1. The Health of The Elderly inThe Health of The Elderly in
Rehabilitation For Health PromotionRehabilitation For Health Promotion
and Preventive Medicineand Preventive Medicine
Assoc. Prof. S.Ufuk Yurdalan, Ph.D. ,PTAssoc. Prof. S.Ufuk Yurdalan, Ph.D. ,PT
9 Eylul University,9 Eylul University,
School of Physical Therapy and RehabilitationSchool of Physical Therapy and Rehabilitation
İzmir-TRİzmir-TR

2. TerminologyTerminology
older , elderly , geriatric , gerontologyolder , elderly , geriatric , gerontology
adult , individuals , people ..men &womenadult , individuals , people ..men &women
aged over 65 & octogenariansaged over 65 & octogenarians

3. What is geriatric ???What is geriatric ???
Geriatric is the medical branchGeriatric is the medical branch
dealing with the care of the aged.dealing with the care of the aged.

4. WhenWhen dodo we old ???we old ???
““ Forty is the old age of youth; fifty is the youth ofForty is the old age of youth; fifty is the youth of
old age.old age.““
young oldsyoung olds 65 -7465 -74
old oldsold olds 7575 -- 8484
oldest oldsoldest olds 85 +85 +

5. DemographyDemography
During the first 50 yrs of the 21st century, theDuring the first 50 yrs of the 21st century, the
world population 65 and over is expectedworld population 65 and over is expected to triple.to triple.
The number of people 80 yrs and older grew at anThe number of people 80 yrs and older grew at an
average rate at 159% between 1960-90, and is expectedaverage rate at 159% between 1960-90, and is expected
to continue growing at 70% until 2020 among countriesto continue growing at 70% until 2020 among countries
belong to OECD.belong to OECD.
Family Community HealthFamily Community Health
Vol.26,No:4,pp.338-349,Aug 2003Vol.26,No:4,pp.338-349,Aug 2003

6. Survival curves in humanSurvival curves in human

7. How big is the increase in years ofHow big is the increase in years of
active life?active life?

8. WHAT IS THEWHAT IS THE ELDERLYELDERLY
POPULATION IN EUROPE ???POPULATION IN EUROPE ???

9. Population PyramidsPopulation Pyramids
Asia (1995 and 2025) Latin America (1995 and 2025)
Europe (1995 and 2025)

10. WhereWhere do we meet the elderly ???do we meet the elderly ???
familyfamily
elderly communitieselderly communities
hospitalshospitals
dispensarydispensary
hospices …hospices …

11. Who are interested in the elderly ???Who are interested in the elderly ???
Multi-professional teamMulti-professional team
geriatrics, PT’s & OT’s, nursesgeriatrics, PT’s & OT’s, nurses
psychologists, social workers…psychologists, social workers…
families, friends, neighbors, etc.families, friends, neighbors, etc.

12. PT - Elderly InteractionPT - Elderly Interaction
GERIATRIC REHABILITATIONGERIATRIC REHABILITATION

13. What does geriatric rehabilitation do ???What does geriatric rehabilitation do ???
……. Focuses on restoring functional independence to older adults, in terms of. Focuses on restoring functional independence to older adults, in terms of
mobility,mobility, activity of daily livingactivity of daily living (ADL’s), and quality of life (QoL).(ADL’s), and quality of life (QoL).
J of Gerontological Nur.J of Gerontological Nur.
Vol.27, Iss.10, pp.7,Oct 2001Vol.27, Iss.10, pp.7,Oct 2001

14. What are the expectations ???What are the expectations ???
Small gains in function can mean large gainsSmall gains in function can mean large gains
in elder patient’s QoL.in elder patient’s QoL.
Disease Management and Health OutcomesDisease Management and Health Outcomes
11(6): 363-374, 200311(6): 363-374, 2003

15. The Seneca study
dietary, QoL, lifestyle, and healthydietary, QoL, lifestyle, and healthy
ageing in Europe ???ageing in Europe ???
1,091men / 1,109 women1,091men / 1,109 women
aged 70 – 75 yrsaged 70 – 75 yrs
Be., Fr., It., NL, Port., Sp., Switz., Pl.Be., Fr., It., NL, Port., Sp., Switz., Pl.
1988 - 19991988 - 1999

16. Mortality riskMortality risk
smokingsmoking
having a low-quality diethaving a low-quality diet
being physically inactivebeing physically inactive
The net effect of a healthy lifestyle on the process ofThe net effect of a healthy lifestyle on the process of
healthyhealthy ageingageing is likely to go together withis likely to go together with decreaseddecreased
morbidity.morbidity.

17. Healthy ageingHealthy ageing
……is provided by “health promotion”is provided by “health promotion”
Age & AgeingAge & Ageing
32(4): 427 - 434, July.200332(4): 427 - 434, July.2003

18. Public health policies are designed to create anPublic health policies are designed to create an
infrastructure toinfrastructure to promote healthy ageingpromote healthy ageing andand
offer support to the growing elderlyoffer support to the growing elderly
population.population.
Disease and Management & Health OutcomesDisease and Management & Health Outcomes
11( 5 ): 299 – 309, 200311( 5 ): 299 – 309, 2003

19. DEFINITION OFDEFINITION OF
HEALTHY / SUCCESSFULHEALTHY / SUCCESSFUL
AGEINGAGEING

20. Definition of healthy / successful ageingDefinition of healthy / successful ageing
…… includes the maintenance of physical andincludes the maintenance of physical and
mental function, as well as continued socialmental function, as well as continued social
engagement.engagement.
Health Screening and Health Promotion for ElderlyHealth Screening and Health Promotion for Elderly

21. Succesful ageing factorsSuccesful ageing factors
racerace
ethnicityethnicity
educationeducation
economic & social resourceseconomic & social resources
Disease and Management & Health OutcomesDisease and Management & Health Outcomes
11 ( 5 ) : 299 – 309, 200311 ( 5 ) : 299 – 309, 2003

22. AGEING PROCESSAGEING PROCESS

23. Begins before birth but the effects onlyBegins before birth but the effects only
become apparent around the age of 30.become apparent around the age of 30.

24. With ageing there is aWith ageing there is a lossloss in size andin size and functionalfunctional
unitsunits within every bodily system and awithin every bodily system and a
decrease in the proficiency of the remainingdecrease in the proficiency of the remaining
functionsfunctions

25. Ageing is characterized by aAgeing is characterized by a decreased abilitydecreased ability
to adapt to and recover from physiologicalto adapt to and recover from physiological
displacingdisplacing stimuli.stimuli.

26. ExerciseExercise is a form of physiologicalis a form of physiological stimulationstimulation
requiring complexrequiring complex interactioninteraction amongamong systemssystems..

27. PT’sPT’s who test and prescribe exercise for middle-who test and prescribe exercise for middle-
aged and older persons should be aware of theaged and older persons should be aware of the
affects of aging on the various systems and onaffects of aging on the various systems and on
thethe abilityability to exercise and train, as well as theto exercise and train, as well as the
generalgeneral characteristicscharacteristics and specificand specific needs ofneeds of
olderolder people.people.

28. Effects of ageing on systemsEffects of ageing on systems
cardiovascular systemcardiovascular system
left ventricular hypertrophyleft ventricular hypertrophy
limited left ventricular fillinglimited left ventricular filling
decreased beta-adrenoceptor med. CV responsesdecreased beta-adrenoceptor med. CV responses
cardiac dysrhytmias with exercisecardiac dysrhytmias with exercise

29. Pulmonary systemPulmonary system
decreased & impaired pulmonary functionsdecreased & impaired pulmonary functions
effects of smoking , chronic illnesseseffects of smoking , chronic illnesses

30. Musculoskeletal system/ bone massMusculoskeletal system/ bone mass
gradual loss of bone massgradual loss of bone mass
begins at age 30 to 35begins at age 30 to 35
-In women, it accelerates after menopause-In women, it accelerates after menopause
-In men, it accelerates at age 50 to 55-In men, it accelerates at age 50 to 55
spontaneous fractures & fractures after mild traumaspontaneous fractures & fractures after mild trauma

31. OsteoporosisOsteoporosis
-Genetic factors-Genetic factors
-Nutrition-Nutrition and life style factorsand life style factors
-Hormonal and reproductive factors-Hormonal and reproductive factors
-Medications-Medications
-Comorbid factors-Comorbid factors
MJA
Vol.180, pp.18-22, March.2004

32. Musculoskeletal system / muscle massMusculoskeletal system / muscle mass
reduces in the number and size of fast-twitchreduces in the number and size of fast-twitch
glycolglycolyytic muscle fiberstic muscle fibers
diminishes muscle massdiminishes muscle mass
stiffening of cartilage, tendons, and ligamentsstiffening of cartilage, tendons, and ligaments

33. Musculoskeletal systemMusculoskeletal system
Distribution of body fatDistribution of body fat
More fat is deposited internally and on the torsoMore fat is deposited internally and on the torso

34. Relation between muscle mass & bodyRelation between muscle mass & body
fatfat
Diminished muscle mass is masked by anDiminished muscle mass is masked by an
increased amount of body fat.increased amount of body fat.
LIFESTYLE !!!LIFESTYLE !!!

35. Neurological systemNeurological system
decreases in the number and size of neuronsdecreases in the number and size of neurons
decreases nerve conduction velocitydecreases nerve conduction velocity
decreased righting reflexesdecreased righting reflexes
increased reaction timeincreased reaction time
loss of ankle jerks and vibratory senseloss of ankle jerks and vibratory sense

36. Neurological systemNeurological system
increased postural swayincreased postural sway
Due to changes of posture, older people’s center ofDue to changes of posture, older people’s center of
gravity shifts to behind the hips.gravity shifts to behind the hips.
ASSISTIVE DEVICES!!!ASSISTIVE DEVICES!!!

37. Neurological systemNeurological system
Control of the movement is:Control of the movement is:
--less coordinationless coordination
--more hesitantmore hesitant
--require more attentionrequire more attention

38. Elderly’s common problemsElderly’s common problems
Muscle weakness, falls, fracturesMuscle weakness, falls, fractures
Arthritis, foot problemsArthritis, foot problems
Cardiovascular diseasesCardiovascular diseases
Alzheimer, Parkinson, CVAsAlzheimer, Parkinson, CVAs
PainPain
CancersCancers
Vision & hearing lossesVision & hearing losses
Cognitive impairmentsCognitive impairments
Depression disorders & dementiaDepression disorders & dementia

39. RELEVANT RESEARCH ON THERELEVANT RESEARCH ON THE
ELDERLYELDERLY

40. Medline / Cinahl 1985 - 2002Medline / Cinahl 1985 - 2002
Muscle strengthMuscle strength should be one of the factors that isshould be one of the factors that is
assessed and treated in elderly at risk for falls.assessed and treated in elderly at risk for falls.
More clinical trials are needed to determine ifMore clinical trials are needed to determine if
muscle strengthening exercises are affective inmuscle strengthening exercises are affective in
preventingpreventing falls.falls.
J of American Geriatric SocietyJ of American Geriatric Society
52 ( 7 ) :1121 – 9, July. 200452 ( 7 ) :1121 – 9, July. 2004

41. Medline, cochrane , embasseMedline, cochrane , embasse
1991-20041991-2004
Vitamin DVitamin D supplements appears to reducesupplements appears to reduce risk ofrisk of
fallsfalls among ambulatory or institutionalizedamong ambulatory or institutionalized
healthy older individuals byhealthy older individuals by more than 20 %.more than 20 %.
JAMAJAMA
291(16):1999 – 2006, Apr. 2004291(16):1999 – 2006, Apr. 2004

42. Strength trainingStrength training in rehabilitation isin rehabilitation is helpfulhelpful andand
safe insafe in managing physical dysfunction, weightmanaging physical dysfunction, weight
control, osteoporosis, and low back paincontrol, osteoporosis, and low back pain

43. Muscle strengthMuscle strength is reliably enhanced byis reliably enhanced by
resistance exercises (once a wk) and may aidresistance exercises (once a wk) and may aid
in reducingin reducing hip fracturehip fracture as well as improvingas well as improving
the ability to undertake daily activities andthe ability to undertake daily activities and
maintain independence.maintain independence.
J of Reh Research & DevelopmentJ of Reh Research & Development
Vol. 37, No: 2, pp. 245 – 254 , March/April 2000Vol. 37, No: 2, pp. 245 – 254 , March/April 2000

44. The Epidos prospective studyThe Epidos prospective study
In ambulatory elderly women the effect of fracture is stronger inIn ambulatory elderly women the effect of fracture is stronger in
the first 6 months and persists for several yrs thereafter.the first 6 months and persists for several yrs thereafter.
Prevention of hip fracture and improved care may contribute toPrevention of hip fracture and improved care may contribute to
increase life expectancy in addition to preserving QOL.increase life expectancy in addition to preserving QOL.
J of The Ame Ger SocJ of The Ame Ger Soc
52 ( 5 ) : 685 – 690, May 2004.52 ( 5 ) : 685 – 690, May 2004.

45. FallsFalls remain a major cause of morbidity &remain a major cause of morbidity &
mortality for the elderly, despite considerablemortality for the elderly, despite considerable
growth in fallgrowth in fall preventionprevention programs in recentprograms in recent
years.years.
Health promotion consist ofHealth promotion consist of group exercisegroup exercise
programs through multidisciplinary,programs through multidisciplinary,
multifactor interventions for high-riskmultifactor interventions for high-risk
populations.populations.

46. Participation in a weekly group exerciseParticipation in a weekly group exercise
program with moderate intensity can improveprogram with moderate intensity can improve
balance and reduce falls.balance and reduce falls.
Age & AgeingAge & Ageing
32 ( 4 ) : 407 - 414, July 200332 ( 4 ) : 407 - 414, July 2003

47. Gymnastics once a week didn’t provide benefitsGymnastics once a week didn’t provide benefits
in HRQOL and functional status after 10 wks.in HRQOL and functional status after 10 wks.
To improve the health of the general public,To improve the health of the general public,
sedentary older adults should be recruited andsedentary older adults should be recruited and
encouraged to combine gymnastics with healthencouraged to combine gymnastics with health
enhancing physical activities.enhancing physical activities.
JJ of Epidemiology & Community Healthof Epidemiology & Community Health
58 ( 2 ) : 83 – 8 , Feb 200458 ( 2 ) : 83 – 8 , Feb 2004

48. ExerciseExercise programs significantly improveprograms significantly improve
balance and mobilitybalance and mobility in patients with balancein patients with balance
problems. Enhanced balance training may , inproblems. Enhanced balance training may , in
addition, improveaddition, improve confidence and QOLconfidence and QOL butbut
needs further research.needs further research.
J of Ame Ger Soc.J of Ame Ger Soc.
51( 6 ): 847–52 , June 200251( 6 ): 847–52 , June 2002

49. AA new methodnew method of exercise prescription isof exercise prescription is
based onbased on walking velocitywalking velocity of the elderly.of the elderly.
Moderate intensityModerate intensity physical activity isphysical activity is
recommended for healthrecommended for health promotion,promotion, diseasedisease
preventionprevention, and especially as a means of, and especially as a means of
delaying functional loss in the elderly.delaying functional loss in the elderly.
Aeyegi, YukitoshiAeyegi, Yukitoshi

50. App 60 % of the max walking velocityApp 60 % of the max walking velocity
representsrepresents
moderate exercise.moderate exercise.
SIMPLY, SAFELY, EFFECTIVELY !!!SIMPLY, SAFELY, EFFECTIVELY !!!

51. Wearing shoes withWearing shoes with low heels and large contactlow heels and large contact
areaarea may help older adultsmay help older adults reduce the risk ofreduce the risk of
fallfall
in everyday settings and activities.in everyday settings and activities.
J of the Amer. Ger Soc.J of the Amer. Ger Soc.
52 ( 11 ): 1840 – 6, Nov 200452 ( 11 ): 1840 – 6, Nov 2004

52. Contrary to findings from gait-laboratoryContrary to findings from gait-laboratory
studies,studies,
athletic shoes are not associated with relativelyathletic shoes are not associated with relatively
low risk of fall in older adults during everydaylow risk of fall in older adults during everyday
activities.activities.
Fall risk was markedly increased whenFall risk was markedly increased when
participants were not wearingparticipants were not wearing shoes.shoes.
J of The Amer. Ger Soc.J of The Amer. Ger Soc.
52 ( 9 ): 1495 – 1501, Sep 200452 ( 9 ): 1495 – 1501, Sep 2004

53. ““InIn blood pressure monitoringblood pressure monitoring as older adult’sas older adult’s
perceptionsperceptions can serve as guidelines forcan serve as guidelines for
gerontologists and others ingerontologists and others in hypertensionhypertension
management effectivelymanagement effectively with olderwith older
adults.”adults.”
J of Gerontological NursingJ of Gerontological Nursing
30 ( 1 ): 44-52, Jan 200430 ( 1 ): 44-52, Jan 2004

54. Managing smoking, obesity, sedentary lifestyle,Managing smoking, obesity, sedentary lifestyle,
homocysteinemia are equally important in reducinghomocysteinemia are equally important in reducing
coronary risks in the elderly.coronary risks in the elderly.
By promoting and monitoring a healthy lifestyle,By promoting and monitoring a healthy lifestyle,
healthcare providers can help older adults improvehealthcare providers can help older adults improve
their CV health.their CV health.
J of Gerontological NursingJ of Gerontological Nursing
29( 6 ): 18-23, June 200329( 6 ): 18-23, June 2003

55. Future researchFuture research
--needs to address compliance issues, and interventions for peopleneeds to address compliance issues, and interventions for people
with cognitive impairment, dizziness and vision loss.with cognitive impairment, dizziness and vision loss.
--is also required in residential care and hospital settings, whereis also required in residential care and hospital settings, where
there is relatively little research evidence to guide us.there is relatively little research evidence to guide us.
Internal Medicine JournalInternal Medicine Journal
34 ( 9-10): 557-564, Se34 ( 9-10): 557-564, Se pp/Oct 2004/Oct 2004

56. Self-rated verbal communication is significantly relatedSelf-rated verbal communication is significantly related
to age, IADLs, intellectual activity, social activity,to age, IADLs, intellectual activity, social activity,
cognitive function, max phonation time, the numbercognitive function, max phonation time, the number
of teeth, the wearing of dentures, self-rated generalof teeth, the wearing of dentures, self-rated general
health and oral function.health and oral function.
……hearing ability and wearing of hearing aids..hearing ability and wearing of hearing aids..
Geriatrics & Gerontology Int.Geriatrics & Gerontology Int.
4 ( 2 ): 100 – 4, June 20044 ( 2 ): 100 – 4, June 2004

57. epidemiological follow-up study over 5epidemiological follow-up study over 5
yrsyrs
Depressed older people are at high risk for physicalDepressed older people are at high risk for physical
disability.disability.
An individualized program to maintain their ADLs andAn individualized program to maintain their ADLs and
IADLs and physical exerciseIADLs and physical exercise
should be included in their treatmentshould be included in their treatment..
J of the Amer. Ger Soc.J of the Amer. Ger Soc.
49( 3 ): 290-6, March 200149( 3 ): 290-6, March 2001

58. Client and family centered care, along with the provision ofClient and family centered care, along with the provision of
enhanced QOL and well-being through appropriate mobilityenhanced QOL and well-being through appropriate mobility
activities and pain management are the corner stones to aactivities and pain management are the corner stones to a
positive hospice approach for the elderly with terminal cancerpositive hospice approach for the elderly with terminal cancer
and other life-threatening illnesses.and other life-threatening illnesses.
Throughout the dying process,Throughout the dying process,
it is essential forit is essential for PT’s & OT’sPT’s & OT’s to focuses on assessments andto focuses on assessments and
interventions for clients to adaptation.interventions for clients to adaptation.
Topics in Geriatric Reh.Topics in Geriatric Reh.
Vol.20, No:2, pp.120-30, 2004Vol.20, No:2, pp.120-30, 2004

59. There is a need to establishThere is a need to establish ethical guidelines,ethical guidelines,
which take into consideration differences inwhich take into consideration differences in
religion, culture, ethnicityreligion, culture, ethnicity and race in theand race in the
elderlyelderly..
Clinical MedicineClinical Medicine
3(3): 232 – 4, May/June 20033(3): 232 – 4, May/June 2003

60. Community Health Care For Older Adults
“Family,and Community
Based Care : The Supports For Care Plan
Implementation” Comhrensive Geriatric Assessment., 2002

61. ComplemComplemaantaryntary,,and Alternative Therapand Alternative Therapyy
-Mind-Mind -body therap-body therapyy
-Manual-Manual,,and body-and body- work therapwork therapyy
-Ac-Acaapuncturepuncture
-- AlternativeAlternative dietary therapdietary therapyy
-- HerbalHerbal medicinemedicine
-- AromatherapyAromatherapy
-- HomeopathyHomeopathy
-- MagneticMagnetic therapytherapy
-- SpiritualSpiritual healinghealing
Topic in Geriatric Reh.
18(2): 63 – 79, 2002

62. ApplicationApplicationss of CAM Therapof CAM Therapyy inin
GeriatricGeriatricalal RehabilitationRehabilitation
StrokStrok AcAcaapuncturepuncture
FallFall Tai-ChiTai-Chi
ArthritArthrit Yoga,relaxation techniqueYoga,relaxation technique
PaPaıınn MindMind -Body therap-Body therapyy
AlzheimerAlzheimer IMIAIMIA
ParkinsonParkinson AlexanderAlexander techniquetechnique

63. Benefit of IntegratBenefit of Integratee CAM TherapCAM Therapyy
intointo GeriatricGeriatric RehabilitationRehabilitation
-- EnhancingEnhancing communicationcommunication
-- IncreasingIncreasing therapeutictherapeutic optionsoptions
-- PromotingPromoting empowermentempowerment

64. ConsiderationConsiderationss in Prescriin Prescribebe ExerciExercisseses
FForor ElderlyElderly
-- Medical –Medical – physiologicalphysiological factorsfactors
-- PsychologicalPsychological ffactorsactors

65. TheThe PhysiotherapyPhysiotherapy EvaluationEvaluation FForor
ElderlyElderly
-- Age /Age / gendergender
-- PrimaryPrimary diagnosisdiagnosis
-- SecondarySecondary diagnosisdiagnosis
-- VisualVisual,,andand sensorysensory impairmentsimpairments
-- MedicationsMedications
-- CognitiveCognitive statusstatus
-..........-..........
J Geront. Nur
Vol.27, Iss.10, pp.19, Octob., 2001

66. TheThe Objectives ofObjectives of Exercise ProgramExercise Program
-- ImproveImprove self-careself-care capabilitiescapabilities andand well-beingwell-being
-- Improve CVImprove CV capacitycapacity andand enduranceendurance
-- IncreaseIncrease muscularmuscular strengthstrength andand enduranceendurance
-- ImproveImprove oror maintainmaintain flexibility,flexibility, coordinationcoordination andand
balancebalance
-- WeightWeight controlcontrol
-- PromotePromote relaxationrelaxation
-- RelieveRelieve anxiety,anxiety, insomniainsomnia andand depressiondepression
-- MaximizeMaximize socialsocial contactcontact andand enjoymentenjoyment allall the lifethe life

67. AnAn ExampleExample
-- Habitual vs.Habitual vs. physicalphysical activityactivity
-- Intensity:Intensity: LowLow
30 –40 VO30 –40 VO2Max2Max 50-70 VO50-70 VO2Max2Max %%
2-32-3 METs (METs ( walking on 2-3walking on 2-3 mphmph ))
-- Duration:Duration: Warm-up/Warm-up/ exercise /exercise / cool-downcool-down
AvoidAvoid rapidrapid oror majormajor changes inchanges in intensityintensity

68. TheThe ResearchResearch Agenda onAgenda on GeriatricGeriatric
RehabilitationRehabilitation
-Structure of-Structure of carecare :: DifferentDifferent settingssettings
-Process of-Process of carecare :: ExercisesExercises
-Process of-Process of carecare :: Assistive technologyAssistive technology
Am. J Phys. Med. Reh.
Vol.83, pp.858-866, 2004