Gerontology Case Studies
Is the MoCA able to best test for MCI?
The MoCA is a very reliable screening tool for MCI. It is known to have a high sensitivity; however, it does not have as great of an ability to distinguish MIC from dementia as other MCI screening tools do.
What implications do her balance deficits have on your intervention plan?
Balance deficits in patients with osteoporosis should be addressed in the plan of intervention in order to reduce the risk of falls and consequential bone breaks or fractures. By applying the principle of progressive overload and specificity we can gain short term benefits from a balance-training program with this patient. Teaching safe gait patterns and utilizing a mobility aid when needed should also be included in the program.
What is the incidence of osteoarthritis?
1 in 4 or 54.4 million US adults have some form of arthritis. Osteoarthritis is the most common and affects 32.5 million US adults. The annual incidence of knee OA is highest between 55 to 64 years old, and 62% of those with OA are women.
How common is gait abnormality in persons age 65 years and older?
13% of those age 65-69 self report feeling imbalance and 35% of adults age 70+ have a gait abnormality.
What test/measure is needed for this patient?
For this patient, we would like to assess if she is at risk for falls since she had a loss of balance causing her skin-tear. Due to her age and being immobilized during her hospital stay, we believe it would be useful to get her TUG score as a pretest measure. We chose the TUG test because it replicates her loss of balance from her sit-to-stand transfer and to assess her mobility. We will determine our plan of care from her TUG score to reduce the risk of falls and recurrence of her skin-tear.
Develop an initial plan of care consisting of four to six interventions.
1. Modalities (moist heat) 2. Manual therapy (long axis distraction) 3. Therapeutic exercise (hip/lower extremity strengthening), that does not involve high impact activites 4. Neuromuscular rehabilitation (balance training) 5. Acetaminophen and NSAAID drugs
What is the importance of the gait velocity?
Gait velocity can be a reliable tool for assessing functional status and the overall health of a patient; it has even been called a "6th vital sign." Gait velocity can determine some of the following predicted outcomes: risk of death, likelihood of hospitalization, falls, and risk for cognitive decline. There is correlation with slower gait speed with the previous predicted outcomes while faster gait speed has correlation to decreased likelihood of hospitalization, increased ability for independent ADLs, and decreased falls risk.
What are the signs of hyperkalemia?
Hyperkalemia is a condition in which you have too much potassium in you blood due to not excreting enough, excess intake or leakage of potassium from cells. It can present itself as paresthesias or fasciculations in arms and legs.
Based on the 6MWT, how does she compare to others her age and what is needed?
A comprehensive meta-analysis (Bohannon) found that the average distance for participants aged 80-89 years old (yo) was 446 meters overall but was 382 meters for females within that age range. Regardless, this patient was much lower at a distance of 310 meters. Several factors could affect the score such as gender, height, body mass index (BMI), and chronic diseases such as chronic obstructive pulmonary disease (COPD) which was the case for our patient.
Which of the risk factors from question 1 are non-modifiable?
A few of the risk factors from question 1 that are non-modifiable are history of falls, gender, and older age. The case does not state that Nancy has a history of falls. However, Nancy is a 76-year-old woman, and it known that older women are more likely to be affected by osteoporosis because of hormonal changes that happen with menopause. Some other non-modifiable risk factors, not mentioned in question 1, that pertain to Nancy are her recent fracture that she sustained, her prior wrist fracture on the opposite arm, and a potential family history of osteoporosis (which may or may not pertain to her, it is not stated).
What type of medication is Altace?
Altace is an Angiotensin-Converting-Enzyme (ACE) inhibitor and an anti hypertensive. It works by inhibiting the angiotensin converting enzyme by decreasing the formation of Angiotensin II. This prevents acute vasoconstriction from Angiotensin II to decrease blood pressure. It also prevents vascular hypertrophy from Angiotensin II (strong vasoconstrictor).
What recommendations would you make today?
Before sending the patient home, we would put an emphasis on knowing when to take his medication and how much, and we would ensure that he understands both. We would tell him to drink plenty of water throughout the day and to always satisfy the "thirst mechanism" with water. We would recommend avoiding deep-fried foods. With regard to his exercise program, We would recommend doing 1-2 10-to-15-minute walks per day and focusing on avoiding a sedentary lifestyle by doing things like standing more when he usually sits or parking further away from the grocery store or a restaurant to get in some extra steps
What is congestive heart failure?
CHF occurs when the heart's capacity to pump blood is unable to keep up with the body's need. The term "congestive" refers to buildup of fluid in the organs, and CHF affects almost 6 million Americans annually. The most common cause of CHF is coronary artery disease, and people with CHF often have symptoms of fatigue, arrythmia, difficulty breathing, and/or buildup of fluid in the legs. Can be caused by sedentary lifestyle, stress, or even smoking. CHF is usually diagnosed by a local cardiologist and may require more than one visit. The outlook for people suffering from CHF is usually good, however transplants or serious intervention may be required.
What specifically should be communicated?
Discussion should include that her vital signs during her PT session indicate hypertension which is not in her past medical history. It would also be pertinent to discuss the relationship between her sarcopenia, osteoporosis, and obesity and the consequences of these chronic diseases. It would also be worth this discussion of diet and nutrition regarding Josie and how malnutrition may be impaction sarcopenia, osteoporosis, and obesity.
What intervention strategies can we offer as physical therapists to help treat osteoporosis?
Combinations of closed kinetic chain (low force) (eg, progressive strengthening, balance training, endurance training), paired with open kinetic chain (high force) (eg, flexibility/stretching, progressive strengthening, endurance training) should be considered to optimize bone health.
Is communication with Josie's primary care physician appropriate?
Communication with Josie's primary care physician is appropriate to communicate the concerns that you have following Josie's evaluation. It is also pertinent to ensure the primary care physician and the physical therapist are on the same page moving forward with Josie's care and that Josie is being educated on the significance of her multiple diagnoses
How does obesity play a role in this case?
Excess weight in the older population has negative effects on their daily functioning, social lives, and even mental health. Obesity even puts people at risk for chronic diseases. Her changes in lifestyle could have led to the increased excessive fat tissue accumulation which is accelerated as one age. Her reduced physical activity and capacity for activity in daily living contribute to her obesity often making her daily living more difficult. This is shown especially after playing with her grandkids as she complains of tiredness and weakness in her muscles.
Certain components of diet and nutrition are more critical to healthy aging. Why is folic acid important?
Folic acid is important to incorporate into the diet because it produces cells, specifically red blood cells. Folic acid deficiency results in fatigue, weakness, concentration issues, irritability, headache, heart palpitations, and shortness of breath. There are recent studies showing folic acid can both prevent cancer and fight against it, although the reasons for this are still unclear. Folic acid can also reduce the risk for cardiovascular disease and stroke by reducing homocysteine.
Outline a comprehensive plan for preventing these types of tissue injuries from reoccurring.
For preventing these types of tissue injuries from occurring in our patient in the future, a comprehensive plan should be put into place. First manner that should be addressed is creating a safe home environment for the patient, thereby reducing the risk of injury. The patient reported initially injuring herself by bumping into the armrest while transferring from the wheelchair to the bed. Small adjustments in the home can make an enormous difference in creating a safer environment. "Ensuring adequate lighting, padding hard-surfaced equipment (such as bed rails or wheelchair arms) and removing rugs & unnecessary furniture, minimizing the risk of trauma." The physical therapist should focus on gait training during transfers to promote safety during dressing, bathing, toileting, and ambulating. Next factor that should be considered for preventing tissue injuries from occurring would be nutritional education by establishing an adequate nutritional balance meal plan throughout the day and maintaining hydration both are critical in promoting tissue integrity and decreases the risk of fall that could lead to skin tears or even fractures. The final factor to ensure the hindrance of tissue injuries would be wearing appropriate clothing such as "long sleeves, long pants, and knee high socks can provide an additional protective barrier and are all recommended garments for patients at risk.'' If skin tears do occur proper wound healing techniques should take place to prevent exposure to infections and trauma recurrence. With this comprehensive plan in place; gait training, nutritional education, and providing clothing barriers should reduce the potential risk for new or recurring skin tears and delayed wound closure.
What strength interventions will you employ to improve your patients mobility?
For strengthening, resistance bands would be used to perform resisted knee and ankle range of motion exercises. Some examples include resisted hamstring curls, resisted plantarflexion/dorsiflexion, and straight leg raises. It would also be important to include a balance training program. Some balance training exercises that would be employed include single leg stance, tandem stance, sideways walking with resistance, and sit-to-stands.
Why would handgrip strength be a useful measure?
Handgrip strength has been shown as a reliable indicator of determining overall muscle strength, which can then help clinicians determine the extent of a disease's progression. Low grip strength in the dominant hand is associated with low bone-mass density in the lumbar spine, femoral neck, and hip. Low handgrip strength is also associated with a risk of falling, which is one of the highest concerns for osteoporosis patients. Handgrip strength has been utilized in osteoporosis patients as a risk factor for the disease and to assess its progression. Furthermore, there is a high osteoporosis risk in postmenopausal women with grip strength below 20 kg. Lastly, handgrip strength will be useful as a measure of progression as the patient works to become stronger.
Will her mental status affect the home exercise program you give to the patient?
Her mental status could affect the home exercise program that the patient is given. She scored a 22/30 on the MoCA. A 26 or above on the MoCA is considered normal, and people with mild cognitive impairment typically score around 22.1, indicating that she could be suffering from a mild cognitive impairment. For her to cooperate with the HEP, you may have to write it down and give her step-by-step instructions and/or pictures of the exercises she should perform to enable her to better remember the HEP.
Should you as a physical therapist recommend her seeing her primary care physician or a neurologist?
I would recommend she see a neurologist. It is important to correctly diagnose cognitive impairments so if there is an issue treatment can be started right away. Also, neurologists can conduct more in-depth tests and procedures that may be a primary care physician does not have access to.
What type of exercise program would you begin with?
In general, patients with congestive heart failure should start with exercise programs that are slow and steady and increase aerobic capacity. Walking is considered the baseline exercise because it can be performed at a slow, fast, or moderate pace. Patients should start walking slowly and increase to a moderate pace over the course of a few minutes. Patients should then walk at a moderate pace for 5-10 minutes. This process should be repeated 3-4 times per day with adequate rest intervals on most days of the week.
What secondary health concern is worrisome?
Indications of undiagnosed hypertension are worrisome especially as hypertension is often tied with sarcopenia, osteoporosis, and obesity. The possibility of hypertension in conjunction with sarcopenia, osteoporosis, and obesity implies the risk of type 2 diabetes mellitus. The combination of sarcopenia and osteoporosis also implies the risk of frailty which is especially important to consider as Josie has reported that fatigues easily and is falling as a result of that fatigue. Also, her gait speed of 0.8 m/s is another indicator that she has an increased fall risk which is especially concerning with her co-morbidity of osteoporosis.
What physical therapy interventions should be included in Josie's plan of care?
Josie's physical therapy interventions should focus on full-body resistance exercises. The lower body muscle groups, such as the quadriceps, hamstrings, and gluteal muscles, should be prioritized to allow the patient to walk, stand up, and go up/down the stairs. The upper body muscle groups including the back, chest, shoulder, and arm muscles should be focused on to assist with functional daily activities. Training frequency should be 2-3 times a week and intensity levels should begin at 40-60% 1RM. Exercise volume should start at 1-3 sets and 6-12 repetitions with rest periods of 60-120 seconds between sets and 3-5 minutes between exercises.
Why is Lewis a good candidate for conservative treatment rather than more invasive treatments such as a total hip arthroplasty?
Lewis is a good candidate for conservative treatment rather than a more invasive treatment because of his prior functional ability and physical activities he participated in. He wants to get back to hiking/walking with his wife without pain. So, conservative, continual physical therapy treatment is preferred because he is an active older adult, and long-term, he will increase his VO2 max, increase muscular strength, decrease pain, increase function, and fewer days sick/hospitalized. All of these will help Lewis get back to him feeling like his normal self.
What other issues related to medical history can impact wound healing?
Medical history details such as alcohol consumption, nutrition, history of smoking, cardiovascular disease, diabetes, and obesity can adversely affect the wound healing process. For example, smoking has shown to delay the process of healing, while also increasing the possibility of wound infection. Tobacco substances and nicotine also affect oxygen diffusion and blood perfusion negatively. Alcohol consumption has a similar effect on wound healing in the way that it promotes infection and suppresses pro-inflammatory responses from the body to a new wound. Hypoxia may be a common side effect of chronic conditions like cardiovascular disease and diabetes. The combination of hypoxia and perfusion would negatively impact wound healing if a patient had these conditions. Due to this patient having a medical history of chronic obstructive pulmonary disease (COPD), hypoxia could be a side effect. Hypoxia could amplify the early inflammatory response in the patient's body, prolonging the recent skin tear injury.
how is gait abnormality defined by Medicare?
Medicare states that the gait evaluation and training to be tailored to a patient who has developed an abnormal gait pattern due to a neurological, muscular, or skeletal abnormality. Medicare says that gait training can be reasonable and necessary for a patient if the patient has a good prognosis for improving their ability to walk. A gait abnormality can be defined as a difference in any of the different gait parameters, like step length varying from step to step. The variability of gait tends to increase as age also increases.
How is MCI diagnosed?
Montreal Cognitive Assessment
What is My Plate for Older Adults?
My Plate for Older Adults serves as a nutritional guide for those advancing in age in efforts to promote healthy eating and physical activity. The graphic includes bright colored vegetables, deep colored fruits, whole grains, low-fat dairy products, lean meat and eggs, dry beans, liquid vegetable oils, water, and fat-free milk.
Is running a risk factor for osteoarthritis?
No, running is not a risk factor for developing hip or knee OA.
What risk factors present are indicative of osteoarthritis?
Nonmodifiable risk factors for OA include age, sex, ethnicity, genetics, previous injury or joint trauma. Modifiable risk factors for OA include excess weight, certain occupations and sports, joint injury, joint malalignment and quadriceps weakness.
What are consequences of poor nutrition?
Nutrition is important in older adult populations. When older adults do not get the proper nutrients, it can lead to consequences. Older adults have a weaker immune system and are more susceptible to infections, slower recovery and slower wound healing when they do not have the proper nutrients. Poor nutrition can also lead to weight loss, decrease in bone mass, and muscle weakness; which can lead to an increased probability of falls and fractures. Depression, memory loss, and the feeling of being tired can also be consequences for malnutrition in the older population.
What in the patient's past medical history can affect the likelihood of delayed healing from a nutritional standpoint?
Nutritional factors such as malnutrition, alcohol and caffeine consumption, vitamin intake, and water intake may affect the integumentary system and the healing process. The patient had a recent weight loss of 20 pounds within 2 months, which is a likely indicator of malnutrition. It is known that malnutrition causes decreased wound healing due to a number of factors. The wound healing process is complex and requires a number of vitamins and minerals from the diet for skin repair to occur. Vitamin A for example is essential for epithelial tissue development. Vitamin C is essential for the production of collagen, proteoglycans, and other components of the intracellular matrix of the skin. Zinc is a mineral that is necessary for protein synthesis and therefore tissue regeneration. It is also known that adequate protein intake is crucial for wound healing as it is the basis for the synthesis of collagen and proteoglycan. The depletion of protein can prolong the inflammatory response and prevent healing of skin tears. It is important that those who are more susceptible to skin tears and those with skin tears are receiving adequate nutrition to support healing and regeneration. The patient's history with inflammatory bowel syndrome may also be contributing to malnutrition as damage to the GI tract can lead to a decrease in nutrient absorption.
Why would we be concerned with frailty?
Older adults are more susceptible to frailty due to a progressive loss of skeletal tissue, muscle mass, and strength, especially in the lower extremities which results in a decrease in the individual's functional ability to maintain balance and gate. Josie a 70-year-old female, has already comorbidities like high blood pressure, obesity, and osteoporosis which add extra risks to average age decline, and thus, she is more likely to have falling events.
Which of the risk factors from question 1 are modifiable?
One risk factor that is modifiable is a lack of physical activity. Regular physical activity helps strengthen muscle and bone in moderate to vigorous exercise for just 90 minutes a week and is recommended with individuals with osteoporosis. This increase in activity can also be beneficial for reducing the risk of falls and fractures related to falls.
Consider the patient's medical history and medications. How do steroids impact the wound healing process?
Our patient's medication list includes Aspirin and Fluticasone. Antiplatelet drugs and prolonged steroid use can have an adverse effect on the healing process. NSAIDs like aspirin inhibit clot formation and have a dual impact on the inflammatory phase. Steroids and anti-inflammatory medications can alter the skin's reaction to daily traumas. Fluticasone is a glucocorticoid steroid that has a general catabolic effect on connective tissue. Bone, ligaments, tendons, and skin are subject to the wasting effect of prolonged glucocorticoid use by inhibiting genes responsible for collagen which is already decreased in the older adult.
1. What risk factors present may lead you to believe that Nancy may have osteoporosis?
Some common risk factors for developing osteoporosis include: a lack of physical activity, increased fall risk, a history of falls, gender, and older age. Nancy is a 76 year old woman who lives alone and lives a sedentary lifestyle which predisposes her to developing osteoporosis. Nancy also shows increased fall risk as shown in her fall efficacy score and 4 square step test (18.5).
What are some of the age-related changes in gait?
Our strength peaks when we are in our mid-twenties, but then it will only slowly decline from mid-twenty until we meet our fifth decade of life, once we turn 50, there will be a much more rapid decline in strength. Sensory function will also decline with age, but usually only modestly in the absence of disease. Gait speed should stay relatively stable until age 70. After 70 years of age, gait speed should begin to slow modestly, about 15% per decade. Due to the slower gait pattern, you will also see a smaller stride length and less time in single limb support, more time in double limb support. These changes will negatively impact a healthy elderly person of being able to walk with speed and efficiency.
Explain the principle of overload and how it relates to this case.
Overload states that physical demands must increase beyond the muscles ability to see strength increases. Similarly, progressive increases in weightbearing on bones is required to encourage bone remodeling and growth. For our patient with osteoporosis, weight bearing is important to encourage maintenance of bone density.
What tests could you use to determine that this individuals is not a risk for falls?
The 30-second Chair stand test, Timed Up and Go (TUG), Dynamic Gait Index, Steadi Four Stage Balance Test, Four Square Step Test, Orthostatic Blood pressure, and Allen Cognitive screen.
How is pitting edema measured & scaled?
Pitting edema is measured by putting pressure on the affected area and then measuring the depth of the depression and how quickly it regains its original form. The grading scale goes from +1-+4. Grade +1: up to 2mm of depression, rebounding immediately. Grade +2: 3-4mm of depression, rebounding in 15 seconds or less. Grade +3: 5-6mm of depression, rebounding in 60 seconds. Grade +4: 8mm of depression, rebounding in 2-3 minutes.
Are there other screens/tests commonly used for cognition?
The Blessed Information Memory Concentration (BOMC)/six-item Cognitive Impairment Test (6-CIT) and the Orientation-Memory-Concentration test, The Clock Draw Test (CDT), The Mini-Mental Status Examination (MMSE), The Short Portable Mental Status Questionnaire (SPMSQ), The Saint Louis University Mental Status (SLUMS), and The Rowland Universal Dementia Assessment Scale (RUDAS)
Would you define/describe this patient as frail, why or why not?
Sarcopenia syndrome and frailty syndrome have yet to be proven to have a causative relationship between two. Though they share similar pathophysiological displays, we cannot deem a patient with sarcopenia syndrome as frail. Sarcopenia syndrome can be part of frailty syndrome, but frailty syndrome has yet to be established as a component of sarcopenia syndrome. In summary, a patient can have sarcopenia syndrome without being frail. Josie demonstrates weakness and fatigue which are signs of both sarcopenia and frailty. Based on her symptoms, there is a chance that Josie has frailty syndrome, but further tests need to be completed. Due to the lack of research and evidence, I would not describe this patient as frail unless the patient has been diagnosed with frailty syndrome.
Why is improving balance and preventing falls a focus of concern for you with this patient?
Since this patient may have osteoporosis, I would want to focus on balance training because balance training has been shown to have a significant effect on lowering the number of falls in patients that have osteoporosis. Because osteoporosis causes a decreased bone density, individuals with the condition are more likely to sustain fractures when they experience falls Even if she doesn't have it, balance training will still lower the number of falls and help her to be more confident and independent at home.
What are the social determinants of health that may be impacting the wound healing and other health-related issues or the PT Plan of Care?
Social determinants of health can be classified as socioeconomic status, environments, psychosocial factors, and social support networks. These factors can impair wound healing by increasing pain, risk for infections, decreasing inflammatory responses and affecting hormonal responses. Our patient is an 82-year-old female who just lost her husband six months ago. Her son and daughter help where they can in assisting her with finances and support where she needs it. She has also lost twenty pounds in two months. Our biggest concerns that we are aware of with our patient are going to be her age, poor nutrition causing weight loss, living alone in her home, losing her spouse only six months ago and lack of constant social support. These factors can impair her wound healing and can lead to other more serious complications. A physical therapist's Plan of Care for our patient needs to accommodate the fact that she has social determinants that will impair her healing. The physical therapist needs to educate the patient and provide additional resources to promote healing and a healthier lifestyle.
What are some of the social and/or economic problems that could interfere with adequate nutrition in aging adults?
Social isolation can cause depression or other mental illnesses which can dampen their appetite. Social isolation can also lead to loneliness which can lower one's interest in cooking or eating. An economic problem could be financial insecurity. Financial problems can make it difficult for many older adults to get the nutrients they need through their diet. Older adults have limited funds. Limited funds can affect their ability to get transportation to the grocery store or allow less money designated for food monthly.
What are some of the physical barriers to adequate nutrition in aging adults?
Some physical barriers to adequate nutrition are that older adults become less active, their metabolism slows, and their energy requirement decreases. Their ability to absorb nutrients can become less efficient as well.
Why did the therapist choose the 2 minute step test to measure endurance?
The 2-minute step test is a quick and simple tool used to assess aerobic endurance and functional fitness in the geriatric population and is also used with populations with cardiovascular disease. Since the patient is a 60-year-old male with acute congestive heart failure, hypertension, and coronary artery disease this test was appropriate to use to measure endurance
What is the Nutrition Checklist and how can it be used?
The Nutrition Checklist is a checklist used to determine how at risk an individual is for having poor nutritional health, which can include not eating enough, not being able to cook for oneself, not getting adequate nutrients, and/or not having the finances to always afford nutritious food. The checklist can be used to assess a person's nutritional health, as the warning signs of poor nutritional health are often overlooked and undertreated, especially in the geriatric population. If an individual scores higher than a 2, they are showing signs of having poor nutritional health.
Would you consider a weight reduction plan for this patient?
The current weight status of the individual is unknown whether they fall into a "healthy weight range" or not. However, being overweight is a risk factor for osteoarthritis as increased weight places additional stress on the hip joint further leading to breakdown of cartilage. If the individual was not in a healthy weight range, I would consider a weight reduction plan as studies suggest weight loss with decreased pain in the joint. Additionally, weight loss will improve function and increase quality of life.
What steps can be taken to assist in wound closure?
The first step to assist in the wound closure is to make sure the site of the wound is clean by applying warm water or saline to remove any debris or dried up blood to protect the area. Since our patient still has about 50% of the epidermal flap, we would want to smooth it over the wound without pulling on it to preserve the skin. Then the remainder of the cut that is still open, we would want to apply adhesive strips to help close up the area to get full healing. Once that is complete, then we would want to apply an atraumatic silicone contact layer to keep that flap in place and connected with the wound. Once that is applied, then we would want to apply another dressing to protect that wound site from any infections and protect the surrounding area. We would want to choose a dressing that would maintain a moist environment and give the patient comfort that their wound will heal. Lastly, we would want to educate our patient and her family members on the importance of checking their wound site periodically to make sure she is not getting an infection and how/when to change the dressing for optimal healing.
What diagnostic test is the gold standard for diagnosing osteoporosis? What does this test measure?
The gold standard diagnostic test for osteoporosis is the dual-energy x-ray absorptiometry. This test measures the bone mineral density of a patient's skeleton and at sites that are more likely to fracture with this disease.
What is the difference between MCI and Alzheimer's?
The main difference between MCI and Alzheimer's is the severity of the symptoms. In both cases, individuals experience cognitive changes such as memory loss leading to missing appointments and losing items. However, Alzheimer's symptoms are more severe than MCI symptoms.
What functional limitations should be addressed?
The major functional limitation to address would be fatigue which causes falls and trouble walking. Fatigue is causing this patient to lose her balance and struggle to keep up with her ADLs and to play with her grandchildren. If she is having trouble walking, fatigue is most likely limiting that because muscle strength is fatiguing. With sarcopenia, there is a loss of muscle mass and strength, followed by functional losses.
Why did the neurologist diagnose your patient with a gait abnormality?
The neurologist diagnosed the patient with a gait abnormality because she has issues in more than one of the four neurological components important in balance/gait. One of the first neurological components affected is the patients peripheral nerves from bilateral lower extremity peripheral neuropathies due to diabetes. Another neurological component affected is the patients vision due to her age-related macular degeneration in both eyes. Finally one of the last neurological components affected is the patients spinal chord from a vertebral compression fracture.
What do the results of the 2 minute step test tell you?
The patient was only able to do 48 steps in 2 minutes. According to APTA, the cutoff score for predicting physical independence for males aged 60-64 is 106 steps, and the cutoff point of older adults with hypertension with associated conditions for normal functional capacity was 65 steps. Since the results were less than the cutoff scores these results would conclude that the patient has poor endurance.
What is the patient's BMI?
The patient's BMI is 18.5 and is technically considered a normal weight (Normal: 18.5-24.9)
What is the goal of medical treatment for heart failure?
The primary goal of medical treatment for congestive heart failure is to combine drug therapy with changes in the lifestyle to prevent further damage and irritation to the heart.
What findings in your physical examination corroborate the patients symptoms of weakness, fatigue, and unsteadiness?
The pt demonstrated weakness at end range extension more on the L LE than R LE, is unable to perform a one-leg heel raise and scores a 3+/5 on her ankle inversion/eversion MMT which points to weakness. The pt performed 5 sit-to-stands in 18.8 sec and completed a TUG in 14.1 seconds which likely indicates fatigue. During the physical examination, the pt was only able to maintain the sharpened Romberg for one second and not at all with her eyes closed. The pt took 14 steps to turn around completely and was only able to maintain a one leg stance for 2 sec and 1 sec on the R LE and L LE respectively. These findings all support the pt's symptoms of unsteadiness.
Why did the therapist examine her shoes?
The therapist examined the patient's shoes because the wear on the sole of the shoes can indicate the patient's gait pattern. For example, not being able to fully lift her foot off the ground may cause a different section of the shoe to be worn down than if there is no gait defect. Additionally, shoes that do not fit well can cause foot pathologies and lead to increased gait defects. If the shoe is too big it can cause the patient to trip or if they are too small, then it can cause foot cramps.
What are some of the physiologic changes involved in aging that make older adults more vulnerable to integumentary injury and delayed healing?
There is a decrease in Lagnerhans' cells, merkel cells, and melanocytes. With age there is decreased strength, impaired skin barriers, altered immunity and protective functions, and vascular changes. These changes impact the health of the skin in that the skin is thinner and more fragile to extraneous factors which lead to an increased risk of infection and less effective wound-healing processes.
Is there another functional test that may be utilized to test for frailty?
There is a plethora of functional tests that can be utilized to test an individual for frailty, however, more research is needed to further validate instruments due to the lack of an agreed-upon operational definition of frailty and to improve the selection of the most appropriate screening tool for frailty assessment. Frailty is largely viewed as a predisposition for various biological susceptibilities to a wide range of age-related adverse health outcomes many of which are comprised of components including weakness/fatigue, fear of falling, weight loss, and decreased capacity for physical activity. Thus, a tool that can be used to assess frailty that encompasses all of these elements and compares the score to a normalized standard is the Timed-Up-and-Go (TUG) Test which measures an individual's functional mobility from a round trip of sitting in a chair to a distance of 10 feet and back. Frail is largely accepted to represent a score greater than 10 seconds to complete.
Can physical therapists conduct cognitive screening?
These different tools can be used to help us see if the patient is having trouble with things such as memory, cognition, hearing, and other components that can be affected by cognitive disorders. We can screen patients, but we cannot diagnose them.
Why did the therapist inquire about her sense of smell?
They inquired about her sense of smell due to her MoCA scores. These scores indicate she has a mild cognitive impairment. Loss of smell can seem like an odd thing to check; however, new research indicates this is an early warning sign of Alzheimer's Disease
is this patient in need of outside nutritional help?
This individual should seek outside nutritional help. Due to his diagnosis of failure to thrive, he most likely has some form of malnourishment or cognitive impairment that may limit his ability to intake adequate nutrition. Because his functional abilities seem rather normal with gross strength measures and ambulation being less affected, incorporating a dietician to ensure proper vitamin, mineral, protein, fiber, and hydration (outside of beer) could positively impact this individual's energy levels and bowel movements. The individual likely lives alone so, social factors surrounding meals and nutrition may be diminished since it is shown that elderly individuals, especially those with cognitive impairments, show decreased appetite and a decreased want to sit and eat.
What is potential for improvement in persons with a gait abnormality?
Using a combination of balance, strength, and coordination can lead to good potential for improvement in individuals with gait abnormalities. As people age, balance and strength decrease which can lead to increased fall risk and gait abnormalities. Strengthening the lower extremities and performing balance training can decrease these risks or improve them if they already exist.
Certain components of diet and nutrition are more critical to healthy aging. Why it vitamin B12 important?
Vitamin B12 helps blood and nerve cells healthy while also contributing to the production of cellular DNA. Vitamin B12 also helps the prevention of megaloblastic anemia.
Certain components of diet and nutrition are more critical to healthy aging. Why is Vitamin D important?
Vitamin D promotes calcium absorption and is needed for bone growth and bone remodeling by osteoblasts and osteoclasts. Older Adults are at risk for osteoporosis and poor bone health. Vitamin D is important for older adults to decrease the risk of these diseases. Vitamin D also increases bone health and strength, reduces bone pain and reduces weakness.
Describe the initial processes and cells involved in hemostasis and the acute phases of tissue repair.
Wound healing consists of four phases: hemostasis, inflammation, proliferation, and maturation. Hemostasis is the stopping of blood flow and occurs directly following an injury. This process occurs due to thromboxane A and prostaglandin 2α being released to cause vasoconstriction at site of injury. The inflammatory phase (4 to 6 days) is what begins the tissue repair process. The purpose of the inflammatory phase is to break down bad bacteria and necrotic tissue. The proliferation phase allows new blood vessels to develop so that the wound can decrease in margin and heal. Lastly, the maturation (remodeling) phase (6 to 9 months) promotes the reorganization of collagen fibers to improve the skin barrier's strength. Aging can delay each stage of tissue repair leading to prolonged wound healing.
Is resistance training indicated in patients with osetoporosis? Why or why not?
Yes, because resistance training has been shown to increase mineral density in older adults with osteoporosis. Since she lives a sedentary lifestyle, resistance training would be highly beneficial in increasing her physical function and decrease risk of injury by increasing strength and bone density.
Does arthritis cause an increased risk for falls?
Yes, hip arthritis is a known risk factor for falls.
Could the muscle weakness in the gluteus medius be related to his osteoarthritis?
Yes, most definitely. Weakness in the glute could cause tranbelenberg gait which can cause abnormal gait leading to osteoarthritis. Strong muscles allow joints to function and move the way that they are supposed to. If there is weakness with the gluteus medius this causes the Ipsilateral hip to move abnormally which can increase friction and lead to osteoarthitis
Is she depressed? What would you do if she is?
Yes, she states that she is depressed. I would encourage her to go for walks around her apartment complex. Exercise can increase the antidepressant effects on the brain along with increasing her chances of having more social interactions which can also decrease her symptoms of depression.
Is the lower extremity functional scale an appropriate outcome measure in this case?
Yes, the LEFS is a self-report questionnaire that evaluates whether the patient would be able to perform a series of activities and how challenging it would be. It is a good way to evaluate a patient with lower extremity issues. Lewis has two LE conditions that contribute to his pain and activity limitations, so this test would be a good way to see where he assesses himself based on his own daily activities and pain level. The test includes activities such as standing for 1 hr, walking a mile, sitting for 1 hr, running, etc.
Are there any technologies that can assist with gait training?
Yes, there is Robot-assisted Gait training (RAGT), this system allows body weight support without the need for manual assistance. RAGT promotes natural and symmetrical gait patterns and can increase intensity and duration of sessions. This system can partially or completely control the movements of the lower limbs and embedded sensors can record patient performance.
What is the Montreal Cognitive Assessment?
a cognitive screening tool to detect MCI that can be associated with dementia, Alzheimer's, or Parkinson's disease. It is administered in 10-12 minutes and looks at many cognitive factors. These include orientation, short-term memory, executive function, visuospatial ability, language abilities, abstraction, verbal fluency, and their ability to pay attention. The MoCA is scored out of 30 points, with 26/30 being considered normal.
What is mild cognitive impairment (MCI)?
defined as forgetfulness or increased difficulty developing thoughts or words
Is taking the blood pressure at the wrist acceptable?
systolic BP measured at the radial artery overestimates the standard systolic BP at the brachial artery. This is because blood vessels at the wrist are not only narrower and stiffer but also sit closer to the skin.
