1. CARE PROTOCOL FOR WELL ELDERLY
Definition
Well elderly is a person that had gone through ageing process without any
medical illness or medication, accomplish ADL independently but some
may have arthritis, diabetes but the disease won’t limit them from involved
in activities.
PREPARED BY
ADLIN HANI BINTI MAZLAN HANAFI
NUR AIMI BINTI ISMON
UiTM kampus Puncak Alam

2. Overview
Changes experience due to ageing
• Endocrine, Gastrointestinal and Metabolic Systems
- decrease amount of total body water and total body fat
- reduce in sense of taste and smell (decrease food enjoyment)
• Integumentary system
- change in skin d/t dry, wrinkled
- uneven discoloration, loss elasticity, delay in wound healing
- capillaries can be fragile and easily bruise
• Cardiovascular system
- cardiac output drops, heart rate slows, heart rate should exceed 60 b/min
- degenerative process affect the ability heart to pump the blood
- wall of heart become hypertrophy and lead to HPT, arteriosclerosis
• CNS (central nervous system)
- elderly experience 45% loss of cells in certain areas in brain
- average of 6-7 % reduce weight of brain
- elderly may have slower reflexes, decreased equilibrium, decreased perception of
touch and temperature

3. • Sense
- deterioration of hearing and vision
- pupils show a decrease in ability to accommodate to light
- diminish hearing capability for high-pitched sounds
• Respiratory System
- result of alteration in respiratory muscle, normal elasticity, recoil of thorax
- the lung tissue loses its elasticity
- respiratory muscle lose their strength and coordination
• Musculoskeletal system
- bones become brittle, susceptible to fracture
- joint lose flexibility, loss skeletal muscle mass
- elderly become easy to fall d/t decrease joint mobility and muscle weakness

4. Scope
• Guideline for physiotherapist to
provide appropriate, safe and
effective management for well
elderly
Objective
• General
- to assist physiotherapist in planning
and implementing activities for well-
elderly to enhance their quality of life
• Specific
- provide knowledge and
understanding to manage the well-
elderly
- maintain independence in ADL and
their social life
- prevention of accidents and injuries
- use of assistive and supportive
devices to suit the needs in specific
environment
- integrate into community

5. Assessment
A. History taking
- general health
- mental status
- medical and surgical history
- medication
- occupation
- social history – living independently/ with family
- past history
B. Current history
- quality of life at present moment (activity and life style)
C. Observation
- getting up from chair
- posture in standing
- gait- limping, waddling, circumduction
- ambulation w or w/o aids
- balance in sitting and standing
- joint swelling and joint deformity
- wearing spectacles or hearing aids

6. D. Palpation
- skin temperature
- skin texture
- tenderness
- any bony deformity
E. Joint movement
- AROM of limbs
- PROM of limbs
F. Muscle power/ coordination/ balance
- oxford’s muscle strength grading system
- finger-nose test
- modified/sharpen Romberg Test
- timed up and go test
- functional reach test
- berg’s balance test
- steps test
- chair rise test
- arm curl test
- 4 square test

7. G. Functional activities
- self care activities : ADL
- locomotion : walking, stairs climbing
H. Neurological
- reflexes
- sensation
- motor
- proprioception
- coordination
I. Short & long term goal
- setting up STG and LTG based on the findings, capabilities of patients and their
psychosocial needs
NB generally the ultimate goals to be achieved :
-maintain and enhance the functional independence in ADL
- improve and maintain psychological well-being

8. KEMENTERIAN KESIHATAN MALAYSIA
PHYSIOTHERAPY DEPARTMENT
GERIATRIC ASSESSMENT FORM
DR’S DIAGNOSIS ANTOMY CHART
DOCTOR MANAGEMENT
PROBLEM
PAIN SCALE : 1 2 3 4 5 6 7 8 9 10
COMMENTS :
SPECIAL QUESTION
GENERAL HEALTH :
MENTAL STATUS :
PMHX/ SURGERY :
IX/ MRI/ XRAY :
OCCUPATION :
MEDICATION/ STEROIDS :
1. Are you taking more than 4 meds Y/N
2. New med within last 2weeks Y/N
3. Are you on tranquilizer sleeping Y/N
pills, anti depressant?
4. While walking, did you experience any of
the following?
a. dizziness/ headache Y/N
b. vertigo Y/N
c. loss of consciousness Y/N
CURRENT HISTORY
PAST HISTORY
OBSERVATION
NAME : AGE : SEX : M/F R/N: DATE :

9. SPECIAL QUESTIONS (cont…)
5. Environmental problem e.g
Lighting, flooring probs. Y/N
6. Any falls within last 12 months
If yes, how many times?______ Y/N
7. Injuries within last 12 months
If yes, how many times?______ Y/N
8. Continence
- urinary Y/N
- bowel Y/N
PALPATION
NEUROLOGICAL
REFLEXES :
MOTOR :
SENSATION :
CLEARING TESTS / OTHER JOINTS
PHYSICAL EXAMINATION
Movement
Joint active passive
PHYSIOTHERAPIST IMPRESSIONS
MUSCLE POWER SHORT TERM GOAL
FUNCTIONAL ACTIVITIES
SPECIAL TESTS
1. GET UP AND GO TEST
2. MODIFIED RHOMBERG TEST
3. TIME UP AND GO TEST
4. FUNCTIONAL REACH TEST
5. BERG’S BALANCE TEST
6. STEP TEST
7. CHAIR RISE TEST.
LONG TERM GOAL
PLAN OF TREATMENT
ATTENDING PHYSIOTHERAPIST

10. FALL RISK SCREENING FORM
DATE :
NAME :
AGE :
I/C NO :
GENDER :
ADDRESS :
RACE :
FILL IN THE YES/NO FOR THE QUESTIONS BELOW YES NO
1. Do you take any medication (including herbal)
2. Do you take more than 4 medications daily?
3. Have you taken any new medications in the past 2
weeks?
4. Do you sometimes feels dizzy when you stand up?
5. Are you sometimes unsteady when you stand or walk?
6. Do you use a cane or a walker?
7. Do you sometimes have to rush to the bathroom?
8. Have you fallen down in the past 3 months?
9. Do you have poor vision?
10 Do you have poor hearing?
* If one or more of the above answers is yes, patient is considered to have risk of fall.

11. PHYSICAL ABILITY EVALUATION FORM

12. TIME UP AND GO TEST

13. MODIFIED RHOMBERG TEST

14. Functional Strength Arm Curl Test (ACT)
-analysis of the patient’s upper extremity strength-
1. Equipment
- straight backed chair (height 17”), dumbbell (5lbs for women, 8lbs for men), stopwatch
2. Starting position
- pt sitting in the middle of chair with back straight and feet on floor.
- the weight is held on dominant. (elb in extension by the side of pt’s torso, perpendicular
with the floor, wrist in neutral)
3. Protocol
- the pt is requested to turn the palm outward(supinate) while curling the arm thru the
full ROM and return to full extension.
- in down ward position, the hand should returned to the original position (neutral wrist)
- therapist demonstrate the test and allow twice practice from pt to ensure the correct
form.
- a 30 secs trial is performed and recorded.
- therapist can help to keep the pt’s upper arm still against their body during the trial.
- pt can squeeze the therapist’s fingers to stabilize the upper arm from moving to ensure
FROM is achieved.
4. Scoring
- the total numbers of curls executed correctly within 30mins.
5. Adaptations of hand use is required
- unable to hold the dumbbell d/t medical condition, a Velcro wrist weight may be used.
- unable to perform 1 repetitions, use the lighter weight and state on assessment form

15. Functional Reach Test ( FRT)
- Analysis of the patient’s postural control-
1. Equipment
- a yardstick mounted on the wall at the sh. height.
2. Starting position
- position the yardstick at the level of pt’s acromion process.
- pt stand with feet shoulder width apart and arm raised to 90degree (parallel to floor)
3. Protocol
- the pt is instructed to reach as far forward as possible w/out letting the feet raise from
the floor.
- location the middle finger is recorded.
- trial distance : final number – start number.
- perform 1 practice trial for patient understanding and 1 test trial for record.
4. Instruction to the patient
- please reach as far as you can without losing your balance.
- keep your feet on the floor.
5. Criteria to stop the test
- patient’s feet lifted up or they feel forward.
- therapist stands at the front because mostly patients fall forward with this test.
5. Prediction
- older adults who score < 6,7 inches indicate limited functional balance.
- healthy people able to score > 10inches.

16. STEP TEST

17. Intervention
• The main treatment will be :
i) Exercise Therapy
ii) Pain Management
iii) Patient Education
iv) General Fitness
1. Exercise Therapy
- Improves overall physical capacity and cardiovascular function in the elderly.
- influences both life span and quality of life
- offers way to maintain physical and mental health
Types of exercise :
i) mobilising exs
ii) strengthening exs
iii) balance exs
iv) relaxation exs
v) breathing exs
vi) proprioceptive exs
vii) aerobic exs
vii) stretching exs

18. 2. Pain management
Help to reduce pain for patients with neuro and musculoskeletal problems
Type of modalities :
i) Cold therapy
ii) Hot pack
iii) TENS/ EMS
3. Patient Education
education programme sholud be include :
i) Explanation on the condition
ii) Advice on home exs programme
iii) Advice on prevention from getting worse
iv) Prescription on exs
4. Fitness
Encourage patient to do regular exs 20-30 minutes per session, 3 x per week
exp : brisk walking and sport activities

19. EXERCISE
PURPOSE :-
1. CARDIOVASCULAR ENDURANCE
- Improve circulation and heart muscle works effectively
- Efficient lungs, muscles and other systems functions
2. MUSCULAR ENDURANCE
- Ability of muscle to perform action for longer period of time
3. MUSCULAR STRENGTH
- Strengthen the muscle and bones
- Improve posture, prevent osteoporosis.
4. FLEXIBILITY
- Level of elasticity of muscles, tendons, joints and ligaments
BENEFITS
1. Physical and psychological – reduce anxiety, improve appetite, alleviates minor
aches/pain, increase muscle endurance, improve postural control, improve balance

20. AEROBIC EXERCISE PERIOD
1. Involved rytmic , repetitive , dynamic exercise of large group muscles from 20-30mins
2. Must within individual tolerance.
Progression should be done to the individual capacity. (heart rate monitored according
Target Heart Rate)
TARGET HEART RATE (KARVONEN FORMULA)
THR : Target Heart Rate
MHR : Maximum Heart Rate (220 – age)
RHR: Resting Heart Rate
% Fitness Level
50-60% - Never exercise before
56-60% - Sometimes only
61-70% - Exercise 3x per week
71-85% - Regular exercise more than 3x perweek, under training program.
e.g : 70 years old elderly with RHR 80bpm never exercise before
THR : RHR + %fitness level(MHR – RHR)
: 80 + 50%(220-70)-80
: 80 + 35
: 115b.p.m

21. 3. Aerobic Exs : walking, brisk walking, treadmill walking, cycling, dancing running, sowing,
stair climbing, and swimming
4. Frequency 3-5 times per week
intensity : Heart rate should reach 115bpm (refer prev exmple)
time : 20-30mins
COOLING DOWN PERIOD
Purpose :
1. prevent blood pooling in extremities
2. Prevent light headedness or fainting
3. Prevent arrhythmias/ CR Cx
Characteristic
1. Repeating a warm p routine (assist venous return)
2. Muscle recovery
3. Period : 5-8mins

22. GUIDELINES ON CHOOSING AN EXERCISE PROGRAM
1. Exs is according to one’s physical capability and pt’s needs.
2. Exs should be enjoyable
3. Consult a doctor beforehand. Patient with medical problem should
adjust exs activity
4. Alert with unusual symptoms ( chest pain, SOB, muscle cramps)
5. Movt should be smooth and lively. (avoid jerky movt)
6. Breathing Exs should be carried out within exs.
7. Do not stop Exs suddenly (slow down)
8. Move as much as possible (more complex movt)
9. Fix a daily exs for yourself.

23. SAFETY
1. Aerobic exs should be conducted after warm up and ends
with cooling down to avoid muscle cramp, pain and injury
2. Wear proper attire and shock absorbing shoes
3. Exercise is safe (good ventilated room and no slippery floor)
4. Avoid exs 2hours after heavy meals
5. Avoid dehydration (drink a lot)
6. Avoid exs when you are sick.
7. Avoid exs on bad wheather (too hot, too cold, highly
polluted air, too dark)
8. Avoid taking warm bath because it may interrupts
physiological cooling down mechanism.
9. Stop exs when you have chest pain or breathlessness

24. DRUG USED AND EXERCISE (PRECAUTIONS)
DIABETES MELLITUS
• no exs when blood glucose above 20mmol/L and less than
3.5mmol/L (exs range between 4-20mmol/L
• if FBG > 20mmol/L, monitor the blood glucose level before
commencing the exs.
• exs should commence at least after half an hour after
medications
•Complications of acute DM
- hyperglycemia : thirsty, polyuria, lethargy, nausea, vomit and
semi consciousness
- hypoglycemia : hungry, headache, tremors, sweating and
behavioral changes. (provides any sweets)

25. HYPERTENSION
• ensure blood pressure is stable before exs
• Severe HPT or poorly controlled pressure should avoid
isometric/ callisthenic exs (they should be monitored closely).
• exs should commence at least after half an hour after
medications
MUSCULOSKELETAL PROBLEMS
• Exs should be performed within pain-free ranges
• Severe arthritis, joint problems should be supervised.

26. PRECAUTION
1. Pt with DM, HPT, HD and MS problems should follow the criteria
before they join the exs program.
2. Screening (DM, HPT, HD and MS problems) should be done earlier
3. Pt on regular medical check up
4. Compliance to medication
5. Evaluation should be carried out regularly

27. TIPS TO PREVENT FALLS
Poor balance Balance training (taichi, gym ball exs)
Muscle weakness of the legs Strengthening exs ( climbing stairs, walking and static
climbing)
Poor coordination Coordination training (taichi)
Cluttered walkway Keep the walkway clear
Oil and water spills on floor Wipe all the spills immediately
Loose rugs Replace with non slip rugs
Poor lighting Maintain adequate lighting
High Bed Height Select the suitable bed height (feet can reach the
floor while sitting)
Unstable chairs with wheels Use stable chairs with suitable seat height
No mobile chair without brake
Slippery floor Walk close with wall for support
Take special care when walking outdoor
Poor vision Wear appropriate glasses
Hold handrail when climbing stairs
Inappropriate use of walking aids Use it correctly and seek professional advice if in
doubt.

28. Algorithm
Referral Assessment Any
dysfunction/
disability
Yes
No
Well with
risk?
Yes
No
Refer to care
protocol elderly
with illness
Advice on
maintain healthy
lifestyle
Well elderly
prog and
activitiesTreatmentRe-evaluationimproved
yes
No
Discharged

29. Balance and
coordination
- exs to improve
balance
- advice
- pt education
- recreational
activities
Musculoskeletal
- exs to increase
/maintain ROM,
flexibility, muscle
strength
- pain mx
- advice
- pt education
- recreational
activities
Cardiorespiratory
- exs to improve
cardiopulmonary
endurance with
emphasis within
limit
- advice
- patient education
- recreational
activity
Psychosocial
status
- exs for physical
function
- relaxation
- functional self
management
- stress
reduction prog
- advice

30. THANK YOU 