Geriatric Assessment and Management

GERIATRIC
ASSESSMENTS
geriatric physiotherapy 1
GENERAL
ASSESSMENT
INTRODUCTION
 Aims,
 The team,
 Efficiency,
 components
INTRODUCTION
It is a complex & time consuming task.
It is important to ensure that the patient is not
exhausted by method of assessment.
The assessment very much depends on a particular
case being assessed.
Two IMP aspects related to the presentation of disease
in old age:
1) Multiple pathology
2) Identification/ recognition of social presentation of
disease.
Aims
 Better recognize common geriatric disorders,
 Plan an effective treatment plan,
 Improve overall health & functional outcomes,
 Reduce vulnerability to subsequent illness,
 Provide better quality of life.
Team
Multidisciplinary or interdisciplinary approach is a key to

geriatric assessment.
The team has many members:
 Physician,
 Physiotherapist,
 Occupational therapist,
 Speech therapist,
 Dentist,
Team (conti..)
Audiologist,
Ophthalmologist,
Dietician,
Psychologist,
Nurse
Social worker
INTRODUCTION(conti..)
 Introduction to physiotherapist is very IMP.
 History taking should begins with eye contact, a
greeting, patients name & aim of meeting.
 Telling your name & purpose to make the person
comfortable.
PERSONAL INFORMATION
 Name :-
 Age/ gender :-
 Address :-
 Occupation :-
 Provisional Diagnosis :-
 Dominance :-
PERSONAL INFORMATION
 Socioeconomic condition :-
 Laboratory Reports :-
 Referred by :-
 Chief complaint :-
History
 Present medical history:-
 Past history :-
 Personal history :-
 Social history :-
 Family history :-
Tab le 3 -4 Cate go rie s o f Phys ical Hea lth Ind ex Mea s uring
Phys ical Comp e te nc e
ACTIVTIES INSTRUMENTAL ACTIVITIES

OF DAILY LIVING OF DAILY LIVING
Fe e ding Coo king

Bat hing Cle an ing
To ilet ing Us ing t e lep ho ne
Dre s s ing Writ ing
Am bulat io n Read ing
Tr an sf e r fro m t oilet Lau ndry
Vis ual a cu it y Driving a ca r
Ot he rs Ot he rs
Observation
See for
 Skin, nails etc..
 Posture,
 Gait,
 General facial expression,
 Clothing,
 Attitude,
 Behavior.
Observation(conti..)
 Trophic changes ,
 Involuntary movements,
 Concentration,
 Orientation,
 Swelling ,
 External aids,
 Psychological features.
Physical examination
 While examining the patient, never keep silence, as
patient may develop a misbelief that something
detected wrong.
 Explain the patient what you are doing & make the
patient comfortable and confident.
 Rom,
 Muscle strength,
 Coordination,
 Sensory status,
 Visual & hearing impairment,
 Cranial nerve examination,
 Higher function,
Higher function
 Consciousness :- (Glasgow Coma Scale)
 Memory :- (Immediate recall, Short term, Long
term)
 Speech
 Reading and writing
 Orientation :- (Time, Space, Person)
Intelligence Rehabilitation
Clock Drawing Test
Normal
Mild
Cognitive
Impairment
Moderate
Cognitive
Impairment
Severe
Cognitive
Impairment
 Body weight,
 Functional status,
 Mental status,
 Emotional status.
 Laboratory tastings.
Simple” Functional Assessment
of Ambulatory Elderly
HISTOR
Y
PHYSICAL EXAMINATION
including: neurologic and
musculoskeletal
evaluation of arm and leg,
evaluation of vision, hearing
and speech
Simple” Functional Assessment
of Ambulatory Elderly
DEPRESSION
If Geriatric
Depression scale
is positive: MENTAL ADL
STATUS &
- check for
adverse IAD
medications L
- initiate
appropriate
treatment
HOME ENVIRONMENT AND
SOCIAL SUPPORT
Evaluation of home
safety and
family and community
resources
Geriatric Depression Scale
 Demented patients frequently suffer from depression
 Measures have been developed to screen for
depression without reliance on patient self-report
› Caregiver asked questions about presence of a number
of symptoms/manifestations of depression
Geriatric Depression Scale
 Geriatric Depression Scale

› Designed specifically for frail older patients
› Series of 30 YES/NO questions covering symptoms
and manifestations of depression
› Takes 10-15 minutes to administer
› Score > 14 greatly increases probability of depression
› Score < 9 greatly decreases probability
Physical evaluation(conti..)
 Balance Measures
› Sitting balance (leaning vs. steady)
› Ability to rise from chair
› Immediate standing balance
› Standing balance (wide based, narrow based or
assisted)
› Standing balance with eyes closed etc..
Physical evaluation(conti..)
 Gait Observations
› Initiation of gait
› Step length
› Step height
› Step continuity
› Step symmetry
› Walking stance
› Amount of trunk sway
› Path deviation
Home safety
 Throughout the interior several common features
› Scatter rugs, adequate lighting, enough room for easy
mobility, emergency telephone numbers posted
 Kitchen
 Bathroom
 Outside the home
Assessment of Social Support
 Assess the patient’s emotional support
 Identify actual/potential caregivers
 Ask who would be available in an emergency
 Social information and background may help assess
coping ability
ASSESSMENT
OF FALLS IN
ELDERLY:
History
A) Circumstances of fall:
 Environmental:
 Including
1. Location,
2. Floor surface,
3. Lightening,
4. Quality of chair
 Direction:
Forward falls typically indicate a trip whereas
backward falls usually indicate a slip.
Tripping falls may occur because of impaired Depth
perception or poor foot clearance.
Backward falls may suggest CNS disease with a
lesion in cerebellum, brainstem or basal ganglia.
 Activity at the time of fall:
Helps in understanding the cause of fall.
Eg. A fall while rising from a chair indicates muscle
weakness or nervous disease.
 Recent meal or alcohol intake:
Eg. A fall occurring 30 minutes after a meal may be
due to postprandial hypotension.
B). Associated symptoms:
Eg.
 Lightheadedness,
 Vertigo,
 Weakness,
 Confusion,
 Palpitations.
C) Relevant co morbid conditions:
Eg :
 Prior stroke,
 Cardiovascular conditions,
 Parkinsonism,
 Osteoporosis,
 Anemia,
 DM.
C) Relevant co morbid conditions:
 Depression,
 Anxiety,
 Cognitive impairment.
D). Previous falls.
E). Review of current as well as past medications,
particularly those having Hypotension, or
psychoactive effects.
Physical evaluation
A) Vision:
 Poor distant vision,
 Decreased visual field,
 Reduced contrast sensitivity,
 Impaired depth perception,
 Cataract.
So visual examination include:
 Assessment of visual fields,
 Assessment of distant vision with or without distance lenses,
 Fundoscopic examination.
Physical evaluation
B) Vestibular function:
 The examination should include:
 Head-thrust test:
 The patient is asked to look at the examiner’s nose
while the examiner rapidly move the patient’s head
to right & left.
 Small, rapid eye movements indicate a positive head-
thrust test.
Vestibular function(CONTI..)
 The Dix-hallpike maneuver:

 A positive response is indicated by nystagmus &
vertigo lasting for 10-30 sec & reproduced within a
few seconds of rapidly positioning a patient from
seated to supine with head turned 450.
Vestibular function(CONTI..)
 Romberg test:
 The patient is instructed to stand with the feet
together for 1o sec, first with eyes open & then with
eyes closed.
 Grading is simple: able or not to able to complete the
task.
Physical evaluation
C) Cardiovascular function:
 Pulse & Blood pressure,
 Cardiac arrhythmias,
 Orthostatic hypotension.
Physical evaluation
D) Muscular function:
 ROM,
 Arthritic changes,
 Leg length discrepancy,
 Skeletal deformities,
 Muscular weakness,
 Foot problems.
Physical evaluation
E) Neurological function:
 Sensations:
Touch,
Kinesthesia,
Proprioceptions
 Reflexes
 Muscle tone,
 Cognitive function
Physical evaluation
E) Neurological function:
 Balance & gait,
 Mobility.
Risk factors taking & improper
assistive device
 Hurrying,
 Climbing on to a chair or ladder,
 Walking with hands in pocket,
 Using assistive devices improperly,
 Wearing improper footwear,
 Using inappropriate eyewear,
GERIATRIC
MANAGEMENT
In different settings
 In acute care hospitals,
 In skilled nursing facilities,
 In OPDs
 At home
In acute care hospitals
 Monitored by interdisciplinary team
 Physical therapy should be started as early as
possible
 It is helpful to prevent secondary functional
loss & promote early restoration of functions.
 Thereby reduce length of hospital stay.
 The patient should receive therapy for 2hrs/day
to have significant improvement.
In skilled nursing facilities
 Elderly patients who are not suitable for acute
care in hospitals may be treated in a skilled
nursing facilities.
 The patient should employed 21/2 hourly
sessions of physical therapy/day.
 The treatment time may be increased after the
reassessment.
At home
 Physiotherapist may visit the patient for
once/twice a day.
 Advantage of this is that it saves the time of
caregivers.
 However disadvantage in the sense that
necessary equipments can’t be used at home.
In OPDs
 Best option for the patients who have the
transport facilities.
 Not suitable for frail elderly.
 Easy to access equipments & peer interaction
are the main advantages.
Components
 Assessment,
 Goal-setting,
 Therapeutic intervention,
 Re-assessment.
Assessment
 It is very helpful before the initiation of a
physical therapy program.
 Modification can be done in some cases.
Goal-setting
 Functional independence is the ultimate goal

 To achieve this long term goal, a physical therapist
should establish several short term goals..
 To improve or maintain ROM of different joints,
 To improve or maintain strength & endurance of
muscles,
 To improve or maintain cardiovascular endurance,
Goal-setting
 To improve or maintain ambulatory status of
an elderly.
 To relive pain.
Therapeutic intervention
 Range of motion exercise: 2 types
THERAPUTIC BENEFITS OF PASSIVE ROM:
To maintain ROM,
To prevent complications of immobility,
To preserve proprioceptive & kinesthetic sensations,
To inhibit pain,
To induce muscle relaxation
Therapeutic intervention(conti..)
THERAPUTIC BENEFITS OF ACTIVE
ROM:
 To provide muscle relaxation,
 To preserve joint functions,
 To increase circulation
 To provide sensory feedback
 To improve neuromuscular coordination etc..
 Stretching exercises:
 General term to improve mobility of soft tissues
and subsequently improve ROM.
 3 most common types:
1. Static stretching,
2. PNF,
3. Ballistic .
 Mobilization exercises:
o Inhibit nociceptive stimuli by stimulating
mechanoreceptors,
o Cause motion of the synovial fluid to the
avascular portions so, improve nutrients,
o To prevent degeneration & pain,
o To elongate hypomobile capsule & ligaments,
 Strengthening exercises:
 Strength is the ability of muscle to generate a
tensile force and it is very essential for day to
day work.
Consideration for elderly people:
o Correct alignment:
 Determine by the direction of muscle fibers &
the line of pull of the muscle to be strengthened.
o Appropriate stabilization:
 To ensure correct muscle action,
 To avoid trick movements.
o Smooth movements:
 To produce movements against resistance at a
steady rate without shacking or jerking.
o Breathing guidelines:
 Avoid holding breath.
o Type of resistance:
 Body weight,
 Manual resistance,
 Mechanical resistance.
o Intensity:
 Start with very law intensity & afterwards
increase
 Best method to check it is 1RM.
o FREQUNCY & DURATION:
 For each level of intensity, session are repeated
2-3 times a week.
 A single session may consist of 3 sets of 10RM
with either progressive or regressive loading in
each set.
o Rest intervals;
 Should rest from 1 to 2 minutes between sets in
a same session.
o Mode of exercise:
 Static
 Dynamic
 Aerobic exercises:
 Improvement in maximal cardiovascular
functional capacity,
 Improvement in energy level,
 Improvement in the body composition ,
 Reduction in disability,
 Psychological well-being,
 Improvement in functional status.
 Gaittraining:
 Postural control training,
 Visual feedback,
 Correction of posture,
 Hold & relax,
 Weight shifting exercises,
 Standing on a balance board,
 Correct sensory input
 Gaittraining:
 Appropriate foot-wear,
 Trunk exercises,
 Resisted exercises etc…
 Orthotics:
 To provide immobilization or controlled
movement s.
 To support weakened structure,
 To promote ambulation,
 To reduce pain,
 To prevent deformity etc..
 Electrotherapeutic modalities:
 Cold modalities,
 Heating modalties,
 LASER
Electrical stimulating currents;
 Direct current,
 Surge faradic current,
 Interrupted direct current,
 IFT,
 TENS.
REASSESSMENT
 A physical therapist can judge the effectiveness
of treatment towards the goals set, with
required modifications in treatment strategies.
PREVENTION OF
FALLS
SAFETY MEASURES
 Take into account the mean walking speed of
the elderly ,
 Use non-slippery surfaces;
 Eliminate bumps on sidewalks and
roadways;
 Indicate steps and other differences in
 Surface heights;
SAFETY MEASURES(CONTI..)
 Equip staircases with bilateral handrails;
 Set escalators to a slow speed;
 Construct walkways away from traffic;
 Include seating in walking zones.
SAFETY MEASURES(CONTI..)
 Improve the living conditions of the elderly
(income, housing, access to social aid, etc.);
 Improve the social environment of the elderly
(social networks, etc.);
 Offer high quality therapeutic and rehabilitation
services.
Fracture prevention
Reduce the number of falls
 Implement fall prevention programs.
Reduce injuries associated with falls

 Reduce the rigidity of surfaces: favor the use of
shock absorbing ground surface materials
(floorings, roadways, sidewalks) .
Fracture prevention
 Favor effective protective responses when
falling (physical exercise programs).
 Limit the time spent on the ground: teach the
elderly how to get back up correctly and,
 Promote the use of smart sensors, wearable
alarms and other security equipment
Fracture prevention
Maximize bone density
 Prevent osteoporosis,
 Assure sufficient intake in calcium and
 vitamin D (with supplements when needed)
 for the elderly, particularly those in a fragile
state and at high risk of falls.
Fracture prevention
 Prevent under nutrition and alcohol abuse.
 Encourage regular physical exercise and
propose muscle strengthening exercises to the
elderly at risk of fractures.
Preserve or reestablish
balance and gait with
physical exercise
 Improvinging proprioceptions may also be
proposed (e.g., picking up marbles with one’s
toes);
 Muscle strengthening and balance training
exercises. These include activities involving
weights and resistance to improve strength and
balance and reduce loss of bone density (e.g.,
Leg lifts with ankle weights, wall push ups);
Preserve or reestablish
balance and gait with physical exercise
 Rapid walking sessions to slow the loss of bone

density.
Orthostatic hypotension
 Increase dietary salt intake (if there are no
contraindications);
 Provide advice on how to change position
(when getting out of bed, pause in the seated
 Position before standing; verify balance in the
standing position before walking);
Orthostatic hypotension
 Encourage moving the legs and feet about
before standing up;
 Encourage the use of compression stockings;
 Raise the head of the bed.
Prevent risk taking in daily
activities
 Suggest walking aids,
 Advise appropriate eyewear,
 Advise well-fitted footwear that is adapted to
the activity: Closed shoes with no or only small
heels are recommended, even in the home, to
avoid increasing the risk of falling.
Prevent and reduce
the fear of falling
 A general education approach including
instructions for getting up off the ground;
 and/or physical exercise.
Reduce dangers in the home
Outdoors:
 Repair cracks and abrupt edges of sidewalks and
driveways.
 Install handrails on stairs and steps.
 Remove high doorway thresholds Trim
shrubbery along the pathway to the home.
 Keep walk areas clear of clutter, rocks and tools.
 Keep walk areas clear of snow and ice.
 Install adequate lighting by doorways and along
walkways leading to doors.
All Living Spaces
 Use a change in color to denote changes in
surface types or levels.
 Secure rugs with nonskid tape as well as carpet
edges.
 Avoid throw rugs.
 Remove oversized furniture and objects.
 Have at least one phone extension in each level
of the home and post. emergency numbers at
each phone.
 Add electrical outlets.
 Reduce clutter.
All Living Spaces
 Check lighting for adequate illumination and
glare control.
 Maintain nightlights or motion-sensitive
lighting throughout home.
 Use contrast in paint, furniture and carpet
colors.
 Install electronic emergency response system if
needed.
Kitchen
 Keep commonly used items within easy reach.
 Use a sturdy step stool when you need
something from a high shelf.
 Make sure appliance cords are out of the way.
 Avoid using floor polish or wax in order to
reduce slick surfaces.
Bathrooms
 Install grab bars on walls around the tub and
beside the toilet, strong enough to hold your
weight.
 Add nonskid mats
 Mount liquid soap dispenser on the bathtub-
wall.
Bathrooms
 Install a portable, hand-held shower head.
 Add a padded bath or shower seat.
 Install a raised toilet seat if needed.
 Use nonskid mats or carpet on floor surfaces
that may get wet.

Living, Dining and Family Rooms
 Keep electrical and telephone cords out of the

way.
 Arrange furniture so that you can easily move
around it (especially low coffee tables).
 Make sure chairs and couches are easy to get in
and out of.
 Remove caster wheels from furniture.
 Use television remote control and cordless
phone.

Stairways, Hallways and Pathways
 Keep free of clutter

 Make sure carpet is secured and get rid of
throw rugs.
 Install tightly fastened hand rails running the
entire length and along both sides of stairs.
 Apply brightly colored tape to the face of the
steps to make them more visible.

Stairways, Hallways and Pathways
 Optimal stair dimensions.

 Have adequate lighting in stairways, hallways
and pathways, with light switches placed at
each end.

LITTLE MODERATE SIGNIFICANT
EFFORT/EXPENSE EFFORT/EXPENSE EFFORT/EXPENSE
REQUIRED: REQUIRED: REQUIRED:
• Wearing of • Placement of light • Ensure adequate

comfortable, switches to allow easy supervision by
supportive access; caregiver/family
footwear and member;
appropriate length of
pant leg;
• Correction of • Use of a change in • Provision of additional
slippery surfaces by colour to denote assistance/observation
using non-slip waxes change in surface when ill and for
on hard floors; type or level (e.g. climatic conditions such
as rain, ice,
flights of stairs); and wind;
• Ensuring that • Use of walking aids, • Modification of
electrical cords do not such as canes, stairs with a low
extend across floor; quad canes or travel height and
walkers. longer depth

LITTLE MODERATE SIGNIFICANT
EFFORT/EXPENSE EFFORT/EXPENSE EFFORT/EXPENSE
REQUIRED: REQUIRED: REQUIRED:
• Provision of • Provision of at least • Installation of

adequate space to one phone handrails that can be
manoeuvre between extension for each gripped easily and
pieces of furniture level in the home, are easy to see.
without turning side- preferably table-top
ways; rather than wall
phone;
• Adequate lighting in •Installation of • Provision of

association with electronic emergency bathroom on same
non-glare paints and response systems, level as
surfaces; use of such as Protect bedroom, living room
nightlights in the Alert/Life Line; and kitchen;
bedroom and
corridor;

THANK
YOU

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GERIATRIC

Multidisciplinary or interdisciplinary approach is a key to

ACTIVTIES INSTRUMENTAL ACTIVITIES

Fe e ding Coo king

Clock Drawing Test

 Geriatric Depression Scale

D). Previous falls.

 The Dix-hallpike maneuver:

 Functional independence is the ultimate goal

THERAPUTIC BENEFITS OF PASSIVE ROM:

Reduce injuries associated with falls

 Rapid walking sessions to slow the loss of bone

geriatric physiotherapy 100

 Keep electrical and telephone cords out of the

geriatric physiotherapy 102

 Keep free of clutter

geriatric physiotherapy 104

 Optimal stair dimensions.

geriatric physiotherapy 106

• Wearing of • Placement of light • Ensure adequate

geriatric physiotherapy 107

• Provision of • Provision of at least • Installation of

• Adequate lighting in •Installation of • Provision of

geriatric physiotherapy 108

geriatric physiotherapy 109

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