Geriatric Physical Therapy 3rd edition

144 CHAPTER 8  Cognition in the Aging Adult TA B L E 8 - 9 Screening Tests for Detection of Dementia or Need for Further Screening Test Instructions Scoring Notes Mini-Mental Status 10 questions with a total score of 30 Educationb 60-64 80-84 Influenced by education, ethnicity Exam (MMSE)a 5-8 yearsb 24 22 and age; requiring different cut 1. Day of the week 9-12 yearsb 27 23 points; copyrighted. Scores on St. Louis University 2. Year Some collegeb 28 26 specific elements may provide a Mental Screen 3. State better picture of the decline than (SLUMS)c 4. Remember five objects High school education: the composite score. 5. Calculation 27-30, Normal Mini-Cogd 6. Name as many animals in 1 min 21-26, Mild neurocognitive disorder Does not test for executive control Short Blessed Teste 7. Recall of five objects 1-20, Dementia Has not been studied extensively 8. Recite list of numbers backwards Less than high school education: Freely available at http://medschool. Clock Drawing Test 9. Clock drawing test 25-30, Normal (CDT)f 10. Place an X in the triangle and 20-24, Mild neurocognitive disorder slu.edu/agingsuccessfully/ 1-19, Dementia pdfsurveys/slumsexam_05.pdf determine which figure is largest 11. Recall of facts in a story read to 1 point for each recalled word after Takes 3 minutes to administer, performing the Clock Drawing requires no special equipment patient Test (CDT) and is less influenced by Executive function. The clock draw- education 2 points for a normal CDT ing is a recall distractor 0-2 (positive screen for dementia) Counting backward, spelling a word 3-5 (negative score for dementia) backward and forward, or Have patient answer 6 questions 0-4, Normal cognition listing the months of the year 1 . Year 5-9, Questionable impairment backward are tests of working 2. Month memory and attention. Then have patient repeat following (evaluate for early dementing disorder) name and address 10 or more, Impairment consistent “John Brown, 42 Market Street, with dementia (evaluate for dementing disorder) Chicago.” Have patient remember name and address The CDT score is considered normal given in question for later recall. if all numbers are depicted, once 3. Without looking at watch or each, in the correct sequence and clock, tell approximate time position, and the hands readably 4 . Count aloud backwards from display the requested time. Do 20 to 1 not count equal hand length as 5 . Say the months of the year in an error. reverse order. 6 . Repeat the name and address The more distorted and inaccurate asked earlier. the drawings, the more likely the Instruct the patient to draw face of a person is to have dementia. clock, and then to draw the hands of the clock to read a spe- cific time (11:10 or 8:20 are most commonly used and more sensi- tive than some others). These in- structions can be repeated, but no additional instructions should be given. Typically 3 minutes is given to complete the task. Continued

CHAPTER 8  Cognition in the Aging Adult 145 TA B L E 8 - 9 Screening Tests for Detection of Dementia or Need for Further Screening—cont’d Test Instructions Scoring Notes To achieve a negative score, indicating Time and change The patient is given 60 seconds to Two attempts to get it right. testg,h read the time on a clock that is The change test has a 3-minute limit, no dementia, the patient must cor- set to 11:10 rectly complete the Telling Time task and two attempts are allowed. in one try within 3 seconds, and cor- The patient must make a dollar from Incorrect responses on either or both rectly complete the Making Change three quarters, seven dimes, and task in one try within 10 seconds. seven nickels tasks are scored as a positive Use of timed cut points increases sen- result, indicating dementia. sitivity of the test, but decreases Sniff testi 10-item sniff test with odors of A correct response on both tasks is specificity. lemon, strawberry, pineapple, scored as a negative result, Original test was of 40 odors, with Namingj lilac, clove, menthol, smoke, indicating no dementia. ,34 odors correctly identified in- natural gas, soap, and leather Misidentification of two odors is creasing the likelihood of pro- Describe similarities predicative of a 5 times more gressing to Alzheimer’s disease. between two Name as many items as possible in a likely change to progress to Tests language ability items such as given category such as fruits or Alzheimer’s disease. an apple and an animals Naming fewer than ten items in Ability to reason and plan orangej 1 minute suggests slowed mental functioning. a From Wind AW, Schellevis FG, Van Staveren G, et al. (1997). Limitations of the Mini-Mental State Examination in diagnosing dementia in general practice. Int J Geriatr Psychiatry, 12(1), 101-108. b From Crum RM, Anthony JC, Bassett SS, Folstein MF. (1993). Population-based norms for the mini-mental state examination by age and educational level. JAMA, 269(18), 2386-2391. c From Tariq S, Tumosa N, Chibnall JT, et al. (2006). Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder—a pilot study. Am J Geriatr Psychiatry, 14(11), 900-910. d From Borson S, Scanlan J, Brush M, et al. (2000). The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15(11), 1021-1027. e From Brooke P, Bullock R. (1999). Validation of a 6 item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry,14(11), 936-940. f From Watson YI, Arfken CL, Birge SJ. (1993). Clock completion: an objective screening test for dementia. J Am Geriatr Soc, 41(11), 1235-1240. g From Froehlich TE, Robison JT, Inouye SK. (1998). Screening for dementia in the outpatient setting: the time and change test. J Am Geriatr Soc, 46(12), 1506-1511. h From Inouye SK, Robison JT, Froehlich TE, Richardson ED. (1998). The time and change test: a simple screening test for dementia. J Gerontol A Biol Sci Med Sci, 53(4), M281-M286. i From Devanand DP, Michaels-Marston KS, Liu X, et al. (2000). Olfactory deficits in patients with mild cognitive impairment predict Alzheimer’s disease at follow-up. Am J Psychiatry, 157, 1399-1405. j From John Hopkins. Memory on dementia screening tests. http://www.johnshopkinshealthalerts.com/reports/memory/1918-1.html. Accessed May 15, 2010. MCI and AD. Cholinesterase inhibitors and neuropeptide- However, a combination of memantine and Aricept ap- modifying agent receptor antagonists are the two medica- pear more effective together than either alone.140 Antide- tions used to reduce the progression of dementia.140 pressants have some effectiveness in treating depression Cholinesterase inhibitors (donepezil, galantamine, and in dementia.140 Atypical antipsychotics are used to man- rivastigmine) were developed to slow the breakdown of age behavioral disturbances but because of their side acetylcholine to make it more available for cellular use effects, are discouraged for long-term use.139 and are prescribed in mild to moderate AD. They have Behavioral and Environmental Management.  E​ vidence- modest benefit for cognition, mood, behavioral symp- based studies support psychosocial interventions in toms, and daily function for approximately 1 to 3 years, dementia both in the community and residential especially when evaluated by caregiver impression.140 facilities. These interventions are designed to manage Neuropeptide-modifying agents (memantine) regulate undesired behaviors through progressively lowering the glutamate availability but have not been shown to be stress threshold management. Triggers or antecedents for particularly effective in improving functional abilities. disruptive behaviors are identified and prevented through Neuropeptide-modifying agents are the only available modification of the environment and schedules. One way drugs for severe AD but have not been shown to be par- to approach challenging behaviors is using Antecedent- ticularly effective in slowing the progression of dementia. Behavioral-Consequences (ABC) strategies. 12,141

146 CHAPTER 8  Cognition in the Aging Adult TA B L E 8 - 1 0 Drugs Used for Dementia Nonproprietary Name Trade Name Common Side Effects Cholinesterase Inhibitors Fatigue, dizziness, ataxia, syncope, nausea, dyspnea, muscle cramps Abnormal dreams; diarrhea; dizziness; loss of appetite; muscle cramps, nausea; tiredness; Donepezil Aricept trouble sleeping; vomiting; weight loss, fainting Galantamine Reminyl Dizziness, fatigue, headache, inability to sleep, indigestion, loss of appetite, nausea, runny Rivastigmine Exelon nose, sleepiness, tremor, urinary tract infection, vomiting, weight loss Dizziness, drowsiness, fainting, fatigue, flu-like symptoms, hallucinations, high blood Neuropeptide-Modifying Agent pressure, increased sweating, tremor, unwell feeling, weakness, weight loss Memantine Namenda Fatigue, dizziness, back pain, confusion Antipsychotics Abilify Dizziness; pain; change in behavior, such as aggressiveness, depression, or anxiety; chest Aripiprazole pain or tightness; fainting; hallucinations; one-sided weakness; severe tiredness; speech changes; sudden severe headache; vision changes Risperidone Risperdal Olanzapine Zyprexa Initial orthostatic hypotension, fatigue, sedation, nausea Quetiapine Seroquel Dizziness; drowsiness; headache; nausea; vomiting; confusion; fainting; fast, slow, or Mood Stabilizers Tegretol irregular heartbeat; fever, chills, sore throat; increased sweating; involuntary Carbamazepine Depakote movements of the tongue, face, mouth, jaw, arms, legs, or back (e.g, chewing Divalproex movements, puckering of mouth, puffing of cheeks); loss of control over urination; loss of coordination; muscle tremor, jerking, or stiffness; new or worsening mental or mood problems (e.g, anxiety, depression, agitation, panic attacks, aggressiveness, impulsiveness, irritability, hostility, exaggerated feeling of well-being, inability to sit still); one-sided weakness; seizures; severe or persistent restlessness; shortness of breath; suicidal thoughts or attempts; swelling of the hands, ankles, or feet; symptoms of high blood sugar (e.g, increased thirst, urination, or appetite; unusual weakness); trouble swallowing; trouble walking; unusual bruising; unusual tiredness or weakness; vision or speech changes. Orthostatic hypotension, arrhythmias, sedation, anxiety, dry mouth, constipation, sexual dysfunction, leukopenia Peripheral edema, headache, orthostatic hypotension, somnolence, seizures, dystonic reactions, constipation, rash, dry mouth Headache, somnolence, dizziness, orthostatic hypotension, tachycardia, bradycardia, irregu- lar pulse, A-V block, prolonged P-T interval, constipation, dry mouth, cataracts Myalgia, arthralgia, cardiac arrhythmias, nausea, dizziness, vertigo, drowsiness Sedation, dizziness, Stevens-Johnson syndrome, leukopenia, neutropenia, aplastic anemia, SIADH, nausea, gastrointestinal distress, diplopia, nystagmus, dyspnea Peripheral edema, drowsiness, ataxia, alopecia, nausea, vomiting, diarrhea, anorexia, abdominal cramps, thrombocytopenia, asterixis, diplopia, spots before the eyes Anxiolytics BuSpar Drowsiness, dizziness, palpitations Busiprone Restoril Daytime drowsiness with repeated dosing Temazepam SIADH, syndrome of inappropriate antidiuretic hormone secretion. The ABC method is based on social cognitive theory. obvious. The three elements that comprise the ABC The theoretical premise advocates that changing what chain are detailed in Box 8-8. happens directly before or after a problem behavior can be used to alter or decrease the frequency of problem Behavior is also managed through consistency and behavior. Recognition that consequences can “reinforce” providing a secure and safe environment.142 Often, the behavior, both positively and negatively, forms a basis individual with dementia is looking for some measure of for management. Behavior that is desired should be re- control and may react to overchallenging tasks or too warded or encouraged and behavior that is undesirable much stimulation, similar to what can occur in a physi- should be negatively reinforced. The first step is to col- cal therapy gym. These behaviors are referred to as lect as much information about challenging behaviors to provoked behaviors and are most often triggered by detect patterns about why the challenging behaviors event-related factors such as the physical environment, occur or what function they might serve for the person physiologic needs, or the social environment. Once the with dementia. After the behavior has been observed for provoked or antecedent behavior is understood, the trig- a week or so, the triggers or antecedents usually become gers can be changed to decrease the challenging behav- ior. Table 8-11 lists the most commonly used behavioral

CHAPTER 8  Cognition in the Aging Adult 147 B O X 8 - 8 A-B-C Behavior Chain Antecedent Anything that happens prior to a challenging behavior or sets the stage for it to happen. Antecedents can be internal Behavior (thoughts or physical sensations) or external (environmental characteristics). Some examples of antecedents are loud Consequences noises, hunger, pain, frustration, busy environment, unfamiliar people or surroundings, or overwhelming tasks. Problematic or challenging behavior. Examples include agitation (restlessness, anxious, upset), aggression (shouting, cornering someone, raising a hand to someone or actually pushing or hitting), repetition (repeating a word, question, or action over and over), hallucinations, suspicion, apathy, confusion, sundowning, and wandering. Anything that happens right after the behavior occurs. Providing calm reassurance, offering a person a desirable item like food or a photo album, yelling, taking something away from the person or removing the person from the situation. (Data from Teri L, Logsdon RG, McCurry, SM: Nonpharmacologic treatment of behavioral disturbance in dementia. Med Clin North Am 86(3): 641-656, viii, 2002.) therapies and the strength of the evidence as reported by Patient Health Questionnaire–9 may be useful to differ- the American Academy of Neurologists. entiate dementia and depression.144 Depression and Dementia.  A​ study by Pearson et al Exercise.  C​ ohort and associational studies indicate examined the relationship between depressive diagnosis that physical activity is associated with better cognitive and cognitive and functional limitations in patients with function and less cognitive decline in later life.145 In a AD.143 They found that depression did affect functional large epidemiological study in Canada, high aerobic status beyond the effects of cognitive impairment. There- exercisers (at least three times per week) had stable or fore, if depression is an overlying condition, functional improved cognition over a 5-year period. This was espe- status may improve with successful treatment of the de- cially true for those who started with high cognitive pressive episode. A trial regimen of antidepressants may levels.74 A recent randomized controlled trial demon- provide information for a clear diagnosis. If the mood strated that a 6-month aerobic exercise program for improves as the depression is resolved, cognitive function older adults with memory decline resulted in modest will return to predepressive level. Should the individual improvements in cognition.145 continue to display characteristics of decline in mental ability, investigation for dementia would be initiated. The Exercise may have several beneficial effects for persons with dementia. These positive effects may TA B L E 8 - 1 1 Strength of the Evidence for Strategies to Improve Function and Modify Behavior Goal Strategy Strength of Evidence Reduce urinary Behavior modification, scheduled toileting, Strong incontinence prompted voiding Good Increase functional Graded assistance, practice and positive independence reinforcement Weak Improve eating behaviors Low lighting levels, music and simulated nature Weak sounds Good Improve ADLs Good Reduce problem behaviors Intensive multimodality group training Weak Music, particularly during meals and bathing Walking or other forms of light exercise Weak Simulated presence therapy, such as use of Weak Weak videotapes of family Weak Massage Weak Comprehensive psychosocial care programs Weak Pet therapy Cognitive remediation Bright light, white noise Using commands at the patient’s comprehension level (Adapted from Dementia_guideline.pdf (application/pdf object) http://www.aan.com/professionals/prac- tice/pdfs/dementia_guideline.pdf. Accessed May 26, 2010.) ADLs, activities of daily living.

148 CHAPTER 8  Cognition in the Aging Adult should assist the caregiver(s) in providing functional, meaningful, pleasant, and safe activities.179 include increased strength and endurance, increased ADL function, improved sleep, increased balance The features of dementia that most influence the reha- and decreased falls, improved mood, decreased anxiety, bilitation process are memory decline and the difficulty and decreased use of medications. The Seattle proto- or inability to learn new material. Because therapy is cols146 are an evidence-based program of exercise viewed as a teaching process, these features of dementia designed for older adults with dementia that includes may be perceived as major obstacles to successful out- encouraging pleasurable and easily achievable activities come. However, research now demonstrates that the and work with caregivers to provide supports, work on presence and severity of cognitive status should not be a problem solving for barriers, and establishing goals factor that denies rehabilitation.151 Therapists should with very small steps. Because of the evidence that modify treatment methods and goals to accommodate exercise effects may be task-specific and exercise with the limitations of the patient’s cognitive disability. less cognitive demand has more effect, the Seattle pro- Therapy should not be denied on the basis of cognitive tocols limit the cognitive component of exercise. dysfunction. Activities included in the Seattle protocol were dancing with simple steps, tandem walking on an imaginary Function should be assessed to provide a baseline and tight rope, walking, stationary bicycle, and Tai Chi to identify problematic areas. Simple tools such as the (sticky-hands technique). Results showed decreased Timed Up and Go, gait speed, and the sit to stand test depression, fewer restricted-activity days, increased can be used to assess mobility.152 Tests to evaluate ADLs physical functioning, decreased institutionalization due include the Barthel Index, The Structured Assessment of to behavioral disturbances, and less awake time at Independent Living Skills (SAILS),153 and the Erlangen night. test of ADLs.154 The focus of these tests is on ADLs that are commonly affected in individuals with a dementia The effects of resistance exercise have received less diagnosis. Task instructions are straightforward and can attention but shows promise in a limited number of stud- be demonstrated, thereby accounting for problems en- ies. Chang and Etnier studied the acute effects of a countered with batteries designed for a general popula- 30-minute bout of high (100% 10 RM), moderate (70% tion. However, currently, no tests to measure ADLs 10 RM), and low (40% 10 RM) loads of resistance in individuals with dementia have strong clinimetric exercise on cognition as measured by the Stroop test (a properties.155 colors naming test) and found a dose response with more effect from the high-intensity group on simple speed of Traditional physical therapy interventions need to information processing and on executive functions.147 focus on task-specific and relevant activities. As Teri et al have shown, individuals with dementia can meaningfully Studies of activity and exercise with institutionalized participate in individual and group exercise if certain persons with dementia also indicate positive effects of modifications are made.146,156 These modifications in- exercise. Volicer et al demonstrated decreased use of clude simple, one-step consistent commands or provid- psychotropic medication, increased nutrition intake, de- ing cues based on the individual’s needs and abilities, creased agitation and improved sleep with a program of making activities pleasurable (avoiding pain or discom- continuous activity.148 Edwards et al demonstrated de- fort), and establishing simple, immediate, and relevant creased immediate and long-term (12 weeks) anxiety goals.146,156 Emphasis is on positive reinforcement while and depression following a 30-minute chair-based, mod- avoiding criticism. The use of consistent, simple com- erate-intensity exercise program performed three times a mands, providing sensory cues, demonstration, provi- week for 12 weeks.149 Improved ADL activity and in- sion of rest periods, and avoidance of environments with creased strength, endurance, balance, and flexibility was overwhelming stimuli are additional strategies to maxi- shown by Kwak et al in a 3-week program of exercise.150 mize the individual’s success in a physical therapy ses- These studies indicate that given proper cueing, a sup- sion.157 Learning should be approached in a simple, portive environment and appropriate exercises, individu- repetitious manner, often requiring cooperation from the als with dementia can participate and benefit from many family or nursing staff for consistency in the approach different kinds and form of exercise. and directions for the individual. Whenever possible, the Physical Therapy Management.  ​The role of the phys- same personnel should work with the client to help es- ical therapist in the presence of dementia is threefold. tablish a trusting and consistent relationship with the First, the physical therapist needs to assist the patient, individual. Caregivers can help provide further rein- family, and caregivers with activities that will maximize forcement of the instructions and functional gains. the individual’s functional abilities and slow down phys- ical declines. For example, maintaining muscle strength, The physical therapy examination may need to be balance, and mobility can prevent falls, contractures, modified to accommodate the individual’s cognitive abil- and pressure sore formation as well as enhance the indi- ities and to provide an accurate picture of the individu- vidual’s well-being and mobility. Second, the therapist al’s abilities. For example, manual muscle testing may can assist in changing and simplifying the environment not be valid with an individual who is inconsistent in to maintain function. Lastly, the physical therapist following directions. Modification to accommodate the

CHAPTER 8  Cognition in the Aging Adult 149 cognitive limitation may result in a generalized assess- pain management that individuals with dementia re- ment of strength documented as “voluntary motion ceived for the same procedure.163 Although surgery for a noted in extremities; unable to grade specifically second- hip fracture is recognized as one of the most painful ary to inconsistency in following directions.” Muscle orthopedic procedures, pain medication is often delivered testing procedures are not familiar tasks to most people, on a request-only basis. Current recommendations are to necessitating learning that can be difficult for a person deliver pain medications on a regular and ongoing sched- with dementia. Although strength can be assessed and ule to help manage pain and prevent delirium.159 reported, the approach is modified in relation to the limitations of the cognitive symptoms. Adults learn bet- Working with persons with dementia requires a care- ter when the information is relevant to their activities, ful balance of simple instructions and repetition without and this may be even more relevant for older adults with treating the person as a child. It is important to avoid cognitive deficits. For example, sit to stand could be a debate or conflict with the person; rather, change the more appropriate functional measure of strength and subject or task if it is too stressful. Finding a connection balance. In addition, strengthening activities may be best with the person, perhaps through their hobbies or past accomplished using functional activities such as sit to employment, can help create a more trusting and less stand activities and weighted ADL activities (weighted stressful therapy session. Manipulating the patient’s clothes or hair brush). environment is often more successful than attempting to teach the person techniques to compensate for cognitive Hip Fracture.  ​Individuals with AD sustain hip frac- loss. Items and surroundings that are familiar minimize tures more often than individuals with normal cognition, the impact of memory deficit, allowing the person to and their hospital and rehabilitation course is typically perform routine daily activities by rote without having longer. However, several studies indicate that many of to problem-solve. The emphasis on the environment these individuals benefit greatly from short- and long- includes safety as a valid factor in the therapeutic pro- term rehabilitation, especially when a multidisciplinary gram. Failure to recognize and react to hazards becomes approach is used.158-162 a major consideration in the person’s ability to remain in an unsupervised situation. Because disorientation is Modifications in the treatment plan may be necessary often an issue, protection of the patient is part of the to achieve optimal benefits for the patient. For example, a treatment program. surgeon-directed limitation of partial weight bearing poses challenges for the physical therapist or physical Because control of the environment seems to help therapist assistant. Given the memory limitations caused with the person’s disorientation and agitation, many by dementia, the patient may not understand or remem- facilities have developed dementia units that emphasize ber the weight-bearing status nor conceptualize the me- a structured, low-key environment with consistent staff- chanics of using a walker, if unfamiliar with a walker. The ing.179 The focus in these units is on safety, specially surgeon must be consulted to determine the purpose of trained staff, admission criteria, physical design, and the limitation and the integrity of the repair if full weight activity schedules.141 Management of behavior is facili- bearing occurs. Many times, the surgeon may mean tated by reinforcing the environment with constant weight bearing as tolerated, assuming pain will inhibit full reminders to orient individuals to time, place, and care- weight bearing until the repair is healed satisfactorily to giver identity. Keeping the treatment environment con- safely allow full weight bearing. Other aids to encourage sistent and avoiding multiple distractions during treat- limited weight bearing might be the use of an elevated ment sessions can be effective. Sloan and Gleason164 shoe on the nonaffected side, no shoe on the affected side, suggest learning to recognize triggers to behavior prob- or a shoe with bumps that would provide negative sen- lems such as room temperature, hunger, and toileting sory sensations with full weight bearing. One study dem- needs. Anxiety can be reduced by a consistent schedule onstrated that treadmill training was more effective than and providing appropriate activities.164 Environmental over-the-ground training.161 Extensive gait training may adaptations for the home include the following: need to be postponed beyond transfer activity, until the repair is sufficiently healed to allow full weight bearing. • Use of visual pictures for key rooms such as the The therapist should be aware of the adverse conse- kitchen and bathroom quences of prolonged immobility and promote and advo- cate for mobility within the imposed constraints. • Storage of medications and harmful materials out of reach of the person An additional issue with regard to hip fracture and dementia deserves to be mentioned. Individuals with de- • Provision of adequate lighting, especially if the indi- mentia may not be able to express their physical discom- vidual wanders fort in recognized ways. In one study whereby pain was evaluated on cognitively intact individuals following hip • Installation of a shut-off switch on the stove fracture, 50% of the individuals reporting severe pain did • Limitation of clutter and mirrors not receive adequate control. The authors also discovered • Lower water temperature to avoid burns that cognitively intact individuals received three times the Finally, therapists may benefit from the Common Mis- takes in Working with a Patient/Client with Dementia (Box 8-9), constructed by Ellen Somers, an Alzheimer’s

150 CHAPTER 8  Cognition in the Aging Adult BO X 8 - 9 Common Mistakes in Working with a Patient with Dementia 1. Don’t assume everything is the result of the person’s dementia. Instead, anticipate the level of cognitive or functional impairment that would be expected for the disease process and assess if this level exceeds your expectations and experience. Also, • Rule out hearing problems, pain, vision, medication side effects, etc. • Address these issues (is the person wearing eye glasses? Hearing aid? Receiving pain management before physical therapy?) • Other medical problems (urinary tract infection, side effects of medications, sleep deprivation?) 2. Don’t discount the person’s opinion or preferences. Instead: • Assess how consistent this is with the person’s prior history (did she or he like to exercise in the past? Did she or he aggressively pursue treatments? Was she or he compliant with medical treatment?) • Work with the family to respect what is most consistent with how the person would likely have responded if she or he didn’t have dementia. 3. Don’t use childish/infantile, “Elderspeak” language. Instead: • Use simpler, but adult, language • Use same voice, one you would use with other older adults 4. Don’t talk in front of the person as if she or he isn’t there or can’t understand. Instead • Assume the person can understand • Include the person in the discussion • Have the discussion away from the person and out of eyesight. 5. Don’t rely only on verbal communication. Instead: • Use written communication • Use visual cues • Use modeling, gestures, and physical prompts 6. Don’t assume new learning can’t occur. Instead recognize that people with dementia do learn new information, especially if it’s: • Salient • Meaningful • Presented properly (e.g, build on current strengths) • Practiced in a way that facilitates development of a new habit (i.e., in the proper environment, with appropriate equipment, with lots of opportunity to practice but spaced over increasing intervals of time) 7. Don’t conduct therapy in a noisy, distracting environment. Instead: • Reduce conversations between therapists or with other patients while working with one person • Use music judiciously (not as background) • Find quieter areas if possible 8. Don’t give too much information. Instead: • Provide step-by-step directions • Focus on one step you want to work on and ignore or use nonverbal cues for other steps • Use as few words as possible • Repeat using same words if necessary • Allow enough time to process the information (spaces between sentences, not words) 9. Don’t focus on the task. Instead: • Focus on the person • Build your relationship with the person first • Find out about the person’s interests, family • Incorporate what you know about the person into the exercises you give her or him and how you communicate with the person 10. Don’t conduct therapy only in the therapy environment. Instead: • Whenever possible, conduct therapy in the environment where the person will need to use the skill • Use materials/equipment that the person will be using upon discharge And finally, if it’s not working, systematically alter what you are doing, reassess and continue to make changes, and remember, what works today may not work tomorrow. (From Ellen Somers, MA, LMAC, Alzheimer’s Service Cooridinator at St. Camillus Health and Rehabilitation Hospital, Syracuse, NY.) services coordinator who has observed physical thera- plan of care. Education and training for the caregiver are pists working with individuals with dementia for several essential because management of the patient is heavily years. dependent on the family support and coping resources. CAREGIVER ISSUES Psychological health of the caregiver is a concern to the therapists and is often related to the function of the The health professional must address not only the pa- patient. Although the health care provider is with the tient’s environment but also available support systems patient for a few hours, the caregiver may be with and family situation in order to implement an individual the person every day, all day. Depression, anxiety, and caregiver burden are reported to be much higher among

CHAPTER 8  Cognition in the Aging Adult 151 caregivers caring for an individual with dementia com- was admitted to a skilled nursing facility for rehabilita- pared with caregivers of persons with physical frailty.166 tion. The physician referral for physical therapy included The increase in these symptoms is due to the changes in a specific request for partial weight bearing on the left. personality, disruptive behaviors, lack of spare time, On initial evaluation, the therapist found the patient to isolation, and progressive deterioration associated with be very confused. He was unable to identify family mem- dementia.166 The relationship was strongest for spouse bers and was not able to tell the therapist where he lived caregivers, followed by children caregivers. Further in- or where he was, with minimal awareness of sustaining vestigation of spouse involvement reveals wife caregivers a hip fracture and the restrictions of his injury. Consulta- experiencing greater degree of negative psychological tion with the family revealed that Mr. Martin was fine well-being than husband caregivers.167 Only modest before the fall, with some signs of “getting old” but effects of caregiving for persons with dementia with re- much more aware than what he was presently display- spect to physical illnesses have been demonstrated.168,169 ing. The therapist modified the treatment program to Interestingly, positive effects of caregiving for persons accommodate Mr. Martin’s cognitive status, including with dementia have also been demonstrated. These in- utilization of an adductor cushion to prevent dislocation clude feeling useful, important, and competent as well as and allowing no weight bearing until the physician was increased satisfaction in their role and the ability to pro- contacted regarding danger of nonadherence to non– vide a good quality of life to a loved one.170 weight bearing status. The therapist considered that postsurgical confusion could be a possible reason for the The therapist’s awareness of the potential for care- cognitive dysfunction. Possible sources of the postsurgi- giver mental health problems is the first step. Identifica- cal confusion could have been infection, metabolic tion of warning signs such as caregiver denial, anger, abnormalities, or medication effects. Consultation with depression, exhaustion, or health problems should be a the physician resulted in medical intervention to modify call for action by the therapist to avoid a complex situa- metabolic abnormalities and reduce medications. When tion. Studies of the REACH (Resources for Enhancing the mental function only slightly improved in the next Alzheimer Caregiver Health) indicate that keys to few days, the therapist scheduled an interview with the decreasing caregiving stress include the following: individuals living with Mr. Martin in his home. • Extensive education regarding strategies to deal with As an introduction for the family, the therapist behavioral problems, including role-playing explained that she was interested in Mr. Martin’s abil- ity to perform daily activities before the accident. She • Enhance ADL abilities with strategies to reinforce indicated that “just getting old” is usually not the rea- • Reinforcement with practice, home visits, and phone son for individuals to change the way they function, and that most people who experience normal aging calls have minimal changes in their memory, personality, or • Encourage self-care with pleasurable activities and intelligence. With questioning, those interviewed recalled that Mr. Martin had become more forgetful health-promoting behaviors.171 about 2 years ago. He began to get lost while driving, only to be returned by a neighbor in the small farming Some stress can be avoided by educating the caregiver community. The animals were neglected, as Mr. Martin on the limitations of the patient. This should minimize either fed them five times a day or not at all for several unrealistic goals that are translated into demands on the days. When he forgot repeatedly to milk the cow, the patients, resulting in failure, frustration, and sometimes nephew moved in to help out with the chores. In the behavior problems. The therapist can assist in identifying past 6 months, the family reported that they had to patient activities that can be performed successfully with- answer the phone, because people outside the family out failure. Identification of community support groups were unable to understand Mr. Martin when he talked. for the caregiver should be part of the treatment plan, Mr. Martin had also become very suspicious of the offering an opportunity for education and emotional as- neighbors, accusing them of taking down his fence. sistance. Numerous sources of information are also avail- After the interview, the therapist conducted a Mini-Cog.172 able on the Internet from the Alzheimer’s Association, Mr. Martin scored 0 out of 5. Based on the presenting American Geriatric Society, and the National Institute on cognitive function, history as revealed by the family, Aging. Respite care either in the home or at long-term and the Mini-Cog score, Mr. Martin was referred to a care facilities can provide the caregiver needed time for psychologist for testing to rule out dementia of the self-care and enjoyable activities. The reader is also Alzheimer type. referred to Chapter 11 on family dynamics. To maximize the benefit of the therapy sessions, CASE STUDY Mr. Martin’s treatment program was modified to accom- modate the cognitive dysfunction. The physician was Mr. Martin was an 84-year-old male living at home with consulted regarding the difficulty of maintaining partial his 72-year-old companion. Also living in the home was weight-bearing status and agreed to allow the patient to the patient’s 17-year-old nephew. According to the fam- ily, Mr. Martin had been fine until he fell and fractured his left hip. After a total hip replacement, Mr. Martin

152 CHAPTER 8  Cognition in the Aging Adult pist. Older adults can be creative, productive, and intel- ligent throughout their later years. Depression is now bear weight to tolerance if a wheeled walker was used. considered a pathology that should be treated aggres- This allowed the patient to transfer with a modified sively with the expectation that older adults will respond standing pivot method and to begin gait training. similarly to younger adults. Depression does not have to Mr. Martin was treated in a quiet and consistent envi- adversely affect the process or outcomes of rehabilita- ronment. Commands and instructions were stated in tion. Clear identification of the clinical presentation of one-step progressions. The family was involved in ther- depression is necessary so as not to misdiagnose an older apy, as Mr. Martin continued to respond to instructions adult with dementia. when a familiar person was present. They also were instructed in simple mobility exercises that they encour- Although the pharmaceutical management of dementia aged Mr. Martin to do whenever they visited. This is still in its infancy, the evidence is strong for the role of modification in the treatment plan compensated for exercise before, during, and after the development of de- Mr. Martin’s inability to perform exercises indepen- mentia. In addition, research about behavioral manage- dently. As the family was vested in Mr. Martin’s returning ment is creating the expectation that undesirable behav- to his prior living situation, a home assessment was con- iors, once thought to be barriers to rehabilitation, can be ducted with suggestions on safety, precautions for danger managed with best practices. Depression, delirium, and when wandering, and cues to minimize the effects of the dementia as well as normal cognitive changes in the older memory loss. Family concerns were also addressed by adult have significant implications for the physical thera- explaining the characteristics and course of AD, which pists’ care. Avoidance of ageist attitudes, awareness of had been confirmed by the consultant, and the effects on current research, and compassionate care are keys to ef- the living situation and the family members. Resources fective physical therapy management of the cognitively were shared with the family to help with their coping and impaired older adult. Research indicates that older adults support of Mr. Martin. As Mr. Martin’s confusion gradu- with dementia can be rehabilitated similarly to older ally improved, he reached treatment goals of independent adults without dementia and that the presence of demen- ambulation and transfers that permitted him to return tia should never be used as the sole reason for the termina- home. A home maintenance program of general exercise tion of physical therapy. Cognition in the aging adult is in and balance was also developed. its infancy with exciting discoveries on the horizon. CONCLUSION REFERENCES Much progress in understanding the pathology and To enhance this text and add value for the reader, all management of older adults with depression, delirium, references are included on the companion Evolve site and dementia has been made in the past 10 years. The that accompanies this text book. The reader can view the idea that the brain is plastic and responds favorably to reference source and access it online whenever possible. physical and cognitive challenges and less favorably to a There are a total of 179 cited references and other gen- lack of challenges similarly to the way the physical body eral references for this chapter. responds has many implications for the physical thera-

9C H A P T E R Evaluation of the Acute and Medically Complex Patient Chris L. Wells, PhD, PT, CCS, ATC, Martha Walker, PT, DPT INTRODUCTION (Box 9-1). As a result of advances in medical manage- ment, people are living longer. As our population ages, The population of older adults is the fastest growing age mortality rates and medical complexity also increase sub- group within the United States and represents a substan- stantially. A study conducted by the National Institute of tial segment of health care expenditures. Physical inac- Aging on postmenopausal women who have been diag- tivity and a sedentary lifestyle are major contributors to nosed with breast cancer is a good example of the increas- disease and disability in this population subgroup.1 Data ing amount of comorbidities. Of the 1800 women in- from 2006 reveal that there was a 17% increase, from volved in this study, only 7% did not have any other 21% to 38%, in hospital admissions in patients who documented disease. Forty-nine percent had 1 to 3 comor- were older than age 65 years, and a 22% increase in bidities, 34% had 4 to 6 comorbidities, and 9% had 7 to patients who were older than age 75 years, whereas 13 comorbidities at the time of the cancer diagnosis.4 there is a decline in admissions for patients younger than age 45 years.2 Some of the increase in admissions among Regardless of the clinical setting, it is vital that the older adults is related to the increase in surgical options physical therapist be able to recognize signs and symptoms for individuals with cardiac problems. More than half of that do not fit within the authorized scope of practice and older adults, approximately 566,000, were admitted for recognize “yellow flags” and “red flags” in order to make fracture management.2 From the Census Bureau, the appropriate referrals with the ultimate goal to improve the most common discharge diagnoses for patients older well-being and health of the client. The purpose of this than age 65 years include congestive heart failure, which chapter is to summarize the knowledge and skills a physical is the leading diagnosis, coronary heart disease, pneumo- therapist needs to demonstrate in order to complete a thor- nia, and septicemia.3 ough screening to provide proper care for the older adult patient in an acute care setting, work effectively with an When considering working with this population, the older individual in an acute phase of illness in other settings physical therapist must recognize the need to address a such as the outpatient primary care clinic, and respond ap- complex medical history and be aware of the interplay propriately to the individual with medical comorbidity in between each body system. Psychological and mood any setting. The goals of examination and evaluation are to states as well as cognitive and social factors can also in- develop a proper plan of care, make appropriate discharge fluence the presentation of the patient and the outcome recommendations, and to facilitate discharge. This is done of therapy. It is important to examine each system in or- by completing a thorough examination of the patient, put- der to identify the complexity of the problem, determine ting primary and secondary diagnoses in proper perspective a proper diagnosis and prognosis, and develop a compre- for the impact on function, establishing a prognosis, and hensive plan of care that incorporates an understanding formulating a comprehensive intervention plan. This pro- of the impact of medical comorbidity on function. The cess begins with gathering information in a thorough and plan of care will be based upon a thorough evaluation systematic fashion from medical and health records and and may address multiple impairments and medical defi- through communication with other health care members cits in order to improve the patient’s functional mobility, and caregivers as well as a comprehensive interview of the health and well-being, and ultimately quality of life. patient. Implementation of the plan of care will depend on the particular setting and the time frame for implementing There are many reasons that have led to the need for the proposed plan of care and discharge recommendations the physical therapist to acquire the necessary skills to if the patient will be going to another facility or type of recognize, examine, and determine the proper plan of residence. care when working within the health care system today Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 153

154 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient BO X 9 - 1 The Impact of Comorbidity the physical therapist’s initial examination. These docu- ments may include the method of admission, informa- It is commonplace for clinicians to focus their attention on the pri- tion from any emergency medical service field treatment, mary diagnosis or obvious impairments and functional limitations. emergency room evaluations and initial testing proce- Many fail to consider the other systems of the body, how they inter- dures, the referring physician’s evaluation for planned act and affect the primary complaint and thus affect the rehabilita- admissions to an inpatient setting, or the patient’s reason tion outcome. Even with a healthy, aging individual, the multiple for the primary care or outpatient visit. An emergency systems of the body are declining in function. This decline may not department report typically concludes with a working be substantial enough to cause an overt dysfunction or failure until differential diagnosis list and a medical problem list. The another stressor is added. primary history and physical (H&P) that is usually completed by the admitting service may also be found Consider the following case: Suppose an 88-year-old healthy, among these documents. It is extremely helpful to review very physically active woman undergoes an aortic valve replace- this data source to the degree it is available because it ment. The operation goes well except the patient experiences a commonly contains the admitting diagnosis and sum- slight decline in contractility of the myocardium in the first 24 hours mary of what led up to the admission, the patient’s chief postoperation. The physical therapist may tend to only be con- complaint, and past medical/surgical history. The H&P cerned with the heart when performing the examination initially also typically contains social history, risk factors, a after surgery. medication list, allergies, medical summary, and plan of care. The working medical problem list for an older However, her decrease in cardiac output leads to hypotension. adult may be extensive due to multiple comorbidities The consequences of hypotension are a decrease in perfusion to the and, therefore, it is important to review all available in- brain and kidneys. The patient’s body cannot tolerate this deviation formation in order to fully understand the patient’s from homeostasis and the result is a clinically significant decline in medical status to prepare the appropriate physical ther- mental status and acute renal failure. Along with the fluid retention apy evaluation. from the renal failure and cardiac impairment, the patient becomes more agitated and is sedated. The therapist should review the medical or health rec­ ord not only to glean information pertaining to physical These complications prolong the time her respiratory system is therapy but also to understand what other services have supported by a mechanical ventilator. She experiences a ventilator- been or should be consulted, what diagnostic tests have acquired pneumonia and a partial bowel obstruction due to im- been requested, and what medications or other treat- mobility. The stress and trauma contribute to temporary insulin ments have been prescribed. All services typically enter a glucose dysfunction, which in turn delays wound healing. Weak- contact note that describes their contribution to the pa- ness and multiple joint pains develop that further complicate the tient’s care. It is important to keep up to date as to who ability to mobilize this patient and successfully wean her from the has been treating the patient, any changes in medical ventilator. The end result of this cascade of events after weeks in status, operative notes, tests that may have been done, the intensive care unit is that the patient undergoes a tracheotomy and updates on the medical plan. The physical therapist and percutaneous endoscopic jejunostomy and will be discharged needs to ensure that the physical therapy plan of care is to a subacute skilled nursing facility for ventilator-weaning and consistent with the medical plan, which can be very com- rehabilitation. plex when the patient has multiple comorbidities. There may also be reports from other health professionals, so- CHART REVIEW cial workers, psychologists, and case managers that may be important to assist the therapist during formulation The information-gathering process typically is initiated of a plan of care or discharge recommendations. when the physical therapist receives a request for consul- tation. This request may be very generic or may include Laboratory Values pertinent information about the reason for the consult and indicate any restrictions or precautions. If the con- The analysis of blood work is critical to full appreciation sult is generic, the therapist should determine if there are of the medical status of the patient. Serum enzymes can any restrictions to care, such as out-of-bed status or be examined to determine cellular damage including weight-bearing precautions. myocardial injury and infarct. Blood lipids can deter- mine the patient’s risks for vascular disease, and the co- Admission or Reason for Visit agulation profile reveals the body’s ability to clot. The complete blood count (CBC) examines such factors as Patients with acute conditions are not always in a hospi- hemoglobin (cells that contain iron used for oxygen tal. Increasingly, physical therapists are part of primary transport), hematocrit (the proportion of blood that is care teams in the outpatient setting, or providing acute red blood cells [RBCs]), RBCs, white blood cells (WBCs), care services in the patient’s own home or other residen- and platelet counts. The body’s ability to regulate the tial setting. If a medical or health record is available cellular pH through respiratory and renal function can prior to the initial clinical encounter, the admission or intake section of the record may contain several important documents that can be reviewed prior to

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 155 be determined by examining the arterial blood gases such as cancer or medical events like myocardial infarc- (ABGs). Finally, electrolyte levels can be examined tion, congestive heart failure, or liver dysfunction. Serum through blood analysis. See Table 9-1 for clinical labora- enzymes can also show muscle tissue breakdown in the tory studies.5-9 event of trauma or rhabdomyolysis. The therapist can Serum Enzymes and Markers.  ​Serum enzymes and review these lab values to obtain an appreciation of the markers are used to assist in the diagnosis of disease extent of tissue involvement or dysfunction as well as the TA B L E 9 - 1 Clinical Laboratory Studies5-9 Reference Chemistry Function Sodium (Na) 136-146 mmol/L Regulates water balance, regulates acid–base balance, membrane integrity, nerve impulse Potassium (K) 3.5-5.1 mmol/L Intracellular fluid osmolality, maintenance of resting membrane potential, Chloride (Cl) 98-107 mmol/L glucose deposition in liver and skeletal muscles Carbon dioxide (CO2) 21-30 mmol/dL Resting membrane potential, osmotic pressure regulation, extracellular Anion gap 8-14 mEq/L enzymatic reactions Blood urea nitrogen (BUN) 6-20 mg/dL Acid–base balance Creatinine (Cr) 0.64-1.25 mg/dL Measurement of the acid–base balance Byproduct of protein breakdown, reflection of kidney function: glomerular Glucose 70-99 mg/dL Calcium (Ca) 8.8-10.2 mg/dL filtration and urine concentration capacity Waste product of body’s protein metabolism, reflects long-term Ionized calcium 1.15-1.29 mmol/L Magnesium (Mg) 1.6-2.6 mg/dL glomerular function Reflects carbohydrate metabolism Phosphate (Ph) 2.3-3.7 mg/dL Bone and teeth health, enzymatic cofactor for blood clotting, plasma Total protein 6.1-7.9 g/dL Albumin 3.5-5.2 g/dL membrane stability and permeability Prealbumin 20-90 mg/dL Free flowing calcium that is not attached to protein Intracellular enzymatic reactions, protein synthesis, neuromuscular Bilirubin total 0.4-1.5 mg/dL excitability Bilirubin (direct) 0.1-0.5 mg/dL Intra- and extracellular anion buffer, energy substrate Aspartate transaminase (serum 10-41 units/L Rough measurement of albumin and globulin proteins Protein synthesized by liver, protein found in blood glutamine-oxaloacetic transaminase) 14-54 units/L Protein synthesized by liver that is source for amino acids for other Alanine transaminase (serum 7-9 a.m.: 4.2-38.4 mg/dL protein production. Short-term measure of nutritional status glutamic pyruvic transaminase) 4-6 p.m.: 1.7-16.6 mg/dL Yellowish pigment from heme (RBC) metabolism found in liver bile, test Cortisol 10-140 units/L 27-131 units/L of liver/gallbladder function Lipase 100-190 units/L Is bilirubin attached to another molecule before being released in bile Amylase Enzyme from liver or muscle cells released upon injury Lactate dehydrogenase Enzyme from liver or muscle cells released upon injury Hormone produced by adrenal cortex that increases blood glucose and liver stores of glycogen in response to stress Enzyme that metabolizes dietary lipids Enzyme that metabolizes dietary carbohydrates Five enzymes in various organs that are responsible for conversion of pyruvate and lactate. Specific enzyme markers can identify type of cellular damage. Complete Blood Count Reference Function White blood cell (WBC) count 4.5-11.0 K/mL Leukocytes, cells of the immune system Red blood cell (RBC) count Erythrocytes, cells that have gas-carrying capacity 4.0-5.7 K/mL Hemoglobin (Hgb) 12.6-17.4 g/dL O2/CO2-carrying capacity protein of the RBC Hematocrit 37%-50% Percentage of a given volume of blood that is occupied with erythrocytes Mean corpuscular volume 80-96 fL Average RBC volume Continued

156 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient TA B L E 9 - 1 Clinical Laboratory Studies5-9—cont’d Chemistry Complete Blood Count Reference Function 32-36 g/dL Average concentration of Hgb in the RBC Mean corpuscular hemoglobin concentration 153-367 K/mL Small cell that contributes to clotting Platelet Blood Gases Reference Arterial 7.35-7.45 32-48 mmHg pH 83-100 mmHg PaCO2 22-26 mEq/L PaO2 Bicarbonate (HCO32) 94%-99% Oxygen saturation Venous 7.32-7.44 pH 38-54 mmHg PvCO2 35-45 mmHg PvO2 22-26 mEq/L HCO32 Oxygen saturation 60%-80% Urinalysis Function Urine specific gravity 1.002-1.030 pH 4.5-8.0 WBC 0-5/hpf RBC 0-2/hpf Urine is also examined for presence of color, blood, protein, ketones, glucose, and nitrates Coagulation Reference Prothrombin time 12.8-14.6 s Partial thromboplastin time 25-38 s International Normalized Ratio 0.8-1.2 Blood Lipid Profile Reference Total cholesterol ,200 mg/dL High-density lipoproteins M: .43 mg/dL F: .33 mg/dL Low-density lipoproteins ,100 mg/dL Triglycerides ,140 mg/dL phase of the event such as the evolution of a myocardial cognitive testing beyond the gross screening, and periph- infarction by monitoring the enzymes and marker values eral perfusion testing.10 Vital signs should be monitored and whether these numbers are trending up or down at rest as well as during exertion to determine if the pa- based upon serial analysis. See Table 9-2 for cardiac en- tient has hypertension that should be further medically zymes and diagnosis for myocardial cellular injury.5-7,9 addressed. Because cardiovascular disease is a multisys- Blood Lipids.  T​ he examination of the patient’s blood tem disease, patients with abnormal blood profiles are at lipid profile helps to risk-stratify the patient for cardio- risk for further declines in cerebral function as well as vascular disease. This finding can be helpful in determin- risk of cerebral vascular events.11 Further screening may ing how to focus part of the interview process (i.e., to- include such brief testing as the Trails A and B test, ward the signs, symptoms, and functional impacts of counting backwards by 7, or the Stroop test12 may give cardiovascular disease), particularly the review of the therapist further documentation that cerebral func- systems as well as what specific tests and measures tion is impaired or has changed from previous admis- the therapist should consider, including more inclusive sions. Data on peripheral perfusion testing and skin

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 157 TA B L E 9 - 2 Cardiac Enzymes5-7,9 Enzyme Normal Cardiac Enzymes Return Abnormal Creatine phosphokinase (CPK) 5-75 mU/mL Rise Peak 3-4 h Lactate dehydrogenase (LDH) 100-225 units/mL 8-14 days Total $ 200 CPK-MB 0%-3% 2-8 h 12-36 h Total $170, $ 100 LDH 1 40% CPK 12-48 h 3-6 days .10 days Total $ 200 with MB $ 4% or total Troponin , 0.2 mg/mL 4h 18-24 h ,200 with MB $10 units .1.5 4-6 h 24 h inspection as well as tolerance to exertion may help to may lead to a peripheral cellular injury or necrosis, in- characterize any clinical hypothesis that a functional cluding limb loss as well as an embolic stroke. Guidance limitation is related to peripheral arterial disease.13 for mobilizing a patient with a lower extremity DVT is Finally, by the therapist appreciating the patient’s blood conflicting and may vary dependent on how clinicians profile along with evaluating for other risk factors, the weigh the site and duration of the DVT as well as time therapist can determine the patient’s risk level for a car- since anticoagulation therapy was started. diovascular event, how to safely prescribe an exercise Complete Blood Count.  ​The CBC is one of the most program, initiate patient education on risk reduction common laboratory studies performed and can be used and prevention, and make appropriate referrals.14 to aid in the formulation of a diagnosis, to assess medi- Coagulation Profile.  T​ he coagulation profile of the cal treatment response, and to monitor recovery. The patient will indicate the ability of the patient’s blood to physical therapist can obtain a wealth of information clot, particularly important for the individual receiving from examining the CBC and should check daily to ad- anticoagulation therapy as a treatment for conditions just the intervention accordingly. such as atrial fibrillation, mechanical heart valves or devices, deep vein thrombosis (DVT), pulmonary embo- The first group within the CBC is RBC count and dif- lism (PE), or trauma. Anticoagulation levels that are ferentiation. The count examines the number of actual considered therapeutic will vary depending upon reason RBCs. This information is valuable since the RBCs re- for coagulation, previous medical history, physician flect the oxygen-carrying capacity of the blood that sup- preferences, and institutional policies. The therapist ports cellular activity. If the RBC count is too high, needs to know the therapeutic level, medical goal, and known as polycythemia vera, there is a significant risk of any functional mobility precautions or restrictions. An blood clot formation and a subsequent loss of perfusion increased risk of thrombus formation also increases risk to tissues. If the RBC count is too low, also known as for stroke, pulmonary emboli, and other embolic activ- anemia, then there are insufficient RBCs to adequately ity. Patients whose coagulation levels are too high are at supply tissue with oxygen, particularly in the presence of risk for bleeding, so the therapist should monitor these cardiac or pulmonary dysfunction. patients for edema, ecchymosis, drops in hemoglobin and hematocrit, limitations in limb range of position, Part of the RBC study is the quantification of hemo- pain, and neurologic changes if there is a cerebral bleed. globin and hematocrit. Hemoglobin is the oxygen- Patients on anticoagulation therapy in the presence of carrying component of the RBC and reflects the ability infection or other causes of physiological stress may de- of the body to sufficiently promote gas exchange to velop a coagulopathy and be at risk for bleeding. regulate pH. Hematocrit is the measure of the number of RBCs within the blood compared to the total vol- Prior to starting coagulation therapy and until the ume of blood, represented as a percentage. These patient’s titer is therapeutic, meaning the hematocrit two numbers are very important to monitor when levels are within a certain designated range, the patient working with patients in general and especially when may be placed on temporary bed rest or restricted to working with the older patient. The incidence of ane- limited mobility. It will be important to look for signs mia is high within the older adult population, with the and symptoms of clotting. For DVT, the signs and symp- primary cause commonly related to gastrointestinal toms may include peripheral edema (typically unilateral), bleeding. Rockey et al reported that 62 of 100 subjects venous distention, and pain; for PE, the patient may pres- had anemia from gastrointestinal bleeding.15 Anemia ent with shortness of breath, abnormal breath sounds, can be the underlying cause and a contributing factor and oxygen desaturation. In those cases where the PE is to fatigue, disability, change in cognitive function, and of a clinically significant size, the patient can suffer from activity intolerance. Patients with anemia in the pres- respiratory failure. The patient may also be at risk for all ence of coronary artery disease (CAD) may experience or a portion of the thrombosis to break away and angina, particularly with exertion, and if the coronary become an embolus in the systemic circulation, which disease is extensive, the anemia may lead to heart failure (HF).16

158 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient Ten percent of people older than age 65 years suffer to maintaining cellular membrane potential, and carbon from anemia.17 However, gastrointestinal bleeding is not dioxide is used to assist in the analysis of the body’s the only cause of anemia and it is important to deter- acid–base balance. Chloride level is used for further mine the actual cause to ensure proper medical treat- analysis of acid–base balance through the calculation of ment. Other causes of anemia, for example, iron, folate, the anion gap. Creatinine and BUN reflect renal function and vitamin B12 deficiencies; renal insufficiency; anemia and reflect the efficiency of glomerular function. BUN is of chronic inflammation; and unexplained anemia, can commonly elevated in the presence of heart or renal fail- be further worked up by analyzing the differentiation of ure, and low levels of BUN are associated with starva- RBCs or indices.17 This set of tests looks at the size of the tion, dehydration, and liver failure. Electrolyte analysis average RBC, otherwise known as the mean corpuscular is very important because the risk of death from chronic volume (MCV). The mean corpuscular hemoglobin kidney disease increases with age, especially in patients (MCH) and mean corpuscular hemoglobin concentra- with concurrent cardiovascular disease.19 tion (MCHC) examine the amount and concentration of hemoglobin in an average RBC, respectively. These tests Calcium levels can also be analyzed to identify para- can aid in the diagnosis of what type of anemia the thyroid dysfunction, malnutrition, and chronic renal patient has and, therefore, allow the medical team to disease. Abnormalities in calcium level are related to prescribe the best intervention. hyperparathyroidism, malignancy such as metastatic breast, lung, or renal cancer, as well as immobility. Mag- The CBC also contains the analysis of WBCs with nesium contributes to various cellular activities such as respect to both total number and differentiation of cells muscle and nerve function, assisting in the maintenance that will provide the therapist with information about of normal cardiac rhythm, bone strength, and health the body’s response to an infectious disease. An elevation status of the immune system. Abnormally low magne- in total WBCs, which is referred to as leukocytosis, may sium levels, hypomagnesemia, can be related to alcohol- be due to a bacterial infection, with urinary tract and ism, chronic diarrhea, hemodialysis, and cirrhosis. Renal pulmonary infections leading the incidence of infections failure, adrenal disease, and dehydration can cause hy- in older adults. This is significant, because with age, the permagnesemia. chance of these infections progressing to bacteremia in- creases, as does mortality.18 Leukocytosis can also be Electrolyte abnormalities are common, and correc- evidence of leukemia or stress related to trauma and in- tions for a toxic or deficient state are important in order flammation. Leukopenia, or low WBC levels, may be to restore normal cellular function. See Table 9-3 for caused by bone marrow depression, acute viral infec- causes and signs and symptoms of electrolyte abnor- tions, or alcohol abuse. Differentiation of WBCs can malities.5-9 In older adults, malnutrition, dehydration, further determine the underlying problem: neutrophils adverse effects of medications, decline in organ function, will be elevated in the presence of bacterial or fungal and increased risk of infections and cancers increase infections, eosinophils are elevated in allergic responses, their risk for electrolyte imbalances. A study by Oliveira and lymphocytes are elevated in viral infections. et al reported that 29.1% of the 240 hospitalized older adult patients they studied were considered malnour- Platelets, which are small cells that aid in clotting and ished. Of those, 13.7% had hypertension, 15.7% had the release of growth factors, are also measured when a diabetes, 3.9% presented with osteoarticular issues, CBC is ordered. When the endothelium is damaged, col- 12.8% had some form of cancer, and 15.7% had the lagen is released into the bloodstream. When the plate- sequelae of stroke.20 lets come in contact with the collagen, the platelets are Special Tests.  ​Serum glucose levels examine the body’s then activated to form a clot to repair the injured area. ability to utilize glucose for cellular activity through the Platelets also release platelet-derived growth factor and production of ATP. Hyperglycemia, elevated blood sugar, tissue growth factor-b, which contribute to cellular re- is generally associated with diabetes mellitus (DM); pair and regeneration. A reduction in platelets, other- however, patients without a history of DM could present wise known as thrombocytopenia, can be caused by with elevated glucose levels in the acute care setting that chemotherapy, a large blood transfusion, or implanta- may be related to physiological stress from trauma or tion of mechanical heart valves among many other rea- surgery, or alterations in medications. Hypoglycemia, sons. Also, heparin-induced thrombocytopenia can low blood sugar, is associated with alcoholism, adverse result from the use of heparin postsurgically. Thrombo- medication reactions, treatment for hyperglycemia, and cytosis, elevation of platelet count, is less common but critical illnesses related to liver or pancreatic disease. is associated with iron-deficient or hemolytic anemia, cancer, or inflammatory or infectious processes such as Serum glucose, glycosylated hemoglobin (HbA1c), and inflammatory bowel syndrome and tuberculosis. routine blood glucose testing are very important for the Electrolytes.  T​ he study of electrolytes, specifically cre- therapist to examine prior to intervention. If the pa- atinine, blood urea nitrogen (BUN), calcium, magne- tient’s glucose is elevated, greater than 250 mg/dL, or sium, sodium, potassium, and chloride reveals the state low, below 70 mg/dL, the body does not have the ability of the cellular function. Sodium and potassium are key to utilize glucose as an energy substrate for exercise. Modifications in therapy will need to be implemented to

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 159 TABLE 9-3 Causes and Clinical Signs and Symptoms of Electrolyte Abnormalities5-9 Electrolyte Calcium Causes Clinical Symptoms Magnesium Increased: Hyperparathyroidism, large consumption of Asymptomatic, constipation, nausea, vomiting, abdominal Potassium calcium and vitamin D, cancer, immobilization, Paget pain, loss of appetite, thirst, and dehydration disease Phosphorus Nonspecific central nervous system signs (e.g., mild diffuse Decreased: Hypoparathyroidism; osteomalacia; decreased brain disease mimicking depression, dementia, or Chloride intake of dairy products; decreased vitamin D intake psychosis), tetany or latent neuromuscular irritability; Sodium cardiac arrhythmias and heart block; osteoporosis; Increased: Mg consumption in presence of renal failure, hypertension antacids, or laxative overdose Weakness, low blood pressure, respiratory distress, asystole Decreased: Dietary depletion; renal loss; gastrointestinal (GI) disorders, including vomiting, diarrhea, and malabsorption Nonspecific, neuromuscular irritability and muscle weakness; syndrome; alcoholism; primary defect in renal tubular arrhythmias; increased sensitivity to cardiac glycosides; reabsorption; GI disorders that impair absorption, such as hypertension; atherosclerosis; loss of appetite; nausea; Crohn disease vomiting; numbness; tingling; muscle contractions and cramps; seizures (sudden changes in behavior caused by Increased: Renal failure, use of potassium-sparing diuretics, excessive electrical activity in the brain; personality acidosis, cell damage, dehydration, uncontrolled diabetes, changes; abnormal heart rhythms; coronary spasms Addison disease, syndrome of inappropriate antidiuretic hormone (SIADH), pneumonia, sepsis, shock, potassium Asymptomatic, bradyarrhythmias supplements in presence of renal failure Fatigue; confusion; muscle weakness and cramps; frank Decreased: Decreased intake of potassium during acute paralysis; breakdown of muscle fibers (rhabdomyolysis); illness, nausea, and vomiting; increased renal loss; atrial and ventricular ectopic beats; atrial and ventricular hypomagnesemia; hematologic disorders; certain tachycardia; ventricular fibrillation; sudden death; antibiotics or diuretics; diarrhea (including the use of too atrioventricular conduction disturbances many laxatives, which can cause diarrhea; diseases that affect the kidney’s ability to retain potassium (e.g., Liddle Asymptomatic, severe arteriosclerosis (angina, poor periph- syndrome, Cushing syndrome, hyperaldosteronism, Bartter eral perfusion, changes in multiple sclerosis), increased syndrome, Fanconi syndrome), eating disorders (such as risk of myocardial infarction, stroke and peripheral artery bulimia); sweating disease, severe itching Increased: Rare unless in presence of renal dysfunction, hypo- Anorexia; muscle weakness; osteomalacia; rhabdomyolysis; parathyroidism. Diabetic ketoacidosis, crush injuries, rhab- hemolytic anemia; impaired leukocyte and platelet domyolysis, severe infections, ingestion of large amounts function; progressive encephalopathy; coma; death Decreased: Deficiency rare because it is so readily available in Rare, changes in mental status, confusion, malaise, brady- the food supply; decreased intake and impaired intestinal arrhythmias, hyperventilation, stupor, muscle twitching, absorption of phosphate; vomiting; acidosis; alcoholic weakness, nausea, vomiting, diarrhea ketoacidosis Dehydration; loss of potassium in the urine; alkalosis Increased: Dehydration, multiple myeloma, kidney dysfunc- tion, metabolic acidosis, hyperparathyroidism, pancreatitis, Hypertension, mental status changes, confusion, thirsty, anemia, prolonged diarrhea, respiratory alkalosis, salicy- seizures, coma late toxicity, alcohol abuse, congestive heart failure (CHF) Delirium and confusion; hallucinations; depressed sensorium; Decreased: Fluid loss (e.g., excessive sweating, vomiting, or depressed deep tendon reflexes; hypothermia; diarrhea); diuretics Cheyne-Stokes respiration; pathologic reflexes; convulsions; fatigue; headache; irritability; loss of Increased: Dehydration, hyperaldosteronism, CHF, hepatic appetite; muscle spasms or cramps; muscle weakness; failure, severe vomiting/diarrhea, steroid administration, nausea and vomiting intake or use of high-protein and nutrient-dense products without enough fluid, diabetes insipidus, Cushing disease, glycosuria, hypervolemia Decreased: Use of low-sodium nutritional supplements; vomiting; diarrhea; GI suction; renal disorders; diuretic therapy; burns; CHF; use of diuretics; kidney diseases; liver cirrhosis; sweating

160 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient shorten the duration of functional activities to avoid 40 mmHg as the reference point, and a value higher or adverse effects of immobility and further metabolic lower being acidotic and alkalotic, respectively. Finally, stress. the therapist also needs to look at the HCO32 level, with a value greater than 24 being alkalotic and below 24 be- Other tests such as serum total protein, including al- ing acidotic. To determine whether the disorder is respi- bumin and globulin levels, contribute information about ratory or metabolic, it is as simple as determining if the acid–base balance, clotting, immune response, and blood PaCO2 or the HCO32 matchces the same state as the pH. and tissue osmotic pressure. Albumin is very important If PaCO2 is consistent with the pH, meaning if both to maintaining vascular pressure, with low albumin re- PaCO2 and pH are acidotic or alkalotic, then the patient lated to significant edema, poor functional outcomes, is suffering from a respiratory acidotic or alkalotic state. and high mortality. The prealbumin level reflects current However, if HCO32 matches the pH, then there is a nutritional status and can be helpful in examining the metabolic acidosis or alkalosis. See Table 9-4 for causes effectiveness of nutritional interventions or to document and signs and symptoms of acid–base disorders.5-7,9 See further progression of the catabolic state.21 For the acute Table 9-5 for an example of respiratory acidosis and care therapist, attending to albumin, total protein, and Table 9-6 for an example of metabolic alkalosis. prealbumin levels will reveal the level of protein stores, state of malnutrition, or responsiveness to nutritional Arterial blood gases further quantify the body’s re- intervention. This factor may greatly influence the pa- sponse to acid–base imbalance. The renal and pulmo- tient’s ability to make gains in therapy and may directly nary systems compensate for these imbalances by alter- impact functional outcomes.22,23 ing PaCO2 (lungs) for metabolic disorders and HCO32 (kidneys) for respiratory disorders. In the case of a respi- Cardiac enzyme studies are used to make the diagno- ratory disorder where the HCO32 is still within the nor- sis of myocardial injury or myocardial infarction. There mal range, the body has not begun to compensate, and are several specific cardiac enzyme studies that can be therefore it is referred to as an absent compensation. analyzed: creatinine phosphokinase–MB isoenzymes, If the pH and HCO32 are both outside the normal lactic dehydrogenase, troponin, and myoglobin. These ranges, this is referred to as a partial compensation. Fi- enzymes are released at variable rates, so serial studies nally, if the pH has been brought back into the normal are needed to determine the peak level, extent of cellular range, the acid–base balance would be referred to as a injury and necrosis, and recovery rate. compensated condition. The compensatory description Arterial Blood Gases.  ​The sampling of arterial blood is is the same for metabolic disorders as well. In the ex- used to determine the oxygenation state and the acid– ample in Box 9-1 earlier, there is an uncompensated re- base balance, specifically the concentration of hydrogen spiratory acidosis because the pH has not been brought ions of the body. The pulmonary and renal systems regu- back to normal levels. late acids, such as carbonic and lactic acids, respectively. The renal system is also the principal regulator of bicar- Understanding at least the basics of ABG analysis is bonate (HCO32), which is the major base of the body. important for the acute care therapist for several rea- sons. First, understanding what diseases or disorders The partial pressure of oxygen (PaO2) declines with may lead to a disruption of pH should guide the physical age. This is due to the combination of a reduction in therapist to tailor the evaluation process, particularly the elasticity of the musculoskeletal system, a decrease due to the pulmonary system compensation. Knowing in muscle fibers, a decrease in the alveolar gas ex- the associated signs and symptoms of the four basic cat- change surface area, and a decrease in the responsive- egories of acid–base imbalance will aid the physical ness of the central nervous system. These natural therapist in detecting medical changes and will alter the changes lead to a decline in PaO2, which normally other health care team members’ concerns. Finally, the ranges from 80 to 100 mmHg from childhood to degree of compensation should be considered when de- middle adulthood, by approximately 1 mmHg per year veloping a current treatment plan or deciding if there is after the age of 60 years, or can be calculated by PaO2 a need to hold therapy for the day. 5 109 2 0.43 3 age.24 It is important to keep this in- formation close, because physical therapists commonly Electrocardiogram (ECG) participate in the pulmonary care of patients and sup- plemental oxygen prescriptions. For a patient who is Abnormalities in the electrical cardiac cycle can lead to 75 years old, it would be perfectly normal to have a various significant medical problems for the older adult PaO2 of 73 to 77 mmHg and show no signs of desatu- patient, including falls, stroke, and HF. There are several ration or respiratory decompensation. changes to the conduction system of the heart with ag- ing, including a reduction in conduction cells within the To examine the acid–base balance, the physical thera- sinoatrial node and delay in the depolarization of the pist should first look at the pH using 7.4 as the normal atria and ventricles.20 level. If the pH is below 7.4, the patient is in an acidotic state, and any level greater than 7.4 is considered an Even if the physical therapist is not familiar with alkalotic state. The physical therapist should next exam- reading an ECG, there are a few things to keep in mind ine the partial pressure of carbon dioxide (PaCO2), with

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 161 TA B L E 9 - 4 Causes and Signs and Symptoms of Acid–Base Imbalances5-7,9 Cause Signs/Symptoms Respiratory acidosis Central nervous system (CNS) injury to respiratory center Hypoventilation, hypercapnia, headache, visual (traumatic brain injury [TBI], tumor, cerebrovascular disturbances, coma, confusion, anxiety, restlessness, Metabolic acidosis accident), airway obstruction, pulmonary disease, drowsiness, g deep tendon reflex, hyperkalemia, Respiratory alkalosis respiratory muscle weakness (Guillain-Barré ventricular fibrillation Metabolic alkalosis syndrome, myasthenia gravis , spinal cord injury), flail chest, h metabolism (sepsis, burns), CNS HCO32 deficit, headache, hyperventilation, mental dullness, depressant drugs (barbiturates, sedatives, narcotics, deep respiration, stupor, coma, hyperkalemia, arrhyth- anesthesia) mias, muscle twitching/weakness, nausea/vomiting/ diarrhea, malaise Uncontrolled diabetes mellitus, starvation, renal failure, acetylsalicylic acid (ASA) overdose, prolonged stress Hypocapnia, tachypnea, lightheadedness, numbness/ or physical stress, hypoxia, severe diarrhea, ethanol peripheral tingling, tetany, convulsions, diaphoresis, abuse, metabolic/ethanol ketoacidosis, lactic acidosis muscle twitching, hypokalemia, arrhythmias Hypoxemia (emphysema, pneumonia, acute respiratory HCO32 excess, hypoventilation, mental confusion and distress syndrome), stimulation of CNS (sepsis, agitation, dizziness, peripheral numbness, muscle ammonia, ASA overdose, TBI, tumor, excessive twitching, tetany, convulsions, hypokalemia, exercise, or stress, severe pain), hyperventilation, arrhythmias hepatic encephalopathy, congestive heart failure, pulmonary embolism, impaired lung disease (internal pancreatic fistulae, ascites, scoliosis, pregnancy) Loss of hydrochloric acid, loss of potassium, diarrhea, exercise, ingestion of alkaline substances, steroids, diuresis, nasogastric suctioning, peptic ulcer disease (PUD), massive blood transfusion TA B L E 9 - 5 Example of Respiratory Acidosis pH Patient Normal Range Reference Acidotic/Alkalotic PaO2 7.4 Acidotic PaCO2 7.24 7.35-7.45 HCO32 74 mmHg 80-100 mmHg 40 mmHg Acidotic 67 mmHg 35-45 mmHg 24 mEq/L Alkalotic 27 mEq/L 22-26 mEq/L TA B L E 9 - 6 Example of Metabolic Alkalosis Patient Normal Range Reference Acidotic/Alkalotic Alkalotic pH 7.5 7.35-7.45 7.4 PaO2 77 mmHg 80-100 mmHg Acidotic PaCO2 48 mmHg 35-45 mmHg 40 mmHg Alkalotic HCO32 37 mEq/L 22-26 mEq/L 24 mEq/L when working with patients. First, when looking at an It is also important to remember that the time the ECG strip, immediately after the QRS complex, the large heart contracts is the period of the highest myocardial vertical spike that represents ventricular depolarization, oxygen consumption or demand. If the patient’s heart the ventricles should contract, which is followed by a rate is high, then there is a possibility that the coronary pulsatile flow of blood that should be felt at the periph- blood flow cannot keep up with demand and the patient eral pulses. It is useful to make sure that the rate of may experience dysrhythmias and angina. Angina is de- contraction heard when the physical therapist auscul- fined as a discomfort that is experienced above the waist tates over the left chest wall is equal to the peripheral that is not associated with any musculoskeletal or neu- pulse. If some of the contractions eject a small amount romuscular dysfunction. Angina is commonly experi- of blood, the peripheral pulse may not be felt. enced substernally with or without radiation down the

162 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient left upper extremity, but it is extremely important that dysfunction may lead to signs and symptoms including the physical therapist does not forget that there are many fatigue, decreased activity tolerance, and shortness of patients who do not present with classic symptoms. breath. Others may report discomfort of the jaw, back, right upper extremity or gastrointestinal discomfort. It is important to know the patient’s history of dys- rhythmias and current ECG rhythm. If equipment per- Another point to remember about the ECG is that the mits, monitoring the rate, rhythm, and regularity during time between QRS complexes is the time that the ventri- activities will allow the therapist to document any cles fill to send blood into the coronary arteries for myo- changes along with any signs and symptoms during ac- cardial perfusion. When the heart rate is high, there is a tivity. Patients with a history of dysrhythmias may have reduction in ventricular filling time that can reduce the a temporary or permanent pacemaker or an automatic forward flow of blood, particularly when the myocardial implantable coronary defibrillator. For the patient with a tissue is not able to compensate. There is also a reduction temporary pacemaker, the physical therapist should un- in myocardial perfusion time that may lead to angina. derstand what the underlying rhythm is and the patient’s heart function (myocardial perfusion and contractility There are other dysrhythmias that are associated with function). The physical therapist should make sure that diseases such as hypertension and coronary disease. the temporary pacer wires are secured, to reduce risk of Hypertension is associated with myocardial left ventric- disconnection during mobilization. For the patients with ular hypertrophy.25 Over time, this may lead to enlarge- an internal defibrillator, it is important to know at what ment of the left atrium because more blood is being held heart rate level the device will deliver a shock to the pa- in the cardiac chambers at the end of contraction. The tient. The physical therapist needs to monitor these enlargement of the left atrium is associated with irritabil- patients and avoid exercising beyond this heart rate level ity of the atrial tissue and an abnormal control of to avoid unwarranted shocks. rhythm, atrial fibrillation (Figure 9-1). The classic pre- sentation of atrial fibrillation is an unpredictable, irregu- Operative Reports lar heart rate. The patient may become symptomatic if the rate becomes too fast and the heart cannot meet the After understanding the inpatient or outpatient opera- oxygen demand or the myocardium cannot compensate tive procedures a patient may have undergone, the thera- for the lower volume of blood delivered to the ventricles pist may alter the examination process and identify pre- for circulation throughout the body. The patient may cautions and restrictions. This information may also report angina, fatigue, shortness of breath, and dizzi- assist the physical therapist in working with the primary ness, and changes in mentation may be noted. care or specialty service team in establishing mobility guidelines with the goal of protecting the surgical site to Arrhythmias generated from the ventricles, premature promote healing and allow the patient to achieve the ventricular contractions (PVCs), are also common with highest level of function and possibly permit the avoid- aging, but are benign when the dysrhythmia is less than ance of complications related to immobility such as pres- 8 beats per minute (bpm) and the patient’s heart is able sure sores, pneumonia, and DVT. to compensate for the premature contractions. Another ventricular dysrhythmia with an increased incidence The chart review, when possible, is an extremely among older adults is referred to as a bundle branch important step in initiating the examination as it pro- block (BBB) (Figure 9-2) which, again, may also be vides vital information about the patient’s past and benign, but in the presence of depressed myocardial present medical status. There is typically a differential diagnosis list and a working medical diagnosis that can V1 help to guide the physical therapist to develop and pri- oritize the examination. The presenting signs and symp- FIGURE 9-1  ​Example of atrial fibrillation. toms associated with a chronic disease such as HF and obstructive lung disease may be helpful for the physical II therapist to document and understand. This informa- tion may lead the physical therapist to educate the pa- V1 tient on proper self-monitoring with the goal that the patient will seek medical assistance prior to the need FIGURE 9-2  E​ xample of premature ventricular contractions and for admission to the emergency department. At the end of the chart review process, the physical therapist bundle branch blocks in leads II and V1. should be able to formulate a clinical picture of the patient in preparation for the examination process, determine the need for possible referrals, and probable discharge recommendations. Beyond the chart review, the physical therapist should discuss the patient’s situation with other members of

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 163 the medical team. The members of the team will have Beyond the review of systems, the physical therapist information that may not be contained within the should examine the patient for specific factors based upon chart at the time of the physical therapist consult. The age, occupation, and other behaviors. The most well-estab- therapist should also extend the information gathering lished risk factor screening is for CAD. Risk factors include to include the family or caregiver and patient. the causative factors of smoking, diabetes, and hyperten- Review of Systems.  B​ eyond the chart review and stan- sion; predisposing factors include obesity, inactivity, abnor- dard interview, the physical therapist should also com- mal lipid profile, and family history. Other factors to con- plete a review of systems. The review of systems is a sider include age, gender, and stress (see Box 9-3 for risk method of screening the major organ systems in order to factors for CAD).14 After establishing how many risk fac- determine if the patient has certain symptoms that may tors the patient exhibits, the physical therapist should de- lead the therapist to make a medical referral for further termine if the patient is experiencing pain or discomfort testing. In the acute care setting, this process is shared by above the waist that cannot be attributed to a musculosk- the medical team, but the physical therapist should be eletal or neuromuscular dysfunction, shortness of breath at aware of the process and may be able to add to this re- rest or with mild exertion, dizziness or syncope, orthopnea view to improve medical care and outcomes. The reader or paroxysmal nocturnal dyspnea, lower extremity edema, is referred to Table 9-7 for an example of a review of palpitations or tachycardia, claudication, known heart symptoms form that shows as an example of what may murmur, and/or unusual fatigue.14 Finally, once all the risk possibly be included in the medical review and places factors are determined, the physical therapist can determine where the physical therapist may contribute to the the risk level of a cardiac event during exertion. Box 9-4 screening process based upon the facility’s practice, par- lists the American College of Sports Medicine’s (ACSM) ticular medical services, and type of clientele. The physi- risk stratification categories.14 cal therapist should recognize the necessity of including in the questioning symptoms in the 3, 6, and 12 months The process of risk-stratifying patients for heart dis- prior to admission. Box 9-2 represents the implications ease and other diseases, even in the acute care setting, of the review of symptoms. can aid the therapist in determining what components of the examination should be completed and up to what TA B L E 9 - 7 Example of a Review of Symptoms Please place an X on any statement or condition that you have been feeling in the last 1 month, and 3 months 1 month 3 months Cognitive/Mood State Decreased ability to recall current events Decreased ability to remember past events Decrease in short-term memory Decreased ability to concentrate Decreased ability to focus in a busy room Decreased ability to complete a task Increase in tripping or falling Increase in making mistakes Difficulty falling asleep Difficulty staying asleep Wakes up coughing Wakes up short of breath Wakes up anxious Wakes up with pain Feeling depressed Feeling anxious Stopped participating in usual activities Stopped traveling out into the community Prefer to stay at home Prefer to be alone More irritable or quicker to being angry Feeling of forgetfulness Continued

164 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient TABLE 9-7 Example of a Review of Symptoms—cont’d 1 month 3 months General Increased fatigue Experiencing fever or chills Unplanned weight loss Change in voice or prolonged sore throat Increase in thirst or appetite Decreased appetite Body aches or malaise Dizziness or lightheadedness Changes in smell Changes in hearing, ringing in ears Dental pain, mouth sores Sweet odor to breath Brittle hair or nails Any lumps or masses Temperature intolerance (heat or cold) Muscles and Nerves Joint pain, swelling, or redness Increase in incidence of headaches Change in vision or hearing Difficulty finding words or speaking clearly Muscle soreness, weakness Numbness, tingling Dizziness or vertigo Decrease in coordination, feeling clumsy Pain radiating into arms or legs Restlessness, or tremors Decreased memory Loss of consciousness Muscle cramps Bones and Skin Joint swelling or stiffness Muscle pain or weakness Significant loss of body height White and painful fingers or toes Change in appearance of nails Skin discoloration Open wounds Skin rashes or itching Moles or skin marks that have changed in size or color Changes in hair (loss, additional growth, brittle) Heart and Blood Vessels Chest pain, pressure, heaviness, or tightness Irregular pulse (heart rate speeds up, slows down, and skips beats) Legs ache with walking or stair climbing Edema in feet or legs Weight gain despite loss of muscle Fatigue Shortness of breath at rest or during activity Avoidance of usual activities Discoloration or painful feet or legs Swelling in one leg or arm Any pain that goes away when you rest Changes in heart rate or blood pressure Persistent cough Bleeding Continued

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 165 TABLE 9-7 Example of a Review of Symptoms—cont’d 1 month 3 months Pulmonary Shortness of breath Persistent cough Chest wall pain Clubbing of finger and toe nails Productive cough, increase in sputum production Abdomen Changes in appetite or taste Difficulty swallowing Abdominal pain Sense of bloating, gas Changes in bowel behavior Incontinence of bowel or bladder Changes in color or consistency of stool Indigestion or heartburn Nausea, vomiting, diarrhea Changes in urination pattern, stream, or color Pain or burning with urination Needing to urinate at night Hesitation or urgency to urinate Gender Decrease in sexual interest or activity Pain with sexual activity Female Changes in menstrual cycle Vaginal discharge Possibility of pregnancy Spotting or bleeding Irregular moods Changes in breast shapes, lumps or masses, painfulness Male Impotence Testicular pain Penile discharge Genital lesion intensity level of exercise the patient can safely partici- SYSTEMS REVIEW pate in, as well as guiding the follow-up interventions, home exercise program, and education. Depending upon Mental Status the type of patient risk factors, the evaluation should be completed by the physical therapist in order to deter- Assessing the mental status of a patient can be difficult mine if the patient is at risk for other pathologies such as in the presence of acute and chronic medical conditions, pulmonary disease, osteoporosis, cancer, or diabetes. and in the older adult population, this can be more of a Box 9-5 demonstrates some of the risk factors for type 2 challenge because of the increased incidence of dementia diabetes, cancer, and osteoporosis.26-28 and Alzheimer’s disease. Changes in mental state may be associated with a variety of factors, including metabolic Risk factor stratification is a very important process disturbances, coexisting comorbidities, medications, and for the therapist to complete for each patient. After the environmental conditions.29 From a metabolic state, the physical therapist has stratified a patient for the likeli- therapist must recognize that hypoxemia, anemia, hood of having cardiovascular or pulmonary disease, or hyperglycemia, electrolyte imbalances, malnutrition, and the likelihood of the patient experiencing medical diffi- dehydration are contributing factors to changes in men- culty during exercise, this information can be used to tal status. Polypharmaceutical use in the older adult direct the examination and patient education and give population is very common and has been associated not appropriate referrals to physicians, program centers, or only with increased risk of falls30 but also altered mental other health care professionals.

166 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient BO X 9 - 2 The Implications of Review of Systems B O X 9 - 4 ACSM Risk Stratification Categories14 Consider a patient with CAD. It is very common for patients to self- Low risk Men younger than age 45 years and women limit themselves to avoid symptoms, so their answers to questions Moderate risk younger than age 55 years who are asymptom- such as “Are you presently experiencing chest discomfort with exer- High risk atic and meet no more than one risk factor tion or excessive fatigue after exertion?” may be negative but fol- low that up to include “Over the past year have you noticed a de- Men age 45 years or older and women age crease in the activities you are willing to do, such as going on 55 years or older or those who meet two or community outings, vacuuming, etc., or an increase in the time it more risk factors takes for you to complete regular daily activities?” Individuals with one or more signs and symptoms Case: a 72-year-old man presents with excessive fatigue, clumsi- or known cardiovascular, pulmonary, or meta- ness, and a recent fall. On the review of systems, the patient reports bolic disease an increase in fatigue, inability to mow his lawn without taking rest breaks, and a decreased frequency in urination. He reports being surgery, as well as the patient’s environment, and use of treated for hypertension and has been experiencing this clumsiness restraints and medical equipment, such as Foley cathe- for about 2 months. Fatigue is such a nondescript symptom and can ters, as contributing factors to a decline in mental status. be caused by multiple pathologies. The physical therapist puts forth other questions to determine if the fatigue is related to pathologies Delirium, also referred to as an acute organic brain such as cardiac or renal disease, diabetes, or cancer. The patient syndrome, acute organic mental disorder, or acute con- revealed that he has been limiting his activity level to avoid short- fusional state, is a syndrome defined as an acute decline ness of breath with exertion. He reported tightness in the waist of in mental status associated with transient changes that, his pants and that he is more comfortable sleeping in his recliner in many cases, are reversible. The patient typically pre­ chair. With this information, the therapist knew to complete a thor- sents with fluctuations in levels of alertness, inability to ough examination of the cardiovascular system, including heart and attend to a task, perceptual disturbance, visual halluci- lung sounds, inspection for pitted edema, and jugular vein disten- nations, and a decline in cognitive skills such as learning, tion. With the findings of these tests, the therapist discussed with processing, and problem solving. Delirium may also be the medical team concerns for uncompensated heart failure. associated with changes in mood state such as with- drawal or agitation and combativeness.29,32,33 There are These types of time-based questions are important to ask when three states of delirium: the hyperactive state in which screening for cardiovascular, metabolic, and oncologic conditions. the patient is restless and agitated; the hypoactive state The review of systems should lead the therapist to formulate and where the patient is lethargic and withdrawn; and a prioritize the examination to eventually determine a plan of care mixed state where the patient’s behavior fluctuates be- that may include recommendations for further medical evaluation tween the hyperactive and hypoactive states.33 Delirium and interventions. is often misdiagnosed as dementia in the older adult pa- tient, which can lead to high mortality rates, longer status.31 The therapist should not overlook the use of lengths of stay in medical facilities, and poorer func- alcohol and over-the-counter or illicit drug use when tional outcomes. Of note, there is a higher incidence of gathering information during the evaluation. Finally, delirium in patients who have a baseline of dementia.32 besides the past medical history of the patient, the thera- pist needs to recognize the effects of surgery, of general Delirium is a significant issue when working with the anesthesia and the physical stress associated with older adult, particularly those in an institutional setting B O X 9 - 3 Risk Factors for Coronary Artery Disease14 Positive Risk Factors Defining Criteria Family history Myocardial infarction, coronary revascularization, or sudden death before 55 years of age in father or other male Smoking first-degree relative or before 65 years of age in mother or other female first-degree relative Hypertension Current cigarette smoker or those who quit within the previous 6 months Systolic BP 140 mmHg, or diastolic BP 90 mmHg, confirmed on at least two consecutive occasions, or on Dyslipidemia hypertensive medication Impaired fasting glucose Low-density lipoprotein .130 mg/dL, high-density lipoprotein ,40 mg/dL, on lipid-lowering medications, total Obesity cholesterol .200 mg/dL Sedentary lifestyle Fasting blood glucose 100 mg/dL confirmed by measurements on at least two separate occasions Body mass index .30 kg/m2, or waist girth .102 cm for men and 88 cm for women, or waist/hip ratio 0.95 for men and 0.86 for women. Not participating in a regular exercise program or not meeting the minimal physical activity recommendations from the U.S. Surgeon General’s Report Modified from ACSM.

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 167 B O X 9 - 5 Common Risk Factors Associated with Three Common Medical Issues in the Older Adult26-28 Type 2 Diabetes Cancer Osteoporosis Obesity Tobacco use Age Hypertension Excessive alcohol use Family history Hypercholesterolemia Excessive sun exposure Low body weight Race (African American) Inactivity Race (Caucasian, Asian) Genetics Being overweight or obese Menopause Inactive lifestyle Others specific to each cancer History of fractures Glucose intolerance Diet (acute care hospital, subacute hospital, or a long-term- including medication prescription as well as surgical care facility), because of its high incidence and its impact management. on medical and functional outcomes. The therapist should Heart Rate.  ​The therapist should begin with an assess- be aware of the features of delirium. This syndrome has a ment of resting heart rate (HR). It is helpful if the pa- typically acute onset of inattention, disorganized thinking, tient can give you an estimate of what their HR and a change in the level of consciousness, disorientation, blood pressure (BP) typically run to establish a baseline. decreased memory, perceptual disturbances, and altered In the assessment of the pulse and heart rate, the thera- sleep–wake cycles.34 It has been reported that as many as pist should appreciate the rate, regularity, and quality. 25% of older adult patients admitted to the hospital will When assessing regularity, the therapist is assessing the exhibit a delirious state, and an additional 30% will de- equal and consistent beat of the pulse. Regularity is velop delirium. In the intensive care units, the incidence of defined as having less than six interruptions in the delirium can reach as high as 90% and there is a higher rhythm in 1 minute. If the pulse is regular, the rate can discharge rate to long-term-care facilities for those with be calculated by counting the number of beats within delirium.32,34 In long-term-care facilities, delirium cases 15 seconds and then multiplying that number by 4 to are reported in approximately 45% of the residents.29 calculate the heart rate per minute. If the rate is irregu- Consequently, the therapist should have the ability to lar, the therapist should count the number of beats contribute to the team by reporting delirium to improve throughout the entire minute. For some patients who morbidity and mortality and decrease health care costs have an irregular pulse and those patients with a history associated with delirium. of left ventricular dysfunction, the therapist should verify the palpatory rate with the auscultatory rate. The Dementia may sometimes be separate or intertwined auscultatory rate can be taken over the left anterior with delirium, which can complicate the evaluation and chest wall, around the second intercostal space where intervention process and significantly affect outcomes. the closure of the aortic valve can clearly be heard. Fi- Dementia is a syndrome of gradual onset and progres- nally, the therapist should appreciate the quality, or how sive decline of cognitive function. It is a common disor- well the pulse is felt upon palpation. A pulse that is der in older adults that progresses with each decade of described as bounding is very difficult to obstruct, life. Alzheimer’s disease and cerebral vascular insuffi- whereas a thready pulse is weak and easily obstructed ciency are the two more common causes of dementia, and is, at times, rapid. Possible causes of a bounding with Alzheimer’s disease accounting for 50% to 60% of pulse include exercise, fever, anxiety, arrhythmia, vol- all cases.35 There are a variety of standardized instru- ume overload, and hypertension. A thready pulse is as- ments that are used to screen and evaluate for dementia, sociated with dehydration, arrhythmias, aortic stenosis, such as the Folstein Mini Mental Status Exam. See ketoacidosis, and shock. Chapter 8, Cognition in the Aging Adult, for specific details related to evaluation of delirium and dementia. The therapist should also consider what is referred to as heart rate reserve (HRR), how much the heart can Vital Signs increase its rate from the resting value to respond to demand and it reflects the heart’s ability to increase car- Every therapist, regardless of the practice setting and diac output. The physical therapist may infer how much type of patient population treated, should be evaluating activity the patient can tolerate from this calculation the patient’s resting vital signs and response to exertion. (Box 9-6). Heart rate reserve can be calculated by sub- Even in the acute care setting where the patient’s vitals tracting the resting HR from the maximal (predicted or are routinely monitored, the therapist can provide valu- actual) HR. Predicted HR is commonly estimated by 220 able information about the patient’s tolerance to upright minus age, which has a standard deviation of 14 bpm. postures, functional mobility, and activity tolerance. Actual maximal HR would be available if the patient This information can assist in medical decision making, had undergone some form of exercise test.

168 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient BO X 9 - 6 Application of Heart Rate Reserve experience visual and speech deficits, confusion, and changes in cognitive function. It is difficult to utilize There are two patients who are 70 years of age with similar medical symptoms as an indication of orthostasis, because the histories and functional abilities. They are admitted to the hospital complexity of the older adult patient’s medical history with pneumonia. They both have a predicted maximal HR of and presentation may be related to various issues. There- 150 bpm. The first patient’s resting HR is 70 bpm, which gives him fore, it is critical that the therapist screen the patient’s BP an HRR of 80 bpm. The second patient has a resting HR of 120 bpm with position changes to rule out orthostatic hypoten- and therefore an HRR of 30 bpm. The physical therapist should ex- sion. To thoroughly rule out orthostasis, the client pect the first patient to have a higher activity tolerance than the should be monitored before and after medications, be- second patient because the first patient’s heart rate is more able to fore breakfast, after meals, and before bed.37 compensate during exertion before reaching maximum HR. Response to Exertion.  ​Blood pressure assessment Blood Pressure and Hypertension at rest and during exertion is a key examination that a Pulse Pressure.  Pulse pressure can be easily assessed physical therapist can provide toward assessing toler- ance during exertion that can assist in medication by the clinician and has significant predictive value in prescription. The incidence of hypertension (HTN) cardiovascular disease. Pulse pressure examines cardio- rises with age, so it is very important to screen BP with vascular compliance—the ability of the arteries to vaso- every patient. Hypertension is an independent risk fac- constrict and vasodilate in order to circulate blood to tor for cardiovascular and renal disease. The Joint properly meet activity demands. Pulse pressure is calcu- National Committee on Prevention, Detection, Evalu- lated by subtracting diastolic blood pressure from ation, and Treatment of High Blood Pressure is urging systolic pressure. With age there is a decrease in compli- the health care field to focus not only on treating ance of the aorta and small arteries, which leads to an HTN, defined as a BP of 140/90 mmHg, but to also elevation of systolic pressure and a decline in diastolic address pre-HTN, BP of 120/80 to 139/89 mmHg, pressure, causing an increase in pulse pressure. Pulse with the goal being to decrease the incidence of CAD, pressure can also be elevated with exercise, aortic insuf- stroke, and renal disease.39 Not only can the therapist ficiency, atherosclerosis, and when a patient has an ele- document the presence of HTN and make the proper vated intracranial pressure, whereas it will narrow in the referral for medical management but they can also as- presence of aortic stenosis, HF, and pericarditis. As pulse sess the effectiveness of antihypertensive medications. pressure widens, there is an increase in the incidence of Evaluation for HTN should be assessed on at least two cardiovascular disease. Generally, a normal pulse pres- to three consecutive sessions,14 and if the patient is sure at rest is approximately 40 mmHg. A study con- found to have either resting or exercise HTN, he or ducted by Weiss et al found that an increased pulse she should be referred for medical management.39 See pressure in the very old hospitalized patients was a pre- Table 9-8 for the classification of HTN. A physical dictor of higher mortality36 and, therefore, when pulse therapist can have a major impact on a person’s health pressure exceeds 60 mmHg, a medical referral should care by assessing the patient’s blood pressure during promptly be made. exertion, which few other practitioners do, so that a hypertensive blood pressure response to activity can be Orthostatic Hypotension.  ​Orthostatic hypotension is documented and appropriately treated. defined as a decrease in systolic BP by 20 mmHg or a drop by 10 mmHg with a reflexive increase in HR with transi- During the examination process, the therapist should tional movements, such as moving from supine-to-sit or monitor the patient’s vital signs with activity to deter- sit-to-stand. The incidence of orthostasis increases 20% in mine if the client is having an appropriate HR and BP community-dwelling people older than age 65 years and response to a given workload. It can be helpful to exam- has been reported to be as high as 50% in frail older adults ine physiological response during common activities of living in nursing homes.37 There are many causes of ortho- daily living (ADLs) and instrumental activities of daily static hypotension, including adverse effects of medica- living (IADLs), as well as during a more formal exercise tions, dehydration, anemia, arrhythmias, immobility, sep- test. It should be noted that patients taking b-blocker sis, adrenal insufficiency, and autonomic dysfunction medications will have some HR and BP response, related to diseases like diabetes, Parkinson’s disease and although blunted, to an increase in workload. In these central nervous system impairments.38 situations, it can be helpful to look at an activity chart to determine the patient’s estimated metabolic equivalent The patient may or may not be symptomatic level (MET level) to examine the relationship between with orthostatic hypotension and regardless of whether vital signs and workload.40 There should be an expecta- the patient demonstrates symptoms they are at risk tion that HR and BP and perception of work should for sustaining injuries, including falls, fractures, myocar- rise with demand. In general, HR should increase 10 to dial infarction, and cerebral injuries. The most common 12 bpm and systolic BP should increase 10 to 12 mmHg symptoms experienced are lightheadedness, dizziness, per MET level in the absence of medications that will weakness, syncope, and angina. Some clients may lead to a blunted response.

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 169 TA B L E 9 - 8 Classification of Hypertension14 The inspiratory-to-expiratory ratio should be 1:2. When the ratio becomes closer to 1:1, it may indicate hyper- Systolic Blood Diastolic Blood ventilation, possibly associated with anxiety or a meta- Pressure (mmHg) Pressure bolic problem such as uncontrolled diabetes, alcohol (mmHg) abuse, or a restrictive pulmonary disease. A ratio that reaches 1:3 or greater can be associated with obstructive Optimal ,120 and ,80 lung diseases like asthma, chronic bronchitis, and em- Pre- 120-139 or 80-89 physema. The therapist should document the patient’s ability to increase the depth and rate of breathing with hypertension 140-159 or 90-99 an increase in exertion. There should be an expansion Hypertension 160-179 or 100-109 of the chest wall in all cardinal planes and the therapist  180 or 110 should see initiation and expansion of the upper ab- Stage 1 dominal wall during inspiration, indicating diaphrag- Stage 2 matic function. The patient should also be able to speak Stage 3 approximately 12 to 15 syllables per breath at rest. If the therapist has access to a pulse oximeter, oxygen To complete the assessment of response to exertion, saturation at rest and during exercise should be docu- the therapist should take note of the vital sign response mented. For people with light complexion, a value during the recovery phase. There should not be any im- greater than 92% at rest is normal and these values mediate increase in HR upon stopping exercise, which should not decrease with exercise, whereas that number would suggest that the patient is experiencing a reflexive increases to 95% for darker-skinned people.42 It should cardiac response to venous pooling or orthostasis. How- be noted that pulse oximeter accuracy decreases signifi- ever, within the first minute of recovery, there should be cantly in darker-pigmented patients, especially with a significant decrease in systolic BP and HR. The rate of saturation values of less than 80%.43 A value of less HR recovery has been linked to mortality and morbidity than 90% at rest or during exercise is abnormal and a related to cardiovascular disease. Heart rate recovery of value less than 88% indicates the need for supplemental less than 12 beats in 1 minute walking recovery is associ- oxygen.44 If the therapist notes deviations in these respi- ated with poor prognosis and a rate of HR recovery less ratory factors, further investigation of the cardiopulmo- than 42 beats at 2 minutes into recovery after a sub- nary system is warranted. The physical therapist must maximal exercise test in older adults is associated with recognize the limits of the pulse oximeter, which include increased mortality rate from a cardiovascular event.14,41 inaccuracies in the reading and the fact that the device is measuring the percentage of existing hemoglobin to Rate Pressure Product.  ​Rate pressure product (RPP) carry oxygen. Depending on the quality of the device, represents an estimate of myocardial oxygen consumption there may be as much as a 5% to 6% error rate, which and should increase as workload increases. Using the HR becomes more inaccurate for patients who have atrial and BP data that were recorded at rest and during the fibrillation or other highly irregular dysrhythmias, or various activities performed, the therapist can calculate the when the oxygen saturation rates drop below 90%.45 RPP by multiplying the HR with the systolic blood pres- sure. This can be valuable when working with a patient Auscultation who has a history of coronary disease and the therapist wants to assess for myocardial limitations to exertion. As part of the assessment, the therapist should listen to Rate pressure product is also known as the anginal thresh- the heart and lungs, both at rest and during exercise. old because once the oxygen demand during exertion ex- Many therapists are unfamiliar and feel very uncomfort- ceeds the coronary artery’s ability to carry sufficient blood able with their auscultation skills, but the only way to and oxygen to the myocardium, ischemia begins and the begin to feel more confident is to listen to the chest walls client will most likely become symptomatic. The point of of many patients. Not only is auscultation an important imbalance between oxygen supply and demand can be examination skill in order to rule out cardiopulmonary predicted by examining the RPP. The therapist can use this disease or dysfunction but it is also important to assess information to document symptoms, the MET level where the heart and lungs during exercise prescription as it may symptoms appear, monitor the progression of the disease, reveal a reason for exercise intolerance. The authors and progress the rehabilitation plan in a patient with encourage every therapist to listen to everyone’s chest known disease. This information can also be helpful in wall to build his or her skills. There are multiple heart making a referral for medical workup and to design a safe and lung sounds posted on the Internet to provide ex- exercise program below the anginal threshold. amples of various sounds for independent learning. Pulmonary Function When listening to basic heart sounds, the therapist should first assess the quality of valvular closure. If the During the interview and examination process the valves are functioning properly, there should be a nice therapist should also note the respiratory rate and breathing pattern. The average resting adult respi- ratory rate ranges from 12 to 20 breaths per minute.

170 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient crisp and definitive sound. The best place to listen to deeper than normal, in and out through the mouth. Re- the atrioventricular valves (tricuspid and mitral) is in the fer to Figure 9-4 for general guidelines for auscultation right fifth intercostal space, midclavicular line. Then the sites and Table 9-9 for a brief description of types of lung therapist should place the diaphragm over the second sounds and associated causes.47-49 The therapist should intercostal space just right of the sternum to hear the appreciate a gentle rustling sound that is louder the aortic valve the loudest. If the therapist does not hear a closer the therapist places the stethoscope to the main crisp, strong closure at rest or a sound that appears or bronchus.50 The therapist should not normally hear any worsens with exercise, the medical team should be noti- wheezing or crackling sounds, as this can be indicative fied. Next the therapist should place the bell of the of lung disease. Lung sounds should be assessed at rest stethoscope back over the mitral valve area. The therapist and during exercise to once again assess for cardiopul- should vary the pressure between the bell and chest wall monary disease and exercise intolerance. in order to hear low-pitched sounds. When the therapist presses the bell lightly on the chest wall, low-pitched Nutritional Status and Physical sounds can be heard and when the therapist then presses Appearance the bell firmly, the low-pitched sound disappears. The appearance of an additional sound may indicate an atrial The therapist needs to recognize the association between or ventricular gallop. If a harsh straining, a lush sound, proper nutrition, body composition, and activity toler- or a low-pitched sound is heard at rest, worsens with ance in order to progress in rehabilitation.51,52 The exercise, or appears with exercise, the therapist should therapist can refer to the Tufts University website for seek further assessment for the patient. Murmurs may be basic dietary recommendations for older adults.53 In the appreciated either during the systolic or diastolic phase of acute care setting, the nutritional status is addressed and the cardiac cycle. Systolic murmurs can be heard between closely monitored by clinical dieticians and physicians, S1 and S2 and are associated with semilunar valve steno- but the physical therapist needs to be aware of the plan sis or atrioventricular valve incompetence. Diastolic mur- and can contribute valuable information to the dietary murs are associated with atrioventricular valve stenosis plan of care. or semilunar valve incompetence. See Figure 9-3 for a diagram of the heart sounds. A stenotic valve sounds There are many reasons why the older individual is harsh or strained, whereas an incompetent valve has a susceptible to malnutrition and this type of screening lush or swish-like sound. Some abnormal sounds may be should be part of the physical therapist evaluation, even benign, but most sounds are associated with a valvular in the acute care setting, because unless a complication problem or a dysfunction of the myocardium and must arises, or the patient has diverted from the expected be further investigated.46 Finally, a leathery rubbing medical pathway, the patient’s nutritional status may not sound heard over the chest wall that persists when the be assessed or addressed during the hospital stay. Com- patient holds his or her breath, could possibly be a peri- mon factors that adversely influence nutritional status cardial friction rub and should be further worked up. A may include poor dentition, limited income, depression, pericardial rub is associated with friction between the cognitive impairments, chronic diseases, decreased pericardium and myocardium and is associated with in- ability to smell, and altered taste, particularly from flammation or fluid within the pericardium. It is very medications. helpful if the therapist is able to inform the physician if the sound worsens or appears with exertion, because In general, a decrease in activity level and decline in many times the patient is examined at rest by the medical muscle mass likely account for the decrease in basal team. metabolic rate and a need for a lower caloric intake, but if the individual was active prior to admission, their di- The therapist should then listen to each major section etary needs may be equal to that of a young adult’s.54 of the lung, anteriorly, laterally, and posteriorly. At rest, There are many reasons why the older adult requires an the patient should be instructed to breathe slightly increase in dietary requirements, such as an increase in protein and total calories at times, such as in the presence S4 S1 S2 S3 of an infection, wounds, or stress. See Table 9-10 for general dietary recommendations for the older adult. Systolic Diastolic murmurs murmurs Energy requirements for the older adult can be diffi- cult to determine because of complex medical histories, FIGURE 9-3  H​ eart sounds. including HF, renal dysfunction, and different types of cancer. A specialized diet recommendation from a registered clinical dietician may be warranted. It is important to discuss with the referring physician and the patient about a clinical dietary referral to ensure the best health and wellness results and to account for the calories spent during rehabilitation (www.health.gov/ dietaryguidelines/dga2005/document/default.htm).

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 171 FIGURE 9-4  L​ ung auscultation sites. (Redrawn from Buckingham EB: A primer of clinical diagnosis, ed 2, New York, 1979, Harper & Row.) TA B L E 9 - 9 Lung Sounds47-49 Normal Breath Sounds Description Location Heard normally adjacent to the sternum. Bronchial Loud, high-pitched sound with a shorter inspiratory Normally heard between the scapulae from T3 to T6 Bronchovesicular than expiratory duration with a pause between and at the costosternal border of ICS 2 and 3 Vesicular each phase of ventilation Normally heard in the peripheral lung fields Softer version of bronchial sounds, except are Dysfunction continuous throughout ventilation Associated with fluid or secretion retention Low-pitched, muffled sound. Inspiratory sound is Associated with opening of proximal airways Atelectasis, pulmonary edema, fibrosis, or compression louder, longer, and higher in pitch than expiration of lung tissue from a pleural effusion Adventitious Sounds Associated with opening of more proximal airways Associated with fluid and secretions in large Description airways Crackles (rales): inspiratory May be heard throughout respiratory cycle Heard in the early inspiratory phase Suggestive of rigid airways, bronchospasm, Heard in the late inspiratory phase foreign-body partial obstruction, or stenosis Crackles (rales): expiratory A rhythmic sound Reflects unstable airways that have collapsed. It is Nonrhythmic sound associated with airway obstruction Wheezes: A continuous, constant pitch of varying durations Associated with obstruction of airway, commonly thick High pitched Inspiratory secretions Expiratory Reflects unstable airways, airway obstruction Inflammation Wheezes: Low-pitched, continuous sound Low pitched (rhonchus) Expiratory Pleural friction rub Course, grating, leathery sound from the pulmonary system Observing the client’s appearance can generally appearance53,55-57 and refer to the American Dietary provide the clinician with valuable information of gen- Association (www.eatright.org) or the U.S. Department eral health and well-being. The appearance of the of Health and Human Services (www.hhs.org) for fur- patient’s skin and fingernails can reveal the presence of ther information and dietary recommendations. pathology. The detection of body or oral odors can suggest diseases such as uncontrolled diabetes, dental Older adults are at an increased risk of wound develop- abscesses, or pulmonary infections. Body odors and ap- ment and complications because of the age-related changes pearance may also suggest alcohol and tobacco abuse, in skin, decreased arteriovenous health, decreased activity, incontinence, and organ dysfunction. Appearance may cardiovascular disease, and an increase in incidence of also suggest the need for a social work consult for refer- malnutrition. Szewczyk et al described a study that exam- ral to community resources and services. See Table 9-11 ined the nutritional status in older adults with or without for signs of nutrient deficiencies that may affect body venous wounds and reported that 48% of the participants were malnourished or at risk for malnutrition.21

172 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient TABLE 9-10 General Dietary Recommendations for the Older Adult53,55-57 Carbohy- Recommendations Cellular Function drates 45%-65% of total daily caloric intake* Supports cell division, leukocyte function, and fibroblast Protein 35-40 kcal/kg/day activation Using complex carbohydrates, not simple sugars Fats 55%-65% of total caloric intake Supports new protein synthesis, cell proliferation, tissue Saturated fats 35-40 kcal/kg/day regeneration, inflammatory and immune function Cholesterol Presence of infections, wounds, catabolic stress: additional Trans fats Builds new cell membranes 25-30 kcal/kg/day 15% of total caloric intake 0.8-1.0 kcal/kg/day May need to be increased 1.25 g/kg in the healthy active adult Presence of infections, wounds, catabolic stress: 1.2-1.5 kcal/ kg/day 20% of total daily caloric intake* Adjust to make food palatable to avoid deficiencies or anorexia, but should not exceed 35% of total caloric intake ,10% ,300 mg/day Minimal to none *May need to be higher to support hormone and bile production. TA B L E 9 - 1 1 Signs and Symptoms of Nutritional Deficiency53,55,56 Signs and Symptoms Abnormalities Hair Dull, dry lack of natural shine Protein deficiency, essential fatty acid deficiency Eyes Zinc deficiency Thin, sparse, loss of curl Hyperlipidemia Lips White ring around eyes Vitamin B12 deficiency, folic acid and/or iron deficiency Tongue Vitamin A deficiency, zinc deficiencies Taste Pale eye membrane Face Niacin, riboflavin, or iron deficiencies Night blindness, dry membranes, dull cornea Riboflavin deficiency Neck Folic acid and niacin deficiency Nails Redness and fissures of eyelid corners Riboflavin deficiency Skin Redness and swollen Zinc deficiency Protein energy deficiency, niacin, riboflavin deficiencies Muscles Soreness, swollen, bleeding Sores, swollen Niacin deficiency Bones Iron deficiency Nerves Soreness, burning Protein deficiency Diminished taste Iron deficiency Loss of skin color, dark cheeks and eyes, scaling of skin around Zinc deficiency Biotin deficiency nostrils Abnormal vitamin A levels Protein energy deficiency Hyperpigmentation Phosphorus and potassium deficiency Thyroid enlargement Protein energy deficiency Fragile, banding Thiamine deficiency Folic acid and thiamine deficiencies Spoon-shaped Abnormal magnesium levels Slow wound healing Decreased chloride, sodium deficiency Calcium, phosphorus, and vitamin D deficiency Scaliness Protein deficiency Thiamine, vitamin B12 deficiency Dryness, rough Magnesium and zinc deficiencies Lack of subcutaneous fat, bilateral edema Weakness Wasted appearance Calf tenderness, absent patella reflex Peripheral neuropathies Muscle twitch Muscle cramps Demineralization Listlessness Decreased sensation, proprioception, depression, and decrease in cognitive function Seizures, behavioral disruption, memory loss

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 173 Each phase of wound healing requires the proper nu- which is defined as a loss of muscle mass, strength, and trition in a sufficient nutrient distribution to promote function,61 and it is associated with an increase in dis- healing. Even a short period of malnutrition, reflected in ability and mortality.51 Sarcopenia is also commonly as- prealbumin levels, may occur early on in a hospital stay sociated with a low BMI, but it has been documented and can delay granulation tissue and collagen forma- that there is a group of older, obese individuals that also tion.57 It has been reported that as high as 62% of hos- have been diagnosed with sarcopenia. These individuals pitalized older individuals are protein deficient with low have a lower muscle mass of the lower extremities and prealbumin and albumin levels. Malnutrition doubles pelvic girdle than individuals with obesity or individuals the risk of developing pressure ulcers and increases mor- of normal weight without sarcopenia. Patients with the tality in the older adult.21 The therapist should keep in combination of obesity and sarcopenia have a decrease mind that many obese patients have low albumin and in physical function when compared to individuals with prealbumin levels and are equally or more at risk for sarcopenia and normal BMI.52 With this in mind, it is ulcers and other associated complications from malnu- important to obtain objective data on strength and func- trition than their normal-weight counterparts. tion such as grip strength, standardized muscle strength, endurance and functional tests, for example, the timed Prealbumin level reflects the current nutritional sta- up and go, physical performance test, Tinetti and Berg tus of a patient and for patients in the acute or sub- balance tests. acute recovery phase of an illness. Monitoring these levels is critical to adjusting nutritional and fluid Another factor the therapist needs to consider when needs. There are many reasons why a patient may not working with older adults is body fat deposition. With be making the expected gains with rehabilitation, and aging, there is a reduction in subcutaneous fat and an the physical therapist must consider that malnutrition increase in visceral fat accumulation. There is also a re- can be one of those causes and work with clinical di- duction in muscle mass along with an increase in total etary staff to ensure that sufficient nutrition and calo- fat mass.62 This change in body fat deposition and com- ries are being provided to account for the rehabilita- position is associated with an increase in mortality and tion process. morbidity. Skin-fold measurements may also be useful in assessing body composition, but the therapist needs to Body Weight/Body Composition fully examine the formula so that it is an appropriate calculation for older adults. Because changes in body fat As part of the patient’s nutritional status, the therapist deposition may lead to an underestimation of percentage must consider the patient’s body composition. The rela- body fat, it is recommended to use a formula that in- tionship between body weight and composition and cludes at least one skin-fold measurement on the function in older adults is a very complex matter. More torso.62,63 research is needed to further understand how factors such as body mass index (BMI), fat mass, and lean Waist circumference can also show areas of fat depo- muscle mass contribute to function, mortality, and mor- sition and is associated with cardiac disease. Women and bidity. men with a waist circumference greater than 35.5 inches (88 cm) and 39.5 inches (99 cm), respectively, have an The research is inconsistent depending upon the sub- increased risk of cardiovascular disease. BMI and waist jects, medical status, and variables measured. One find- circumference can be used to assist the therapist in ing that appears to be consistent is that a BMI lower stratifying the risk of diseases such as diabetes, hyperten- than 19 is associated with an increase in mortality in sion, and cardiovascular disease.63 hospitalized patients as well as older adult community dwellers. It has been suggested that under health stress, The authors suspect that nutritional status and body such as infections, hip fractures, or cancer, the older composition are not commonly assessed or considered in adult patient has less energy stores to combat the cata- working with the older adult patient, but these factors bolic state that the patient’s body is experiencing.58-60 It have significant consequences to the rehabilitation also appears that patients older than age 60 years, and process. It has been documented that older adults have more significantly in patients older than age 75 years, a significant reduction in neuromuscular recruitment with a BMI between 30 and 38 have an equal mortality and muscle mass that was not recovered with rehabilita- rate when compared to age-matched subjects with nor- tion after a 2-week period of immobility when compared mal BMI (20 to 25).52,59 BMI, however, provides limited to a young group of subjects with a similar prior level information for the clinician to truly assess the patient’s of activity.51 For the patient who is medically compro- body composition as well as mortality and morbidity mised, the therapist needs to consider the level of protein rate. BMI does not speak to the percentage of body stores and current nutritional impact to focus on regain- weight that is fat versus lean muscle that can contribute ing muscle strength to positively affect functional to function. outcomes.64 Protein deficiency, common among older adults, along According to the National Health Statistics reports, with a reduction in activity can lead to sarcopenia, the five main causes of hospitalization among the older adults are CAD, HF, pneumonia, urinary tract

174 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient infections (UTIs)/sepsis, and dizziness/falls.2,65 Of late, and atherosclerosis and is associated with an increase the hospital admissions for adults older than age in functional impairments and disability but not di- 65 years continue to rise, despite the downward trend rectly associated with mortality.71 Besides inactivity among those younger than age 65 years.66 With heart being linked to obesity, inactivity is also associated disease being the leading cause of death in the United with a reduction in muscle mass, activity intolerance, States, it is important to evaluate and educate our pa- and functional limitations.66 The reduction in muscle tients to optimize health. Although the other main mass is independently a predictor of higher mortality causes for admission are also prevalent, they may also rates in older adults.51 be the sequelae to heart disease once an older adult is admitted to the hospital. The following section will Coronary artery disease compromises the blood flow cover all these topics in more detail. to the myocardium. An imbalance between oxygen sup- ply and demand initially results in myocardial ischemia Coronary Artery Disease (CAD) and may lead to myocardial necrosis if the imbalance is not resolved. Angina in the older adult typically does Coronary artery disease is the leading cause of morbidity not present itself with the normal symptoms. After the and mortality in the older adult, with the highest age of 74 years, patients commonly report signs and incidence between the ages of 65 and 84 years. Eighty symptoms including general weakness, dyspnea, fatigue, percent of all deaths related to CAD are individuals syncope, and decrease in mental status and there is no older than age 65 years.67,68 gender difference in presentation and common reports.72 Angina can be classified as stable or unstable. Stable There is a wealth of research linking risk factors to angina refers to typical or predicted symptoms upon the development of atherosclerosis, but recent research exertion over time for patients with a diagnosis of CAD. is beginning to document the difference in the degree of Unstable angina means there is a progression in symp- risk of CAD for the older individual and differences toms with exertion or the patient is experiencing angina between the genders. Cardiac risk factors in the young- at rest. old (age 75 years or younger) appear similar to those of middle-aged adults and include diabetes and smoking. If CAD progresses to the point where blood flow to Elevated low-density lipoproteins (LDL) and total cho- the myocardium becomes significantly compromised, lesterol are independent risk factors associated with the patient is at risk for acute coronary syndrome CAD for individuals younger than age 75 years; how- (ACS) or a myocardial event. The risk of ACS can be ever, this risk is lower after the age of 85 years. A low from a severe imbalance of oxygen demand and supply level of high-density lipoproteins (HDL) along with el- during exertion or a further decrease in perfusion. evated total cholesterol carries a higher risk for CAD in Acute coronary syndrome refers to unstable angina, women than men.67 The incidence of systolic hyperten- non-ST elevation myocardial infarction (NSTEMI), or sion increases with age along with the various changes ST-elevation myocardial infarction (STEMI). With ACS that affect arterial function. With age, there is an in- in the older adult, there is a reduction in incidence of crease in arterial stiffness and wall thickness that leads ST-segment elevation from 85% of patients younger to a decrease in the compliance of the arteries and arte- than age 65 years to less than 35% in patients older rioles. There is also endothelial dysfunction that leads than age 84 years. There is also an increase in respira- to an increase in substances that cause vascular con- tory failure, syncope, and stroke associated with myo- striction as well as the increase in leukocytes and plate- cardial infarction and increase in mortality rates for the let adherence and migration.69,70 Untreated HTN leads older adult.72,73 to left ventricle hypertrophy, which happens to be an independent factor of CAD in the older adult. Left ven- Exercise testing and cardiac catheterization are the tricular hypertrophy then results in a decrease in the principal procedures used to diagnose CAD. During compliance of the heart to allow for proper filling and the graded exercise testing, the clinician attempts to in- ejection, and a subsequent increase in oxygen demand duce myocardial ischemia and observe the onset of of the myocardium.70 These changes increase the risk of angina along with changes in the 12-lead ECG for myocardial ischemia and cellular loss, potentially evolv- diagnostic testing purposes. The pattern of ECG changes ing into HF. on the 12-lead ECG can determine the wall that is underperfused. (For example, ECG changes in leads II, Aging is also associated with an increase in inactivity III, and the augmented AVF leads suggest inferior wall and obesity, which are also clear risk factors for CAD, impairment.) Box 9-7 lists the signs and symptoms but there is a decreased link to mortality for the older of CAD. The gold standard for CAD diagnosis is adult in comparison to the younger adult.52,71 The in- cardiac catheterization that examines the patency of crease in obesity with aging is due to a reduction in the coronary arteries. Cardiac enzymes will be activity level, excessive caloric intake, a decrease in very important for diagnostic purposes and determine muscle mass, and lower basal metabolic rates. Obesity extent of injury. Clinical findings upon examination is linked to chronic diseases such as diabetes, cancer, will vary depending upon the degree of CAD and its stability.

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 175 B O X 9 - 7 Signs and Symptoms of Coronary 50% to 70%, is depressed to less than 40% with systolic Artery Disease dysfunction. In diastolic dysfunction, the left ventricle EF is normal, although it accounts for at least 50% of Vitals • Varies; dependent on degree and HF in the older adults.77 However, with diastolic dys- stability of coronary artery disease/ function, the ventricle walls thicken with normal or Auscultation acute coronary syndrome (ACS) slightly smaller chamber size and reduce the myocardi- Palpation um’s ability to relax to allow sufficient filling. Heart Arterial blood gases • Heart rate and blood pressure will failure with normal EF is commonly associated with Observation typically be elevated at time of ACS chronic HTN with left ventricle hypertrophy.72,77 Exercise tolerance • Pulse rate may become irregular Clinically, the signs and symptoms of HF are associ- • Tachypnea associated with pulmonary ated with the type of dysfunction: Either the myocardium is causing insufficient filling of the ventricles leading to an edema, anxiety, and pain increase in venous blood volume or the ventricular con- • Rales associated with pulmonary traction is unable to sufficiently eject the blood forward into the arterial circulation. See Box 9-8 for a list of the edema signs and symptoms of HF. In general, the most common • S3 and S4 cardiac sounds associated symptoms related to HF are fatigue, shortness of breath, and decreased physical capacity. with contractility dysfunction • Apical pulse will shift to left with left To clinically assess diastolic dysfunction of the right ventricle, the physical therapist should inspect for pitted ventricular hypertrophy edema, commonly of the lower extremities. It is impor- • Peripheral edema, jugular vein tant not only to document the score but the degree of edema. In the pitted edema scale, a zero means no pitted dysfunction with heart failure edema noted and goes up to a 4, which means the pitted • Varies impression remains for longer than 30 seconds. Venous • h Work of breathing engorgement can also be assessed by examining jugular • Facial distress vein distention. The external jugular vein should rarely • Reduction in tolerance be noticeable while the patient breathes comfortably in • Reports of angina the sitting position. If the vein is very prominent while • ST-segment depression with ischemia the patient is sitting or is distended more than 3 cm • ST-segment elevation with cell injury above the horizontal line level to the sternal angle with the patient reclined to 45 degrees, it is positive for right Heart Failure ventricle dysfunction. The clinical findings for diastolic Heart failure (HF) develops when cardiac output cannot BOX 9-8 Signs and Symptoms Associated meet the metabolic needs of the body. Heart failure with Heart Failure typically is associated with a functional or structural defect such as valvular disease, CAD, or hypertrophic Right Ventricle Left Ventricle cardiomyopathy.74 There are approximately 5 million Diastolic Dysfunction Diastolic Dysfunction individuals in the United States who have been diagnosed Jugular vein distension Dyspnea with HF and more than a half million people are diag- Liver engorgement Tachypnea nosed annually. The prevalence of HF increases with age, Peripheral edema Cough with 10.3% of individuals ages 65 to 74 years versus Wheezing 20.7% of those age 85 years and older. Approximately Systolic Dysfunction Rales 300,000 individuals die annually with the primary diag- Dyspnea S3 abnormal heart sound nosis of HF.74,75 Desaturation Systolic murmur Cyanosis Hypoxemia The most common cause of HF is ischemic left ven- Tachypnea Orthopnea tricular dysfunction secondary to CAD, with hyperten- Hypoxia sion as the second leading cause.76 Heart failure can also Systolic Dysfunction be associated with depressed left ventricular dysfunc- Fatigue tion, low ejection fraction (EF), and systolic or diastolic Angina dysfunction, but may also be associated with normal left Activity intolerance ventricular function. Heart failure can also be classified Exertional dyspnea as right ventricular or left ventricular failure. In most Narrow pulse pressure cases, individuals have components of both ventricular Decreased mental status dysfunction or both phases of cardiac cycle (systolic and Decreased urination diastolic) dysfunction Cool, pale, diaphoresis In systolic dysfunction, the left ventricular wall, which typically begins in a hypertrophic state, dilates, enlarging the chamber. This dilated state does not permit the myo- cardium to effectively contract and eject sufficient blood into systemic circulation. The ejection fraction, percent- age of end-diastolic volume ejected per beat, normally

176 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient dysfunction of the left ventricle are commonly found (HCAP) as defined by the American Thoracic Society is upon assessment of the pulmonary system with depen- pneumonia that is acquired while the individual is in the dent rales consistent with interstitial edema, and a non- hospital or a resident of some other type of institutional productive cough with high-pitched wheezing. Often, care facility, or an individual who has been exposed to a there is an additional low-pitched heart sound, S3, family member with a multidrug resistance.81 The inci- which can be heard over the left chest wall using light dence of HCAP has been reported to be as high as contact of the bell of the stethoscope. The patient may 55 cases per 1000 for the older adult, accounting for also report orthopnea, or the need to have the upper more than 2 million acute care hospital admissions and body elevated while in the supine position secondary to more than 26,000 pneumonia-related deaths.82 an inability to lay completely flat without progressive shortness of breath. This is most commonly experienced There are multiple factors about the age-related changes at night. to the pulmonary system that explain the higher incidence in pneumonia with advanced age. In the upper airway, Systolic dysfunction is associated with fatigue and a there is a natural reduction in mucociliary function and decrease in activity tolerance, and therefore it is impor- oropharyngeal clearance, increasing the risk of aspiration. tant that the physical therapist complete an assessment In the lower airways, there is also a decrease in the cellular of muscular, cardiovascular, and pulmonary endurance and humoral immune response and phagocytosis.81 These and monitor vitals including pulse rate and regularity changes reduce the ability of the bronchial system to im- during activity and at the peak exercise stage as well as mobilize pathogens and clear the airways. Older adults during the recovery phase. also are more susceptible to pneumonia after surgery sec- ondary to the depressive effects of anesthesia and the Pneumonia number and severity of comorbidities.80 Pneumonia is an acute inflammation of the lungs caused Aspiration has been clearly identified as a common by a bacterial, viral, or fungal pathogen. The normal contributing factor to the development of pneumonia. defense mechanism of the respiratory system, a muco- Aspiration is associated with malnutrition, tube feeding, ciliary blanket of macrophages, fails to keep the lower contracture of cervical extensor muscles, and use of de- respiratory tract sterile, causing an accumulation of exu- pressant medications.78 Other events have also been date in the small bronchioles and alveoli. The inflamma- linked to aspiration, including dysphagia due to loss of tory process is then activated, along with the immune dentition and poor hygiene, decreased saliva production, response, causing localized edema. A vicious cycle devel- and weakening of muscles of mastication. Aging is as- ops between the immune response and the infectious sociated with a delay in the neural processing needed to growth. With an increase in alveolar edema, the immune perform the proper swallowing sequence and decreased cells’ ability to phagocytize the invader will be impaired. sensation of the oral cavity. Finally, there is an increased The collection of edema, RBCs, and WBCs will consoli- incidence of aspiration in the presence of Parkinson’s date, leaving the lung tissue unable to perform ventila- disease, cerebral vascular accident, gastroesophageal re- tion and perfusion. This infection can also spread to flux disease, connective tissue disorders, and Alzheimer’s other segments of the lungs as well as to the pleural disease.78,80 space and pericardium.78 Pneumonia is the third leading discharge diagnosis for individuals between the ages of The typical clinical presentation for pneumonia in- 64 and 85 years, and the second leading diagnosis for cludes a fever and a productive cough with sputum individuals older than age 85 years.79 Pneumonia can be production that is usually yellowish green or rust col- classified by the infectious agent or by the environment ored. There is also an elevation in the WBC count and, in which the patient became infected with the agent that in most cases, a positive sputum culture identifying the produces the pneumonia. The type of classification di- infectious agent. Diagnosis is made based upon symp- rects the pharmacologic intervention. Pneumonia can toms and a positive finding of infiltrates or consolida- also be classified as the environment in which the indi- tion on chest x-ray. There may be reports of chest wall vidual contracted the infection. This system allows pain, pleuritis, hemoptysis, or dyspnea, and if sufficient health care professionals to identify specific interven- lung tissue is affected by the pneumonia with or without tions to treat, minimize, and prevent the common char- an underlying pulmonary disease, the patient may de- acteristics of the environmental setting. saturate at rest or with exertion. The older adult, how- ever, may present with more atypical signs and symp- Community-acquired pneumonia (CAP) is an infec- toms, including a change in mental status, anorexia, tion that occurs while the patient is living out in the com- decrease in function and activity tolerance, and an ele- munity or the infection manifests itself within the first vated HR.80 Once the patient has been treated for acute 72 hours after hospitalization. CAP has an incidence rate pneumonia, it is important for the physical therapist to of 8.4 cases per 1000 for individuals between age 60 and objectively assess activity tolerance through some form 69 years and 48.5 cases per 1000 for individuals older of exercise test (e.g., the 6-minute walk test, or a bike than age 90 years.80 Health care–acquired pneumonia or treadmill test). These data can be used to ensure stable vitals with exertion, rule out desaturation, and

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 177 document activity tolerance so the rehabilitation plan BOX 9-10 Reasons Patients Have an Increased can be appropriately prescribed. See Box 9-9 for clinical Risk of UTI82,85,86 evaluation findings associated with pneumonia in the older adult. Female sex Urinary obstruction Prolonged catheterization Kidney stones Urinary Tract Infections Errors in catheter care Enlarged prostate Weakened pelvic floor Alzheimer’s disease Urinary tract infections are the most common infections Parkinson’s disease among older adults and have become a major clinical musculature History of neurogenic bladder issue regardless of current health and mobility status, Diabetes History of stroke place of residence (home or nursing home), or amount of Multiple sclerosis comorbidities.83 With age, there are a multitude of rea- Spinal cord injuries sons that can put a person at risk of developing a UTI including comorbidities that affect the bladder’s nerve an infection of the urethra can affect other structures of supply (diabetes, multiple sclerosis, and spinal cord inju- the urinary system such as the bladder, ureters, or the ries), urinary flow obstructions from kidney stones and kidneys. tumors, prolonged catheter use, and weakened pelvic floor musculature from pregnancy in women and en- According to Liang, urinary stasis is the primary con- larged prostate in men.84 Patients with Alzheimer’s dis- tributor to UTIs in the older adult.85 In older women, ease, Parkinson’s disease, patients who have a stroke there is a decrease in the strength of the pelvic floor mus- history, or have neurogenic bladders may also not fully culature from prior pregnancies and a change in estrogen empty their bladder and are prone to UTIs.85 Box 9-10 levels that contribute to urinary stasis and incontinence. lists common comorbidities that increase the older Older men, on the other hand, have decreased bladder adult’s susceptibility for a UTI.82,85,86 emptying due to obstruction secondary to benign pros- tatic hypertrophy.86 Regardless of the reason for de- The urinary tract is usually sterile, except for the most creased urine flow, bacterial colonization is the result of distal portion of the urethra.86 The urinary tract is de- urinary stasis. Also, the change in the normal vagina signed to prevent the spread of bacteria with the outflow flora in women and bacterial prostatitis in men contrib- of urine; however, with age, physical and functional utes to recurrent infections. changes increase the risk of bacteria in the urinary tract to cause an infection. Urinary tract infections primarily Having an indwelling catheter is another risk factor in start in the lower portion of the urethra. If untreated, the development of a UTI. Hazelett et al,87 in a retro- spective study, determined that 73% of patients who B O X 9 - 9 Clinical Evaluation Findings received an indwelling catheter in the emergency depart- Associated with Pneumonia ment were 651 years old. Of those patients, 28% were diagnosed with a UTI during their hospital stay; how- Vitals Tachycardia ever, 59% of those were diagnosed in the emergency Tachypnea department and therefore prior to receiving the catheter. Auscultation Hypotension This study suggests that many of the older patients with Dyspnea catheters who are diagnosed with a UTI may, in fact, Palpation Desaturation have had the UTI prior to receiving the indwelling cath- Arterial blood gases Diminished normal breath sounds eter. This is somewhat contrary to common belief, but it Observation Rales demonstrates that older adults do not present in the Temperature Low-pitched wheezes in presence of thick same manner as their younger counterparts.87 There are many types of bacteria that can cause UTIs, including secretions Staphylococcus aureus, Proteus, Klebsiella, and Entero- High-pitched wheezes (associated with coccus. However, they are mostly caused by Escherichia coli, a normal intestinal bacteria.84,85 aspiration) Bronchial breath sounds (associated with Symptoms such as pain with urination, increased fre- quency, persistent urge to urinate, and hematuria, which consolidated pneumonia) are typically used to diagnose a UTI in the younger Increased tactile fremitus population, cannot necessarily be used with the older Dull percussion over consolidation adult because of the changes mentioned above. For Possible g chest wall excursion example, an older male with prostatic hypertrophy g PaO2 may have difficulty urinating, strong and sudden Possible altered PaCO2 urges to urinate, pain, and hematuria. These are all h Work of breathing symptoms of a UTI; therefore, it is difficult to determine Facial distress the diagnosis of UTI in the presence of other genitouri- Cyanosis nary comorbities.88 Fever

178 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient Diagnosis of a UTI in the younger population requires may represent infections of other systems.89 Diagnosis 105 colony-forming units (CFUs)/mL with associated of sepsis is important as there are many conditions that symptoms as described earlier.86 Diagnosis can be made in can mimic sepsis, including hemorrhage, PE, myocar- the older adult with a bacterial colony count of 102 or 103 dial infarction, pancreatitis, diabetic ketoacidosis, and CFUs if they are also symptomatic.85 However, with the diuretic-induced hypovolemia, just to name a few. It is older patient, diagnosis is not that easy as they frequently important to get a blood culture that might determine pres­ent without symptoms or have UTI symptoms such as the underlying bacterial infection that needs to be decreased urine flow, which can be a symptom of prostatic treated. However, a CBC is not always helpful because hypertrophy. Frequently, the first symptom that is noted is results may mimic the above conditions, which are not acute confusion. Other symptoms are a sudden functional technically sepsis. Along with urinalysis, intravenous decline and delirium. It is important to diagnose a UTI lines should also be cultured to fully rule out the early in the older patient because it can quickly spread to source. A chest x-ray is important to rule out pneumo- the kidneys and to the blood, causing sepsis. Juthani- nia and PE.91 Mehta reports that diagnostic criteria for nursing home residents who do not have a catheter include having three Patients who become septic usually present with a fever of the following clinical signs or symptoms: (1) a fever of higher than 101.3°F, have an elevated heart rate greater 100.4°F or greater; (2) new or change in burning of urina- than 90 bpm, a respiratory rate greater than 20 breaths tion, frequency, or urgency; (3) new flank or suprapubic per minute, and a probable or confirmed infection from pain; (4) change in color, consistency, or cloudiness of cultures. If sepsis is not diagnosed and the source of the urine; and (5) change in mental or functional status. For infection not identified, it can progress to severe sepsis or nursing home residents who have catheters, two of the fol- septic shock. Box 9-11 lists the signs and symptoms of lowing characteristics must be present: (1) fever as noted sepsis, severe sepsis, and septic shock.89,91,92 earlier; (2) new flank or suprapubic pain; (3) change in presence of urine; and (4) change in mentation or func- Medical care and treatment of sepsis is aimed at tional status.86 maintaining all organ perfusion and a ventilator may be necessary for respiratory support. Refer back to previous The physical therapist needs to consider the effects of sections in this chapter for guidelines on appropriate the UTI during the evaluation and treatment process be- evaluation and treatment of patients. Evaluation and cause for the older patient with a UTI, the acute confu- treatment may need to be deferred until the patient is sion and decline in functional mobility may be transient stabilized. and not appropriately represent the patient’s true status. The therapist will need to constantly reassess function OTHER MEDICAL ISSUES and needs to make the most appropriate discharge rec- ommendations as the infection is medically treated. There are a multitude of reasons why an older adult might present with a decline in function and health. The Sepsis previous section addressed the most common diagnoses from acute care admissions. Following is a brief descrip- Sepsis is a term used to describe systemic bacteremia tion of medical issues that may compromise the older with or without organ dysfunction. Basically, sepsis is an adult’s health, result in a decline in function, or lead to immunologic response to bacteria and can easily attack further medical complications contributing to increased any organ system. Those that are most affected are the morbidity and mortality rates. pulmonary and renal systems. Diagnosis and treatment of the cause of sepsis are of utmost importance because BOX 9-11 Signs and Symptoms of Sepsis, it is related to increased mortality.89 Severe Sepsis, and Septic Shock89,91,92 Twenty percent of all in-hospital deaths are related to Sepsis Severe Sepsis Septic Shock sepsis, and the incidence of sepsis increases with age. • Fever above 101.3°F • Mottled skin • All signs of Overall, 3 of 1000 patients are diagnosed with sepsis; • Heart rate • g Urine however, 26 of 1000 patients older than age 85 years are severe diagnosed.90 The function of the immune system changes . 90 beats per output sepsis with age and ultimately puts the older patient at in- minute • Mental status • Extremely creased risk for developing sepsis. • Respiratory rate low blood . 20 breaths per change pressure There are many reasons a patient in the hospital can minute • g Platelet become septic. Some sources of infection are intravenous • Probable or lines, central lines, intra-abdominal or pelvic infections, confirmed infection count abdominal surgery, and patients with UTIs, diabetes, • Respiratory lupus, or alcoholism. difficulties Many older adults have multiple comorbidities mak- • Changes in ing diagnosis of sepsis difficult as the clinical picture cardiac function

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 179 Dizziness to determine if there are blood flow abnormalities. Faint- ness during standing or bowel movements may relate to Dizziness is a common complaint of the older adult and orthostatic hypotension or to a Valsalva maneuver, re- it is difficult to determine the root cause because it can spectively. be caused by multiple etiologies, including vestibular, visual, or proprioceptive system dysfunctions.93 It is very Inability to describe symptoms may be related to de- important to determine the cause because treatment mentia or psychiatric disorders. Individuals with demen- varies greatly depending on the system involved. A study tia may be trying to describe the confusion they experi- by Uneri and Polat determined that the most common ence and not true dizziness. An evaluation for depression, causes of dizziness in older adults are benign paroxysmal anxiety, and dementia may be included in the differential positional vertigo, vestibulopathy (an abnormality of the diagnosis, if symptoms are difficult to describe. Finally, vestibular apparatus), migraine vestibulopathy, and mi- iatrogenic postural hypotension that causes positional graines.94 dizziness is more common in older adults than in younger adults because of the increased prevalence of The incidence of patient presentation with dizziness polypharmacy. Medications are always implicated ini- to the emergency department is alarming. In the 10-year tially as causative agents, until proven otherwise. These period from 1995 to 2004, 29% of emergency visits include antihypertensives, diuretics, and drugs that cause were secondary to dizziness in the 651 age group.95 To sedation. ensure proper diagnosis, appropriate screening and test- ing is of utmost importance. There are many diagnostic With age, there are many changes that happen to bal- procedures that can be performed, including a thorough ance, perception, as well as the changes in sensation, and physical examination, provocation studies, and neuro- neurologic and skeletal functioning. Chronic illnesses logic, visual, vestibular, cardiac, and psychiatric exami- like diabetes can also contribute to sensory deficits.94 nation. The patient report will assist in ascertaining a Polypharmacy and orthostatic hypotension are also clear picture of the symptoms and precipitating events. common causes and can be differential diagnoses for diz- ziness. Whatever the cause, dizziness is a precursor to Vertigo, the most common cause of dizziness among falls, which can be life threatening for the older adult. the older adult population, is defined as the abnormal Proper examination and treatment of dizziness can aid in sensation of movement that is brought on by certain reducing the incidence of falls and the morbidity and positions. There are many causes of vertigo, including mortality from them. trauma, idiopathic, and inner ear diseases. Box 9-12 lists some of the common causes of vertigo. Diagnosis Dehydration of vertigo can be easily made, as nystagmus is com- monly seen in the eyes.94,96,97 The direction of eye move- Dehydration is a common problem in the older adult ment is indicative of the part of the inner ear that is af- and directly increases rates of morbidity and mortality. fected.96 Vertigo can be a symptom of basilar artery Dehydration is a costly societal as well as individual migraine, so migraines also need to be ruled out as the problem. Nearly 40% of all hospitalization admissions cause.97 Patients with vertigo will often report a “spin- in older adults is associated with dehydration.98 ning” sensation. Balance is dependent on sensory cues and vestibular function, both central and peripheral. There are three primary reasons why the older adult Therefore, inner ear problems and gait disturbances af- is susceptible to dehydration. First, there is a blunted fect balance and increase the risk of falls. thirst mechanism. Second, there is a reduction in total body fluid with the reduction in muscle mass and an in- Near-syncope, or fainting, is often related to cardio- crease in body fat. Finally, a decrease in renal function vascular disease rather than to a peripheral or central that concentrates the urine prevents the body from re- nervous system disorder. If syncope is present, a search taining enough fluid to avert dehydration.98 These for a cardiac etiology should be initiated. An ECG and a changes along with a variety of comorbidities lead to the Holter ambulatory cardiac monitor are obtained to increased risk of dehydration. evaluate for rhythm disturbances. Syncope also requires a careful physical examination and an echocardiogram Dehydration is categorized by the relationship be- tween free water and sodium and can be caused by B O X 9 - 1 2 Common Causes of Vertigo94,96,97 many factors. Hypertonic dehydration occurs when there is a greater loss of water when compared to so- Idiopathic Otosclerosis dium loss. This type of dehydration is more common Trauma Sudden sensorineural hearing loss in the presence of infection or exposure to hot environ- Ear diseases Central nervous system disease mental temperatures. In isotonic dehydration, there Chronic otitis media Vertebrobasilar insufficiency is an equal loss of water and sodium, and vomiting Vestibular neuronitis Acoustic neuroma and diarrhea are the two most common causes. Meniere disease Cervical vertigo Hypotonic dehydration is caused by a greater loss of sodium than water. The use of diuretics is the most common cause of hypotonic dehydration. Hypotonic

180 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient dehydration is the most common cause of dehydration BOX 9-14 Clinical Criteria for Metabolic in the older adult.99 The most significant laboratory Syndrome100-102 abnormality is sodium imbalance and should be care- fully monitored. Risk Factors Criteria Abdominal obesity There are multiple risk factors associated with dehy- .102 cm dration, including advanced age; being of the female Men .88 cm gender, because of the higher percentage body fat; and a Women 150 mg/dL (1.69 mmol/L) BMI lower than 21 and greater than 27. Individuals with Triglycerides dementia, history of stroke, urinary incontinence, infec- High-density lipoprotein (HDL) .40 mg/dL (1.04 mmol/L) tions, use of steroids, polypharmaceutical use, and a Men .50 mg/dL (1.30 mmol/L) decrease in functional independence also increase the Women risk of dehydration.98 Blood pressure .130 mmHg Systolic .85 mmHg Presenting symptoms of dehydration may include Diastolic .110 mg/dL confusion, lethargy, rapid weight loss, and functional Fasting glucose decline, all of which will interfere with rehabilitation goals. Therefore, the physical therapist is in a good posi- syndrome (IRS) is more recently used to label this tion to monitor for dehydration and alert the medical clinical issue.100,102 team to the emergence of this syndrome. See Box 9-13 for the signs and symptoms of dehydration. Aging is associated with an increased incidence of obesity due to a reduction in activity level, a decrease in Metabolic Syndrome muscle mass, and an increase in visceral fat mass.63 The link between obesity and metabolic syndrome, or IRS, is Metabolic syndrome is characterized as a cluster of no not fully understood but obesity is associated with in- fewer than three cardiovascular risk factors that are strongly creases in free fatty acids and triglycerides and an in- associated with myocardial infarction. Risk factors from crease in inflammatory cytokines that is also linked to the National Cholesterol Education Program Adult Treat- IRS.102 Visceral adipocytes produce resistin, proinflam- ment Panel III Report include increased abdominal fat, high matory substances, interleukin-6, tumor necrosis factor, levels of triglycerides, low levels of high-density lipopro- and plasminogen activator inhibitor-1, which promotes teins (HDLs), HTN, and an elevated level of fasting plasma the development of insulin resistance as well as HTN glucose.100 The International Diabetes Foundation defini- and dyslipidemia.101,103 tion criteria is slightly different, with abdominal circumfer- ence being more than 94 cm for men and more than Insulin resistance and abdominal obesity appear to be 80 cm for women, and fasting glucose level greater than predictors for the development of metabolic syndrome. 100 mg/dL.100,101 See Box 9-14 for specific criteria which Insulin resistance occurs when the cells become less sen- may differ according to source.100-102 sitive and eventually resistant to insulin that leads to the inability of glucose to be absorbed by the cells. A vicious It is estimated that around one-quarter of the world’s cycle develops with higher levels of glucose that leads to adult population has metabolic syndrome, which in- the release of more insulin. With the elevated release of creases their morbidity and mortality from a cardio- free fatty acids, there is a reduction of glucose oxidation vascular event including stroke and myocardial infarc- and glucose transport inducing liver production of LDLs tion and HF. Metabolic syndrome was also referred that elevates triglycerides and lowers HDL levels.100 to as syndrome X, but the term insulin resistance With the increase in free fatty acids, the liver is stimu- lated to produce more LDLs, release more triglycerides, BO X 9 - 1 3 Signs and Symptoms of Dehydration and lowers HDL levels.100,101 Examination Clinical Signs and Symptoms With obesity and the normal effects of aging, there is Interview • g Cognitive function and mental status an increase in HTN. There is a further increase in the Observation • Dry mucosa incidence of HTN with a BMI greater than 27 in people Palpation • g Skin turgor older than 40 years.104 Older adults are among one of Vitals • Tachycardia the high-risk groups for a cardiovascular event along • g Blood pressure with African Americans.105 Jugular vein distention • Orthostatic hypotension Finally, there is an increase in incidence of type 2 dia- • Weight loss in short time, ,1 kg/day betes and cardiovascular events in older adults with IRS. Function • In supine, nonappreciable external It is estimated that 29 million older adults will be diag- nosed with type 2 diabetes by 2050.103 Diabetes itself is jugular vein defined as a fasting glucose level greater than 126 mg/dL, • g Muscle strength, balance, and or a 2-hour postprandial glucose level greater than 200 mg/dL after a 75-g glucose load, or symptoms of function diabetes plus casual plasma glucose concentration of

CHAPTER 9  Evaluation of the Acute and Medically Complex Patient 181 200 mg/dL.100 Prediabetes is defined as having a fasting and the prevention of further deterioration.106 An plasma glucose level between 100 and 125 mg/dL and a example of tertiary prevention while caring for a 2-hour postprandial glucose between 140 and 199 mg/ patient with HF due to CAD would be to manage the dL. Diabetes is an independent risk factor for the older cardiac dysfunction, protect renal function, medicate adult suffering a serious cardiovascular event and in- to improve cardiac function, control food and fluid creases mortality and morbidity rates.14 The reader is intake, and introduce job simplification and energy directed to review the sections on Coronary Artery Dis- conservation techniques. ease and Heart Failure within this chapter for the conse- quences of the cardiovascular risk factors including If we consider CAD the leading cause of deaths in the obesity, HTN, dyslipidemia, and glucose–insulin dys- United States, United Kingdom, and Europe, 83% of function. deaths related to ischemic heart disease involve patients older than age 65 years and the mortality rates continue PREVENTION to rise substantially after 75 years of age. In the geriatric population, there is a shift in the signifi- The stratification process is also an important step in cance of typical risk factors with a reduction in the disease prevention and in assessing the risk of experienc- incidence of smoking and diabetes and an increase in ing a medical event during exercise or exertion. Every hypertension, sedentary lifestyle, and obesity.107 physical therapy plan should address prevention, start- ing with the initial examination and evaluation regard- It should be very common for physical therapists in less of clinical setting. It is important that the therapist all settings to address risk factor modifications for pa- completes a thorough interview in order to determine tients with known cardiac disease or HF, with the goal the level of prevention the therapist should address for to minimize functional limitations and decrease hospi- the primary and secondary diagnoses. talizations. An example of prevention across the spec- trum: primary prevention could focus on prevention of The ultimate goal of prevention is to optimize health osteoporosis and diet to maintain proper weight and and decrease functional limitations and impairments. All maintain muscle mass. Secondary prevention may in- members of the team should address prevention and clude strength, aerobic exercise, and functional training that, ultimately, should lead to the reduction in health to minimize skeletal muscle atrophy, promote airway care utilization and costs. The three levels of prevention clearance to minimize the effects of atelectasis, and are primary, secondary, and tertiary. proper nutrition to promote general health to avoid exacerbation of HF. Tertiary prevention may focus on • Primary: focuses on instilling healthy behaviors and functional training and education about signs and symp- reducing risk factors by intervening prior to the toms of HF, including progressive exercise intolerance, biological signs of a disease. An example of primary fatigue, and shortness of breath. Prevention in the prevention for CAD would be to instruct your client young older adult, ages 65 to 75 years, may focus on to eat well, avoid smoking, exercise routinely to con- primary or secondary prevention, including fitness, trol blood pressure, and control weight to minimize weight management, smoking cessation, and encourage- risk of diabetes. Another example may be the initia- ment for routine lipid profiles and fasting glucose tion of a weight training program for an older adult testing. In the older-old, age 85 years or older, preven- patient to improve muscle strength for the prevention tion may focus on fitness and function, hypertension of osteoporosis. control, and weight management. In any prevention program, the therapist will need to consider the age of • Secondary: the pathology or disease is present, but the patient, as advanced age is associated with an in- intervention is focused on behavior modification to crease in comorbidities. manage the disease. The goal is to control progres- sion of the disease, improve strength, avoid loss of SUMMARY function, and minimize or eliminate pain. In treat- ing a client already diagnosed with CAD, the physi- Clinical management of the health and function of the cal therapist would educate them on the reduction older adult is complex. It should be the common goal of or elimination of risk factors (see Box 9-3), activi- all professional practitioners in geriatric health care to ties to reduce blood pressure and cholesterol levels, treat illnesses and promote optimal health. There have importance of monitoring for diabetes, as well as been two shifts in geriatric health care: an increasing at- management of the disease by percutaneous coro- tention to wellness and prevention for the older adult, nary intervention. and the acutely ill patients are being seen by the physical therapist outside the traditional acute care hospital. The • Tertiary: the patient has a disease and is also afflicted physical therapist needs a basic understanding of the with dysfunction associated with that disease includ- common medical diagnoses that lead the older adults ing a decrease in activity tolerance and function. The to seek medical care and how these diagnoses affect focus of tertiary prevention is on functional mobility and education of signs of symptoms of the disease

182 CHAPTER 9  Evaluation of the Acute and Medically Complex Patient function and quality of life. Physical therapy interven- REFERENCES tion should consist of constant screening for signs and symptoms that suggest medical concerns, adjusting reha- To enhance this text and add value for the reader, all bilitation goals to minimize functional limitations and references are included on the companion Evolve site physical impairments, education, and healthy lifestyles. that accompanies this text book. The reader can view the Finally, the therapist needs to be an active member of the reference source and access it online whenever possible. older adult’s health care team to maximize health care There are a total of 107 cited references and other gen- services and ultimately maximize quality of health and eral references for this chapter. outcomes.

10C H A P T E R Motivation and Patient Education: Implications for Physical Therapist Practice Barbara Resnick, PhD, CRNP, FAAN, FAANP, Dale Avers, PT, DPT, PhD MOTIVATION AND COMPLIANCE engaging in self-regulation activities over the course of a lifetime.1,2 Motivation is an important factor in the older adult’s ability and willingness to participate in functional ac- Changes in Motivational Strategies: Focus on the tivities and engage in healthy behaviors such as exercise. Positive.  ​There is a tendency to use motivational strate- By definition, motivation is the inner urge that moves or gies that focus on losses; for example, if you do not go to prompts a person to action. Motivation refers to the therapy you will not be able to get back home, indepen- need, drive, or desire to act in a certain way to achieve a dently ambulate, or be able to walk without an assistive certain end. In contrast, compliance refers to doing what device. Older adults, however, respond better to empha- others want or ask rather than being driven by an inner sizing the positive outcomes of engaging in a behavior, desire. Ideally, health care providers want older adults to avoiding regret, and maximizing satisfaction associated be motivated to comply with behaviors that are known with a behavior.3-9 Specifically, older individuals are inter- to be effective in preventing disease and disability and ested in the immediate benefits of behaviors such as im- improving overall health and quality of life. proved functional ability, improved mood, and overall sense of well-being, or improved strength and ability to Unfortunately, motivation to engage in behaviors carry grocery bags or laundry. In contrast, they do not such as physical therapy, going to exercise class, or ad- respond well to long-term benefits such as the possibility hering to a special diet are not often addressed nor are of decreased evidence of cardiovascular disease. In addi- interventions utilized to improve motivation with regard tion, older individuals tend to be more focused on positive to these activities. Rather, we consider motivation only rather than negative emotions.65 Therefore, disappoint- when the older individual is not doing the desired behav- ments following behavior change (e.g., slower improve- ior. It is at this time that he or she is labeled as unwilling ments in strength) are less likely to undermine the new to participate, unmotivated, and noncompliant. To help behavior than they are for younger people. motivate older adults to comply with health-promoting Stronger Adherence to Behavior Change.  O​ lder behaviors, it is important to comprehensively consider adults tend to be slower to initiate changes in behavior. the factors that influence motivation and implement ap- Once initiated, however, they are more likely to adhere propriate interventions to ensure the desired behavior. to the new behavior. The difficulty of initiating change, as well as the ease of maintenance, may be related to the Age Changes in Motivation stability of contextual cues in late adulthood.10 Although older individuals are known to avoid novelty and lean Self-Regulation.  Self-regulation is the process by which toward what is familiar, with regard to physical activity people control or alter their thoughts, emotions, and be- they have indicated that new and different exercise ac- haviors. Behaviors around self-regulation include such tivities are motivating.11 Thus, new activities, such as things as self-monitoring, reinforcements, goal setting, and incorporating Wii activities into therapy sessions, should corrective self-reactions. Older adults may have greater not be totally ignored for the comfortable and routine self-regulatory capacity simply from the experience of activities for which older adults may be familiar. Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 183

184 CHAPTER 10  Motivation and Patient Education Positive Self-Concept.  I​t has been repeatedly noted that TABLE 10-1 Normal Physiological Changes individuals, including older adults, who feel personally System Associated with Aging That Can deficient are most likely to break their diets, stop exer- Skin Influence Motivation cise, spend excessively, or binge drink.12,13 Fortunately, Lungs older adults tend to have positive self-concept14 rather Brain Age-Associated Changes than conceptualizing themselves as personally deficient. Heart/Vascular Consequently, older adults succeed at self-regulation Decreased flexibility due to decreased collagen more often than younger adults because they do not ex- Kidney Increased wrinkles perience as much dissatisfaction. Increased dryness Social Supports.  T​ he impact of social support on behav- Stomach Decreased turgor ior change around activities such as physical activity has Decreased compliance due to changes in been quite variable in older individuals.15-20 Generally, Immune system African American older adults seem to be more influenced collagen by social supports,11 although overall these external forces Decreased FEV1 seem to be less influential on engaging in physical activity Decreased total lung volume than noted in younger individuals. Changes in vascular system, neurons, glial cells Hypoperfusion Providing social support to others is also an impor- Atrophy tant motivator to older adult patients. Specifically, older Decreased response to beta-adrenergic adults who are caregivers of spouses, friends, or children are often highly motivated to engage in physical therapy stimulation to be able to fully resume caregiving activities. Decreased cardiac output Information-Seeking Behavior.  ​Older adults tend to Decreased cardiac index seek less information when making a decision21 than do Decreased compliance of ventricles/arteries younger individuals. Without extensive information Calcification of valves about an activity and the pros and cons of engaging Increased systolic hypertension in the activity, older individuals rely on their intuitions, Decreased ability to concentrate urine, gut feelings, and simple heuristics to form attitudes and make choices (e.g., if an expert said it, it must be resulting in loss of free water and increased true).22-24 This process may be more efficient and thus sensitivity to salt decrease the time required for the individual to decide Decreased glomerular filtration rate about making a change. It also means they are less likely Decreased blood flow to be influenced by negative input from others. Decreased digestive secretion enzymes Increased gastric pH Normal Physical Changes with Age Decreased absorptive surface Decreased motility When working with older adults, it is important to re- Decreased blood flow member there are a number of changes that occur as a Decreased memory of previous antigenic result of the process of aging itself. The changes that oc- stimuli cur are normal for all people but take place at different Decreased responsiveness to immunization rates. Table 10-1 lists the normal physiological changes Increased energy that occur with age in the major body systems. The Decreased T-cell proliferation and function changes that occur in the sensory system can indirectly influence motivation and learning. Specifically, the fol- determinism in which behavior, cognition, and other per- lowing changes can occur: (1) there is an increase in the sonal factors and environmental influences all operate threshold needed for each sensory modality to be stimu- interactively as determinants of each other. According to lated; (2) the activation of the corresponding receptors social cognitive theory,2 human motivation and action are requires stimuli of increased intensity, and therefore a regulated by forethought. This cognitive control of behav- greater stimulus is needed for the sensation to occur; and ior is based on two types of expectations: (1) self-efficacy (3) it is more difficult for the older individual to differ- expectations, which are the individuals’ beliefs in their entiate between different stimuli. capabilities to perform a course of action to attain a de- sired outcome, and (2) outcome expectancies, which are Factors That Influence Motivation the beliefs that a certain consequence will be produced by personal action. To consider the many factors that influence motivation in older adults, it is helpful to use a model of motivation Self-efficacy and outcome expectations are dynamic and based on social cognitive theory as well as empirical find- are both appraised and enhanced by four sources of infor- ings.25-31 Social cognitive theory is based on reciprocal mation2: (1) enactive mastery experience, or successful performance of the activity of interest; (2) verbal persua- sion, or verbal encouragement given by a credible source that the individual is capable of performing the activity of interest; (3) vicarious experience, or seeing like individuals perform a specific activity; and (4) physiological and

CHAPTER 10  Motivation and Patient Education 185 affective states such as pain, fatigue, or anxiety associated establish goals such as regaining self-care abilities and with a given activity. The theory of self-efficacy suggests being able to return home alone. Social supports can also that the stronger the individual’s self-efficacy and outcome indirectly affect motivation by strengthening the indi- expectations, the more likely he or she will initiate and vidual’s beliefs in his or her ability to participate in reha- persist with a given activity. bilitation activities, for example, or engaging in a regular exercise program. Beliefs, both in relationship to outcomes (outcome expectations) and with regard to what older adults be- The ability to develop personal goals and evaluate lieve they are capable of doing (self-efficacy expecta- one’s performance toward that goal can influence mo- tions), have been noted to influence motivation to en- tivation to engage in a given behavior.2 Articulated gage in health-promoting behaviors.32-35 Physical goals give older adults something to work toward, and sensations associated with a treatment plan, such as help motivate them to adhere to a specific health- pain, fear of falling or exacerbating underlying medical promoting activity. In addition, input from therapists problems, or medication side effects, influence beliefs is important to goal development and motivation as and actual behavior. Some older adults believe, for the goal delineates for the individual what others be- example, that exercise will exacerbate arthritis pain and lieve he or she is capable of doing in a particular func- therefore will not engage in a regular exercise program. tional area, for example. Articulated goals should be These unpleasant sensations and their beliefs about short- and long-term. Short-term goals should provide them must be addressed and eliminated to facilitate the older individual with exactly what he or she should motivation. do on a daily basis (e.g., walk for 20 minutes; do ten sit-to-stands). Long-term goals should focus more on Individualized care and demonstrating caring have an ultimate goals that the individual wants to achieve, important influence on the older adults’ motivation to such as being able to ambulate without an assistive perform a given activity. Individualized care includes device, care for oneself, walk to the grocery store, or recognizing individual differences and needs, using kind- to go on a trip. Goals are most effective when they are ness and humor, empowering older adults to take an (1) related to a specific behavior, (2) challenging but active part in their care, providing gentle verbal persua- realistically attainable, and (3) achievable in the near sion to perform an activity, and positive reinforcement future.2 Goals will be further explored later in this after performance of an activity.11,30,36 An essential com- chapter. ponent of individualized care is letting the individual know exactly what it is that you recommend they per- Lastly, the individual’s personality, self-determination, form. This may be simple written instructions about and resilience have an important influence on motiva- what exercise program to engage in or what medication tion. Older adults report that it is their own personality, to take, why it is important, and exactly how the activity that is, determination, and their own firm resolutions should be done or the medication be taken. At each care and adherence to those resolutions, that motivates them interaction, it is critical to reevaluate how the individual to perform specific tasks.5,115 Resilience is a psychosocial is doing with the behavior of interest as it demonstrates factor that is defined as an individual’s capacity to make caring and remembering. Individualized care is, in part, a “psycho-social comeback in adversity.”41 Resilient in- effective because the older adult simply wants to recip- dividuals tend to manifest adaptive behavior, especially rocate for the care given to him or her by doing what the with regard to social functioning, morale, and somatic therapist requests (e.g., doing a certain exercise or a health,42 and are less likely to succumb to illness.43,44 home revision such as getting a grab bar). Once the be- Resilience, though a component of the individual’s per- havior is initiated, however, it is likely that the older in- sonality, develops and changes over time through ongo- dividual will experience the benefit(s) associated with the ing experiences with the physical and social environ- behavior and thus continue to adhere for reasons beyond ment.45-47 Resilience, unlike basic personality factors, initial reciprocity for care received. may be more of a dynamic process that is influenced by life events and challenges.48-50 Thus, there is the oppor- Social support networks including family, friends, tunity to influence personality, in a sense, by strengthen- peers, and health care providers are important determi- ing resilience. nants of behavior.37-40 Repeatedly, motivation to exercise has been found to be influenced by the social milieu of Older adults are a heterogeneous group with very rich the individual and/or the care setting. These social inter- and diverse life experiences. Consequently, the factors actions can alter recovery trajectories by disrupting the that facilitate motivation in one may not work as effec- progression of functional limitations to disability. The tively for another individual. As noted previously, the influence of any member of the individual’s social net- model of motivation can be used to explore the many work can be positive or negative depending on his or her factors that influence motivation and behavior in older philosophy and beliefs related to exercise. Social sup- adults. In so doing, interventions can be developed to ports can directly serve as powerful external motivators specifically address identified areas, which may be nega- by (1) providing encouragement, (2) helping the older tively influencing the individual’s motivation to engage adult feel cared for and cared about, and (3) helping to in a certain activity.

186 CHAPTER 10  Motivation and Patient Education Instruments to Measure Motivation activity.55-60 Self-efficacy expectations were associated with recovery following stroke,61 cardiac,62 and orthope- Conceptually, motivation can be considered as intrinsic dic events.63 Outcome expectations are particularly rele- to the individual and as part of his or her personality vant to older adults.35 Older adults may have high self- (i.e., a trait) as well as extrinsic to the individual and efficacy expectations but if they do not believe in the influenced by the many factors addressed above. Mea- outcomes associated with the behavior such as the bene- surement of motivation, therefore, should ideally ad- fits from specific exercises done during therapy, then it is dress all of these components. A list of tools to measure unlikely that they will be willing to perform the activ- motivation, directly and indirectly by considering such ity.51,53,64 The interventions that have been developed things as their beliefs about a behavior, is provided in using a self-efficacy approach have generally included the Table 10-2. Measures of self-efficacy, which focus on the following components to address motivation: verbal en- individual’s confidence in his or her ability to engage in couragement, goal setting, role modeling, mastery experi- the behavior of interest, and outcome expectations, ences, and decreasing unpleasant sensations. Alterna- which are the beliefs that doing the behavior will result tively, technologically focused interventions have included in a specific outcome, are behavior specific. Table 10-2, the use of hand-held computers to increase physical activ- therefore, provides some examples of different measures ity among middle-aged and older adults. of self-efficacy and outcome expectations that can be Social Ecological Model Based Interventions.  ​The used to focus on the beliefs associated with a given be- social ecological model provides an overarching frame- havior of interest (e.g., exercise, functional activities, work for understanding the interrelations among diverse diet, and medication adherence). Measures of pain and personal and environmental factors in human health and fear of falling are important to consider, as they are illness. There is increasing recognition that this type of known external factors that influence motivation. Like- multilevel perspective is needed to address health behav- wise, social support for exercise, specifically related to ior change and facilitate changes in current care philoso- social support from friends, family, and experts is also phies and care practices as has been done with regard to known to have an important impact on motivation in use of physical restraints,67 promoting healthy behav- specific behavioral areas such as exercise. iors,68,69 and understanding caregivers’ expectations and care receivers’ competence.70 The social ecological model Theoretically Driven Interventions addresses intraindividual factors such as cognitive status, to Improve Motivation and Behavior physical condition, mood, and underlying diseases such as anemia. Interpersonal interactions are addressed using Both self-efficacy and outcome expectations play an in- social cognitive theory and the interventions delineated fluential role in the performance of functional activi- above that strengthen self-efficacy and outcome expecta- ties51-54 and the adoption and maintenance of physical tions. Environmental issues focus on making changes in the physical environment that will optimize the individu- TABLE 10-2 Tools to Measure Motivation al’s access to opportunities for physical activity or facili- and Factors That Influence tate function by altering the person–environment fit Motivation (e.g., altering the height of a chair). Lastly, organiza- tional, state, and national policy issues attempt to influ- Aspect of Motivation Source for the Measure ence or alter policies in the event they inhibit or prevent Being Measured Identified participation in functional or physical activities. Alterna- Self-efficacy expectations tively, policies can be developed, or appropriate policies Functional performance6 used, to encourage older adults to engage in physical and Outcome expectations Exercise102 functional activity. The current public health guideline Health-related diet103 for physical activity for older adults established by the Physical sensations Medication adherence104 American College of Sports Medicine and the American Social supports Exercise102 Heart Association is a good example of this type of Functional performance6 policy.71 Self-determination Diet105 Medication adherence104 The Res-Care-Assisted Living (Res-Care-AL) Interven- Pain: McGill Word Scale106 tion was revised using the social ecological model. Interven- Fear: 0 to 4 Fear of Falling Scale107 tions for the participants in this study were focused at both The Norbeck Social Support the individual and facility level. At the intraindividual level, a number of factors that can lead to functional limitation, Questionnaire108 disability, and sedentary behavior in older adults were con- The Social Support for Exercise sidered, including anemia, vitamin D deficiency, cognitive impairment, comorbid and acute medical problems, de- Habits Scale109 pression, and fear of falling. Individualized interventions Apathy Evaluation Scale110 were implemented such as replacement of vitamin D if Self-Motivation Inventory111

CHAPTER 10  Motivation and Patient Education 187 appropriate for the participant. At the interpersonal level, outdoor access, assuring that there are flat and smooth using social cognitive theory, the following four interper- walking paths, placing chairs or benches at strategic sonal interactions were implemented to engage the resident locations to allow for brief rest periods during a walk), in physical activity and functional tasks: (1) enactive and increasing access to opportunities for physical activ- mastery experience, or helping the individual to success- ity, such as providing more exercise activities as part of fully perform the activity (e.g., breaking down the task the general activity programs offered in the facility. into simple steps that could be successfully performed, Lastly, policy/organizational factors included an evalua- or starting with a sitting exercise and increasing the diffi- tion of the marketing materials within the facility to culty); (2) verbal persuasion, or providing verbal encour- ensure they focused on optimizing function and physical agement so that the individual believed that he or she was activity among residents, and review of the resident’s capable of performing the activity of interest and setting plan of care (required by the State) so that it focused on goals to reinforce that; (3) vicarious experience or exposing what the resident would do with regard to function and the individual to like others exercising; and (4) implement- physical activity and not what the caregivers would do ing interventions to decrease any unpleasant sensations for the resident. associated with an activity (e.g., pain or anxiety with exer- cise) and increasing the benefits from exercise and other Effective Strategies to Help Motivate associated positive feelings (e.g., the sense of enjoyment or the Older Adult accomplishment associated with going to an exercise class). These techniques were taught to the caregivers who were The theoretical guidance for motivational interventions encouraged to use them in all care interactions with with older adults is extremely important for ensuring a residents. successful outcome for any intervention geared toward increasing physical or functional activity. Appreciating Environmental interventions focused on evaluation of the techniques that can be used in the development the person–environment fit using the Housing Enabler,72 of theory-based interventions is likewise helpful. Table making appropriate changes to improve the fit and opti- 10-3 describes specific interventions that have been used mize physical activity and function (e.g., improving TA B L E 1 0 - 3 Interventions to Strengthen Motivation Components of Motivation Specific Interventions to Improve Motivation Beliefs Interventions to strengthen efficacy beliefs: 1. Verbal encouragement of capability to perform Unpleasant physical sensations (pain, 2. Expose older adult to role models (similar others who successfully perform the activity) fear) 3 . Decrease unpleasant sensations associated with the activity 4. Encourage actual performance/practice of the activity Individualized care 5. Educate about the benefits of the behavior and reinforce and underline those benefits 1. Facilitate appropriate use of pain medications to relieve discomfort. Social support 2 . Use alternative measures such as heat/ice to relieve pain associated with the activity Goal identification 3 . Cognitive–behavioral therapy: • Explore thoughts and feelings related to sensations • Help patient develop a more realistic attitude to the pain—i.e. pain will not cause further bone damage • Relaxation and distraction techniques • Graded exposure to overcome fear of falling 1 . Demonstrating kindness and caring to the patient 2 . Use of humor 3 . Positive reinforcement following a desired behavior 4 . Recognition of individual needs and differences, such as setting a rest period or providing a favorite snack 5. Clearly and simply write out/inform patient of what activity is recommended 1 . Evaluate the presence and adequacy of social network 2 . Teach significant other(s) to verbally encourage/reinforce the desired behavior 3. Use social supports as a source of goal identification 1. Develop appropriate realistic goals with the older adult 2. Set goals that can be met in a short time frame—daily or weekly—as well as a long-range goal to work toward 3. Set goals that are challenging but attainable 4 . Set goals that are clear and specific

188 CHAPTER 10  Motivation and Patient Education successfully in the past and can be considered useful Complex Motivational Challenges building blocks for more comprehensive motivational interventions. First and foremost, it is critical to establish Overcoming Fear.  Fear of falling is common among whose motives are being addressed in the motivational older adults and occurs in 42% to 73% of those who interaction. If goals are established without the input of have fallen.76-78 Fear of falling is associated with reduced the older individual, it is not likely he or she will be will- physical activity,78-82 decreased participation in func- ing to participate in the activities needed to achieve the tional activities,83,84 lower perceived physical health sta- goal. For individuals who are cognitively impaired and tus,85,86 and lower quality of life and life satisfaction.87,88 cannot articulate goals, it is useful to review old records When trying to increase participation in functional ac- and speak with families, friends, and caregivers who tivities and time spent in physical activity, it is important have known the individual previously. Goals can then be to decrease or eliminate fear of falling. Most of the re- developed based on their prior life and accomplish- search that has been done to address fear has focused on ments.73,74 Further, it is important that the goals estab- fear of back pain. The interventions utilized for fear of lished be realistic and achievable so as to ensure feelings experiencing back pain, however, are theoretically based of success. and may be effective if translated to fear of falling. Demonstrations of caring and confidence in the skills Interventions to decrease fear of back pain are based on necessary to help the individual (e.g., providing assis- cognitive–behavioral therapy and include either Graded tance with transfers) are central to motivating older Activity or Graded Exposure treatment.89-91 Graded Activ- adults in this area. Care can be demonstrated by behav- ity starts by finding out how much activity each patient iors and activities perceived by the individual as expres- can do before pain occurs. Then the patient is enrolled in sions of love, attention, concern, respect, and support.75 a program that starts with that level of exercise or activity. Another important aspect of caring is setting some guide- The therapist guides the patient in building tolerance by lines or limits with regard to behaviors. This does not slowly increasing duration, intensity, and frequency of the relate to punishment or threats. Rather, it is focused on exercise or activity that was noted to cause pain. Educa- being firm and informing the individual of the activity tional strategies are incorporated into the intervention to they need to do and why they need to do it. For example, teach the patient that pain is not harmful in terms of his an older individual may need to get up and walk to the or her underlying back problems and that the exercise/ bathroom to prevent skin breakdown, optimize conti- activity recommended is beneficial in spite of the pain that nence, and regain strength and function. In addition, in- may occur. Positive reinforcement is provided as the indi- dividualized care includes recognizing individual differ- vidual works toward achieving success and overcoming ences and needs, using kindness and humor, empowering fear associated with the activity. older adults to take an active part in their care, providing gentle verbal persuasion to perform an activity, and posi- In contrast, Graded Exposure treatment involves pre- tive reinforcement after performance, or even attempts at senting the participant with anxiety-producing material performance.4,5,66 Examining the setting in which motiva- (e.g., having him or her engage in an activity that causes tional interventions are occurring, although basic, is im- pain) for a long enough time to decrease the intensity of portant to ensuring successful interactions. If the older their emotional reaction. Ultimately, the feared situation adults cannot see or hear what a therapist is telling him no longer results in the individual becoming anxious, or or her to do, for example, he or she will not perform the avoiding the activity. Exposure treatment can be carried activity and thus be labeled noncompliant or unmoti- out in real-life situations, which is called in vivo expo- vated. Simple interventions such as eliminating back- sure; or it can be done through imagination, which is ground noise and speaking slow, low, and loud can called imaginal exposure. The Graded Exposure inter- greatly help these situations. For profound hearing loss, vention starts by looking at which activities cause fear or if the therapist is soft spoken, an external device that (e.g., walking, stair climbing, twisting) and then having amplifies sound can be used. In addition, establish an the individual engage in that activity repeatedly. As fear environment in which the older individual does not feel associated with the activity decreases, the frequency, in- stressed that he or she has to move quickly. If stressed in tensity, and duration of the activity is increased. this manner, it is likely the individual will freeze and not be able to perform at all. Other interventions to decrease fear of falling have included exercise activities (walking, strengthening, bal- Lastly, recognizing and appreciating the heterogene- ance activities, Tai Chi), educational programs, and use ity of older adults and the fact that what is effective in of hip protectors. There was some, albeit limited, evi- motivating one individual may or may not be useful dence for the effectiveness of these interventions on de- when working with a different individual is important. creasing fear of falling.92-94 Outcomes are better when Moreover, multiple interventions (e.g., individualized interventions are combined, such as when an educa- care, setting goals, providing verbal encouragement, tional program is combined with an exercise program. and ensuring mastery experiences) may be necessary to Giving In and Giving Up: Dealing with Apathy.  A​ pathy, optimally motivate the older individual. or a lack of interest, concern, or emotion, has been concep- tualized as the opposite of motivation.95 Although apathy

CHAPTER 10  Motivation and Patient Education 189 is commonly noted in those with dementia and depres- in physical therapy schools, with effective techniques the sion,96 it can occur independent of either of those two least understood. Physical therapists often do not per- conditions.95 Unfortunately, the presence of apathy is as- ceive themselves as educators despite the fact that the sociated with a decrease in functional and physical activi- therapist spends much of any treatment session instruct- ties in older adults.97 Numerous pharmacologic interven- ing patients in new techniques or home programs or fa- tions have been used to decrease apathy and improve cilitating relearning of motor skills. Using appropriate participation in rehabilitation activities. These include education strategies grounded in sound theory and re- amantadine, amphetamine, bromocriptine, bupropion, search may make the difference between the patient’s methylphenidate, and selegiline,98 and more recently the success and failure in achieving rehabilitation goals. In cholinesterase inhibitors,99 as well as the selective serotonin the second half of this chapter, patient education and the reuptake inhibitors.100,101 physical therapist’s role as a patient educator are empha- sized in terms of a practical yet philosophically based Medication management for apathy may be a useful, experience that can influence the older patients’ direc- even necessary, first step in engaging the older adults with tion in prescribed interventions. A review of learning apathy. Behavioral interventions, however, should like- theories is presented, followed by a philosophical wise be initiated. Behavioral interventions focus on struc- approach to learning and patient education. Character- ture and stimulation such that the individual is encour- istics of older adult learners and some common barriers aged to engage in activities that he or she can easily do to their learning also are summarized. The role of the successfully. New and different activities such as partici- caregiver and teaching strategies to enhance this role pating in a visiting pet program or a Tai Chi class gener- are discussed, and selected assessment methods are ally tend to be good sources of stimulation and motiva- presented. The chapter concludes with three typical tion. Individuals with apathy will likely say “no!” to patient education scenarios that illustrate some of the participating in any of the activities that are recom- concepts presented relative to patient education as an mended or that he or she is invited to attend. In situations intervention. in which the apathy is profound and persistent, it may be necessary to ignore the “no” and engage the individual— Learning Theories if only for a short period of time—in the activity. This can sometimes be done by walking with the individual to the Learning by its very nature defies easy definition and activity and sitting with him or her for a period of time. simple theorizing. The concepts of behavioral change Persistent and regular encouragement to participate in and experience are central to learning theories. Learning activities in the community or within a facility, or encour- is defined as the capacity to behave in a given fashion, agement to participate in simple bathing and dressing ac- which results from practice or other forms of experience tivities, is critical. All too often, health care providers and that causes an enduring change in behavior.112 Learning lay caregivers stop asking apathetic older individuals to as a process, rather than an end product, focuses on engage in activities and thus propagate the disease. what happens as learning takes place. Explanations of The Comprehensive Approach to Motivation.  Moti- this process are called learning theories. It is necessary to vation in older adults is a complex multidimensional understand the components of how learning occurs to factor that must be evaluated on an individual basis. The effectively address specific learning situations. evaluation should include intrapersonal, interpersonal, Behaviorist Orientation.  ​Behaviorism focuses on ob- environmental, and larger social policy implications of servable behavior shaped by environmental forces. motivation. Interventions can then be individualized Learning occurs when there is a change in the form or based on where challenges are identified. Assessing mo- frequency of observable performance.113 The key ele- tivation and intervening is an ongoing process, and per- ments in learning under behaviorist principles are the sistence and determination to overcome motivational stimulus, the response, and the association between the problems is needed on the part of the health care provid- two. The environment plays the most important role in ers and lay caregivers. Working together, motivation can the behaviorist theoretical approach. Behavioral theo- be treated and improved with regard to function and rists believe that the teacher’s role is to design an envi- physical activity. In so doing, the individual will be able ronment that elicits desired behavior and to extinguish to obtain and maintain his or her highest level of func- behavior that is not desirable. An example in physical tion and optimal quality of life. therapy patient education would be the therapist ver- bally reinforcing a correct transfer technique as it is be- PATIENT EDUCATION ing performed while ignoring the behavior when the transfer technique is done incorrectly. Another example Introduction might be when the therapist instructs a patient in stair climbing and consistently reinforces the “correct tech- Imparting information to a patient is one of the most nique,” such as a particular foot advancing first. The common interventions a physical therapist uses. How- patient eventually performs according to the therapist’s ever, patient education is often the least addressed topic

190 CHAPTER 10  Motivation and Patient Education instructions but may not know why, so when encounter- example, may initiate change over a period of time in- ing unfamiliar situations, may have difficulty adapting stead of creating a total change at one time. A commit- his or her behavior to the new situation. The systematic ment to monitor food intake would also be important design of instruction, behavioral objectives, notions from the social learning viewpoint. of the instructor’s accountability, programmed instruc- tion, computer-assisted instruction, and competency- The term locus of control is used to explain which based education are strongly grounded in behavioral behavior in the individual’s repertoire will occur in a learning theory. The behaviorist orientation is thought given situation. Typically, people with an internal locus to be ideal for learning that requires rote responses of control will adhere more consistently and longer than and recall of facts. Behaviorist principles are less appro- those with an external locus of control, which requires priate for higher order thinking skills, such as problem external motivation such as praise and material rewards. solving.113 Social learning theories provide an additional factor in Cognitive Orientation.  ​Cognitive processes such as how adults learn by acknowledging the importance of thinking, problem solving, language, and concept forma- context and the learner’s interaction with the environ- tion are stressed in the cognitive approach. Learning is ment to explain behavior. equated with discrete changes between states of knowl- Adult Learning Orientation.  A​ ndragogy is a term edge rather than in the probability of response. Cogni- popularized by Knowles to explain a philosophical ori- tive theories focus on the conceptualization of students’ entation for adult education.114 His four main assump- learning processes and address the issues of how infor- tions of changes in self-concept, role of experience, mation is received, organized, stored, and retrieved by readiness to learn, and orientation to learning lay the the mind.113 An example of applied cognitive theory in foundation for the instruction of older adults. geriatric physical therapy would be demonstrated in how the therapist organizes a treatment session with the Changes in self-concept occur as individuals grow goal of instructing the patient how to weight shift prior and mature. Their self-concept moves from one of total to ambulation. In such an example, the therapist would dependency (as is the reality of an infant) to one of in- build on the simple tasks of supine weight shifting, mov- creasing self-directedness. Any experience that adults ing to more complex tasks such as sitting weight shifting perceive as putting them in a position of being treated as and then standing weight shifting. Progression would a child will interfere with their learning, commonly re- then advance from bipedal weight shifting to unilateral sulting in expressions of resentment and resistance. As weight shifting to advancing a foot forward. Concern for mentioned earlier, older adults tend to have a positive the proper pacing of instruction would be addressed self-concept. throughout the treatment session. Humanist Orientation.  ​Humanist theories consider Role of experience defines the role of lifetime experi- learning from the perspective of the human potential for ences. As individuals mature, they accumulate an ex- growth. From a learning theory perspective, humanism panding reservoir of experience, producing an older emphasizes that a person’s perceptions are centered in adult who has a rich and varied background to facilitate experience, as well as the freedom and responsibility to new learning and knowledge. If older adults perceive become what one is capable of becoming. These tenets their experiences to be devalued or ignored, they may underlie much of adult learning theory that stresses the then perceive this as rejecting their experience and even self-directedness of adults and the value of experience in their person. the learning process. Social Learning Theory.  S​ ocial learning theory is a The concept of readiness to learn explains the shift system of thought based on imitation or modeling. Ban- from an external stimulus to an internal stimulus. As dura postulated that one can learn from observation individuals mature, their readiness to learn is decreas- without having to imitate what was observed.2 He fur- ingly the product of biological development and aca- ther explored self-directed behaviors. In order for people demic pressure and is increasingly the product of the to regulate their own behavior, well-defined objectives or developmental tasks required for the performance of goals are selected; contractual agreements are negotiated evolving social roles. Learning experiences must be to further increase goal commitment; objective records timed to coincide with the learners’ developmental tasks. of behavioral changes are used as additional sources of For example, an older patient may need to attempt am- reinforcement for their self-controlling behavior; and the bulation and find that it is difficult before comprehend- stimulus condition under which the behavior customar- ing the importance of general strengthening or balance ily occurs is altered. For example, for the older adult activities. who has difficulty adhering to his or her diabetic diet, removing the source of temptation or storing the forbid- Orientation to learning reflects the adult’s purpose for den food in a different place would alter stimulus condi- learning. Adults tend to have a problem-centered orien- tions. The progressive narrowing of stimulus control, for tation to learning. Real-life problems are the purpose for seeking educational opportunities. The immediate ap- plication of information is a primary need of the adult learner.114 Transtheoretical Model.  T​ he transtheoretical model (TTM) of behavior change was developed in the early

CHAPTER 10  Motivation and Patient Education 191 1980s by Prochaska and DiClemente115 to describe how • Active participation in learning improves retention. people changed their behavior. The model suggests that • Environmental factors affect learning. people go through change as a process over time • Adults learn throughout their lifetime. and that receptivity to information is dependent on the • Adults exhibit learning styles that illustrate various stage of change in which the person is in. Table 10-4 describes the stages and the appropriate types of infor- learning theories, such as the following: mation for each stage. The TTM has been used to pro- • Having personal strategies for organizing infor- mote adaptation of healthy behaviors such as engaging in exercise.116 The key feature is the stage approach in mation. that different strategies and interventions are used for • Perceiving in different ways—cognitive procedures. individuals at different stages of readiness to change or • Perceiving learning activities to be problem- adopt behavior.116 centered and relevant to life. In conclusion, the following principles developed by • Desiring some immediate appreciation. Darkenwald and Merriam summarize the principles ap- • Having a concept of themselves as learners. plicable to patient education as intervention117: • Being self-directed. • Adults’ readiness to learn depends on their previous The learning theories and principles presented in this learning. section are diverse but can also complement each other. The effective health care provider will use a variety of • Intrinsic motivation produces more pervasive and patient education interventions based on the outcomes permanent learning. desired. • Positive reinforcement is effective. Psychological Factors of the Learning • Material to be learned should be presented in an or- Situation ganized fashion. To develop a philosophical approach to patient educa- • Learning is enhanced by repetition. tion, physical therapists must understand their own • Tasks and materials that are meaningful are more motivations and biases toward their role as the helper, fully and more easily learned. TA B L E 1 0 - 4 Transtheoretical Model of Behavior Change Stage Description* Learner Characteristics Type of Information Useful† Precontemplation Not engaged in the targeted Resistant to change, if thinking Personalized information about benefits of activity with no intention to about change at all targeted activity, feedback about risks of do so current behavior May fear failure Contemplation Intend to engage in the targeted May lack information Information about how to reduce barriers to activity in the next 6 months May be overwhelmed with barriers targeted activity May be open to information about Identify role models benefits of new behavior Continue to provide education about May be curious about results that personal risks and benefits could be obtained from changing Help to make a definite commitment to Ambivalence is common change Preparation Intend to engage in the targeted May take small steps toward change Identify alternatives to targeted activity that activity in next 30 days will accomplish same goal and make a Action Begins the targeted activity for at Requires commitment and energy to plan Maintenance least 1 day up to 6 months make it work Make a public commitment Involve others Engaged in targeted activity for May be looking for reinforcement Frequent positive reinforcement at least 6 months and encouragement Log of activity Provide support networks Challenge is to sustain behavior and overcoming barriers that can Meaningful reward cause relapse Long-term goals Support groups and networks *Data from Lach HW, Everard KM, Highstein G, Brownson CA: Application of the transtheoretical model to health education for older adults. Health Promot Pract 5(1):88-93, 2004. †Data from Burbank PM, Reibe D, Padula CA, Nigg C: Exercise and older adults: changing behavior with the transtheoretical model. Orthop Nurs 21(4): 51-61; quiz 61-3, 2002.

192 CHAPTER 10  Motivation and Patient Education their attitudes toward their patients, and their attitude patients to make decisions for themselves. A patient may toward the information they are sharing. Understanding not be able to make his or her own decisions in times of the older adult’s perceptions of self and of learning is grief or extreme stress or with certain medical condi- also important. This section discusses factors that con- tions. This approach also takes longer, making it less tribute to the therapists’ and patients’ attitudes toward efficient. Finally, the health care provider may not use his teaching and learning. or her extensive knowledge as overtly as in the cure Therapist’s Perception of the Patient Educator.  ​One model, perhaps putting the patient at a slight disadvan- motivation for entering the health care field is to help tage.127 people. People become helpers because they really enjoy Older Adults’ Perception of Self.  M​ ultiple internal helping others and want to affect their lives positively. and external forces affect older adults’ behavior, atti- Although the motive to help others focuses on the needs tudes, and conditioning. Any number of these forces can of the patient, the desire to control may also be present. affect how older patients respond to medical situations The desire to exert control, to be in charge, and to have and their attitudes toward the learning situation. Inter- some noticeable impact on the world is particularly rel- estingly, older individuals, over the age of 60 years, evant when attempting to “teach” a patient. This atti- ranked their role as learners significantly below other tude of control can make the physical therapist the au- age groups.119 This section briefly presents several of the thority of the learning situation, perhaps inhibiting the forces that affect the older patient related to learning. learning situation. The authority role may be in direct conflict with the stronger self-perception of the older Sensitivity to Failure.  M​ any therapists treating adult as a critical consumer of health care and thus make older adults will be significantly younger than their the learning situation less effective. patients. An older adult’s sensitivity to failure may be affected by the age difference and by the perceived ease Another common but deeper and less obvious thought with which the younger therapist performs complicated that can interfere with the physical therapist’s role as an tasks and physical movement. The therapist also must educator is the fear of being in a similar situation some- realize the patient may be comparing current perfor- day when the patient becomes a disturbing mirror image mance with previous normal performance, which can of the physical therapist’s real or potential suffering. As- enhance the perception of failure. A negative self- serting authority or avoiding the person through mini- concept and the older adult’s view of his or her own mal and superficial involvement are ways the physical personal crisis, for example, disability, illness, or per- therapist defends against this phenomenon. sonal loss, also may accentuate the sensitivity to failure. The cure model of health care still is prevalent in to- Resistance to Change.  ​Resistance can be a normal day’s health care environment. Paternalism places the coping strategy to change and fear and should not be health care provider in the role of decision maker about viewed as rigidity of attitude or behavior and thus result the type and amount of information the patient receives. in a person being less amenable to change. Rogers stated Paternalism is most often associated with the traditional that resistance may be observed when the individual medical model, which uses authority, power, and supe- feels threatened. The older patient also may express total rior knowledge to act on the patient’s behalf. Paternal- hopelessness for improved function and exhibit a resig- ism tends to reinforce the passiveness of the patient and nation to accepting the present limitations. This attitude communicates expectations of compliance and unques- may be manifested in resistance to suggestions, change, tioning obedience. The role of the health care provider is or help. Skepticism and even some degree of fear may a “father” figure, that is, authoritarian and all-knowing. underlie resistance. If paternalism is supported by the environment, the older adult may view the physical therapist as overbearing. In summary, the older patient in treatment sessions is The physical therapist may not consider the patient’s an individual with a complex psychosocial profile that needs, concerns, and choices and therefore may act in- will influence the degree of willingness to learn. The completely or inappropriately.118 therapist also has complex attitudes and beliefs regarding the role of the health care professional that affect the tone, An alternative to the cure model of health care is the manner, and flexibility of the therapist in the teaching/ care model. The care model values patient autonomy learning situation. The initial step in becoming an effec- and mutual collaboration between the patient and the tive patient educator is to recognize underlying attitudes physical therapist. In the care model, the role of the affecting the learning situation. physical therapy provider is one of consultant and en- abler, peer, and adviser, facilitating the patient’s needs Education can be viewed as the process of facilitating and desires. In this model, the type and amount of infor- the learner’s problem-solving skills with the goal that the mation are determined by the patient with a commit- learner will gain control over any specific problem.120,121 ment from the physical therapist to be honest and forth- Teaching does not imply learning. Teaching in the tradi- coming. Individualized care, compassion, warm personal tional sense is one-sided and asks nothing of the patient regard, and open communication are additional values. except that the patient be present. The “teacher” should Limitations of the care model involve the need for place the responsibility for learning on the learner, the patient. An example of this concept is seen in motor

CHAPTER 10  Motivation and Patient Education 193 learning. Motor learning uses the strategy of the patient’s feel free and unthreatened to tell the therapist what has internal feedback to provide stimulus for learning, rather affected or lowered his or her self-esteem. The basic than the therapist’s stimulus of telling the patient his or characteristics a teacher needs to exhibit to facilitate this her movement is “right or wrong.” For instance, while open communication as described by Rogers are realness assisting a patient with the task of stair climbing, instead or genuineness, prizing the learner, acceptance, trust, of directing the patient in a certain “technique” of stair and empathic understanding.121 When the health care climbing, the therapist may instead suggest that the pa- professional exhibits realness or genuineness, the facade tient begin to climb the stairs and then to facilitate the is lifted, and the therapist comes into a direct personal patient’s internal feedback mechanism by asking ques- encounter with the learner and meets the learner on a tions such as “how did that feel” when the patient starts person-to-person basis, as peers or equals. There is no to lose his or her balance or “did you notice the differ- hiding behind an authoritarian role; there is no sterile ence” when the patient tries a technique that was more facade. The physical therapist can express emotions and complex.122,123 attitudes and becomes, to the patient, a real person with convictions and feelings. Payton et al assert that only the patient can make the decision that a goal is worth working for.124 Lindgren Rogers describes prizing the learner as valuing the states that older patients should be viewed as individuals learner’s feelings, opinions, and the person as a whole. who are capable of making their own decisions.125 These Prizing is caring for the learner, accepting the learner as two statements clearly convey the important message a separate person, appreciating the learner’s differences, that older adults can and do exercise choice in whether and exhibiting a belief that the learner is fundamentally they will participate in treatment sessions. Rogers be- trustworthy. The physical therapist who exhibits this at- lieves that it is impossible to “teach” anyone anything titude can fully accept the fear and hesitation of the unless the learner wants to learn.120 Think of the patient older adult as the patient approaches his or her own who sits through a detailed exercise program. A strong personal crisis. This attitude allows the therapist to ac- feeling is transmitted that the patient really is not listen- cept the “poor motivation” of the older adult and to ing to the therapist and is, in fact, in a hurry to leave. make attempts to understand the factors contributing to No matter how great a “facilitator of learning” the the motivational problem. Empathic understanding is therapist is, if the patient does not want to learn, he or the therapist’s ability to appreciate the patient’s reactions she will not. from the patient’s perspective and to have a sensitive awareness of the way the processes of education and Basically, one learns what one wants to learn. learning seem to the patient. The likelihood of significant When one wants to learn, one is described as being learning is increased when these characteristics are ex- “motivated,” an internal phenomenon. Bille relates hibited by the therapist.120 Maslow’s needs hierarchy to patient motivation in an interesting and relevant manner.126 Maslow theorized To increase the patient’s self-directedness, the thera- that one’s basic physiological needs (air, food, water, pist should provide opportunities for the patient to make movement, sex, avoidance of pain) and safety and decisions about treatment and to identify what is to be security needs (assurance that the world is regular learned. The next section explores a specific model that and predictable; that death, destruction, or physical/ encourages full patient participation in goal setting and social/emotional/economic harm is not imminent) intervention. must be met before affiliation and esteem needs can be met. PATIENT PARTICIPATION IN GOAL SETTING Bille applies this concept to the patient who has expe- rienced physical trauma and whose current needs basi- Facilitating the patient’s full participation in each thera- cally are physiological and safety oriented. The patient peutic interaction should be a primary goal of the thera- may find it difficult to focus on adjusting to the trauma pist, and especially in the goal-setting process. Increasing and the necessary rehabilitation and may not be able to patient participation in goal setting and treatment plan- envision managing the changes that may result from that ning improves clinical outcomes and patient satisfaction trauma. Motivation will be enhanced, therefore, when and is recommended or required in regulatory and prac- instruction is centered on procedures that are, in the tice guidelines.127-131 Although the vast majority of clini- patient’s perspective, physiological and safety oriented, cians believe that they attempt to involve patients in a such as strength, mobility, ambulation, or activities of goal-setting process, the literature demonstrates that daily living (ADLs). When these needs are met, self- most clinicians involve patients at far less than optimal esteem increases as progress is made. levels.132-136 Tripicchio et al.137 identified two areas where therapists failed patients when eliciting goals. Bille relates the need for esteem to the motivation to First, therapists often confused goals with means. Means learn and states that as self-esteem increases, motivation are the ways in which goals are accomplished, whereas to learn will increase. The therapist can foster the goals are the patient’s outcomes; that is what the patient patient’s self-esteem, and therefore motivation, which promotes two-way communication. The patient needs to