ASPECTS OF AGING AND REHABILITATION OF OLDER ADULTS

LECTURE OUTLINE

Robert S. Stall, MD

Last updated December 27, 1995

1. Brainstorming
   1. What are the Important Elements of Geriatric Functional Assessment?
   2. How is Rehabilitation Potential Determined?
2. Videotape & Critique
   1. "Functional Assessment" (UNC Program on Aging)--starring Dr. "Rusher"
3. Demographics/Statistics
   1. Currently, 12% of population >65 years old, compared to 4% in 1900.
   2. By 2030, >20% of population will be >65 years old.
   3. The old-old (>75 years old): 29% in 1900, 38% in 1970, 44% by 2000.
   4. For each active year added to life, approximately 3.5 compromised years are added.
   5. Approximately 30% of NH admissions are for convalescence/rehab (2o 1983 PPS); all NH admissions are for some kind of functional impairment.
4. Why are "frail" elderly frail? How do you assess "frailty"?
   1. Physiology of Aging
   2. Concept of Functional Reserve and Disease Threshold
   3. Holistic approach essential to maximize "Total Body" functional reserve
      1. Mind (Cognitive Ability, Mood)
      2. Body (Physical Ability, Pain)
      3. Spirit (Hope, Love, Connectedness, Goals, Sense of Purpose)
   4. Impairment, Disability and Handicap
5. Functional Assessment
   1. Listen and Observe! Take a Good History and Focus on Change.
   2. Cognitive Status: Mini-Mental Status Exam (MMSE)--Folstein
   3. Psychological Status: Geriatric Depression Scale (GDS)--Yesavage
   4. Physical Status: FIM, Barthel, Katz ADL, Lawton IADL, Tinetti Balance and Gait Scale, Dartmouth COOP Function and Health Status Measures for Adults, Medication Review, Pulmonary Function Tests, Echocardiography, Stress Testing
   5. Environmental Status: Home Safety Assessment, Medication Review
   6. Quality of Life Status: Life History, Functional History, Joys/Fears/Frustrations, Favorite Music
6. Rehab Goals for Older Adults
   1. Maximize Function/Maintain Function
   2. Promote Independence
   3. Provide Needed Help
7. Treatment Approaches
   1. Ask yourself, "What one thing can I do to improve this patient's quality of life?"
   2. Prevention--may delay onset of morbidity (i.e., crossing disease threshold) (e.g., periodic screening & counseling of patient and family (home safety, caregiver stress, medication use, diet, exercise))
   3. Cure--many problems can be well-defined and treated definitively (e.g., hypothyroidism, obstructive uropathy, restorative rehab)
   4. Palliation--attempt to maximize functional ability & quality of life (e.g., maintenance rehab, pain control, emotional support)
8. Choosing a Treatment Setting--The Continuum of Care
   1. Hospitalization/Acute Inpatient Rehabilitation
   2. Short-Stay Nursing Home Rehabilitation/Subacute Care
   3. Outpatient Rehabilitation/Home Health Care
   4. Adult Day Care/Hospice Care/Long-term Nursing Home Care
9. The Team Approach--Key to Success
   1. Activities Staff/Administrator/Children/Dietary Staff
   2. Family/Friends/Hairdresser/Housekeeping Staff/Inservice Staff
   3. Maintenance Staff/Medical Records Staff/Nurses & Nursing Assistants
   4. Other Patients or Residents/Occupational Therapy Staff/Pets
   5. Pharmacist/Physical Therapy Staff
   6. Primary Care Practitioner (Physician, Nurse Practitioner or Physician's Assistant)
   7. Public Relations Staff/Receptionist/Social Work Staff/Speech Therapist
   8. Volunteers
   9. Others? ________________________________________________
10. Challenges
    1. Ageist Attitudes/Behavioral Disturbances/Dementia
    2. Depression & Anxiety/Frustration/Futility/Multiple Medical Problems
    3. Multiple Medications/Pain
    4. Regulatory Compliance (especially with regard to catheters, contractures, pressure sores, psychotropics, restraints)
    5. Special Issues: Driving, Drug Abuse (Alcohol, Medications)
11. Meeting the Challenge--Teamwork, Creativity and Positive Attitude!
    1. Good Baseline Assessment to Find Opportunities for Improvement.
    2. Define clearly previous and current functional status.
    3. Ask "Has a catastrophic event occurred?" (e.g. amputation, MI, stroke)
    4. Organize your team.
    5. Clarify/Understand the Main Problems and Possible Side Issues.
    6. Set specific goals/Select Appropriate Interventions.
    7. Reassess Response to Treatment/Try New Interventions/Go Back to A.
    8. What is your "Quality Zone"?
12. References
    1. Merck Manual of Geriatrics
    2. Working With Your Older Patient: A Clinician's Handbook (available free from the National Institute on Aging--800 222-2225)
    3. Clinics in Geriatric Medicine, November 1993 (Geriatric Rehabilitation)
    4. Clinics in Geriatric Medicine, May 1993 (Medical Considerations in the Older Driver)
    5. University of North Carolina Program on Aging Videotape Series
    6. On-Line Resources: Internet/World Wide Web (WWW)
       1. Disability Resources on the WWW (e.g. http://mac10a.shrs-uparc.pitt.edu/RST/DisabilityLinks.html)
       2. Dr. Stall's WWW home page http://www.acsu.buffalo.edu/~drstall/index.html
       3. Administration on Aging home page http://www.aoa.dhhs.gov/aoa/index.html