physiotherapy in geriatric

1. PHYSIOTHERAPY
IN
GERIATRIC
PRESENTED BY: DR.SHILPA K PRAJAPATI

2. CONTENTS
 1. ASSESSMENT
 2. GOAL-SETTING
 3. THERAPUTIC INTERVENTION
 4. RE- ASSESSMENT

3. GERIATRIC ASSESSMENT
 AIMS:
 Better recognize common geriatric disorder.
 Plan an effective treatment program.
 Improve over all health and functional outcomes.
 Reduce vulnerability to subsequent illness.
 Provide better quality of life.
 THE TEAM:
 many members work together to develop a single
treatment plan

4. EFFICIENCY OF ASSESSMENT
Problem area Screening measure Abnormal
response
Mobility Note the time after asking the patient: ’RISE Unable to task
FROM THE CHAIR, WALK 20FT, TURN , WALK 15 second
BACK TO THE CHAIR AND SIT DOWN’
Physical 1.Have you had any fall in last year? Yes to all six
disability
2.Do you have trouble with the activities of personal Questions
life like bath, dress, toilet or eat?
3.Do you have trouble with light house hold work
like cooking?
4. Do you have trouble with heavy house hold work
like washing cloths?
5.Are you able to go out for shopping or to see a
family friend?
6.Are you able to do strenuous activities such as
cycling or fast walking?

5. EFFICIENCY OF ASSESSMENT
Problem area screening measure Abnormal response
Vision Test each eye with Snellen eye chart, Can’t read 20 /40
with glasses if applicable
Hearing Whisper short sentences at 6-12 inches Unable to hear
Urinary incontinence Do you have problem with urine leaks? Yes to the question
Nutrition , weight loss Have you lost weight ? If yes, how Loss of 5 per cent
much?
Weight /BMI BMI< 21
Memory Name 3 objects ask to recall in 5 min If remember <3
Depression Have you often been bothered by Yes to the question
feeling sad or depressed?

6. COMPONENTS OF ASSESSMENT
 HISTORY TAKING: General Guidelines
 Remember that patient having age related changes in
one or more body system.
 Keep the pace slower than usual
 Introduce yourself in start of history taking
 Address each individual as per her/his preference.
Sir, Madam, Mr., Mrs. Use rather than grandma or
grandpa
 Adopt the most effective way of communication such as

7. COMPONENTS OF ASSESSMENT
- Do not discuss the case with relative to the questions
as if he is not allow to participate in discussion. Never
ignore the presence of elderly
 Ensure that patient can hearing what is being said
 Provide glasses if needed
 Speak at eye level facing the patient
 Never treat the elderly as is a child
 Respect elderly as an individual.

8. COMPONENTS OF ASSESSMENT
 Subjective information and personal history:
 Age/sex
 Education/occupation
 Socioeconomic status etc.
 Chief complaints: reflecting the presence of multiple
pathologies
 Present physical illness: chronic disease previous surgeries
or hospitalization
 Drug history: prescribed or non-prescribed drugs, drug
allergies
 Nutritional history: number of meals/day, contents of diet
 Family history: major disease in family, cause of death of

9. PHYSICAL EXAMINATION
 -Height, weight and BMI
 Orthostatic BP and pulse -Edema
 Skin integrity, pallor -Rang of
motion
 Muscle strength -Sensory
status
 Coordination -Vision and

10. FUNCTIONAL STATUS
 1. Basic self-care and personal hygienic activities of daily
living(BADLs)
Here; I-Independent, A-Assistance requires, D-Dependent
 2. More complex activities essential to live in
community(IADLs)
3. Balance
Modified performance oriented mobility assessment( poma)
GAIT SCORE =_____/12, BALANCE SCORE =_____/16
TOTAL SCORE (Gait + Balance ) =_____/28
{< 19 high fall risk, 19-24 medium fall risk, 25-28 low fall risk}
 4. Gait
 5.Mini-cog assessment instrument

11. GOAL-SETTING
 Functional independence is the ultimate goal.
 To relieve pain
 To improve or maintain ROM of different joint
 To improve or maintain strength and endurance of
movement
 To improve or maintain cardiovascular endurance
 To improve or maintain ambulatory status

12. THERAPEUTIC INTERVENTION
 RANGE OF MOTION EXERCISES
 Flexibility
decreases with age and joint become stiff
 Development of contracture, it develop within 1
week of inactivity
 Passive ROM: therapeutic benefits
 To maintain range of motion
 To prevent complication of inactivity
such as - contracture formation
- cartilage degeneration
-deep vein thrombosis etc

13. RANGE OF MOTION EXERCISES
 Active ROM: therapeutic benefits
 To preserve joint function
 To maintain physiological elasticity and contractility of muscle
 To maintain and improve ROM
 To induced muscle relaxation
 To decrease pain
 To increase circulation and thereby preventing DVT.
 To provide sensory feedback from the contracting muscle
 To provide a stimulus for bone and joint tissue integrity
 To improve neuromuscular coordination

14. STRETCHING EXERCISE
 1. Static stretching: the muscle tendon unit under a slow, gentle
stretch that is maintain for a period of 20 to 60 seconds
 2. proprioceptive neuromuscular facilitation stretching: the
inhibition technique that attempt to reduce muscle tone
 The most popular technique is Hold-Relax
 3.Ballistic stretching: it is contraindicated in
- elderly individuals
- sedentary individuals
- musculoskeletal pathology and
- chronic contracture
 Because,
 the high velocity, high intensity movement are difficult to control.
 Tissue weakened by immobilization or disuse, can be injured easily
 Dense connective tissues of chronic contracture become more brittle and
tears more readily

15. MOBILIZATION EXERCISE
 Joint mobilization stretching technique: specially use for
restricted capsular tissue
 Therapeutic benefits
 To stimulate the mechanoreceptors that may inhibit the
transmission of nociceptive stimuli at the spinal cord or brain
steam level
 To cause synovial fluid motion, this is the vehicle for bringing
nutrients to the avascular portion of the articular cartilage
 To prevent painful or degenerative stasis when a joint is
swollen or painful
 To elongate hypomobile capsular and ligamentous
connective tissue
 To mechanically distend the shorten tissue

16. STRENGTHENING EXERCISE
 Force-generating capability is prerequisite for
performing many everyday activities.
 Therapeutic benefits
 The increase in muscle strength
 Improve in neuromuscular co-ordination
 Improve stability of joint
 An increase in bone mineral density
 Lessen the amount of stress placed on the joints
that are mostly affected by degenerative process in
older adults

17. STRENGTHENING EXERCISE
 TYPES OF RESISTANCE:
 1. body weight:
 Body weight offers sufficient resistant for initial
training, similar to active ROM.
 Progression can be done by performing exercises
in different positions
 2. manual resistance:
 The main disadvantage of this exercise is that the
amount of resistance can not be measured
quantitatively.
 But experience therapist very well judge the amount
of resistance

18. STRENGTHENING EXERCISE
 3. mechanical resistance:
 Equipment ranges from simple to complex
 Incase of old-olds(>85 years) this equipment should not
be used, as it my result in to muscle soreness or
inhibition
 4.intensity of exercise:
 Start with base line assessment of intensity,
 Popular method is find out repetition maximum(RM)
 5.Frequency and duration:
 For each level of intensity, session are 2- 3 time a week
 A single session consist of 3 set of 10RM
 Resistance can be increase when 1 or 2 sets done in a

19. STRENGTHENING EXERCISE
 6.Rest intervals:
 Patient should rest from 1- 2minutes between sets
in a same session
 7. mode of exercise:
 Functional strength is affected not only by the
absolute ability to generate force but also by the
ability to generate force across the varying lengths
of the muscle during movement.
 So the strengthening exercise include dynamic
exercise as well as static exercises

20. AEROBIC EXERCISES
 This endurance activities that do not require
excessive speed or strength but do require on
cardiovascular system
 Therapeutic benefits
 Improvement in maximal cardiovascular functional
capacity: Older people can increase vo2 max to the
same relative degree as young people
 Improvement in the energy level:
decrease LDL and triglyceride level
increase HDL.
 Improvement in the body composition
 Reduction in fat mass and increase in muscle mass

21. AEROBIC EXERCISES
 Reduction in disability:
 improve stability of joint and thereby reduce disability
 Psychological well-being:
 lessen depression and improve belief in self-efficacy.
 Improvement of functional status
 Reduction in the risk of developing age-related
disease
 like coronary heart disease, HT, Atherosclerosis,
Diabetes and osteoporosis.

22. AEROBIC EXERCISES
 EXERCISE PROGRAM
 1.Aerobic warm-up: 5-7 min
 Indication: to reduce the chances of injury
 2.aerobic conditions:
 Protocol: mode,
 intensity- 60% of MHR,
 duration- 30 minute,
 frequency- 5 days in a week
 3.Cool down: 10 min
 Indication: To expedite the recovery process after aerobic
exercise
To prevent injury
 Protocol: slow walk for 5 minutes and slow exercises

23. GAIT TRAINING
 The purpose is to make a patient walk at functional speed.
Factors contributing the physical therapy intervention
altered gait of patient
1.difficulty in rising from place feet close to chair by flexing knees >90d,
sitting bend forward in sitting,
push from chair,
strengthening of triceps & latissimus dorsi,
adaptation height of chair
2.Increased thoracic correction in cervical spine position in sitting,
kyphosis with flexion in postural control training,
lower cervical spine and visual feedback in standing,
extension in upper Hold-Relax
cervical spine-
weight in all directions- forward, Backward, side
3.Unequal weight ways- for equal distribution in standing,
distribution- decreasing the size of support, eg. alternately raising
on toes and heels,
standing on balance board,

24. GAIT TRAINING
4.Increased stiffness suitable heat modality ,
and/or tightness of joint mobilization with precaution in case of osteoporosis,
soft tissues in Hold-Relax,
trunk, hip, knee and passive stretching or self stretching
ankle-
rhythmic stabilization ,
standing on different types of surfaces like foam,
5. Difficulty in concrete to alter sensory input,
maintaining weight standing with eyes closed,
bearing postures- isometric contraction of the postural extensor muscles in
shortened range against resistance ,
assess foot wear , hard sole, well fitted , lace- up shoes
with thick, absorbent socks are preferred,
recommended walking aid according to deficits and needs
of patient
faradic stimulation to ankle dorsi flexors,
hip hiking in parallel bar,
6. Foot clearance weight shifting to forwards and backwards,
problems- ankle mobilization to increase DF. ,

25. GAIT TRAINING
7.Difficulty with reciprocal swing of trunk rotation on mat,
legs- trunk twisting in sitting and standing,
4-point gait drills
resisted exercise with therabands or
8. Decrease strength of muscles – weights, training on isokinetic device ,
PNF technique
administration of aerobic exercise in
9. Decrease cardiovascular endurance – graded manner
strengthening of planter flexors ,
10. Decrease push-off – ankle mobilization to increase planter
flexion, standing on toes

26. ORTHOTICS
 The responsibility of physical therapist is to identify abnormal
positions and movements that are responsible for;
 pain,
 Misalignment of body segment,
 Difficulty in maintaining weight bearing position,
 Unequal weight distribution and
 Gait deviation
 Indications:
 To provide mobilization or to control movement
 To support a weakened structure
 To prevent deformity and correct anatomical alignment
 To promote ambulation and assist motion to improve body
function
 To relieve pressure on areas and to reduced pain

27. ORTHOTICS
 Principles:
 There should be a practical balance between the
objective that are ideally desired and the tolerance of
elderly patients
 The basic principle refers to the application of force to
the involved body segments.
 Comfort and tolerance are important for an elderly
patient
 Attempting biomechanical control is not appropriate in
most of geriatrics,
 Plastic orthosis is the choice in elderly patient,
 AFOs are well tolerated by elderly individual
 HKAFOs usually not recommended, as they are
cumbersome
 A hip orthosis is used to restrict the movement of hip

28. RE-ASSESSMENT
 There should be ongoing reassessment
while administering geriatric physical therapy
program.
 This enables to judge the effectiveness of
treatment towards the goal set, with a
required modification in the treatment
strategies.

29. REFERENCES
 1.principles of Geriatric Physiotherapy
By: Narinder Kaur Multani &
Satish Kumar Verma
 The core of Geriatric Medicine
By: Leslie S. Libow & Fredrick T. Sherman
 Rehabilitation of the older person
Third edition by: Amanda squires and Margaret
Hastings

30. THANK YOU..

31. BASIC ACTIVITIES OF DAILY LIVING
(Here; I-Independent, A-Assistance requires, D-
Dependent)
 A. Toilet:
I- Able to get to, on and off toilet, cleans self
A-Needs help, soiling or wetting while asleep more than 1week
D- Completely unable to use toilet
 B. Feeding:
I- Able to completely feed self
A- Feed self with assistance
D- Completely unable to feed self or need parenteral feeding
 C. Dressing:
I- Able to select cloths, dress and undress self
A-Need assistance

32. BASIC ACTIVITIES OF DAILY LIVING
 D. Grooming: (neatness, hair, nails, face, clothing)
I- Able to groom well without help
A-Needs assistance in grooming
D-Completely unable to care for appearance
 E. Physical Ambulation:
I-Able to get in/out of bed, roam around without help
A-Needs human or mechanical assistance
D-Completely unable to get in/out of bed/chair, walk
 F. Bathing:
I- Able to bathe(tub, shower) without assistance
A-Need assistance for getting in and out of tub or washing
more than one body part
D- Completely unable to bathe self

33. INSTRUMENTAL ACTIVITIES OF DAILY
BY: LIVINGM.P. LAWTON & E.M. BRODY
 A. Ability to use telephone:
I-Able to operate telephone on own initiative
A-Answered telephone but needs special phone or assistance in getting number
dialing
D- Unable to use telephone at all
 B. Shopping:
I-Able to take care of all shopping needs independently
A-Able to shop but needs to be accompanied on any shopping trip
D- Unable to shop
 C. Preparing meals:
I-Able to plan and prepare meal independently
A-Unable to cook full meal alone
D-Unable to prepare any meal
 D. Housekeeping
I-Able to maintain house independently
A-Able to do light work bt need assistance with heavy task
D-Unable to do any house work

34. INSTRUMENTAL ACTIVITIES OF DAILY LIVING
 E. Laundry
I-Able to launder independently
A-Launder small items such as socks, handkerchief
D-Unable to launder at all
 F. Travelling
I-Able to drive own car or travel independently
A-Needs assistance for travelling
D-Unable to travel
 G. Responsibility for own medication
I-Able to take medication in correct dose and time
A-Able to take medication if it is prepared in advance
D-Unable to take medication
 H. Ability to manage finances
I-Able to maintain finance s independently eg. Pay bills
A-Able to manage day to day purchases but needs assistance
D-Unable to handle money

35. MODIFIED PERFORMANCE ORIENTED
MOBILITY ASSESSMENT( POMA)
- Balance Tests -
Initial instructions: Subject is seated in hard, armless chair. The following
maneuvers are tested.
1. Sitting Balance Leans or slides in chair =0
Steady, safe =1
_____
2. Arises Unable without help =0
Able, uses arms to help =1
Able without using arms =2
_____
3. Attempts to Arise Unable without help =0
Able, requires > 1 attempt =1
Able to rise, 1 attempt =2
_____

36. MODIFIED PERFORMANCE ORIENTED
MOBILITY ASSESSMENT( POMA)
4. Immediate Standing Balance (first 5 seconds)
Unsteady (swaggers, moves feet, trunk sway)=0
Steady but uses walker or other support =1
Steady without walker or other support =2
_____
5. Standing Balance
Unsteady
=0
Steady but wide stance( medial heals > 4 inches
apart) and uses cane or other support =1
Narrow stance without support =2
_____
6. Nudged (subject at maximum position with feet as close
together as possible, examiner pushes lightly on subject’s
sternum with palm of hand 3 times)
Begins to fall =0

37. MODIFIED PERFORMANCE ORIENTED
MOBILITY ASSESSMENT( POMA)
7. Eyes Closed (at maximum position of item 6)
Unsteady
=0
Steady
=1 _____
8. Turing 360 Degrees Discontinuous steps =0
Continuous steps =1 _____
Unsteady (grabs, staggers) =0
Steady =1
_____
9. Sitting Down
Unsafe (misjudged distance, falls into chair) =0
Uses arms or not a smooth motion =1
Safe, smooth motion =2
_____

38. MODIFIED PERFORMANCE ORIENTED
MOBILITY ASSESSMENT( POMA)
- Gait Tests -
Initial Instructions: Subject stands with examiner,
walks down hallway or across room, first at
“usual” pace, then back at “rapid, but safe” pace
(using usual walking aids)
10. Initiation of Gait (immediately after told to
“go”
Any hesitancy or multiple attempts to start=0
No hesitancy=1

39. MODIFIED PERFORMANCE ORIENTED MOBILITY
ASSESSMENT( POMA)
11. Step Length and Height
Right swing foot
Does not pass left stance foot with step =0
Passes left stance foot =1 _____
Right foot does not clear floor completely
With step =0
Right foot completely clears floor =1 _____
Left swing foot
Does not pass right stance foot with step =0
Passes right stance foot =1_____
Left foot does not clear floor completely
With step =0
Left foot completely clears floor =1

40. MODIFIED PERFORMANCE ORIENTED
MOBILITY ASSESSMENT( POMA)
12. Step Symmetry
Right and left step length not equal (estimate) =0
Right and left step length appear equal =1
_____
13. Step Continuity
Stopping or discontinuity between steps =0
Steps appear continuous =1
_____
14. Path (estimated in relation to floor tiles, 12-inch
diameter;
observe excursion of 1 foot over about 10 ft. of the course)
Marked deviation =0
Mild/moderate deviation or uses walking aid =1
Straight without walking aid =2

41. MODIFIED PERFORMANCE ORIENTED
MOBILITY ASSESSMENT( POMA)
15. Trunk
Marked sway or uses walking aid =0
No sway but flexion of knees or back or
Spreads arms out while walking =1
No sway, no flexion, no use of arms,
and no Use of walking aid =2 _____
16. Walking Stance
Heels apart =0
Heels almost touching while walking =1 _____
GAIT SCORE = _____/12, BALANCE SCORE =
_____/16
TOTAL SCORE (Gait + Balance ) = _____/28
{< 19 high fall risk, 19-24 medium fall risk, 25-28 low fall risk}

42. MINI-COG ASSESSMENT INSTRUMENT
 1) Inside the circle, please draw the hours of a clock
as they normally appear
 2) Place the hands of the clock
to represent the time: “ten
minutes after eleven o’clock”
 The Mini-Cog Assessment Instrument for
Dementia
 The Mini-Cog assessment instrument combines an
uncued 3-item recall test with a clock-drawing test
(CDT).
 Mini-Cog can be administered in about 3 minutes,

43. MINI-COG ASSESSMENT INSTRUMENT
 Administration
 1. Instruct the patient to listen carefully to and
remember 3 unrelated words and then to repeat the
words.
 2. Instruct the patient to draw the face of a clock, either
on a blank sheet of paper, or on a sheet with the clock
 circle already drawn on the page. After the patient puts the
numbers on the clock face, ask him or her to draw the
 hands of the clock to read a specific time, such as 11:20.
These instructions can be repeated, but no additional
 instructions should be given. Give the patient as much time as
needed to complete the task. The CDT serves as the
 recall distractor.
 3. Ask the patient to repeat the 3 previously presented
word.

44. MINI-COG ASSESSMENT INSTRUMENT
 Scoring
 Give 1 point for each recalled word after the CDT distractor. Score 1–
3.
 A score of O indicates positive screen for dementia.
 A score of 1 or 2 with an abnormal CDT indicates positive screen for
dementia.
 A score of 1 or 2 with a normal CDT indicates negative screen for
dementia.
 A score of 3 indicates negative screen for dementia.
 The CDT is considered normal if all numbers are present in the
correct sequence and position, and the hands
 readably display the requested time.

45. GERIATRIC DEPRESSION SCALE
(MOOD SCALE)
 Choose the best answer for how you have felt over the past week:
 1. Are you basically satisfied with your life? YES / NO
 2. Have you dropped many of your activities and interests? YES / NO
 3. Do you feel that your life is empty? YES / NO
 4. Do you often get bored? YES / NO
 5. Are you in good spirits most of the time? YES / NO
 6. Are you afraid that something bad is going to happen to you? YES /
NO
 7. Do you feel happy most of the time? YES / NO
 8. Do you often feel helpless? YES / NO

46. GERIATRIC DEPRESSION SCALE
(MOOD SCALE)
 9.Do you prefer to stay at home, rather than going out and doing new
things? YES / NO
 10. Do you feel you have more problems with memory than most? YES /
NO
 11. Do you think it is wonderful to be alive now? YES / NO
 12. Do you feel pretty worthless the way you are now? YES / NO
 13. Do you feel full of energy? YES / NO
 14. Do you feel that your situation is hopeless? YES / NO
 15. Do you think that most people are better off than you are? YES / NO
 Answers in bold indicate depression. a score > 5 points is suggestive of
depression and should warrent a follow-up interview. Scores > 10 are almost
always depression.