Download PT Intervention/Examination in Geriatrics

Frailty,
Complex Cases in
Geriatrics
Min H. Huang, PT, PhD, NCS
Learning Objectives
• Define frailty from Fried model and dynamic
frailty model
• Explain the measurement of frailty in older
adults
• Adapt physical therapy management for frail,
complex geriatric clients
• Utilize Modified Physical Performance Test to
measure frailty for geriatric clients
Reading Assignments
• Guccione 2012 Chapter 9, Chapter 26
Frailty
• NOT a disease or a characterization that
differentiate disability or old age
• A combination of a variety of medical
problems or conditions
• A biological syndrome of decreased reserve
and resistance to stressors
• Resulting from cumulative declines across
multiple physiological systems
• Cause vulnerability to adverse outcomes
Frailty
• Cognitive impairment should be included in
the definition of frailty
―cognitive impairment was associated with
chronic disability, long-term nursing home
stay, and death
• Frailty is associated with cardiovascular
disease, low education and poverty,
hospitalization, institutionalization, death,
increased risk for falls, deteriorating mobility,
and disability.
Association of brain pathology with the
progression of frailty in older adults
• The accumulation of common brain
pathologies contributes to progressive
physical frailty in old age
• The presence of macroinfarcts, Alzheimer
disease, Lewy body pathology, and nigral
neuronal loss was associated with a more
rapid progression of frailty (all p values
≤0.010)
Buchman 2013. Neurology. 2013 May 28;80(22):2055-61.
A chronic inflammation process,
impaired immunity, neuroendocrine
dysregulations and metabolic
alterations seem to be related to
frailty but true comprehension of
the involved pathway is still lacking
Traditional Definition of Frailty: Fried
Model
• Frail: a person meets > 3 of the criteria
• Prefrail: a person meets 1 or 2 of the criteria
Fried 2001
Criteria used to define frailty in Fried
model
• Weight loss: loss > 10 lb unintentionally in the
past year
• Exhaustion: CES-D Depression scale (selfreport question)
• Physical activity: men < 383 Kcals; women <
270 Kcals
• Walk time: time to walk 15 ft stratified by
gender and height
• Grip strength
Fried 2001
Fried 2001
Lally & Crome,
2007
Lally & Crome, 2007
Relationships between frailty,
comorbidity, and disability (Fried 2001)
Comorbidity: >2 diseases
Frailty Defined by Deficit
Accumulation: Dynamic Model
• Instruments to measure frailty have been
developed based on the recent concepts
of frailty as a result of cumulative deficits
• Frailty instruments are mainly developed
as risk assessment tools, i.e. prognostic
instruments, NOT as outcome measures
• Instruments typically consider multiple
factors that are associated with frailty.
N.M. de Vries et al. / Ageing Research Reviews 10 (2011) 104–114 105
8
Categories
of Frailty
Factor
Dynamic concepts of frailty measured
by Frailty Index
• Score based on the accumulation of deficits
• Number of health deficits (symptoms, signs,
disabilities, laboratory, radiographic) out of a
list of possible deficits
• Use a continuous scoring system
―Thereby can discriminate and measure change after
an intervention
―Can capture the dynamic nature of frailty
• A cut-off value for frailty has not been NOT
specified
Frailty IndexComprehensive
Geriatric
Assessment
(FI-CGA)
The number of deficits is important:
more deficits  increased risk of an adverse
health outcome  more risk of frailty  more frail
Rockwood
& Mitnitski
2011
PT to prevent functional decline in
physically frail, elderly person (Gill 2002)
• n=188; 75+ y.o. physically frail elderly living
at home
• 6 month home based program
―Intervention: PT focusing on improving balance,
strength, transfer and mobility
―Control: an educational program
• Intervention group had significantly less
functional decline (8 ADLs) over time (up to
12 months) than control group.
―Effect was seen among elderly with moderate frailty
but NOT those with severe frailty
PT to prevent functional decline in
physically frail, elderly person (Gill 2002)
PT to prevent functional decline in
physically frail, elderly person (Gill 2002)
Physical and performance measures
to identify mild to moderate frailty
• Brown et al (2000) studied the correlation of
physical measures (UE and LE strength,
ROM, balance, coordination, sensation, and
gait) with a 36-point Modified Physical
Performance Test (Modified PPT)
• Physical measures correlated with PPT
• Frailty according to the PPT score
―NOT frail = 32-36
―Mildly frail = 25-31
―Moderately frail = 17-24
Comprehensive Geriatric Assessment
(CGA)
• Multidimensional, multidisciplinary diagnostic
instrument
• Usually coordinated by a case manager
• Used to collect data on the medical,
psychological, functional capabilities and
limitations of complex elderly patients.
• To develop a coordinated and integrated plan
for treatment and follow-up, including primary
care and rehabilitation, and make the best
use of health care resources.
Comprehensive Geriatric Assessment
(CGA)
• CGA focuses on
―Elderly individuals with complex problems
―Functional status and QoL
―Frequently takes advantage of an
interdisciplinary team of providers
• The "Five I's of Geriatrics“ are easily
missed in a standard medical evaluation
―intellectual impairment, immobility, instability,
incontinence and iatrogenic disorders
• http://ocw.tufts.edu/data/42/499797.pdf
Benefits from the utilization of CGA
• Provide diagnostic and prognostic indicators
• Reduce length of hospital stay and
readmission
• Predict survival and detect tolerance for
chemotherapy in older cancer survivors
• Reduce the prevalence of orthostatic
hypotension
• Identify elderly patients at risk for mortality,
post-discharge institutionalization, adverse inhospital events, and prolonged length of
hospital stay with pre-operative CGA
Components of the CGA
•
•
•
•
•
•
•
•
•
•
MMSE or Mini Cog for cognition
Geriatric Depression
ADL scale (Katz Index)
Physical Performance Test (PPT)
Vulnerable Elders-13 survey (VE-13)
Barthel Index (BI)
Pain Scale
Nutritional assessment
Functional assessment
Gait assessment (various tools used)
PT consideration for frail elderly
• Evaluation: thorough including PMH, lab values,
meds, social hx, nutritional status
• Goal creation: modified as needed depending on
level of illness/disability
• Falls in SNFs 3x the rate of community dwellers
• Fall risks: history of falls, weakness (1° quads),
balance deficit, gait deficits (slowed walking
speed), presence of ophthalmic disease, also a
change in living conditions in the past 2 years
J Blackwood
Comparison
of Causes of
Falls in
Nursing
Home and
CommunityLiving
Populations
Ranked by
Prevalence
Case 1
• 71-year-old female, widowed, lives alone in a
2-story home 3 steps to enter/ B/B on 1st
floor
• PMH: osteoarthritis, CHF with an ejection
fraction of 30%, COPD, bladder incontinence,
hypothyroidism, gout, osteoporosis, noninsulin-dependent diabetes mellitus, and a
history of a left distal femur fracture in 2007.
• PSH: CABG x4 in 2001, lumbar laminectomy
(L3-L5)in 1998, and pacemaker implantation
six months ago.
J Blackwood
Case 1 (continued)
• Meds: acetaminophen Flexeril, digoxin, Lasix,
Levothyroxine, nitroglycerin, Zoloft,
Coumadin, Cipro, and Zocor
• HPI: The patient fell onto her right side 1
week ago at home while going outside to
retrieve the mail and was hospitalized for
three days for dehydration and a UTI. All xrays were negative for fracture.
• PT eval and treat in her home.
Systems review: mental status
• Common causes of mental status change
―hypoxemia, anemia, hyperglycemia, electrolyte
imbalances, malnutrition, dehydration, and
polypharmacy
• Delibrium vs. dementia
―Can coexist.
―Delirium is a typically acute onset of inattention,
disorganized thinking, a change in the level of
consciousness, disorientation, decreased memory,
perceptual disturbances, and altered sleep–wake
cycles.
Systems review: vital signs
• HR regularity: < 6 interruptions in the rhythm
in 1 minute
• Normal pulse pressure= 40 mmHg (e.g.
resting BP = 120/80 mmHg, 120-80 = 40)
• OH: a drop in systolic BP by 20 mmHg after
standing 2-3 min from supine, or a drop by 10
mmHg with a reflexive increase in HR with
transitional movements, e.g. supine-to-sit or
sit-to-stand
• Response to exertion, pulmonary function
Systems review: OH
• Causes: adverse effects of drugs, anemia,
dehydration, arrhythmias, immobility, sepsis,
adrenal insufficiency, ANS dysfunction due to
DM, Parkinson's CNS impairments
• Patients may or may not have symptoms and
thereby it is difficult to use symptoms as an
indicator
• PT must screen the patient's BP with position
changes to rule out orthostatic hypotension
• Patients with OH are at risk for sustaining
injuries, including falls, fractures, and MI
Systems review
• Senses: vision, hearing
• Bowel/bladder continence
―Detective work
• Nutrition and body composition
• Tests: ROM, strength, aerobic capacity, selfcare activities, various outcomes measures
(Berg, Tinetti, TUG)
• Gait speed: 0.4-0.5 m/sec in institutionalized
elders
Tests and measures
• Choose ones that reject or confirm a
hypothesis
• ‘Correct’ tests and measures are ones that
provide data that allow the PT to make a
plausible inference about the patient’s
condition.
• Used to clarify the extent of a functional
limitation or disability
Test of muscle strength
• Limitations of MMT
― NOT a quantitative assessment tool
― LACK accuracy due to its severe ceiling effect
―Does NOT correlate with functional tasks on certain
patients
―Some patients with cognitive impairments, ROM, or
mobility limitations have problems with MMT
• Functional testing for muscle strength:
―If a patient is able to stand up from a chair without the
use of his or her arms, it is safe to assume that
strength on the quadriceps is at least 4
MRC (Medical Research Council) sum
score
• Quantify global muscle strength
―3 muscle groups in UE (shoulder abduction, wrist
extension, grip strength)
―3 muscle groups in LE (hip flexion, knee extension,
ankle dorsiflexion)
―Score between 0 (no muscle movement) and 5
(normal strength) for each muscle group
―A maximum total score of 60
• Reliable and valid too for critically ill patients
―Severe weakness score < 36
―Significant weakness <48
Evaluation
• Purpose
―To indicate which deficiencies in function are
present
―To identify the impairments most associated
with the current level of function and which
may be remediated
• Consider quality of data, likelihood of
error, and the risk to the patient when
evaluating the meaning of the data
Impairments as related to function
ICU acquired weakness
• Minimal criteria for diagnosing ICU-acquired
weakness = 1, 2, 3 or 4, 5
1. “Generalized weakness developing after the onset of
critical illness
2. Weakness is diffuse (involving both proximal and
distal muscles), symmetric, flaccid, and generally
spares cranial nerves
3. MRC sum score <48 or mean MRC score, 4 in all
testable muscle groups noted on <2 occasions
separated >24 hours
4. Dependence on mechanical ventilation
5. Cause of weakness not related to the underlying
critical illness has been excluded
Diagnostic criteria of UTI in nursing
home residents
• Nursing home residents without a catheter
― 3+: (1) a fever > 100.4°F or greater (2) new or
change in burning of urination, frequency, or
urgency (3) new flank or suprapubic pain (4)
change in color, consistency, or cloudiness of
urine (5) change in mental or functional status.
• Nursing home residents with catheters
―2+: (1) fever as noted earlier (2) new flank or
suprapubic pain (3) change in presence of urine
(4) change in mentation or functional status
Dehydration
• Account for nearly 40% of all hospitalization
admissions in older adults.
• Older adults are susceptible to dehydration
because
―a blunted thirst mechanism
―a reduction in total body fluid with the reduction in
muscle mass and an increase in body fat
―a decrease in renal function that concentrates the
urine prevents the body from retaining enough fluid to
avert dehydration.
―comorbidities
Type of dehydration
• Hypertonic dehydration
―Water loss > Sodium loss
―Common in presence of infection or exposure to hot
environmental temperatures
• Isotonic dehydration
―Water loss = Sodium loss
―vomiting and diarrhea
• Hypotonic dehydration (*Most common type)
―Water loss < Sodium loss
―Use of diuretics (e.g. Diuril, Lasix)
Metabolic syndrome: > 3 cardiovascular risk factors
associated with MI
* specific criteria which may differ according to source