors That Affect Long-Term Rehabilitation
Interventions
1. Some older patients may require extended periods of time to recover
from disease or disability.
2. The presence of multiple chronic conditions such as arthritis, vascular
insufficiency, and pain may be superimposed on a primary problem
such as a hip fracture.
3. A greater number of clinical considerations can complicate
rehabilitation efforts.
4. Some patients may benefit from prolonged rehabilitation because the
additional time permits more elaborate examination and evaluation.
5. Similar Interventions and aims of rehabilitation as for Short term care
but needs more time.
INTERVENTIONS THAT KEEP PEOPLE LIVING AT
HOME
1. Probably the single most important aspect of keeping older people living
at home is injury prevention.
2. Unfortunately, common ailments associated with aging, such as knee
osteoarthritis, have a relationship to loss of balance and falls.
3. Severe injuries, causing reduced mobility and dependence
4. Various strategies have been developed to help prevent falls in the older
population
5. The importance of a comprehensive approach to fall prevention should
adopted.
6. Physical therapists must keep normal age-related changes in mind and
differentiate those changes from other factors such as polypharmacy,
inadequate food intake, and inactivity.
Home Based Problems & solutions
• Home assessments can reveal common problems such as poor

lighting, loose carpets or slippery surfaces, and clutter
• Typical problems for the older adult living at home include:
• Difficulty getting in and out of the bathtub or shower,
• Using a toilet,
• Turning faucet handles and doorknobs, and
• Negotiating steps.
Home Based Problems & solutions
• A therapist can reduce or eliminate all of those problems by
recommending adaptive equipment such as:
• Grab bars,
• Transfer benches,
• Elevated toilet seats,
• Appropriate footwear
• Handle extensions, and railings.
• Updated eyeglass prescriptions.
additional Home interventions
• Two additional types of interventions may assist an older adult to remain at home:
1. Program assistance
2. Technology.
Program assistance includes services from home health agencies, private
aides or certified nursing assistants, hospice organizations, Meals on Wheels
and chore services.
Technology includes devices and equipment that allow aged people to
perform tasks for themselves or call for assistance if required.
• Staying at Home with a Care-Giver
• Staying at Home without a Care-Giver
MOBILITY IN THE COMMUNITY
• Pedestrian
• Driving
• Transportation
SUMMARY
• Remaining at home can be difficult for the older adult. Adequate and
appropriate physical therapy interventions can improve the odds for
living successfully at home.
• Adaptation of the environment, especially in the context of the
community, often requires the cooperation of many interested
parties.
• Sometimes, the functional abilities and support resources needed for
independent living are not achievable.
• An accurate and thorough examination and evaluation of the patient
and the environment should provide the data needed to make a
judgment about living at home.
Case Study
• Mr. CS is a 76-year-old male who received a total knee joint arthroplasty of

the right knee on June 6,1997.
• Mr. CS has a long history of degenerative joint disease of the right knee. He
experienced a gradual increase of pain in the knee and a gradual decline of
ambulation ability over a 2-year period.
• Before onset of significant pain 2 years ago, Mr. CS had been an active out-
of-doors ambulator with no significant concomitant medical problems.
• When pain with ambulation could no longer be controlled by conservative
measures and ambulation became limited to within the home only, Mr. CS's
physician recommended surgery.
Case Study
• The postoperative recovery was uneventful.

• After an acute-care hospitalization of 5 days, the patient was transferred
to a rehabilitation hospital.
• Since Mr. CS lived alone, the therapists at the rehabilitation hospital
concentrated on independence with ADLs as functional outcomes.
Normal Bench Marks
S. No. PARAMETER BENCHMARK
1 Walking speed 1.22 m/s· (4.0 feet/second2)

2 Walking distance 300 m (984 f)
3 Curb height 20.32 em (8 in)
FUNCTIONAL MEASURES FOR MR. CS UPON
DISCHARGE FROM REHABILITATION HOSPITAL
S. No. Parameters Measurements
1 Passive range of motion: Extension minus 5°
Right knee (all other Flexion 1000
ranges within normal
limits for 76-yearold
male)
2 Strength: Right knee (all Extensors 3 +/5 , Flexors 3+/5
other strengths within (10" quad lag noted i.e., active range of extension limited to
normal, limits for 76- minus 10Q)
year-old male)
3 Ambulation 61 meters (200 feet) with walker, allowed weight bearing as
tolerated on right
4 Stairs Transfers Up and down 12 stairs with railing
5 Transfers Independent to and from bed, chair, toilet
Case Study:
• Case 1: Impaired Joint Mobility, Motor Function, Muscle Performance,
and Range of Motion Associated with Joint Arthroplasty
• Case 2: Impaired Gait, Locomotion, and Balance Secondary to Lower
Extremity Amputation
• Case 3: Impaired Joint Mobility, Motor Function, Muscle Performance,
and Range ofMotion Associated with Localized InjlJlmmation
• Case 4: Impaired Aerobic Capacity and Endurance Associated with
Cardiovascular Pump Dysfunction
• Case 5: Impaired Aerobic Capacity and Endurance Secondary to
Deconditioning Associated with Systemic Disorders
Ventilation And Respiration In
Older Adults
Introduction
The purpose of this lecture is to:

1. Provide a detailed overview of the anatomical and physiological functions of
ventilation and respiration.
2. Describe the tissue and pulmonary system changes that occur with normal aging as
well as the subsequent impact these changes have on function.
3. The differences between the consequences of normal aging and the impairments
produced by cellular and system pathology are examined.
4. Special attention is afforded to the investigation of dyspnea in the older adult, with
emphasis on the role that symptom evaluation plays in differential diagnosis.
5. The scope of therapeutic interventions based on examination findings is presented
with consideration of specific tests for and diagnosis of impairments of the
pulmonary system.
6. The lecture will conclude with suggestions for optimizing function and preventing
pulmonary dysfunction in the older adult.
VENTILATORY PUMP, AIRWAY, AND LUNG
ALTERATIONS WITH AGING
• The physiological function of ventilation can be, described as:
1. The activity performed by the biomechanical action of the ventilatory muscles
on the anatomically elliptical thoracic cage to achieve the intrathoracic
pressure changes required for gas flow.
2. The WOB is the work performed by the ventilatory muscles, and the
integrated musculoskeletal activity of ventilation is described as the
physiological work of the ventilatory pump.
Effect of aging on Ventilatory Muscles
1. Both the strength and endurance of skeletal muscles have been found to
decline with age.
2. The ventilatory muscles are a mix of type I slow-twitch and type II fast-twitch
muscle fibers, which is similar to other skeletal muscles.
3. During normal resting breathing, the slow-twitch motor units of respiratory
muscles are active. These fiber types generate tension more slowly but are
resistant to fatigue.
4. The fast twitch motor units fibers respond quickly during more strenuous
breathing efforts and are susceptible to fatigue.
Alterations in Physiological Ventilation with Age
1. Lung Volumes: Lung volumes such as total lung capacity (TLC), vital capacity (VC),
and residual volume (RV) gradually reduces with advancing age due to the
reduction in height of the individual.
2. Maximal static respiratory pressures (MSRP) : Tolep and Kelsen describe that
Maximal static respiratory pressures (MSRP) declined 15% to 20% from 20 to 70
years. The decline, however, did not become significant statistically until age 55.
3. Diaphragm Strength: Tolep and Kelsen also described that diaphragm strength
reduced 20% to 25% in older individuals.
4. Work of Breathing (WOB):There will be increased WOB because of reduced
strength and endurance of respiratory muscle with age.
Therefore, the older individual is at greater risk for developing respiratory muscle
fatigue and subsequent failure when subjected to injury or disease
Structural Airway / Lung Alterations
Structural Airway / Lung Alterations
1. Wright has described normal lung tissue having a network of elastic fibers that
provides a supporting framework for the primary lobule, including the terminal
bronchiole, respiratory bronchiole, alveolar ducts, and alveoli.
2. In young individual, in large bronchus the elastic fibers are longitudinally
arranged in a layer in the mucosa and small fibers may be circumferential and
intermeshed with the thick longitudinal fibers while Circular fibers are
abundant in the bronchioles.
3. The alveolar ducts and alveoli showed a generalized and uniform reduction in
the number of elastic fibers causes dilatation of their openings and results in
the loss of elastic recoil in the lungs of older adults that leads to the progressive
retention of volume and increased residual lung volume
4. Other tissue changes described by Wright's included localized deposits of
granular black pigment mostly in the walls of respiratory bronchioles and
alveolar ducts
Thoracic Pump Alterations
• The mobility reduction in the thoracic rib cage is suggested to result from two
primary tissue alterations.
1. The first is an increase in the cross-linking of collagen fibers both in the ribs
and in the connecting sternal cartilage.
2. The second is primarily a vertebral column change where the intervertebral
annulus fibrosis becomes stiffer due to water loss, causing a subsequent
reduction in the cushioning distance between the intervertebral disks.
• The composite result is a shorter, more rigid thorax that is resistant to
deformation and therefore requires greater ventilatory muscle force to
achieve a change in the intrathoracic pressure.
• The combination of a rigid thorax, reduced ventilatory muscle strength, and
loss of elastic recoil in older individuals combines to produce physiological
alterations in both the ventilation and gas exchange functions of the
respiratory system.
PULMONARY ANATOMICAL AND PHYSIOLOGIC AL
CHANGES WITH AGING
CHANGE IN PHYSIOLOGICAL MEASURES OF LUNG FUNCTION
WITH AGING
Ventilatory Work of Breathing
• The Structural and Physiological changes described above means that the
chest wall is actually held in a position of partial inspiration.
• This altered position serves to shorten the inspiratory muscles' resting length
and primarily flattens the diaphragm and hence reduces the muscle's
potential contractile force, so a greater muscle force is needed to achieve a
change in intrathoracic pressure or volume.
• Simultaneously, the disruption in the elastic framework of the lung at the
alveolar level results in increased lung compliance with loss of elastic recoil.
• The summary effect on ventilatory work is a higher oxygen cost for the WOB
at any given tidal volume or an overall decrease in the efficiency of
ventilation.
EXAMINATION AND EVALUATION TO
DISCRIMINATE BETWEEN AGING AND
PATHOLOGY
Examination
1. The consistent combined symptom presentation in older adults that includes
dyspnea, early onset fatigue, and slowed activity rate challenges clinicians to be
careful and thorough during examination and evaluation to ensure accuracy of
diagnosis and appropriateness of prognosis and treatment plan.
2. The overlapping signs and symptoms of aging, deconditioning, and
cardiovascular or pulmonary pathology present an excellent rationale for
performing a standardized examination and evaluation with every patient.
3. A complete history, review of systems, and use of standardized tests and

measures provide a baseline set of information and test values that can be
compared with known normative values for identification and classification of
actual pathology, impairment, and functional limitation.
History and Systems review
• Past medical history, review of different systems, functional status and the current problem
evaluation through standardized examination and evaluation procedure can be used to
establish a functional baseline and to compare the patient with others or himself/herself
over the course of therapy.
• Clinical Tests and Measures
• Physical examination steps including palpation, percussion, and auscultation are performed
initially and repeatedly over the course of care since these tests may illustrate change fairly
rapidly in response to changing conditions.
• Tests that document cardiovascular and pulmonary function at rest and with activity are the
essential components of this examination. These may include:
1. LFT’s:
2. ABG’s
3. Dyspnea Through Standardized Testing
4. A cardiopulmonary exercise test
Evaluation, Diagnosis, Prognosis
1. The final step in evaluation is the clinical judgment process. The clinician considers
all the findings from the examination to determine what impairments are
amenable to physical therapy intervention,
2. Patients who have localized problems such as reduced muscle performance or the
systemic problems associated with deconditioning may be well-managed in a short
treatment course and quickly achieve an improved functional performance.
3. Older individuals with serious and significant impairment of ventilatory pump
function or gas exchange mechanisms may require more complex interventions
and a longer course of care and may never achieve a return to full functional
capacity.
4. The goals and expected outcomes for seniors should consider the slowed healing
process, the decreased maximum capacity of the system, and a realistic functional
potential.
THERAPEUTIC INTERVENTION
• Design of an accurate and effective treatment program is dependent on the
previously described processes of examination and evaluation. For example:
1. Individuals with reduced ventilatory pump capacity will receive programs
that effectively reduce the work of breathing or improve the strength and
endurance of ventilatory muscles.
2. Reduction in the WOB is often accomplished through change in body
position
3. Muscle length and stretch can be achieved by increasing intrathoracic lung
volume; body position (supine vs upright); and degree of external
compression., e.g., abdominal binder .
4. Therapeutic intervention is directed at the balance between minimizing
load and maximizing efficiency.
Breathing Strategies
• From a physical therapy perspective there are strategies that can be
used to decrease the work of breathing for patients with an increase
in both the elastic and the flow resistive work of breathing.
• Selecting the appropriate technique for each patient is based on the
previous examination or re-examination
• To reduce the WOB, decrease the oxygen cost of ventilation, and
improve the efficiency of ventilatory pump function, following
Techniques / strategies will be employed:
1. Diaphragmatic breathing
2. Pursed lip breathing, and
3. Paced breathing with exercise
Diaphragmatic breathing
• Diaphragmatic breathing as a technique focuses on reduction of the RR to improve
efficiency of alveolar ventilation in multiple ways
1. A lower rate reduces the V/Q mismatch by decreasing inefficient ventilation of the anatomical
dead space.
2. It also slows the velocity of diaphragmatic contraction, which facilitates recruitment of
intercostal and other accessory muscles.
3. It increases the overall strength of each muscle contraction by allowing time for motor unit
recruitment.
4. Recruitment of the abdominal muscles to facilitate use of the diaphragm.
5. decreasing the repetitive contraction of the accessory muscles
6. It lengthens the time before the onset of fatigue in an impaired individual.
7. Tactile facilitation of efficient and effective diaphragmatic contraction assists with expiration
through muscle cueing.
8. Abdominal pressure in the sub-xiphoid region generates a quick stretch before the next
inspiratory effort, improving inspiratory contraction.
Pursed lip breathing
1. Pursed lip breathing is a strategy used to diminish the symptom of

dyspnea.
2. It is spontaneously adopted by some individuals with obstructive lung
disease.
3. It facilitate an increased inspiratory tidal volume by increasing the volume
exhaled with each breath
4. It decreased respiratory rate by:
5. Slowing and prolonging expiratory flow,
6. decrease peak and mean expiratory flow rates that in turn decrease
turbulent flow and airway collapse,
7. It also improved alveolar ventilation.
Paced breathing with exercise
1. Paced breathing is another technique that is expected to reduce

the work of breathing and diminish the symptom of dyspnea
during activity.
2. Varying ratios of inspiratory time to expiratory time have been
tested with multiple functional activities in an effort to find a ratio
that provides subjective comfort during activity performance.
3. Practice or repetition of maneuvers during basic activities of daily
living (BADL) may enhance the process of integrating the behaviors
into daily living. Thus, the patient's ability to participate in social
and work activities and also enhancing overall quality of life.
Strength and Endurance Conditioning of Ventilatory
Muscles
• Once the patient has begun to master some of the strategies or techniques for
reducing the work of breathing and improving the efficiency of the pattern of
breathing, there may be an opportunity to address strength and endurance needs
of the ventilatory muscles.
• The same principles that accomplish skeletal muscle strength training apply to
training the ventilatory muscles. e.g Loading Priciple, specificity principle and
reversibility principle.
• Treatment Methods:
1. THRESHOLD TRAINING has been suggested to achieve both strength and
endurance goals
2. An alternative method for addressing the strength and endurance needs of the
ventilatory muscles is to have the INDIVIDUAL PERFORM EXERCISE, as the WOB
itself presents the overload training stimulus.
Airway Clearance
• Similar methods applied as of young but with great care such as:
1. Manual techniques of percussion, shaking, and vibration in appropriate
segmental drainage positions can enhance the mobilization of secretions.
2. Clearance of secretions by cough, huff, forced expiratory techniques, or
suctioning removes the obstruction to airflow-at least on a temporary
basis---and reduces the work of breathing.
3. There are conditions of excessive mucus production (chronic bronchitis,
bronchiectasis) or impaired mucociliary transport (immotile cilia
syndrome) that may require secretion clearance measures on a chronic or
long-term basis to assist in managing airway obstruction and in
maintaining a tolerable work of breathing.
Other Methods
1. Endurance Conditioning
2. WelinesslPrevention Techniques
3. Smoking Cessation
4. Nutrition
5. Immunizations
THANKS
Rehabilitation of Older Adults

Assistant Professor
LMDC
INTRODUCTION
• The decline in physical function associated with the
reduced physical activity so commonly present in
older adults.
• Older people become increasingly limited in their

abilities to perform activities of daily living because
of:
• Poor balance,
• Reduced endurance,
• Generalized weakness, or
• Repeated falls.
INTRODUCTION
• It is still not clear whether these changes are due to the aging process
or inactivity. For example,
• lean body mass,

• basal metabolic rate,
• aerobic capacity, and
• insulin sensitivity
• All decline with decreasing levels of physical activity and are also
reduced with aging.
Inactivity VS Aging
CHARACERISTIC AGING IMPOSED INACTIVITY EXERCISE
BODY COMPOSITION
Lean body mass
Fat mass
Bone mass
Total Body Water /=
METABOLISM
Basal metabolic rate
Glucose tolerance
Muscle glycogen
Insulin responsiveness
Calcium balance
LDL cholesterol =
..l = Decrease; 1l increase; no change.
FUNCTIONAL PERFORMANCE
THRESHOLD
• The ability to perform activities of daily living is
important in maintaining independence for the older
adult.
• There is a minimum criteria of physical functioning,
e.g., strength, range of motion, endurance, balance,
required to perform activities of daily living; this is
defined as the functional performance threshold.
• FPT in Young adults:
• FPT in Older adults:
Functional capacity, measured as Vo2max, declines with aging. The
amount of reserve decreases with age, such that the older individual
functions closer to the minimal threshold.
70
60 Functional
performance
50 Threshold
40
30
Reserve
VO2 max 20
Ml/kg/m
in 10
0
0 20 40 60 80 100 120
Age in years
FUNCTIONAL PERFORMANCE THRESHOLD
Young adults Oldr adults
• Function well above • Reduce the physiological capacity
and reserve and Changes to the
the functional various organ systems, particularly
performance threshold. the heart and skeletal muscles
results in:
• Possess a large • Reduce functional capacity below
Physiological reserves. this critical threshold of
functioning
• Healthy Heart • Extended period of immobile
• Detoriation in health status.
• Healthy MSK System • Unable to do self-care activities
and live independently.
• Healthy NM Control • Progressive age related changes
• Good Aerobic Capacity reduce functional capacity
• loss of physiological reserve
increases the risk of disability.
Rehabilitation Objective
The Ultimate objective of any
rehabilitation program for older
adults is to maintain physiological
capacity and reserve well above the
functional performance threshold.
Mosqueda defines physiologic reserve
as the buffer that allows us to cope
with and recover from stressors.
Rehabilitation Potential
• The definition of rehabilitation Potential included the

maintenance of self-care activities at a higher level.
• A person's ability to perform functional activities is
primarily dependent on:
1. The integrity of the cardiovascular system and its ability to
influence oxygen transport and tissue oxygenation.
2. The integrity of the Skeletal muscle system to perform
functional activities, such as walking, stair climbing, and
carrying packages (ADLs).
• A person's rehabilitation potential influenced by
many factors, e.g., age, cognition, strength, co-
morbidities, depression, and medications.
• Since age-related decline in physiological capacity,
reduces the functional performance threshold,
therefore, may influence his/her rehabilitation
potential.
• For example, an older adult with a large physiological
capacity who falls and breaks a hip may recover
immediately with therapeutic intervention.
• In contrast, an individual with a minimal physiological
capacity. The rehabilitation process may be hindered due
to the poor health status, and the benefits of therapeutic
intervention resulting in independent living will be
reduced.
Effects of Rehabilitation Potential
• ADLs require a minimum amount of muscle strength and
muscle endurance.
• Both the structural and the physiological changes that
occur in the cardiovascular and Muscular system with aging
decrease cardiac functional reserve capacity; results in
• Limit the performance of physical activity
• Lessen the ability to tolerate a variety of stresses, including
cardiovascular disease.
• A reduction in muscle mass and muscular strength Limit ADL
performance.
• Ultimately, older persons perceive activities associated with a
relatively low metabolic demand as physically demanding.
• Certain activities may no longer be able to be performed whereas
others may require frequent rest periods.
• Thus the falling of Cardiac functional reserve

capacity and muscle strength and endurance below
the functional performance threshold can lead to:
• A more dependent life-style
• Eearlier entry into long-term care facilities.
• Contributes to the risk of falls,
• A decline in bone density,
• Incidence of hip fractures and orthopedic injury in older
adults.
Conclusion
• Physiologically, aging is associated with a variety of
alterations in cardiovascular function, yet despite these
changes, the cardiovascular system continues to function
reasonably well in supplying the needs of tissues, at least
at rest.
• When the cardiovascular system is stressed, during
exercise or in response to situations imposing an
increase in metabolic demand for oxygen, age-related
alterations are evident and limit function.
• Ultimately, it is possible that older persons perceive
activities associated with a relatively low metabolic
demand.
• Certain activities may no longer be able to be performed
whereas others may require frequent rest periods.
Thanks
Age-Related Structural
Changes in the CVS

Assistant Professor
INTRODUCTION
• Structural changes with aging involve:
• The myocardium,
• The cardiac conduction system,
• The endocardium.
• There is a progressive degeneration of the cardiac structures
with aging, including
• A loss of elasticity,
• Fibrotic changes in the valves of the heart
• Infiltration with amyloid.
Age-Related Structural Changes in the CVS
A. Age related changes in Heart Mass and Myocytes

B. Age-Related Structural Changes in the Blood Vessels
C. Age-Related Changes in the Electrical Conduction System of the
Heart
A. Age related changes in Heart Mass and
Myocytes
1.Cardiac Myocytes
a. Cellular hypertrophy
b. Increase in non-cellular components.
2.Age related Changes in Heart Mass
3.Age related Changes in Heart Valves
4.Myocardial Subcellular Changes
5.Cardiac Muscle Compliance
1.Cardiac Myocytes
1. Cellular hypertrophy
• For decades, it was thought that the heart undergoes atrophy with advancing
age
• But the use of echocardiography confirmed that 25% increase in left
ventricular wall thickness and chamber size between the second and the
seventh decades.
• This increase in heart mass (Hypertrophy) with aging, is due to an increase in
the average myocyte size, whereas the number of myocardial cells declines
1. Cardiac Myocytes
2. Increase in non-cellular components.

a. Collagen content:
• Within the myocardium Collagen content increases results in fibrosis of
many structures.
• The pericardium, becomes stiffer, which contributes to the decrease in
compliance of the left ventricular wall.
• valvular changes with aging include thickening and calcification of the
cusps and leaflets.
• This may cause degenerative changes (aortic valvular stenosis and mitral
valvular insufficiency) with age.
1. Cardiac Myocytes
b. Lipofuscin, a brownish lipid-containing substance, accumulates at the

poles of the nuclei of myocardial cells.
• Lipofuscin is thought to arise by the peroxidation of lipid/protein mixtures,
and in the myocardium increases at a rate of about 0.3 percent per
decade.
• Thus, at the age of 90, the pigment occupies 6% to 7% of the intracellular
volume.
1. Cardiac Myocytes
c. Amyloid is another a lipid like substance.

• The progressive deposition of amyloid in the myocardium, usually in the
atria, occurs in up to one third of elderly people.
• This protein infiltrates tissue, rending it dysfunctional.
d. Adipose deposition between muscle cells is also common, resulting in
fattier heart tissue in the ventricles and the interatrial septum.
• Fat deposits in the inter-atrial septum may displace conduction tissue in the
sino-atrial node and lead to conduction disturbances.
2. Age related Changes in Heart Mass
Stimulus for Ventricular Hypertrophy
• In younger adults, ventricular hypertrophy occurs in response to an increased pressure work
load, e.g., during high-resistant weight training.
• What is the stimulus for the increase in left ventricular wall thickness in the older adult.
• We know with age there is increase in peripheral resistance (afterload) may result increase in
systolic blood pressure and aortic compliance.
• For example, with age the volume of blood in the ascending aorta increases due to age-related
aortic dilatation.
• This increase in volume of blood must be advanced by the heart for ejection to occur; thus
there is an increase in work load (afterload) that has to be performed by the heart.
• The increase in work load acts as the stimulus for muscle hypertrophy.
3. Age related Changes in Heart Valves
• An age-related increase in valvular circumference has been reported in all four cardiac valves
(aortic semilunar valve, pulmonary semilunar valve, bicuspid valve, tricuspid valve), with
the greatest changes occurring in the aortic valve (the valve between the left ventricle and
the aorta).
• The age-associated increase in valvular circumference does not appear to be associated with
valvular incompetence.
• Other valvular changes with aging include thickening and calcification of the cusps and
leaflets.
• These changes do not usually cause significant dysfunction, although in some older adults,
severe aortic valvular stenosis and mitral valvular insufficiency are related to degenerative
changes with age.
• Clinical heart murmurs are detected more frequently.
4. Myocardial Subcellular Changes
• Subcellular changes take place within the myocardial cells.
• The nucleus, containing DNA, becomes larger and may show invagination of its membrane.
• Nucleoli (the dense body within the nucleus that contains a high concentration of RNA) increase
in size and number.
• The chromatin shows clumping, shrinking, fragmentation, or dissolution, and there is an
increased likelihood of finding chromosomal abnormalities (due to DNA damage).
• The mitochondria show alterations in size, shape, cristal pattern, and matrix density, which
reduce their functional surface (due to accumulation of damage).
• The cytoplasm is marked by fatty infiltration or degeneration, vacuole formation, and a
progressive accumulation of pigments such as lipofuscin.
• The combined age related changes in the subcellular compartments of the cells
result in decreased cellular activities such as altered homeostasis, protein synthesis,
and degradation rates.
5. Cardiac Muscle Compliance
• In general, the walls of the heart become less compliant with age.
• The decreased capacity of the left ventricular wall to expand during diastole results
in a reduced and delayed filling of the left ventricle.
• Subsequently, during the systolic (emptying) phase of the cardiac cycle, the left
ventricle contracts less and ejects less blood (Frank-Starling relationship).
• This decline in left ventricular compliance provides an increase work load on the
atria, resulting in hypertrophy of the atria.
• This causes gradual Increased left atrial size.
Age-Related Structural
Changes in the Blood Vessels
INTRODUCTION
• To distribute blood to the working tissues, blood vessels require varying degrees of
distensibility or compliance depending on their specific function.
• The forward motion of blood on the arterial side of the circulation is a function of the
elastic recoil of the vessel walls and the progressive loss of pressure energy down the
vascular tree.
• The peripheral vasculature provides the delivery system by which blood pumped by the
heart reaches the various body tissues
• Age-related changes in the blood vessels may limit the maximal perfusion of these tissues
and affect cardiac performance as well.
• The decrease of elasticity of the arterial vessels with aging may result in chronic or
residual increases in vessel diameter and vessel wall rigidity, which impair the function of
the vessels.
Changes in Aorta
• Increase Aortic Stiffness:
• Due to the collagen infiltration and cross linckage Aorta becomes stiff
and Less flexible
• This causes resistance to blood flow
• Blood cannot reach far into arteries.
• Results in further reduced elasticity of arties.
• Reduced Buffering Capacity:
• The aorta acts as a buffer for the total blood volume in the arterial
system because about one half of the stroke volume is stored in the
aorta.
Changes in Peripheral Vessels
• Arterial Stiffness –
• Increase in arterial stiffness in aged is thought to result from a diffuse cellular
process that occurs in the vessel wall due to;
• Increase of collagen and collagen cross-linking.
• An increase in chondroitin sulfate and heparin sulfate
• A decrease in hyaluronate and chondroitin content.
• And a relative loss of elastin fibers due to first decrease in glycoprotein component of
elastin fibrils and then increase in calcium content results in frayed elastin and
eventually disappearance.
Changes in Peripheral Vessels-Continue
• These Structural Changes causes:
• Less flexibility,
• Reduced capacity to accommodate blood large volume.
• And also to propel blood into the capillaries.
• Therefore reduced destensibility and compliance.
• Impedance of blood flow through the arteries is further influenced by the:
• Accumulation of lipids that occurs over the individual's lifetime.
• increase in the concentrations of total plasma cholesterol, triglycerides, and the
low-and very-low-density lipoproteins (LDLs and VLDLs).
Function
• These histological, morphological, and stiffness changes found in the aging
aorta and arteries are similar to those seen with essential hypertension.
• The age-related increase in arterial stiffness may have an important impact
on myocardial performance.
• The stiffer aorta with no change in heart rate can result in
• Higher systolic ventricular pressure
• Decreased aortic diastolic pressure.
• Increases in ventricular diastolic pressure and volume may be observed.
Function
• These changes require greater left ventricular stroke work and result in
increased wall tension and myocardial oxygen consumption during systole.
• Thus, these findings suggest that the resistance to ventricular emptying
increases with age; this increase in afterload may explain, the age-related
increase in left ventricular mass.
• The age-associated increases in arterial stiffness and pressure can be modified
by life-style and diet because arterial stiffness varies inversely with aerobic
capacity
AGE-RELATED CHANGES IN THE CARDIOVASCULAR AND
ARTERIAL SYSTEMS AND THEIR FUNCTIONS
MORPHOLOGICAL AND STRUCTURAL FUNCTIONAL SIGNIFICANCE
CHANGES
Changes in Veins
• The walls of veins may become thicker with age because of:
• An increase in connective tissue and Calcium deposits.
• The valves also tend to become stiff and incompetent.
• Varicose veins develop.
• Because of low blood pressure in veins, these changes probably
are not significant for cardiovascular function.
• But they may be of concern because of the possibility of phlebitis
and thrombus formation.
Venous Circulation
• The venous circulation is dependent on its being highly compliant to
accommodate the greatest proportion of the blood volume at rest.
• Although the mechanical characteristics of venous smooth muscle have been
less well-studied compared with arterial smooth muscle, the efficiency of its
contractile behavior can be expected to be reduced with aging.
• Further, its electrical excitability and responsiveness to autonomic nervous
systems tend to be less rapid and less pronounced.
Blood
• The blood appears to be rather resistant to the aging process and under normal
conditions blood values remain normal.
• The volume and composition remain consistent.
• Blood cells retain their normal size, shape, and structure.
• The amount of red bone marrow decreases with age
• the capability for blood cell formation decreases,
• but the hemopoietic mechanisms are still adequate for normal replacement so that blood
counts and hemoglobin levels stay within normal ranges.
• Unusual circumstances, such as hemorrhage, may put a strain on the hemopoietic mechanism
so it takes longer to rebuild after a hemorrhagic event.
Age-Related Changes in the
Electrical Conduction System
of the Heart
Age-Related Changes in the Electrical
Conduction System of the Heart
• With aging, the heart's conduction system changes such that the frequency and
regularity of cardiac impulses may become abnormal (dysrhythmia).
• First, cardiac conduction is affected by the decrease in the number of pacemaker
cells in the sinoatrial node with age.
• Beginning by age 60 there is a pronounced "falling out:' or decrease, in the
number of pacemaker cells in the sinoatrial node, and by age 75 less than 10%
of the cell number found in the young adult remains.
• A less dramatic cellular decrease is noted in the atrioventricular node and the
intraventricular bundle of His.
Cont:
• There is also fibrotic changes in the specialized nerve conduction system.
• An increase in elastic and collagenous tissue in all parts of the conduction system.
• Fibrous infiltration of the bundle of His and bundle branches is common.
• A variable degree of calcification of the aortic and mitral anuli, the central fibrous body,
and the summit of the interventricular septum, occurs.
• Fat accumulates around the sinoatrial node, sometimes producing a partial or complete
separation of the node from the atrial musculature. This occurrence in extreme cases may be
related to the development of sick sinus syndrome.
• Because of their proximity to these structures, the atrioventricular node, A-V bundle,
bifurcation, and proximal left and right bundle branches may be damaged or destroyed by this
process, resulting in so-called primary or idiopathic block.
ECG changes
• Several features of the electrocardiogram are altered by normal aging
based on the structural changes
• the P-R and Q-T intervals show small increases with age
• The age related increase in the P-R interval has been shown to be due
to conduction delay occurring proximal to the bundle of His.
• The conduction time from the bundle of His to the ventricle is not
altered.
• There is a leftward shift of the QRS axis with advancing age,
• The S-T segment becomes flattened, and the amplitude of the T wave
diminishes
IMPACT OF ECG changes
50% of older persons have been reported to have electrical
conduction abnormalities at rest, which has considerable
implications for the mechanical behavior of the heart and the
regulation of cardiac output, particularly when stressed during
activity and exercise.
Summery
• The heart pumps less effectively with age.
• Additionally, changes with age in the integrity of the valves and those changes in
the ventricles result in less efficient pumping action of the heart.
• The age-related anatomical changes of the heart and blood vessels result in
reduced capacity for oxygen transport at rest and, in particular, in response to
situations imposing an increase in metabolic demand for oxygen.
• Therefore, older individuals may experience fatigue with minimal exertion and
may no longer be able to perform certain activities.
• The functional capacity and reserve decrease, bringing the older individual closer
to the minimum criterion of functioning.
THANKS
Elder abuse
Introduction
• What is meant by "expectation of trust"

• It is the core element of harm of elder person toward their abuser.
• Thus, it includes harms by people the older person knows or with whom
they have a relationship, such as:
• A spouse, partner or family member,
• A friend or neighbor, and
• People that the older person relies on for services.
• Many forms of elder abuse are recognized as types of domestic violence or
family violence.
Definition
(Elder abuse, also called "elder mistreatment," "senior
abuse," "abuse in later life," "abuse of older adults,"
"abuse of older women," and "abuse of older men") is "a
single, or repeated act, or lack of appropriate action, occurring
within any relationship where there is an expectation of trust,
which causes harm or distress to an older person (WHO)
Introduction
• The abuse of elders by caregivers is a worldwide issue.

• In 2002, the work of the World Health Organization brought
international attention to the issue of elder abuse.
• Over the years, government agencies and community professional
groups, worldwide, have specified elder abuse as a social problem.
• In 2006 the International Network for Prevention of Elder Abuse
(INPEA) designated June 15 as World Elder Abuse Awareness Day
(WEAAD).
Types of Elder Abuse
There are several types of abuse of older people that are generally recognized as
being elder abuse, including:
• Physical. • Neglect:
• Psychological/Emotional • active neglect
• Financial abuse • Passive Neglect
• Scam by strangers • Self-neglect:
• Sexual: • Rights abuse:
• Abandonment:
• Institutional abuse
• Hybrid financial
exploitation (HFE):
Warning signs
• The key to prevention of elder abuse is the ability to

recognize the warning signs of its occurrence.
• Signs of elder abuse depends on the type of abuse the
victim is suffering.
• Each type of abuse has distinct signs associated with it
Warning signs
Type of Abuse Warning Signs
Physical abuse It is detected by visible signs on the body, including:
• bruises, scars, sprains, or broken bones.
More subtle indications of physical abuse include:
• Signs of restraint, such as rope marks on the wrist, or
broken eyeglasses.
Emotional It often accompanies the other types of abuse and can usually be
abuse detected by:
• Changes in the personality or behavior.
• The elder may also exhibit behavior mimicking dementia.
Sexual abuse It can be detected by:
• Visible signs on the body, especially around the breasts or genital area.
• Other signs include infections, bleeding, and torn underclothing.
Warning signs
Type of Abuse Warning Signs

Financial exploitation Signs of financial exploitation include:
• Significant withdrawals from accounts,
• Missing of belongings or money from the home,
• unpaid bills, and
• unnecessary goods or services.
Neglect Signs of neglect include:
• Malnutrition and dehydration,
• Poor hygiene,
• Non-compliance to a prescription medication, and
• Unsafe living conditions.
Health consequences
❖ The health consequences of elder abuse are very serious.

❖ Elder abuse can destroy an elderly person's quality of life in the forms of:
• Declining functional abilities • Premature mortality and morbidity

• Increased dependency • Depression and dementia
• Increased sense of helplessness • Malnutrition
• Increased stress • Bed sores
• Worsening psychological decline • Death
Risk factors
There are several risk factors, which predisposes an elderly person will become a
victim of elder abuse. Such risk factors for elder abuse include an elderly person who
has:
❖Memory problems (such as dementia)
❖Physical disabilities
❖Depression, loneliness, or lack of social support
❖Uses alcohol or other substances
❖Verbally or physically combative with the caregiver
❖A shared living situation
REPORTING SUSPECTED ELDER ABUSE
• Geriatric rehabilitation professionals have a legal duty to to identify

elder abuse and to take appropriate action to prevent further abuse.
This may include:
• Reporting suspected elder abuse to:
• Social service departments or agencies
• Law enforcement agencies.
• Can inform to their own health care agency to take further action
• Can wait for a subsequent event of elder abuse.
References
1. Elderabuse.org.uk, accessed October 12, 2007.
2. Cook-Daniels,L., (2003b, January/February). "2003 is the year elder abuse hits the
international state." Victimization of the Elderly and Disabled. 5, 65-66, 76.
3. Rinkler A.G. (2009). "Recognition and perception of elder abuse by prehospital and
hospital-based care providers". Archives of Gerontology and Geriatrics 48: 110–115.
4.International Network for the Prevention of Elder Abuse, accessed June 26, 2007.
5.Robinson, De Benedictis, Segal. "Elder Abuse and Neglect". Help Guide. Retrieved15
December 2012.
6."What is Elder Abuse?". Administration on Aging. Retrieved 17 December 2012.
7.Shilling, D. (2008, November/December). "Improving the court system's response to
elder abuse," Victimization of the Elderly and Disabled, 11, 49, 51-52, 59, 62-63.
References
8. Jackson S, Hafemeister T (2012). "Pure financial exploitation vs. Hybrid financial exploitation co-occurring with physical abuse
and/or neglect of elderly persons". Psychology Of Violence 2 (3): 285–296. doi:10.1037/a0027273.
9. Jump up^ Nursing Home Abuse Laws (NHAL)
10. ^ Jump up to:a b Oregon Revised Statutes.
11. Jump up^ Tina de Benedictis, Ph.D., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., (2007) Elder Abuse Types, Signs, Symptoms,
Causes, and Help. Helpguide, helpguide.org.
12. Jump up^ Johnson, Christopher, JD. "Elder Abuse: Neglect and Self Abuse", California, 19 February 2015. Retrieved on 25
February 2015.
13. ^ Jump up to:a b c d e Robinson, Lawrence; Tina De Benedictis; Jeanne Segal (November 2012)."Elder abuse and neglect:
Warning signs, risk factors, prevention, and help". Retrieved16 December 2012.
14. Jump up^ "Signs and symptoms of elder abuse and neglect in care". Advocare Incorporated. Retrieved 16 December 2012.
15. ^ Jump up to:a b c Dong X (2005). "Medical Implications of Elder Abuse and Neglect". Clinics in Geriatric Medicine 21: 293–
313. doi:10.1016/j.cger.2004.10.006.
16. Jump up^ American Medical Association White Paper on Elderly Health (1990). "report on the Council on Scientific
Affairs". Arch Intern Med 150: 2459–72.doi:10.1001/archinte.1990.00390230019004.
17. ^ Jump up to:a b Hildreth C.J. (2011). "Elder Abuse". JAMA 306 (5): 568.
Types.
• Physical: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining,

false imprisonment / confinement, or giving excessive or improper medication as
well as withholding treatment and medication.
• Psychological/Emotional: e.g. humiliating a person. A common theme is a
perpetrator who identifies something that matters to an older person and then uses
it to coerce an older person into a particular action. It may take verbal forms such
as yelling, name-calling, ridiculing, constantly criticizing, accusations, blaming, or
non verbal forms such as ignoring, silence, shunning or withdrawing affection.
• Financial abuse: also known as financial exploitation. e.g. illegal or unauthorized
use of a person’s property, money, pension book or other valuables (including
changing the person's will to name the abuser as heir). It may be obtained
by deception, coercion, misrepresentation, undue influence, or theft. This includes
fraudulently obtaining guardianship or use of a power of attorney. Other forms
include deprivation of money or other property, or by eviction / removal from their
own home
Types
• Scam by strangers: e.g. worthless "sweepstakes" that elderly persons must pay in order to
collect winnings, fraudulent investment schemes, predatory lending, and lottery scams.[7]
• Sexual: e.g. forcing a person to take part in any sexual activity without his or her consent,
including forcing them to participate in conversations of a sexual nature against their will; may
also include situations where person is no longer able to give consent (dementia)
• Neglect: e.g. depriving a person of proper medical treatment, food, heat, clothing or comfort
or essential medication and depriving a person of needed services to force certain kinds of
actions, financial and otherwise. Neglect can include leaving an at-risk (i.e fall risk) elder
person unattended. The deprivation may be intentional (active neglect) or happen out of lack
of knowledge or resources (passive neglect).
• Hybrid financial exploitation (HFE): e.g. financial exploitation that co-occurs with physical
abuse and/or neglect. HFE victims are more likely to be co-habiting with abusive individual,
to have fair/poor health, to fear the abusive individual, to perceive abusive individual as
caretaker, and to have a longer duration of abuse
Types
• In addition, some U.S. state laws[9] also recognize the following as elder abuse:
• Abandonment: deserting a dependent person with the intent to abandon them or leave them
unattended at a place for such a time period as may be likely to endanger their health or
welfare.[10] Elder abuse includes deserting an elderly, dependent person with the intent to
abandon them or leave them unattended at a place for such a time period as may be likely to
endanger their health or welfare.[10]
• Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared
by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being
recognized and adopted by nations
• Self-neglect: any persons neglecting themselves by not caring about their own health, well-being
or safety. Self-neglect (harm by self) is treated as conceptually different than abuse (harm by
others)
• Institutional abuse refers to physical or psychological harms, as well as rights violations in
settings where care and assistance is provided to dependant older adults or others
Types
• In addition, some U.S. state laws[9] also recognize the following as elder abuse:
• Abandonment: deserting a dependent person with the intent to abandon them or leave them
unattended at a place for such a time period as may be likely to endanger their health or
welfare.[10] Elder abuse includes deserting an elderly, dependent person with the intent to
abandon them or leave them unattended at a place for such a time period as may be likely to
endanger their health or welfare.[10]
• Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared
by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being
recognized and adopted by nations
• Self-neglect: any persons neglecting themselves by not caring about their own health, well-being
or safety. Self-neglect (harm by self) is treated as conceptually different than abuse (harm by
others)
• Institutional abuse refers to physical or psychological harms, as well as rights violations in
settings where care and assistance is provided to dependant older adults or others
Warning Signs
• The key to prevention and intervention of elder abuse is the ability to recognize the warning signs of its
occurrence. Signs of elder abuse differ dependent on the type of abuse the victim is suffering. Each
type of abuse has distinct signs associated with it
• Physical abuse can be detected by visible signs on the body, including bruises, scars, sprains, or broken bones.
More subtle indications of physical abuse include signs of restraint, such as rope marks on the wrist, or broken
eyeglasses.[13]
• Emotional abuse often accompanies the other types of abuse and can usually be detected by changes in the
personality or behavior. The elder may also exhibit behavior mimicking dementia, such as rocking or
mumbling.[13]
• Financial exploitation is a more subtle form of abuse, in comparison to other types, and may be more
challenging to notice. Signs of financial exploitation include significant withdrawals from accounts,
belongings or money missing from the home, unpaid bills, and unnecessary goods or services.[13]
• Sexual abuse, like physical abuse, can be detected by visible signs on the body, especially around the breasts
or genital area. Other signs include inexplicable infections, bleeding, and torn underclothing.[13]
• Neglect is a type of abuse in that it can be inflicted either by the caregiver or oneself. Signs of neglect include
malnutrition and dehydration, poor hygiene, noncompliance to a prescription medication, and unsafe living
conditions.[13]
Effect of Exercise in Aged
Cardio-vascular System

Assistant Professor
How you can measure fitness level of a patient
in order to start an exercise program?
Lectures Objective
• At the end of the lecture student shoud be able to:
• Understand response of CVS to Exercise.
• Identify different methods of estimating the CVS respone
to exercise.
•
Todays lectures will discuss different methods
of estimation of fitness level of different level
of patients with different type of equipment.
Cardiovascular Response to Exercise
• Exercise performance is determined by a multistage continuous
treadmill or bicycle test.
• Each successive stage requiring greater energy expenditure than the
preceding one.
• The cardiovascular system supports this exercise by distributing
increasing amounts of blood to the working muscles.
• The working muscles need sufficient oxygen to satisfy their increased
metabolic requirements.
• Vo2max is considered an indicator of cardiovascular fitness.
Cardiovascular Response to Exercise
• The ability to deliver oxygen to the working muscles is quantified by
measuring the maximal oxygen consumption (Vo2max).
• (Vo2max) = CO X a-v O2
• The term maximal systemic a-vo2 difference is the difference in the
oxygen content of arterial and mixed venous blood.
• At rest, a-V02 difference is normally 4 to 5 ml of oxygen per 100 ml of
blood.
V02 MAX-MAXIMAL AEROBIC POWER
• The best physiological measure of an individual's endurance work capacity
is the amount of oxygen consumed at maximal exercise (maximal aerobic
power, or Vo2 max).
• Therefore any age-related change in these factors could alter Vo2max.
• Thus, the decline in Vo2max or physical work capacity can be attributed
partly, age-related reductions. in maximum heart rate, contractility, and
cardiac output in exercise and partly to decreased muscle mass and quality
of skeletal muscle.
Estimation of VO2 max
• VO2 max is properly defined by the Fick equation:
VO2 Max = Q X (CaO2 – CvO2) Fick Equation
• where Q is the Cardiac output of the heart, CaO2 is the arterial oxygen content,
and CvO2 is the venous oxygen content. (CaO2 – CvO2) is also known as the artrio-
venous difference which is 4 to 5 ml at rest.
• Uth–Sorensen–Overgaard–Pedersen estimation
• Another estimate of VO2 max, based on maximum and resting heart rates, was
created by a group of researchers from Denmark. It is given by:
VO2 max = 15x (HRmax) / (HRrest)
• This equation uses maximum heart rate (HRmax) and resting heart rate (HRrest) to
estimate VO2 max in ml/(kg/min)
• Cooper test:
• Based on the measured distance, an estimate of VO2 max [in mL/(kg/min)] is:
VO2 max = d12 – 505/45
• where d12 is distance (in metres) covered in 12 minutes
• Normal Values;
Male = approximately 35–40 mL/(kg/min)
Female= approximately 27–31 mL/(kg/min).
• These scores can improve with training and decrease with age
• There are many fitness tests to estimate your VO2max, and choosing the right one
for you is the first step.
• There are many things to consider, such as age, fitness level, equipment, time and
general surroundings.
• Types of Fitness testing:
• Treadmill Tests
• Cycle Ergometer
• Bench Stepping Test
• Submaximal Tests
Treadmill Tests
• Two treadmill tests that are commonly used are:
• The Balke Protocol
• The Bruce Protocol.
• Both tests involve a subject on the treadmill with increasing speed, grade or both.
• These tests are effective in estimating VO2max without using too much time, effort
or equipment.
• Using these tests, the subject walks or runs, and factors including grade and speed
are changed.
The Balke Protocol
• With the Balke test the grade is changed every minute with a constant speed
until the subject can no longer perform.
• The final time is recorded and then put into an equation to estimate VO2
max.
• The equation for the Balke test is
• VO2max= 1.444(time)+14.99 for men and
• VO2max=1.38(time)+5.22 for women.

.
The Bruce Protocol
• Using the Bruce test, the speed and grade are changed in stages until the
subject is exhausted.
• The final time is taken and used in an equation to estimate VO2max.
• The equation for the Bruce test is
• VO2max=14.76-1.379(time)+0.451(time2)-0.012(time3) for men and
• VO2max=4.38(time)-3.90 for women
Cycle Ergometer
• Another maximal test to estimate VO2max is the Cycle Ergometer test.
• The Cycle Ergometer Maximal Test Protocol involves either a friction-type
cycle ergometer or an electrically braked ergometer.
• The subject sits on the cycle and goes to a rhythm while the work load is
increased until the subject can no longer keep pace.
• This test is widely used to assess cardiorespiratory fitness, and works well for
subjects who would rather not run on a treadmill.
Bench Stepping Test
• The bench stepping test involves stepping up and down on a
bench.
• The variable changed is either the height of the bench or the
speed of the cadence.
• The subject steps up and down until they can no longer keep pace
with the cadence and are fatigued.
• This test is not an ideal mode of exercise for maximum exercise
testing, but it requires little equipment, space and training.
Sub maximal Tests
• The tests described above are designed for maximal exercise testing, but in
most protocols, there is a modified or different test designed for submaximal
effort.
• This means that the subject will take the test for a certain amount of time, but
does not reach complete max, or fatigue.
• Then, information gathered from a submaximal test is then used in equations
to estimate maximal effort and VO2max.
• Maximal tests, of course, are more desirable and accurate, but are not always
convenient or desirable for the subject.
THANKS
Heart Rate and Exercise
• In Elders, during exercise, the expected rise in cardiac heart rate is much lower
than in the youngs.
• The maximum achievable heart rate may be calculated empirically, using 220 beats
per minute as the maximum in the adult much lower in the elderly than in the
young.
• The age changes can be calculated by subtracting the age of the individual from
the 220 values.
• The age-associated changes in heart rate influence the maximal cardiac output,
significantly influencing VO2 max.
Mechanisms for Heart Rate Changes During
Exercise
• In older adults, there is a consistent smaller tachycardia (increase in heart
rate) during both isometric and dynamic exercise compared with younger
adults.
• One possibility for the lower response in heart rate in the older adult is
that there is a reduction in cardiac vagal influence on heart rate under
resting conditions and that this limits the degree of reduction in vagal
tone possible in response to exercise.
Mechanisms for Heart Rate Changes During
Exercise
• The other possibility is that older adults have some impairment in Beta-adrenergic
activation of heart rate during exercise. For example, there could be lower synaptic
concentration of nor-epinephrine in older subjects due to
• a diminished neural activation,
• impaired neuronal release,
• and/or enhanced neuronal reuptake
• circulating levels of epinephrine may rise less during exercise in older adults;
• or older adults may have impaired Beta-adrenergic receptor and/or
postreceptor responsiveness.
Stroke Volume and Exercise
• The stroke volume during exercise is 10% to 20% smaller than in a
young adult.
• The ability to increase stroke volume in the older adult during exercise
is achieved with an increase in end-diastolic volume through the
Frank-Starling relationship.
• The Frank-Starling relationship links the volume and pressure of blood
in the ventricle (filling pressure) to the force of contraction of the
ventricular muscle so that an increased filling of the ventricle causes
an increased stretch of the wall and results in an increased force of
contraction.
Cardiac Output and Exercise
• Cardiac output increases similarly with increasing work loads in various
age groups; however, the mechanism of augmentation of cardiac output
is different between the age groups.
• In young adults, stroke volume increases with exercise because of a large
decrease in end-systolic volume compared to rest.
• Older adults, likely because of the age-associated decreased responsiveness to
catecholamines, show a failure of end-systolic volume to incrrease and a
decreased response to exercise
Role of Afterload
• One major determinant of afterload, the characteristic aortic impedance to flow, is
derived from the relationship between pressure and flow during the cardiac cycle
• At low exercise levels in younger individuals, there is a stepwise increase in stroke
volume with increasing work load and no change in impedance from resting values.
pressure and flow during the cardiac cycle.
• In contrast, the older subjects demonstrate a striking increase in impedance during
exercise, with minimal augmentation of stroke volume.
• Thus, the increased afterload imposed by the vasculature of older subjects during
exercise may be a factor in stroke volume responses (altered ejection fraction).
• The increased afterload in the older population may reflect an impaired vasodilator
response to catecholamines on the heart and peripheral vasculature.
• Thus the Increased Level of Plasma catecholamines during maximal treadmill exercise
have diminished effects in old age on cardiac resonsiveness
Left-Ventricular Contractility and Exercise
• Left ventricular systolic performance is well-maintained with aging under

resting conditions but is reduced even in healthy older subjects during
strenuous exercise.
• This Is because of :
• Ventricular Stiffness
• Reduced Beta adrenergic responsiveness
Arthro-kinesiologic
Consideration in Aged
Adults

LM&DC
Introduction
• Arthrokinesioalogy is the study of the structure,

function, and movement of skeletal joints.
• The purpose of this topic is to Address :
• Specific arthro-kinesiologic issues.
• Age-related changes in peri-articular connective tissue.
• Effect of natural age-related changes on joint function
even in the absence of disease.
• Finally, age-related changes at the tissue level can
cause changes in movement at the joint level.
REVIEW OF BASIC PRINCIPLES OF ARTHROKINESIOLOGY
• Bone and Joint Kinematics.
• Osteokinametics
• Open kinematic chain
• Close Kinematic chain
• Arthrokinametics
• Translation – Glide - Slide
• Rotation – Roll
• Bone and Joint Kinetics.
• Forces – active Forces – Passive Forces
• Torques – motion about an Axes
• Posture and Positions of Natural Joint Stability.
• Close Packed Position
• Open packed Position
AGE-RELATED CHANGES IN JOINT
CONNECTIVE TISSUE
• First, changes in the structure and function of

joint connective tissue.
• Second, the effect of type and degree of physical
activity on the structure and function of
connective tissues.
• Third, Effect of Pathology on functional
limitations and disability.
• Fourth, Other Factors, such as genetics, previous
postural habits, and earlier injury.
Periarticular Connective Tissue (PCT)
• Periarticular connective tissue includes ligament,

joint capsule, aponeurosis, tendon, intramuscular
connective tissue, and skin.
• All these tissues are physically linked to joints, and
therefore their extensibility influences a joint's range
of motion.
• The predominant histological components of all PCT
are fibroblasts and fibrous proteins (collagen and
elastin), extracellular ground matrix, and water.
Collagen and Elastine
• Collagen provides tensile strength to all connective

tissues in the body.
• Collagen fibers strongly resist stretch and are capable
of providing great strength to the tissue.
• The mechanical stability provided by collagen is
maintained throughout life by a complex mechanism
referred to as intermolecular cross-bridging.
• Connective tissues with abundant elastin stretch
easily with almost perfect recoil.
• The physical alignment and relative proportions of
collagen and elastin determine the PCT's ability to
limit, guide, or stabilize joint motion.
Structure and Properties of PCT.
• Periarticular connective tissue includes:

• Ligaments
• Joint capsule
• Aponeurosis,
• Tendon,
• Intramuscular connective tissue, and
• Skin.
Age-Related Changes in PCT
• The mechanical properties of PCT change with

advanced age.
• The major changes with age PCT are mostly due to
structural and functional changes in the collagen
protein.
• Animal research suggests that ligaments and
tendons
• Increase in stiffness and demonstrate a decrease
in the maximal length at which rupture occurs.
Age-Related Changes in PCT
• A biochemical analysis of aged tissue usually
shows an increase in
• The relative amount and diameter of collagen,
• An increase in fibril size and
• A relative decrease in water, elastin, and proteoglycan
content.
• Aged collagen shows increased numbers of
cross-links between adjacent tropo collagen
molecules.
• Results an increase the mechanical stability of collagen
and may explain the increased stiffness in the tissue.
Hyaline Cartilage Review Of Tissue
Structure And Function
• Structure:
• Hyaline cartilage consists of a small population of chondrocytes widely
dispersed and a relatively dense extracellular matrix.
• Hyaline cartilage lines the articular ends of bone and protects the joint
from damaging transarticular forces.
• Functions:
• Major functions of hyaline Cartilage are:
• Shock absorbtion
• Lubrication
• Joint protection by reducing compression
• Subchondral bone protection due to elastic quality that
dissipates high loads.
Structure of Hyaline Cartilage
Structure of Hyaline Cartilage
Hyaline Cartilage
Review Of Tissue Structure And Function
• Hyaline cartilage consists of a small population of

chondrocytes widely dispersed in a relatively dense
extracellular matrix
• The matrix is chiefly composed of water, collagen
fibers, and long branching proteoglycan
macromolecules.
• The collagen fibrils within the matrix provide
"scaffolding" to the cartilage, lending both shape and
tensile strength.
Hyaline Cartilage
Review Of Tissue Structure And Function
• This structure provides healthy articular cartilage the
ability to deform and re-form repeatedly after an
exceedingly large number of compressions
throughout a lifetime.
• The rate of the deformation of the articular cartilage
is controlled somewhat by the action of water slowly
oozing through the impedance offered by the matrix.
• The water under pressure flows toward the relatively
unloaded areas.
• As the joint is unloaded, the water returns to its
original location
Age-Related Changes in Articular Cartilage
• Density of chondrocytes and the amount of collagen within

the extracellular matrix remain essentially unchanged.
• The water content in the tissue, however, does reduced due
to reduced ability of hydrophilic proteoglycans to hold water
in the matrixs.
• Dehydrated articular cartilage may have a reduced ability to
dissipate forces across the joint.
• Aged articular cartilage may become more susceptible to
mechanical failure and loss of physical strength causes
fragmentation of collagen network and high incidence of
structural disintegration called fibrillated cartilage
• Aged fibrillated cartilage experiences mechanical fatigue
that causes the proteoglycans to "leak out" of the tissue
causing damping effect of cartilage result in a weakening of
articular cartilage.
Discussion on Development of Osteoarthritis
in Aged
• Osteoarthritis is not an imminent consequence of the

natural fragmentation of cartilage.
• Fibrillated tissue does not always lead to the disease
of osteoarthritis.
• The link between the hypothesized wear-and-tear
theory of fibrillated cartilage and the development of
osteoarthritis has not been shown conclusively.
Discussion on Development of Osteoarthritis
in Aged
• Osteoarthritis does occur with greater frequency in the elderly.
• Nevertheless, one cannot assume that the disease of osteoarthritis is
purely a mechanical result of aging.
• If this logic were true, then all old persons should develop
osteoarthritis.
• Genetic, biochemical, traumatic, and morphological factors may also
be interrelated with the effect of aging and development of
osteoarthritis.
Clinical consequences of the disease.
• Due to the relatively high incidence of osteoarthritis in
the aged population, the physical therapist should be
aware of the basic clinical consequences of the disease.
• Osteoarthritis often presents with severely degenerated and
thinned articular cartilage.
• The severe collagen weakening and proteoglycan depletion
observed in advanced osteoarthritis markedly reduce the
cartilage's ability to resist tensile and compressional forces.
• As a consequence, undampened joint may cause a reactive
hardening or sclerosis of the unprotected subchondral bone.
• This reactive response is in accord with the Wolff's law (1892)
that bone is laid down in areas of stress and reabsorbed in areas
of non-stress.
Clinical consequences of the disease
• Degenerated cartilage and stiffer subchondral bone
are not able to adequately attenuate high trans-
articular forces.
• Osteophytes and various remodeling may occur as a
further progression of Wolff‘s law, and the entire
morphology and geometry of the joint surfaces may
change.
• Physical therapists need to understand the
deleterious consequences of having their patient's
arthritic joints subjected to large and repetitive joint
forces.
• Concepts of "joint protection" need to be used with
these patients.
Wolff's law
• Wolff's law is a theory developed by the German
anatomist and surgeon Julius Wolff (1836–1902) in the
19th century that states that:
Bone in a healthy person or animal will adapt to the loads
under which it is placed.
• Explaination:
• If loading on a particular bone increases, the bone will remodel
itself over time to become stronger to resist that sort of loading.
• The internal architecture of the trabeculae undergoes adaptive
changes, followed by secondary changes to the external cortical
portion of the bone, perhaps becoming thicker as a result.
• The inverse is true as well: if the loading on a bone decreases,
the bone will become weaker due to no stimulus for continued
remodeling that is required to maintain bone mass.
Mechanotransduction
• The remodeling of bone in response to loading is achieved via mechanotransduction,
A process through which forces or other mechanical signals are converted to biochemical
signals in cellular signaling.
• Mechanotransduction leading to bone remodeling involve the following steps:
• mechanocoupling,
• biochemical coupling,
• signal transmission, and
• cell response.
• The specific effects on bone structure depends on the duration, magnitude and rate of
loading, and it has been found that only cyclic loading can induce bone formation.
• When loaded, fluid flows away from areas of high compressive loading in the bone matrix.
• Osteocytes are the most abundant cells in bone and are also the most sensitive to such
fluid flow caused by mechanical loading.
• Upon sensing a load, osteocytes regulate bone remodeling by signaling to other cells with
signaling molecules or direct contact.
• Additionally, osteoprogenitor cells, which may differentiate into osteoblasts or osteoclasts,
are also mechanosensors and may differentiate one way or another depending on the
loading condition
Summary
• In summary, some degree of mechanical degeneration of aged human

articular cartilage should be considered a normal process.
• The wear may be from repeated loading of joints over the good part
of a lifetime.
• The ability of even "healthy" articular cartilage to dissipate
transarticular forces may diminish in the aged population.
THANKS
Neuromuscular
CHANGES AND ADAPTATION

Assistant Professor
Lahore College Of Physical Therapy
Lahore Medical And Dental College
INTRODUCTION
• Aging is typically characterized by
• Declines in the control and organization of
movement. Most prominent among these are
• Slowing of movement (both movement initiation and
execution).
• Deterioration in the quality of executed movement.
• Loss of muscular strength and power.
Factors affecting SM Changes
• Decline in the quality and quantity of movement is focused on a
number of factors that may contribute to a decline in sensorimotor
performance.
• These factors could be the result of changes:
• intrinsic to the individual,
• factors extrinsic to the individual, or
• a combination of both.
Intrinsic Factors
• Some intrinsic factors associated directly with the integrity of
the individual's cognitive status and also with the
neuromusculoskeletal system include changes in such
variables as;
• Neurons,
• Central or peripheral synaptic mechanisms,
• Peripheral nerve & peripheral receptors,
• Muscle, bone, or joints.
• Other intrinsic factors, such as
• The status of hormones,
• The cardiovascular system,
• The respiratory system, and
• Basal metabolism,
• play an indirect but critical role in guaranteeing the integrity
of the sensory and muscular systems.
Extrinsic Factors
• Extrinsic factors that can affect the normal function
of the neuromusculoskeletal system include:
• Death of a spouse,
• Retirement from an occupation,
• Retirement from community involvement,
• Loss of income,
• Change in nutritional status,
• Decline in physical activity level, and
• Inadequate health care.
"Why should a physical therapist
care about biological, cellular, or
systems changes associated with
aging?"
Domain of Sensory motor changes
• The chapter is subdivided into five major sections:
• Neuroanatomical and neurochemical changes in CNS.
• Changes in various sensory systems including the visual,
auditory, vestibular and somatosensory systems
• Changes reported in the motor unit, including the muscle and
its peripheral efferent connections;
• Snsorimotor system and includes a discussion of reflex and
reaction time testing
• The potential for adaptation in the older individual.
NEUROANATOMICAL CHANGES WITH
AGING
• One theory associated with the process of aging is that
mitotic cells undergo a programmed number of cell
doublings until cell division ceases in the senescent cell.
• Loss of the ability to replicate is, therefore, thought to be
a primary mechanism in the aging process.
• How does this theory apply to the neuron when Most neurons
are post mitotic cells, i.e., cells that do not divide.
• What causes the loss of neurons and synapses?
• Is there an indication that the morphology of the aging brain is
different from the younger brain?
• When is the neuron considered an aged cell.
• Clinically, the assumption has been made that loss of
synapses and, therefore, loss of communication among
neurons leads to the development of dementia.
Morphology and Physiology
Neuroanatomical Changes in the CNS
• Gross Brain Changes:

• A linear, age-related
decrease in adult brain
weight and volume.
• The two most
prominent age-related
features are a decline
in the physical
dimensions of gyri,
known as gyral
atrophy, and
ventricular dilation
CNS Metabolism and Cerebral Blood
Flow (CBF)
• The classic view is that cerebral blood flow (CBF) is
regulated to meet the requirements of cell
metabolism.
• Gulucose is the main energy source for cerebral
metabolism.
• There is proven evidence based strong relationship
exist between the rate of cerebral glucose utilization,
oxygen requirements to support glucose metabolism
and the integrity of CNS function.
• Metabolic rates of glucose utilization can now be
examined using radioactive glucose.
• Various studies have demonstrated the relationship
among analogues and dynamic imaging techniques
Cortical Cell Loss Absent With Normal Aging
• As recently as a decade ago the common teaching was of progressive
neuronal loss with aging.
• More recently, research has demonstrated across species that cortical
neuronal loss is not evidenced with normal aging. however, that loss
of cortical neurons is manifest with dementing processes and,
importantly, that approximately 5% of individuals older than 65 years
and 50% of individuals older than 85 years are affected with dementia
Subcortical Nuclei: Neurotransmitter Systems
• If cortical cell loss is not directly related to aging, what
then are neurobiological changes that can truly be
attributed to aging?
• Evidence points to significant neuronal loss in subcortical
regions, including the thalamus, striatum, and locus
coerelus and notable cell loss from the basal forebrain
and hippocampus.
• It is noteworthy that these regions project to and
function as modulators of higher cortical function acting
through a variety of neurotransmitters.
• Further, the "reticular core"-the diffuse network of
neurons and fibers that projects from the spinal cord,
through the brainstem, throughout the brain, and
ultimately to the cortex-is dramatically affected with
aging
Subcortical Nuclei: Neurotransmitter Systems
• The grave significance of cell loss in subcortical areas
is the depletion of neurotransmitter functions.
• All affected subcortical systems (i.e., substantia
nigra, the midbrain raphe system, and basal
forebrain) are significant sources of
neurotransmitters, i.e., respectively, dopamine,
serotonin, acetylcholine, choline acetyltransferase.
• Consequently the most significant neuro-
behavioralloss with aging is the ability to modulate
activity.
• Thus, there are anatomical substrates that explain
the frequent assessment of important nervous
function with aging as a "loss of flexibility:’
Loss of Purkinje cells
• Another age-related change evidenced across species is
the pervasive loss of Purkinje cells from the cerebellum
(2.5% per decade ).
• From the perspective of motor control, this CNS structure
plays a critical role in regulating the execution of a wide
variety and multiple aspects of movement, including:
• control of posture and balance,
• locomotion,
• sequencing of movement,
• repetitive and alternating movements, and
• smooth pursuit eye movements.
Cerebellar dysfunction
• Importantly, age-related loss of motor coordination is directly
correlated with oxidative damage in the cerebellum and Age-related
impairments in myelin.
• The cerebellum is also important in controlling critical parameters of
movement, including temporal patterning, velocity/acceleration, and
scaling of force magnitude.
Declines in motor and cognitive function
• Declines in motor and cognitive function occur at different rates but
reflect regionally specific levels of oxidative damage
• Further, loss of noradrenergic modulation important to cerebellar
plasticity, e.g., motor learning, by acting as a GABA-ergic agonist,
correlates directly with rate of learning a novel motor task in old rats.
• Hence we are presented with of a body of evidence indicating
significant age-related impairment in modula-tory activity, plasticity,
and global cerebellar regulation of movement.
Cellular and Sub-cellular Components
• Myline
• The most salient neural changes with aging is a
progressive decrease in brain weight beginning in the 5th
decade and totaling approximately 100 grams, or 7%,
across the life span.
• It is now evident that much of the loss in brain mass
occurs in white matter, or myelinated structures.
• This suggestion is made from results of both
histochemical and dynamic imaging techniques. (PET
Scan, TMRI).
• Thus, causing:
• slowing of psychomotor speed,
• delayed processing requiring communication and activity of
cortical association areas, and
• transmission of motor responses via corticospinal and
peripheral neural pathways
Cellular Components and Processes
• Impairment has been documented in a number of
important cellular features, including;
• membrane properties,
• neurotransmitter synthesis,
• integrity of neurotransmitter receptors, and
• oxidative metabolism.
• The most common reported age-related changes at
the cellular level are the presence of;
• lipofuscin,
• the senile or neuritic plaque, and the
• neurofibrillary tangle (NFT).
Cellular Components and Processes
• Lipofuscin is a dark, pigmented lipid found in the
cytoplasm of aging neurons. There is speculation that an
excessive accumulation of lipofuscin may interfere with
the function of the neuron, although its primary role at
this time is as a biological marker of aging.
• Neuritic (senile) plaques are discrete structures located
outside of the neuron and comprised of degenerating
small axons, some dendrites, astrocytes, and amyloid and
found in human disease (e.g., in Parkinson's disease and
dementias).
• Neurofibrillary tangle (NFTs) have been reported to occur
in the healthy aging brain and displaces the nucleus and
distorts the cell body. The presence of NFTs in the cortex
is a hallmark of dementia
Other important Changes
• Degeneration in dendritic number.
• Loss of dendritic branches is a frank decrease in overall
dendritic population.
• Dendritic proliferation typically accompanies
improvements in
• learning,
• memory, and
• performance,
• Thus loss of these delicate and sensitive structures causes
decreased capacity for important neural processing and
performance.
• Decreased synapses between cells also appears to be an
age-related phenomenon and an important mechanism
subserving integrated neural function
Summary: Neuroanatomy
• Evidence from current research suggests that changes that include gyral atrophy,
decreased brain weight, and ventricular dilation fail to map directly to functional
change in higher cortical function in normal aging.
• Evidence has been presented that cortical neurons are lost progressively with age.
• Thus, age-related change in the central nervous system shifts its focus to selective
cell loss in specific subcortical formations, including the substantia nigra, the basal
forebrain (nudeusbasalis of Meynert), locus ceruleus, brainstem, and cerebellum.
• Neuronal loss in these subcortical regions appears to occur most in regions
projecting to the cortex, thus compromising modulation of higher cortical
function.
• Age-related decrease in brain weight and dimension is very closely associated
with deterioration of myelin.
• Lipofuscin accumulates intracellularly with aging
• Other cellular level features of normal aging are inclusions of phagocytic debris,
clumping of mitochondria, and deterioration ofneurotransmitter receptors.
• Reduced metabolic activity, importantly, synthesis of neurotransmitters is
reduced.
• NFTs and neuritic plaques are present in the brains of individuals with Alzheimer's
disease.& dementia.
NEUROCHEMICAL CHANGES IN THE CNS
WITH AGING
• Morphological changes in the aging brain described
are significant neurochemical changes. Primary
neurotransmitters (NTs) include:
• acetylcholine,
• dopamine,
• norepinephrine,
• serotonin,
• gammaaminobutyric acid (GABA),
• excitatory amino acids,
• opioid peptides, and
• other peptide neurotransmitters.
Acetylcholine
• Acetylcholine (ACh) is essential to the function of the central and
peripheral nervous systems and is utilized in both the somatic and
autonomic nervous systems
• A primary site for ACh is in the basal forebrain, where the cholinergic
system innervates the hippocampus, neocortex, and amygdala.
• Evidence suggested a profound loss of acetylcholine in specific cortical
sites in patients with Alzheimer's disease.
• A review of the vast literature related to the role ofACh suggests that
there are age-dependent changes in the cholinergic system and that
ACh plays a critical role in cognitive function.
• Damage to the cholinergic neurons that connect with more rostral
portions of the basal forebrain structures disrupts learning and memory;
• damage to regions of the neocortex that receive the basal cholinergic
neurons results in deficits in attentional function.
• Note there is a little evidence that memory can be improved with deit
or medicine. However evedence suggest that memory enhance by
practice.
Dopamine
• Although dopamine is widespread in the CNS, the most
frequently studied dopaminergic neurons are those
located in the substantia nigra that project to the
striatum of the basal ganglia.
• The dysfunction of these neurons is directly related to
Parkinson's disease.
• Dopamine is also located in the diencephalon and the
medulla.
• Changes in the synthesis, inactivation, catabolism,
content, and receptors have all been reported with aging.
• In general, there is consensus that the amount of
Dopamine presence and the number of receptors in the
striatum of the basal ganglia decrease after the fourth
decade.
SENSORY CHANGES WITH AGING
• It is a generally accepted concept that sensory
integrity declines with aging.
• The clinician is interested in learning which sensory
systems are affected and which part of the system is
affected.
• Are there specific targets of the pathway that are more
susceptible to the process of aging?
• Is there a decrease in the speed with which the nervous
system responds to external stimuli in the older individual?
• If so, where is the change occurring?
• Are the afferent, central, and efferent systems equally
affected by age?
The Visual System
• Visual acuity may decline gradually as much 80% by the
ninth decade.
• Impairment of visual accommodation by the age 40 to
55, visual correction is necessary in most people for
accurate near vision.
• Common ophthalmological disorders in the older person
include cataracts, glaucoma, and macular degeneration.
The ocular motor system also There is a symmetrical
undergoes a progressive loss: restriction with age in:
❑Convergence is compromised. ❑upward gaze.
❑ptosis occurs ❑Smooth pursuit,
❑saccades, and
❑optokinetic nystagmus
The Auditory System
• Although changes in the auditory system have been
demonstrated as early as the fourth decade,
functional impairment is not typically evident until
the seventh decade.
• More than one half of all Americans who suffer
significant hearing loss are 65 or older.
• Hearing has been related to independent lifestyle:
39% of individuals 75 or older and living in the
community have been reported to have a hearing
loss, whereas as many as 70% of institutionalized
older adults have difficulty hearing.
The Vestibular System
• Complaints of dizziness and disequilibrium are common in older
persons.
• The vestibular end organs are responsible for:
• transforming the forces associated with head acceleration into action
potentials,
• producing awareness of head position in space (orientation), and
• motor reflexes for postural and ocular stability.
• The utricles and saccule sense linear acceleration, and the
semicircular canals monitor angular acceleration.
The Vestibular System
• Studies of the vestibular system indicate an age-related
20% decline in hair cells of the saccule and utricle and a
40% reduction in hair cells in the semicircular canals.
• A recent report of changes in the vestibular nuclear
complex of persons aged 40 to 93 years suggests a 3%
neuronal loss per decade
• Vertigo, nystagmus, and postural imbalance may be
symptoms of age-related decline if underlying vestibular
pathology is ruled out.
• Presbyastasis is the term to describe age-related
disequilibrium when no other pathological condition is
noted.
The Olfactory and Gustatory Systems
• Decrements in the chemical senses of smell and
taste are common aspects of aging.
• Hyposmia, a diminished sensitivity to smell,
and hypogeusia, a diminished sensitivity to
taste, are both reported as age-dependent
changes in the olfactory and gustatory systems,
respectively.
The Somatosensory System
Anatomical Changes
Changes in Component Change Function
Nerve Cells 1. Meissner's 1. Reduced 1. Detect touch and
corpuscles 2. Become sparse, irregular in are limited to
distribution. hairless skin,
3. Variable in size and shape.
2 Pacinian 1. Drease in density Sensing vibratory
corpuscles stimuli
3. Merkel cells 1. No Change Touch receptors,
Afferent 32% loss of fibers in both the dorsal and ventral roots of T8 and T9 at age
nerve fibers 90.
Peripheral Spinal & 1. Loss of fibers in Sciatic' Anterior tibial, and Sural nerves.
nerves cranial nerve 2. No loss in Superficial radial nerve.
Internodal length Shortening Reduced Conduction Velocity
• Anatomical Changes
• In addition to an age related decline in some of the
receptors,
• an age-related decline in afferent nerve fibers also
occurs.
• The degeneration of the dorsal columns that occurs
with aging may reflect the loss of centrally directed
axons of the dorsal root ganglion cells.
• Age-related loss of nerves in cranial and spinal nerve
roots affect thick fibers more than thin fibers
• Aging is also associated with a gradual shortening of
the inter-nodal length.
• Physiological Changes:
• Physiological age-linked alterations in the PNS have
also been documented.
• Somatosensory evoked potential (SEP) is recorded.
• Th collective data on age-related changes in
conduction velocity do not suggest that changes are
substantial enough to account for the degree of
sensory loss reported in older individuals.
• The latencies appear to increase with age.
• The amplitude of the (SEP) recorded from the scalp
appears to decrease with age.
• The older subjects demonstrated a 400% deterioration in spatial
acuity in the great toe and 130% decrease in the fingertip.
• Stereognosis and graphesthesia usually remain intact with aging.
• Diminished or lost vibratory sensation in the lower extremities has
been reported to be present in 10% of individuals at age 60 and in
approximately 50% of individuals beyond the age of 75.
• Cutaneous pain threshold increases with age, but limited research
exists on age-related changes in pain sensitivity and perception
• Research studies suggest an age-related increase in thresholds to
thermal pain but no age-related change in pain threshold when
electrical stimulation is used to produce pain.
• Proprioception has undergone relatively little study in the aging
population.
• No Change in Perception of passive movement.
• Joint position sense deteriorated with increasing age
• Potvin and colleagues assessed neurological status on 61
right-hand-dominant men ranging from 20 to 80 years
old.
• lOne hundred and thirty-eight tests were used to
measure cognition, vision, strength, steadiness, reactions,
speed, coordination, fatigue, gait, station, sensation, and
tasks of daily living.
• Tests were excluded if reliability was not demonstrated.
• Age-related linear decreases were reported for many
neurological functions.
• The declines throughout the age span varied from less
than 10% to more than 90% depending on the function.
• Larger losses of function were observed on the dominant
body side.
NEUROMUSCULAR FUNCTION WITH AGING
• Muscle and Muscular Strength
• Reduced both isometric and dynamic strength and function due to
significant loss of type II muscle fibers.
• Significant grouping or "clumping" of muscle fibers disrupts the
mosaic, or heterogeneous, distribution of types I and II fibers and
their respective motor units across a muscle's cross-sectional area.
• Reinnervation capacity of the muscle has been sufficiently diminished
• The muscle fiber is lost and the tissue volume becomes replaced by
fat and fibrous tissue.
• In addition morphological changes in mitochondria, sarcoplasmic
reticulum, and the transverse tubular system, within both types I and
II fibers also noted resulted impaired activation of the myofibrils.
• Modest decreases in high-energy metabolites (ADP, ATP, and
phosphocreatine).
• Enzymes necessary for glycolysis are reduced.
• Motor Neurons Are Lost with Aging
• Up to third decade of life, anterior horn cells in the spinal
cord demonstrate significant accumulation of lipofuscin,
• By the fifth decade, loss of anterior horn cells (a-motor
neurons) begins, and
• By age 60 loss of these neurons can be as high as 50%,
• In conjunction with motor neuron (MN) loss are notable
changes in the electrophysiological properties of the motor
unit.
• The significance of MN and MU loss lies in their role to
generate and modulate muscular force through recruitment
of MUs.
• Peripheral Structures:
• Peripheral nerves demonstrate a progressive reduction in myelinated
fibers, most notably in the largest diameter fibers.
• Ventral roots appear to be more affected than dorsal roots and
lumbosacral segments more than cervical.
• Interestingly, the epineurial and perineurial sheaths thicken, the
endoneurial sheath demonstrates fibrosis due to an increased
presence of collagen.
• The microcirculation of peripheral nerve is particularly reduced.
• Peripheral nerve motor conduction velocities decrease.
• The neuromuscular junction (NMJ) also demonstrates degeneration
with aging. Synaptic transmission is obviously affected by impaired
NMJ integrity.
• Sensory nerve conduction (NCV) appears to deteriorate in advance of
motor nerve conduction
• The net result of peripheral nervous decline includes elevated
thresholds to all modalities of sensation, diminished tendon jerk
reflexes (monosynaptic) in a distal-to-proximal pattern, and moderate
progressive delays of motor nerve conduction.
• Spinal Segmental Pathways :
• Spinal segmental pathways have demonstrated
adaptation, or plasticity, to task-specific training.
• Alteration in the degree of presynaptic inhibition on
spinal segmental pathways indicating deterioration in
the ability to modulate task dependent motor
output, e.g.,
• development of muscular force and postural responses
with aging.
• Chronic changes in spinal segmental pathways may
be responsible for increased demonstration of
antagonist muscle co-contraction observed across a
broad range of motor activities in older adults.
Summery
• Muscular strength, whether assessed in an isometric or
dynamic context, declines after the fifth
• The most salient change is loss of type II, or fast-twitch,
muscle fibers. coupled with increased prevalence of type I,
or slow-twitch, fibers.
• As early as the fifth decade, anterior horn cells that
innervate skeletal muscle die off, and by age 60 their loss
can be as great as 50%.
• Large ventral horn neurons corresponding directly to large
motor units with fast-twitch contractile characteristics were
lost.
• Mechanically, 32% reduction in twitch force, contraction
time is increased by 45%, and half-relaxation time is
increased by 206% suggest that the transfer of force to the
tendon will be conspicuously altered with potential effects
on the quality of muscular force production.
Summery
• The neuromuscular junction demonstrates progressive
impairment in alignment of presynaptic and postsynaptic
elements, therefore, synaptic transmission becomes
compromised, affecting the responsiveness and potential
to activate muscle. Hence prolonging the muscle
contractile state
• Motor neuron loss leaves muscle fibers behind and
incorporated into remaining motor units through
collateral reinnervation
• In extremely active individuals and in response to
strength training, however, maximal MU discharge rates
in elders have been observed to be comparable with
those of young individuals.
• Finally, changes in segmental pathways are notably
altered with aging, affecting the ability to modulate
motor activity in response to task demands
SENSORIMOTOR CHANGES WITH AGING
• Sensorimotor integrity has been examined using a variety of protocols
including the study of reflexes, the time it takes the subject to
respond to and execute a task, and functional performance.
• Reflex Testing
• The Central Efferent Pathway
• Reaction Time
 Reflex Testing:
• Reflex testing is performed to assess the integrity of the
sensorimotor pathways without the influence of cognitive
processing.
• The reflex change most commonly noted with aging is
diminution or absence of the Achilles tendon response,
which has been reported to occur in 10% of older subjects.
• Other investigators note only small increases in the latency
of the Achilles and patellar tendon reflexes
• The Central Efferent Pathway:
• Magnetic and electrical stimulation of the motor cortex
through the scalp are two recently developed, non-
invasive techniques used to study the integrity of motor
pathways in the human.
• Motor evoked potentials (MEPs) are recorded from a
muscle contralateral to the stimulated motor cortex.
• Conduction times can be recorded within the CNS by
recording over the spinal cord at the L4-S1evel of the
spinal cord and Tibialis anterior.
• Results from subjects ranging from 19 to 50 years old
indicate a trend for decline in central conduction time with
age.
• Reaction Time:
• Reaction time (RT) is defined as the time required to
initiate a movement after stimulus presentation.
• Simple RTs result have shown to increase with age.
• A 20% increase in RT in 60-year-old subjects
compared with 20-year-old subjects.
• Some investigators have used EMG activity to
separate premotor time (PMT) and motor time (MT).
• PMT is defined as the time between stimulus onset
to EMG activity, and
• MT is defined as the time from EMG activity to the initiation of the

movement.
• PMT and MT are affected by aging, depending upon the nature, complexity
and cognition level invoved in different tasks demonstrate more slowing in
PMT or MT.
• Slowness of movement reflects a change in the neural pathways that does
not appear to improve significantly with increased physical activity.
• Premo tor time is slower in older individuals regardless of the task
• Motor time appears to depend on the amount of muscle activity required
to produce the task,
VOLUNTARY MOVEMENT
• Movement Organization
• Posture and Balance
• Sensory-Perceptual Component
• Central Integrative Component
• Neuromusculoskeletal Component
• Locomotion and Gait
• Functional movement
VOLUNTARY MOVEMENT
• Movement Organization
• With aging, significant and demonstrable alterations in
the organization of movement range from isometric
force control tasks to locomotion.
• The factors involved in the movement organization are:
• Impaired psychomotor speed,
• a higher proportion of slow contracting muscle,
• muscular weakness,
• deterioration of neural conduction pathways, or
• some combination of these,
• The peak velocity/average velocity raio (Vm/Va) is lower in
older subjects and remains lower than in young subjects.
VOLUNTARY MOVEMENT
• Posture and Balance:
• Among the most serious concerns with advancing age is the fear of
falling and sustaining serious injury.
• Changes in the CNS, including loss of neurons, impaired cerebral
metabolism, and altered neurotransmitter activity, may disrupt the
activation of postural responses to unexpected motion.
• Literature suggests that there are age-related changes in the control
of spontaneous postural sway, suggesting an increase in the amount
of correction activity required to maintain stability.
• Older subjects have been reported to fail to produce the normal
postural adjustments before performing a voluntary movement
• Evidence suggests that in the older person lateral stability is more
affected than stability in the sagittal plane.
• These changes correlate with age-related impairment in the
vestibular system, hip proprioception, and integrity of sensation
from the plantar surface of the foot.
VOLUNTARY MOVEMENT
• Sensory-Perceptual Component
• Control of posture and balance is governed by inputs from
three systems: visual, vestibular, and proprioceptive-each
of which is referenced to a separate external coordinate
system and none of which senses the body's center
ofgravity directly.
• Proprioception, which provides information of support
surface conditions, is considered the dominant sensory
guide to balance, followed by vision and finally vestibular
inputs.
• With aging there is detoriation in proprioception due to
peripheral neuropathy processes and reduced ROM.
• Vision is also reduced with aging.
• Vestibular input may decline with age due to reduction in
haircells in uticle, sculae and semicercular canal
VOLUNTARY MOVEMENT
• Central Integrative Component:
• Contributions from multiple sensory systems require integrative action of the
central nervous system to choose and weigh correct versus incorrect
perceptual information.
• This process of sorting out the varied sensory inputs has been termed by
Nashner sensory organization.
VOLUNTARY MOVEMENT
• Neuromusculoskeletal Component:
• The primary task of the motor effector system is to maintain the
body's center of gravity (COG) within its base of support, whether
the context of the task involves sitting, standing, or locomotion
and, if perturbed, to restore the COG within the base of support.
• Postural adjustments are not thought of as hard-wired, stereotyped
reflex responses, but as behavioral responses that are functionally
adaptive in a context-specific mode.
• Effective postural responses require appropriate timing or response
latency to the given task, scaling of the particular response
amplitude, and suitable intersegmental coordination to produce an
effective kinematic pattern for maintenance or restoration of
posture.
• older subjects demonstrate increased sway or COG displacement;
however, the increased magnitude of sway magnitude does not
appear to place the elder directly at risk for injury.
VOLUNTARY MOVEMENT
• Locomotion and Gait
• The phenomenon of "slowing down" often observed in older
individuals has also been attributed to the aging process.
• Gait speed is reported to decline 1 % to 2% per decade for individuals
younger than 62 years and 16% per decade for individuals aged 63
years and 0lder.
• Common changes in gait associated with aging include a slower speed
of walking, decreased step length, and increased time spent in double
support.
VOLUNTARY MOVEMENT
• Functional movement
• There is a significant gap in understanding between laboratory studies
of human movement and outcome studies that report an older
person's ability to perform activities of daily living (ADLs).
• Whereas laboratory studies attempt to quantify movement parameters
and provide a comprehensive description of the quality of movement
and mechanisms that may be interacting to produce the movement.
• Outcome studies focus on the person's ability to complete a task
successfully without regard to the quality of the movement.
• The greatest age-related declines in function in the upper extremity
• The most difficult task involving the lower extremities was standing on
one leg and maintaining balance with the eyes dosed.
• Average loss of function for 10 ADL tasks was 30%.
ADAPTATION
• Adaptation is the evolutionary process whereby an organism
becomes better able to live in its habitat or habitats.
• Adaptedness is the state of being adapted: the degree to which an
organism is able to live and reproduce in a given set of habitats.
• An adaptive trait is an aspect of the developmental pattern of the
organism which enables or enhances the probability of that organism
surviving and reproducing.
ADAPTATION
• Adaptation is a process, rather than a physical part of
a body.
• Adaptation is one of the two main processes that
explain the diverse species we see in biology
• Adaptation is not always a simple matter, where the
ideal phenotype evolves for a given external
environment.
• All adaptations help organisms survive in
their ecological environment.
ADAPTATION
• Adaptation believe to occurs due to neuromuscular perturbation in
geriatric population because of two mechanisms:
• Plasticity:
• plasticity to explain structural or physiological change in the CNS as a result
of input from the environment.
• Mutability:
• The term mutability is often used to describe the muscle fiber's ability to
change in response to a new demand.
Plasticity
• Plasticity is viewed as an "adaptive" response to a perturbation.
Although the changes may be the nervous system's attempt to adapt,
it is not clear whether the changes in neural networks correlate with
functional adaptation.
• Specific molecular, biochemical, electro-physical and structural
changes takes place throughout life in CNS neurons and neuronal
networks in response to activity and behavior (Cotman and Neito-
Sampedro 1982).
• According to Carr Shepherd 1987 and Shepherd 1995, the training
following the brain lesion involves the person’s learning again, how
to perform action and mental process which were performed with
ease pre-lesion, is critical stimulus to the making of new or more
effective functional connections within remaining brain tissue.
Plasticity
• During most of the 20th century, the general consensus
among neuroscientists was that brain structure is
relatively immutable after a critical period during early
childhood.
• This belief has been challenged by new findings,
revealing that many aspects of the brain remain plastic
even into adulthood.
• Of course, if recovery and reorganization is successful,
patient may have different connections mediating action
than before the lesion.
• The clinician observes the behavioral consequences of
plasticity that may result from the sparing of function,
substitution of function, or recovery of some lost function
despite the lack of correlation between cellular and
functional changes, in the aged individual
Plasticity
• The plastic responses may include alteration in dendritic
or axonal morphology, synapses, receptors, or
metabolism.
• There is also evidence in the human brain of an age-
related increase in the number of dendritic branches and
dendritic spines.
• New synapses (synaptogenesis) have been demonstrated
to form in the adult brain in respose to activity.
• n the CNS, partial denervation results in sprouting by the
remaining fibers. Sprouting continues to be
demonstrated in the aging animal brain.
• plasticity is possible in the aging human and that the
clinician may be able to potentiate this process through
activities performed in the clinical environment
Mechanisms of Brain Plasticity
• Compensatory Masquerade: This mechanism involves “learning,”
the result of which permits one body part to compensate for loss of
function in another body part. It is the basis of many clinical
approaches used in rehabilitation.
• Functional Map Expansion: This mechanism of neuroplasticity
provides for an area of the “healthy” brain to “grow into” an
adjacent area of the “damaged” brain that has lost its function. The
area of growth is usually in the border zone bounding both areas.
• Homologous Region Adoption: This mechanism of neuroplasticity
provides for one area of the brain to take over the function of a
distant area that has been injured. The new functional area can be
in the same half or in the other half of the brain.
• Cross Model Reassignment: This aspect of neuroplasticity provides
for one sensory input to replace another. This mechanism
resembles compensatory masquerade (point 1 above) but generally
involves the sensory systems (vision, hearing, touch, pain).
Mutability
• The possibility of preventing age-related decline in motor
unit function is theoretically greater than for age-related
changes in other tissues
• In response to appropriate stimuli, muscle fibers can
enlarge several-fold, as well as increase oxidative
capacity.
• Are age-related functional changes in part a result of dis use?
• Can activity prevent or reverse these regressive changes?
• Aging is associated with an evolving reduction of physical
activity, and deconditioning occurs fairly rapidly.lI
• Literature suggests that the older individual is capable of
regaining strength.
Conclusion
Buskirk concludes that a general
adaptation occurs with exercise.
Although the adaptation is age-
dependent, he suggests that regular
exercise retards the downward trends in
systems of the body that are commonly
associated with aging.
THANKS

Geriatrics Sir Zahid

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Geriatrics Sir Zahid

Uploaded by

Copyright:

Available Formats

GERIATRICS

ZAHID MEHMOOD BHATTI

A. Young elderly: ages 65-74

• Understand incidences of mortality and morbidity for pathological

• Use this background info to formulate the bases for assessment

• Gain an understanding of prevention as a treatment modality

Older women outnumber older men; 145 women

65 years and older persons utilization of different services.

• Incidences of many diseases are influenced by age advances

• Death rate for atherosclerosis, myocardial degeneration, HTN, and CA all

• Age predisposes an individual to develop condition or to a fatal outcome

Health conditions commonly treated by geriatric physical therapists include:

ZAHID MEHMOOD BHATTI

Comprehensive geriatric assessment (CGA) is defined as a

➢The Use of Standardized Assessment tools in aforementioned areas

• Frontal Lob • Points finger each time the examiner

• Quality of life assessment is directly related to functional assessment

• Different scales used for Functional assessment Includes;

• Higher scores indicate greater caregiver distress.

• The adequate assessment of pain is pertinent to the care of

• The assessment is a brief, 10-statement form that is completed.

• Determine Your Nutritional Health (Scale)

• The aspects of mental status, functional status, social situation, values

• An individualized plan for health promotion and disability prevention

• Although age-related changes are frequently associated with physical and

• Exclusionary criteria have also included identifying older persons who

• Identify the structural and functional changes in the skeletal

• The mechanisms underlying these limitations are complex, but

• Reduction in Muscle Mass.

• There is a decrease in the number of functional motor units

• In response to reduced activity of the type II fibers (Strengthening):

• A decrease in the number of nerve terminals;

Specific strength Endurance training

Maximal power after

ZAHID MEHMOODF BHATTI

B. Neurological disorders and diseases

D. Cardiovascular disorders and diseases

E. Pulmonary disorders and diseases

Format / Outlines of Presentation

Musculoskeletal disorders and diseases

A. 1. Osteoporosis - Etiological Factors

A. 1. Osteoporosis - Characteristics 128

5. Goals, outcomes and Interventions

➢ Patients education and counseling

6. Goals, Outcomes and Interventions

➢ Teach patient extension exercises: avoid flexion activities

Fine, hairline fractures (insufficiency fracture)

A Non inflammatory progressive disorder of joints, typically affects hips, knees,

1. Pain, swelling, stiffness

Stroke (Cerebrovascular accident, CVA)

➢Affect about 20% of patients above 65 years

➢Common complications are

Fluctuating attention state causing temporary confusion and loss of mental

Loss of intellectual functions and memory causing dysfunction in daily living.

➢ Kidney, Liver failure ➢ Psychosis

1. Affects estimated 1.6 million individuals

5. Sign & Symtoms:

3. Examination for impairments in higher cortical functions

5. Examine self care

2. Support individuals remaining functions

A disorder characterized by depressed mood and lack of interest or

1. Family history, prior episodes of depression

2. Avoid excessive cheerfulness