FACULTY OF HEALTH SCIENCES COVER SHEET for SUBMISSION of INDIVIDUAL/GROUP ASSIGNMENTS

DEPT/SCHOOL:PHYSIOTHERAPY

Course/Unit CodeAssignment No.Date Due

PTH4221111/10/2015

Course/Unit Name

BPHTI

Lecturer Name

THIRUMALAYA BALARAMAN

Markers Name

THIRUMALAYA BALARAMAN

Assignment Title

GERIATRIC ASSESSMENT

STUDENT(S)

Given NameStudent Number

LEONG QIYAOI13003935

Declaration and Statement of Authorship:

1. I/we hold a copy of this assignment which can be produced if the original is lost/ damaged.

2. This assignment is my/our original work and no part of it has been copied from any other students work or from any other source except where due acknowledgement is made.

3. No part of this assignment has been written for me/us by any other person except where such collaboration has been authorised by the lecturer/teacher concerned.

4. I/we have not previously submitted this work for this or any other course/unit.

5. I/we give permission for this work to be reproduced, communicated, compared and archived for the purpose of detecting plagiarism.

6. I/we give permission for a copy of my/our marked work to be retained by the School for review and comparison, including review by external examiners.I/we understand that:

7. Plagiarism is the presentation of the work, idea or creation of another person as though it is your own. It is a form of cheating and is a very serious academic offence that may lead to expulsion from the University. Plagiarised material can be drawn from, and presented in, written, graphic and visual form, including electronic data, and oral presentations. Plagiarism occurs when the origin of the material used is not appropriately cited.

8. Plagiarism includes the act of assisting or allowing another person to plagiarise or to copy my/our work.Student Signature(s)

1)

For Lecturer /Markers comment :

LECTURER COMMENT SHEET

Introduction: Patient DataDemographic Data

Age : 75 years

Sex : Female

Occupation : Housewife

Marital status : Married, staying with her husband

Medical History

Has a known case of diabetes mellitus, cataract on right eye and osteoarthritis on her right knee. Had a fall a month ago.

Drug History

On 7 types of medications

Social History

Stays with her husband

Assessment Techniques

As the patient is presented with a history of cataract, diabetes, osteoarthritis and fall risk, the assessment techniques chosen will be specified to the patients condition.

1. Cataract

By referring to (Howard M. Fillit et al, Brocklehursts Textbook of Geriatric Medicine and Gerontology)16, cataract has been shown to be more common in diabetic patients. Therefore, this patients cataract could be related to her history of diabetes. I will assess her vision with a Snellens eye chart to check the severity of her visual impairment and whether or not her daily living activities are affected by it. In addition to that, a referral to an ophthalmologist will be given to the patient for follow up on her right eye cataract.

2. Osteoarthritis

History Taking

A thorough history interview is necessary in the examination of the extent of her osteoarthritic (OA) knee. Therefore, it is important that the interview covers these aspects:

Activity and participation Symptoms and signs Occupation/Activity Health condition/Injury/Surgery Family history Living EnvironmentTests and Measures

Based on (Andrew A. Guccione, Rira A. Wong, Dale Avers, Geriatric Physical Therapy)17, there are four types of tests and measures categories for impaired joint mobility. These categories of measure enables the therapist to quantify all levels of potential dysfunction as defined by the International Classification of Functioning, Disability and Health which are impairments, activity limitations and participation restrictions.

Observational Task Analysis : This guides the formation of the hypotheses should OA be the potential of her fall. Therefore the best way to analyze it is to observe her walking gait. Should her knee ROM be impaired or pain is present in weight loading, a noticeable change of gait can be observed. Self-Report Measures of Activity and Participation : This aspect allows the patient to take part in the assessment procedure where the patient explains her activity performance in her own perspective. These self-report measures provides the therapist with information unobtainable during observation. Performance-Based Measures of Activity : Supplementary to the two aspects above, this allows the therapist to quantify a performance based activity. For this patient, I will use the Oxford Knee Score3 with the grading as follows :

Joint-Specific Mobility Testing : Lower limb joint range of motion is assessed with a goniometer and is conducted on both sides. The reading acquired allows a comparison to be made with normative values for people of the similar age.3. Fall Risk

The framework above, taken from Rubenstein LZ, Powers CM, MacLean CH: Quality indicators for the management and prevention of falls and mobility problems in vulnerable elders 18, will be the basis of my fall risk assessment to this patient.

History Taking

It is important to fully assess the mechanism of the fall. The patient should be thoroughly asked to recall her fall as accurately as possible. The data collected enables the therapist to acquire information about the etiology and contributions to the fall and risks of future falls. According to Thurman DJ, et al. (2008)5 a recent history between 3 months to 2 years is an important indication for future falls whereas recurrent fallers are at a higher risk of additional falls. Knowing the direction of the fall could also help the therapist with patient education as a side fall results in a higher chance of a fractured hip than a forward or backward fall (Smeesters C., et al ,2001)4. A summary of key questions to be addressed to the patient is referred from Andrew A. Guccione, Rira A. Wong, Dale Avers, Geriatric Physical Therapy17, in Table 1.

Medication

The patient is currently on 7 different drug prescriptions taken on a daily basis. A drug review can be made by referring to her physician or pharmacist on whether they are presenting as a risk to her fall. According to a study by by Berdot S, Bertrand M, Dartigues JF, et al (2009)2,side effects of medications are shown to be related with 30% of preventable problems like falls and hospital admissions among elderly. Similarly, a personal feedback will be obtain from the patient on whether or not the side effects of her prescribed drugs are causing side effects pertaining to her recent fall.

Environmental Factors

These extrinsic factors are often overlooked but they play a vital role in the etiology of a fall. A study conducted by Garin.N, et al (2014)1 suggests that built-environment variables could impact on health. It is also important to have her husband to take part in this assessment to rule out any chances of the patient overlooking on important key factors. The key factors that will be questioned are as follow:

Height of her bed

Lighting in room and around house

Placement of carpets and whether they are loose

Free hanging or excess cords

Floor material around house

Presence of railings or bars next to steps

Test and Measures

A thorough examination of a few key components of postural control will be conducted after history taking which includes these aspects:

Sensory (Vision)

According to Menz HB, Morris ME, Lord SR (2006)6,it is important to examine sensory components such as vision, vestibular and somatosensory which contributes to postural control.

Visual Acuity: This test can be conducted by having the patient to a read a Snellen chart with both her eyes, followed by each eye individually and finally with and without her glasses. A study conducted by Lord SR, Dayhew J., (2001)7 claims that an extreme loss in visual acuity is linked to gait instability in elderly. In another study by Lord SR, Dayhew J, Howland A., (2002)8, the usage of bifocal, trifocal and progressive lenses could increase the chances of a fall, more so with steps.

Depth perception: A difficulty in differentiating distances between objects could pose a threat to a fall. A simple test (refer to figure below) can be conducted by holding up both index fingers, one nearer and another further away from the patient. Gradually move both fingers towards one another and have patient to identify when both the fingers are parallel. Should the perception of depth is off by more than 3 inches, a referral to an ophthalmologist is recommended for further investigations.

Source : Andrew A. Guccione, Rira A. Wong, Dale Avers, Geriatric Physical Therapy, 3rd Edition.Neuromuscular Testing

By referring to the American Geriatrics Society, Guideline for the Prevention of Falls in Older Persons (2001)9, there will be a 4 to 5 times increased of fall risk in patients with a loss of muscle mass, endurance and strength particularly in the lower limbs. Therefore, it is crucial to assess the patient for muscle strength, range of motion and aerobic endurance.

Muscle strength: It is already indicated for the patient to be subjected to several muscles as they are indicated for her knee OA. Therefore it is equally crucial to collect data for her fall risk as well. Manual Muscle Testing (MMT) will be used to assess both her lower limb muscles. The five times sit to stand test (FTSTS) will be used to assess her lower limb muscle performance. This is because a study conducted by Nandy S, et al, (2004)11 suggests that a patient with poor performance in rising from a chair can strongly predict a fall risk in the elderly. Having a good test-retest reliability (intraclass correlation 0.89), the FTSTS predicts suggests that scored above 15 seconds are abnormal in elderly.

Range of motion: Assessing both her lower extremity joints plays a vital role in comparison and outcome measure. Standard goniometry methods will be applied on her to investigate for any ROM impairment which could affect her balance.

Aerobic Endurance: A study by Bittner V., et al, (1993)10 suggests that the 6 minute walk test (6MWT) can assess the endurance level of frail elderly. This quantitative test will be conducted after the patient is briefed on the procedures and clearing her off all contraindications.

Functional Balance and Gait Tests

Balance assessment requires a variety of tests as some emphasizes on specific control of the posture while some assess balance across multiple systems while performing complex activities.

Romberg Test: This test examines the patients standing balance with feet together. It is more indicated towards the testing of the patients proprioception.

Four-Square Step Test (FSST): This test examines her dynamic standing balance via multidirectional movements. A study conducted by Dite W, Temple VA (2002)13 concludes that this test is valid and reliable with high scores found for interrater (n=30, intraclass correlation coefficient [ICC]=.99) and retest reliability (n=20, ICC=.98). It enables the quantification of the patients speed in directional changes and quick backward movements.

Timed Up and Go (TUG): A study by Shumway-Cook A, et al (2000)12 concludes that the TUG is sensitive (sensitivity=87%) and specific (specificity=87%) in fall prediction. A result of more than 13.5 seconds places the patient at a high fall risk.

Other tests such as the Berg Balance Test, Physical Performance Test and Dynamic Gait Index can also be administered to further identify any deficits in balance and gait which could affect the patients overall function.

4. Diabetes Mellitus

If the patient is not referred to any physician, a referral to an endocrinologist will be made for condition monitoring and drug review.Exercise Program

Based on the American College of Sports Medicines Guideline for Exercise Testing and Prescription, 9th Edition21, this patient is indicated to a few exercise protocols namely for Older Adults, Osteoarthritis and Diabetes Mellitus (Appendix 1-3). Therefore, my exercise programme for her will be based on these protocols.

A justified version of the Frequency Intensity Time Type (FITT) for her conditions are as follows:

Frequency: 5 days a week for aerobic exercise varying from moderate to vigorous intensity,3 days a week for strengthening exercise, 3 days a week for flexibility exercise (before strengthening exercise)daily range of motion exercise if possible for her arthritic knee joint. Strengthening exercises will be based on OTAGOs Exercise Program with a frequency of 15 repetitions of 3 sets per exercise.

Intensity: Under the older adult protocol, it is recommended for her to perform her aerobic exercises at moderate intensity(5-6) and vigorous intensity(7-8) on a scale of 0-10 for level of physical exertion. Justifying her arthritic condition, she should be performing her exercises varying at moderate to vigorous intensities until unless her knee condition exacerbates. In terms of strengthening exercises, moderate intensity (60-70% of 1 RM) and light intensity (40-50% of 1RM) should be varied with the use of weight cuffs and light dumbbells. For flexibility exercises, she should stretch until a tightness or slight discomfort is felt.

Time: For aerobic exercises, 30-60 minutes daily, 150-300 minutes per week. For flexibility exercises, hold stretch for 30 - 60 seconds.

Type: For aerobic training, low-impact exercises such as walking, swimming, yoga and cycling are highly recommended. For muscle strengthening, exercises that involves large groups of muscles particular her lower limbs in rhythmic and continuous fashion. As study conducted by Whipple RH, Wolfson LI, Amerman PM (1987)15 suggests that lower limb weaknesses in elderly is high associated with recurrent falls. Therefore, the OTAGO Exercise Program will be used for this patients muscle strengthening protocol.On the other hand, ballistics stretching should be avoided for flexibility exercises. The patient will also be advised to take up Tai Chi as according to a research by Wolf SL, et al (1996)14 , it has been suggested that Tai Chi can be considered as a balance training program as it combines slow movements which stresses postural control. The patient can join a group class with her husband to encourage positive company. By referring to the same study by Wolf SL, et al (1996)14, Tai Chi has shown to reduce fall risk by 47%, decrease fear of falling and lowers blood pressure.

A sample exercise schedule for this patient :

DayExercise

MONDAYCycling

Stretching for warm up

Strengthening exercise (OTAGO)

TUESDAYBrisk Walking

WEDNESDAYSwimming/Water aerobics

Stretching for warm up

Strengthening exercise (OTAGO)

THURSDAYBrisk walking

FRIDAYSwimming/Water aerobics

Stretching for warm up

Strengthening exercise (OTAGO)

SATURDAYRest

SUNDAYYoga or Tai Chi sessions

The Otago Exercise Programme for Muscle Strengthening and Balance Training

This exercise programme19, developed and tested in 4 control trials by a research team from University of Otago Medical School, New Zealand was conducted among 1016 subjects (65-97 years of age). The results from this programme was proven to be effective in reducing fall risk and number of falls by 35%. The list of exercises is shown in Table 2 and illustrations for these exercise can be found in Appendix 4.

Basic protocols of the programme for strengthening exercise. Source : Johnson AJ, et al, Otago Exercise Programme (2003)19Table 2: List of strengthening exercises for fall prevention. Source : Johnson AJ, et al, Otago Exercise Programme (2003) 19Progessions :

Additional weight cuffs can be added to the ankles. Similarly number of sets can be increased per exercise.

The patient should be able to perform 2 sets of 10 reps of each exercise before attempting to progress to the next level

Additional preparations and precautions :

Based on ACSMs Exercise for Older Adults (2014)20 :

Keep a source fast acting carbohydrate available throughout exercise such as fruit juices and cereal bars

Stay hydrated before, during and after exercise

Maintain proper foot care by using appropriate sport shoes, with cotton socks with through feet inspection pre and post exercise

Carry along her medication identification tags if available

Appendix 1

Appendix 2

Appendix 3

Appendix 4

MANDATORY: to be include on all cover sheets

Dept. /School Date Stamp

(For Office Use only)

Table 1, taken from Andrew A. Guccione, Rira A. Wong, Dale Avers, Geriatric Physical Therapy, 3rd Edition.

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