Reabilitare Geriatric!

II

Daiana Popa
Spitalul Clinic de Recuperare Medical! B!ile-Felix
Aging is a multidisciplinary field:
Biology, sociology, and psychology
public policy and economics
Gerontology is the study of the aging:
the study of physical, mental, and social changes in older people as
they age
the investigation of the changes in society resulting from our aging
population
the application of this knowledge to policies and programs
Geriatrics is:
the study of health and disease in later life
the comprehensive health care of older persons
Aging
As people age, some physiologic changes are
inevitable
Other changes, while not universal, are far more
common than among younger people
Older people also face unique psycho-social
challenges
These changes and challenges can lead to a variety
of geriatric syndromes and issues
These in turn can lead to:
Poor health outcomes
Functional decline,
Frailty,
Disability and dependence
Social Problems More Common
with Aging
Loss of income
Loss of close family
Loss of community
Social isolation
Geriatric Interdisciplinary Team
Medicine
Nursing
Social Work
Psychiatry
Psychology
Case Management
Physical Therapy
Occupational Therapy
Speech Pathology
Pharmacology
Chaplaincy
Recreation Therapy
Fiziologia Imbatranirii
Tegumente
Compozitia
corporala
Tulburari
senzoriale
Sistem Nervos
Musculoscheletal
Renal
GI
Cardiovascular
Pulmonar
Rezerva Functionala
Redundanta un numar mai mare de celule de
cat strictul necesar

Odata cu imbatranirea rezerva functionala se
reduce - orice injurie poate avea consecinte
mult mai grave
Fiziologia Imb!trnirii
Sc!derea capacit!"ii de rezerv! a organelor
si sistemelor
Sc!derea controlului intern homeostatic
Sc!derea adaptarii la diferi"i factorii de mediu
(temperatura, pozi"ia ortostatic!, schimbarea
posturii)
Sc!derea capacit!"ii de a r!spunde la stress
Modific!ri SNC
Tulbur!ri cognitive (memorie, vitez! de
procesare,etc)
Tulbur!ri de conducere nervoas! (n. motor,
senzitiv)
Modific!ri de postur!, proprioceptie si mers
Declinul Sensorial:

Vederea si auzul
Gustul si mirosul
Somestezia: tactila, terminca, dureroasa
Proprioceptia
Kinesthesia
Tulburarile de vedere
afecteaza 20-30% dintre persoanele peste
75 de ani.
Cele mai frecvente la varstnici:
Cataracta
Glaucomul
Degenerarea Maculara
Retinopatia diabetica
Orbirea
Cataracts
Glaucoma
Macular Degeneration
Diabetic Retinopthy
.
Imbatranirea pielii
Susceptibilitate crescuta la leziuni
Vindecarea intarziata
Scaderea raspunsului inflamator
Scaderea protectiei UV
Scaderea elasticitatii riduri
Sensibilitate la alergii
Scaderea sensibilitatii tactile, termice, dureroase
Scaderea termoreglarii
Modific!ri musculo-scheletale
Sc!derea For"ei Musculare: (factori
metabolici, celulari, neurali)
MI cu 14-16% / decad!
MS cu 2% (femei) 12% (barbati) / decad!
Osteoporoza
Osteartita (artroza) / modific!ri degenerative
peste 60 ani
La articula"iile portante
Scade rezisten"a cartilajului articular
Modific!ri musculo-scheletale
Scaderea performantei neuro-musculare:
Scade forta musculara
Scade viteza de reactie
Oboseala precoce

Inactivitate
Tulburari de echilibru
Limitari functionale
Modific!ri musculo-scheletale
Scade masa musculara
Modificarea compozitiei muschiului
Scade numarul fibrelor musculare tip II
Reducerea nr. celulelor musculare SARCOPENIE
Scade IMS (sub 5,75kg/m2 femei; 8,50kg/m2 barbati)
Reducerea proteinelor contractile
Scaderea fortei musculare:
Incepe in decada a III a
Se accelereaza in decada a VI-a si a VII-a
Rata pierderii = 8% pe decada
Scade si mai mult in caz de boli cronice
Modific!ri musculo-scheletale
Scade anduranta
Creste fatigabilitatea musculara
Scade afluxul sanguin
Scade densitatea capilarelor
Scade transportul glucozei
Scade activitatea enzimelor oxidative
Scade sinteza PC

Alterarea unitatilor motorii
Reducerea motoneuronilor din c. anterioare
ale MS
Scade viteza de conducere nervoasa
Scade transmiterea joctionale
Scade neurotransmitatorii
Scade recrutarea unitatilor motorii
Aparat respirator
Scade capacitatea pulmonar!:
Scade rezerva func"ional!
Acumularea noxelor
Scade elastictatea cutiei toracice
Scade for"a mu#chilor respiratori
Scade circula"ia pulmonar!
Cre#te riscul de infec"ii
Sistemul Genito-urinar
Hiperplazia de prostat!
Incontinen"a urinar!
Hipereactivitatea detrusorului
Prolapsul genital
Obstuciile uretrei
Vezica neurogena
Cancerele genitale
Aparat cardio-vascular
Frecventa cardiac! de repaus nu se modific!
Frecven"a cardiac! la efort se reduce:
barbati: 220 (0,8 X varsta)
femei: 190 (0.8 X varsta)
Scade extrac"ia de oxigen la nivelul "esuturilor
Scade capacitatea aerobica
Risc de insuficien"! cardiac!
Scade sensibilitate baroreceptorilor vasculari
risc de hipotensiune ortotstatic!
Modificari articulare
Mobilitate
Articulatii sinoviale
(diartroze)
Stabilitate
Articulatii nonsinoviale
(sinartroze)
9-26
Modificarile Articulatiilor Sinoviale
Scade flexibilitatea capsulei
Creste rigiditatea ligamentelor
scade numarul fibrelor de colagen
Se reduce cantitatea si calitatea lichidului sinovial
9-27
Calcificare
Rigidizare
Articulatii Fibroase -- Suturi
9-28
Articulatii Cartilaginoase -- Simfize
2 oase unite printr-un
fibrocartilaj
Simfiza pubiana
Discul interrvertebral

grad minim de mobilitate
Deshidratare
Degenerescenta
Rigidizare
Reducerea mobilitatii
Ligamentele periarticulare
Modificarile cartilajului articulatiior
sinoviale
Scade continutul hidric /
imbibitia cu lichid sinovial
Scade cantitatea de
condroitina, glucozamina,
proteoglican
Creste rezistenta la alunecare
Apar neregularitati ale
suprafetelor
Scade grosimea cartilajului
Scade ROM
Scade propripceptia
Stg: aspect normal
Dr. artoza avansata
Modificari articulare
Noduli Heberden
Noduli Bouchard

Sindroame Geriatrice
Deficite Senzoriale
Deficite de mers
Caderi
Incontinenta
Dementa
Depresie
Delir
Polipragmazie
Tulburari de somn
Leziuni de decubit (escare)
Vulnerabilitatea varstnicului
Declinul biologic al tuturor tesuturior si functiilor
organismului
Prezenta comorbiditatilor
Tulburari cognitive, dementa, delir
Opreste, intarzie sau modifica programul de
recuperare
Frail elderly understood in terms
of exercise capacity
Minimal aerobic power compatible with full independence
is about 12-14 ml/[kg.min], or about 3.5 - 4 METs
This level of aerobic power allows performing most light
ADL without fatique (ADL: ~ 5 -7 ml/[kg.min]
Capacity of healthy elderly: 24-28 ml/[kg.min], or about
7 - 8 METs
Roy J. Shephard (1997) In: Clinical Exercise Testing and Prescription Theory
and Application, p. 81.
Deconditionarea
Deconditionarea
declinul andurantei cardiovasculare
Declinul fortei musculare
Activitatile uzuale zilnice:
Ajuta la mentinerea mobilitatii si a fortei
musculare
Nu au efect de antrenare a andurantei
cardiovasculare
Imobilizarea cauza majora a
deconditionarii
Pierderea rapida a fortei musculare: 2-3% pe zi
/ 25-30% in 2 saptamani
Accelerarea pierderii de Masa Osoasa
Contracturi cauzate de aderenta colagenului din
muschii flexori si positionarea inadecvata
Edemul
Risc de TVP
Scaderea volumului pulmonar
Incontinenta urinara
Re-conditionarea

Antrenametul Cardiovascular este eficient
dar trebuie supravegheat

Exercitii de grup ca Tai Chi amelioreaza
forta musculara a MI, echilibrul, starea
psihologica, dar nu are efecte demonstrate
asupra andurantei cardiovasculare
Combinate cu exercitii rezistive pot avea
efecte asupra rezistentei fizice
Aerobic Exercise Prescription
for Elderly
Prescription Active elderly Sedentary Elderly
HR max 60-80% 40-60%
Duration 20 min 10 min
Frequency 3 x / week 5 x / week
Period 14 weeks 14 weeks
Star with low intensity
Intervalize shorter exercise
Keep total session time at > 30 min
Training threshold for the elderly

Is there a lower threshold below which there is no
benefit effect at all?
For unconditioned elderly, submaximal exercise
even at 40-50% max HR can benefit.
This is also the rationale for reconditioning training
in patients with chronic renal failure or congestive
heart failure.
Recommendations for Physical Activity
in Older Adults

Minimum activity for achieving important health benefits
Two hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (e.g.,
brisk walking) a week, plus muscle-strengthening activities on at least two days of
the week or
One hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (e.g.,
jogging, running) a week, plus muscle-strengthening activities on at least two days of
the week or
A combination of moderate- and vigorous-intensity aerobic activity equivalent to the
recommendations above, plus muscle-strengthening activities on at least two days of
the week
Increased activity for achieving additional health benefits
Five hours (300 minutes) of moderate-intensity aerobic activity a week, plus muscle-
strengthening activities on at least two days of the week or
Two hours and 30 minutes (150 minutes) of vigorous-intensity aerobic activity a
week, plus muscle-strengthening activities on at least two days of the week or
A combination of moderate- and vigorous-intensity aerobic activity equivalent to the
recommendations above, plus muscle-strengthening activities on at least two days of
the week


KEY RECOMMENDATIONS FOR PRACTICE American
Heart Association

To promote and maintain health, older adults should participate in moderate-intensity
aerobic activity for at least 30 minutes on five days of the week, or vigorous-intensity
aerobic activity for at least 20 minutes on three days of the week.
Moderate- and vigorous-intensity activity can be combined to meet the minimum
recommendation for aerobic activity.
To promote and maintain health and physical independence, older adults should perform
muscle- strengthening activities on at least two days of the week.
Participation in more than the minimum recommended amount of aerobic and muscle-
strengthening activities leads to additional health benefits and higher levels of fitness.
To reduce the risk of falls and related injuries, community-dwelling older adults with
substantial risk of falling should perform exercises that maintain or improve balance.
To maintain the flexibility necessary for regular physical activity and daily life, older adults
should perform activities that maintain or increase flexibility for at least 10 minutes on at
least two days of the week.
Health Benefits of Physical Activity in Adults

Strong evidence
Decreased risk of early death, heart disease, stroke, type 2 diabetes mellitus,
high blood pressure, adverse blood lipid profile, metabolic syndrome, and colon
and breast cancers
Prevention of weight gain, weight loss, when combined with healthy diet
Improved cardiorespiratory and muscular fitness
Fall prevention
Reduced depression
Improved cognitive function (older adults)
Moderate to strong evidence
Improved functional health (older adults)
Reduced abdominal obesity
Moderate evidence
Weight maintenance after weight loss
Decreased risk of hip fracture
Increased bone density
Improved sleep quality
Decreased risk of lung and endometrial cancers