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What are the dual functions of the pancreas?

• Endocrine gland secreting hormones – insulin and
• Exocrine gland producing digestive enzymes


Islets of Langerhans are cells of pancreas involved in _____ function

Islets of Langerhans are cells of pancreas involved in
*endocrine* function


What causes diabetes mellitus?

Defective endocrine function in pancreas
• Pancreas produces little or no insulin
• Pancreas makes insulin, but insulin doesn’t work as it should


What is diabetes mellitus?

Disease that prevents body from properly using energy from food


What is a simplified review of metabolism?

• Food broken down to glucose (simple sugar)
• Glucose provides energy our body needs
• Pancreas releases insulin which attaches to and signals cells to absorb glucose from bloodstream
• Without insulin, glucose can’t be utilized by cells for energy and glucose remains in the blood (hyperglycemia)


What is the normal fasting plasma glucose level?

< 100 mg/dL


What is the prediabetes fasting plasma glucose level?

100-125 mg/dL


What is the diabetes fasting plasma glucose level?

> 125 mg/DL


What is the normal two-hour oral glucose tolerance plasma glucose level?

< 140 mg/dL


What is the prediabetes two-hour oral glucose tolerance plasma glucose level?

140-199 mg/dL


What is the diabetes two-hour oral glucose tolerance plasma glucose level?

> 200 mg/DL


What are the characteristics of type 1 DM?

• Previously called insulin dependent DM
• Absolute deficiency of insulin production and secretion
• Require exogenous insulin


What are the characteristics of type 2 DM?

• Previously called non-insulin dependent DM
• Much more prevalent
• Caused by combination of cellular resistance to insulin action and an inadequate compensatory insulin secretory response
• Can be controlled with diet, exercise, and oral hypoglycemic agents


What are the features of type 1 DM?

• Age at onset: Usually < 20 y/o
• Proportion of all cases: < 10%
• Type of onset: Abrupt
• Etiologic factors: Possible viral/autoimmune, resulting in destruction of islet cells
• Body weight at onset: Normal or thin


What are the features of type 2 DM?

• Age at onset: Usually > 40 y/o; increasing number of cases in all ages, including kids
• Proportion of all cases: > 90%
• Type of onset: Gradual
• Etiologic factors: Obesity-associated insulin resistance
• Body weight at onset: Majority are obese (80%)


What are the characteristics of Latent Autoimmune Diabetes in Adults (LADA)?

• Slow progressing form of autoimmune diabetes
• Similar etiology to Type 1, but onset usually > 30 y/o
• Don’t need insulin for several months up to years after diagnosis


What are the characteristics of Maturity onset diabetes of the Young (MODY)?

• More likely to be inherited, stronger genetic risk factor
• Shares type 2 diabetes symptoms
• NOT linked to obesity
• Develops before age 25


What is pre-diabetes?

When body can’t utilize glucose correctly
• Body cells do not recognize all of the insulin
• Cells stop responding to action of insulin


What does pre-diabetes result in?

In rise of blood glucose (high but not high enough)


What are the characteristics of pre-diabetes?

May have trifecta of prediabetes, HTN, and dyslipidemia – increases risk of developing Type 2 DM and heart disease


What are the cardinal signs and symptoms of type 1 diabetes?

• Polyuria (excessive urination)
• Polydipsia (excessive thirst)
• Weight loss with polyphagia (excessive hunger)
• Blurred vision


What are the cardinal signs and symptoms of type 2 diabetes?

• May have polyuria and polydipsia
• Visual blurring
• Neuropathic complications
• Infections
• Significant blood lipid abnormalities
• Often asymptomatic


What are the non-modifiable risk factors for type 2 diabetes?

- History of gestational diabetes
- Race/ethnicity
- Age over 45 years
- Family history of diabetes


What are the modifiable risk factors for type 2 diabetes?

- Physical inactivity
- High body fat or body weight
- High blood pressure
- High cholesterol


How is DM diagnosed?

• Classic symptoms + plasma glucose concentration ≥
200 mg/dL
• Fasting plasma glucose ≥ 126 mg/dL
• A1c > 6.5%


What are the long term consequences of DM to the eye?

Retinopathy: damage to retina due to abnormal blood flow


What are the long term consequences of DM to the kidney?

Leading cause of end-stage renal disease


What are the long term consequences of DM to the MSK system?

• Distal joints/segments
• Syndrome of limited joint mobility and stiff hand syndrome
• Dupuytren contracture
• Adhesive capsulitis
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Arthritis
• Osteoporosis


What are the long term consequences of DM to the nerves?

Sensory, motor and autonomic neuropathy


What are the long term consequences of DM to the cardiovascular system?

• CVD leading cause of M/M in DM
• 1.5-4 fold increased risk of CAD, stroke, or MI
• Diabetic cardiomyopathy
• Atherosclerosis begins earlier and is more extensive in Type 1
• Higher risk of CAD, stroke, and PVD in those with Type 2


What are the long term consequences of DM to the skin?

Neuropathic Ulcers


At what blood glucose level does hypoglycemia occur?

At blood glucose of <70 mg/dl


What are the causes of hypoglycemia?

Overdose of insulin, late or skipped meals, or
overexertion in exercise


What are the s/s of hypoglycemia?

Headache, weakness, irritability, poor muscular
coordination, inability to respond to verbal commands


What is needed to be done in order to combat hypoglycemia?

Need to ingest carbohydrates


What are the causes of hyperglycemia?

Infection, missed insulin doses, surgery, pregnancy,
renal failure, uncontrolled DM


When does hyperglycemia occur?

Can occur in those with/out DM
• High intensity aerobic exercise


What is Ketoacidosis?

Typically occurs with prolonged
hyperglycemia (more common in type I)


What are the presentation of Ketoacidosis?

Fruity breath (acetone), dehydration, weak and rapid pulse, Kussmaul respirations


What are the PT Considerations for Exercise in those with

• To control DM, exercise must be done with no more than 2-3 days between sessions
• Avoid exercise late at night
- Delayed hypoglycemic reactions can occur during sleep
• Blood glucose levels of 250-300 mg/dl- CAUTION
- Do not exercise if >250 with evidence of ketoacidosis
- >300 generally considered a no go point
- < 100 mg/dl consider a snack and retest or make decision based on symptoms
• Exercise is best about 1 hour after meal
• Do not inject insulin in muscles that will be involved in exercise
• Those with DM should not exercise alone


What are the benefits of exercise in diabetes?

• Improved skeletal muscle glucose transport
• Improved whole body glucose homeostasis
• Increase insulin sensitivity 12-72 hours post exercise
• Increases carbohydrate metabolism
• Reduced risk of cardiovascular mortality


What do we do when we have patients with diabetes?

• Educate:
- Online resource: diabetesselfmanagement.com
• Exercise: Glucose before and after to determine needed levels of intake
• Safety: higher risk for falls secondary to peripheral neuropathy
• Exercise!!!


What are the characteristics fo hypoglycemia?

• Onset: Rapid
• Mood: Labile, irritable, nervous, weepy
• Mental Status: Difficulty: concentrating, speaking, focusing, coordinating
• Skin: Pale, sweating
• Pulse: Tachycardic
• Respirations: Shallow
• Breath: Normal


What are the characteristics fo hyperglycemia?

• Onset: Gradual
• Mood: Lethargic
• Mental Status: Dulled sensorium, confused
• Skin: Flushed, dehydrated
• Pulse: Less rapid, weak
• Respirations: Deep, rapid (Kussmaul)
• Breath: Fruity


What is the continuum of care?

The system of services supporting the well-being of older adults at every stage of


What are the characteristics of continuum of care?

• Doesn’t necessarily start w/an entry point in the hospital
• Services range from adults w/o service needs to those requiring total care or
• Services vary from community-based, transportation needs, housing, medical
facilities, and so on
• May require a comprehensive assessment to determine specific needs
- Usually interdisciplinary in nature
- Essential that older adults receive the level and type of services required to address needs


What are the physical settings included in the continuum of care of the older adult?

• Acute Care
• Subacute Care
- Long term acute care (LTAC)
- Inpatient rehabilitation hospital (IPR)
- Skilled nursing facility (SNF)
• Post-acute Care or Home Care
- Long term care (nursing home) (LTC)
- Assisted living (ALF)/ group home
- Memory care home
- Personal home
- Family home


What is aging in place?

Allowing an older adult to live in their residence of choice for as long as they are able.


What are the components of aging in place?

• Provision for daily life needs
• Maintain quality of life
• Requires planning
• Living in a community with some level of independence instead of residential care
• Community-based collaborations between healthcare and social service


What are the characteristics of aging in place?

Can involve livable communities, facilities with range of care options, or personal home:
• Available alternative modes of transportation
• Increase opportunities for safe, regular physical activity
• Increase accessibility of home
• Develop walkable communities
• Promote pedestrian safety and safe driving for older adults
• Funding for home and community-based services
• Improve end of life and palliative care services


What does the admission to a post-acute inpatient therapy settings(Inpatient Rehab vs Skilled Nursing) depend on?

Diagnosis, ability to tolerate intensity of services,
and insurance arrangements


What type of patients are admitted into an inpatient rehab?

In general, more complicated dx and ability to tolerate at least 3 hrs/day therapy


What type of patients are admitted into Skilled Nursing?

Single joint replacements, conditions requiring much longer recovery period, or pt who cannot tolerate 3 hrs/day therapy


What are the characteristics of an inpatient rehab and skilled nursing?

• Both covered by Medicare Part A
• Both serve as bridge between living at home and being hospitalized, especially those with functional decline (sometimes serve as “testing ground” for whether home even an option ultimately)


What are the avenues of entrance into a nursing home (long-term care)?

• Patient may need 24 hour care, but has no primary
need or does not quality for skilled nursing therapy
- Nursing staff available around the clock
- Rehabilitation services available as an outpatient for residents (services billed under part B)
• Patients may initially have Part A services either by being admitted to
- As a prior non-resident under skilled nursing status and then
transition to residency
- As a resident with a qualifying hospital stay that requires follow-up skilled nursing services and/or rehabilitation with eventual transition back to LTC status


What are the characteristics of an Assisted Living Facility (ALF)?

• Patients who need housing, support services, and health care
• Services/Amenities (Facility dependent)
- 3 Meals/day in common dining area
- Housekeeping
- Transportation
- Laundry services
- Exercise/Wellness programs
- Social/Recreational activities
- Assistance with ADL’s
- Medication assistance
- Rehabilitation services
- Emergency call systems
• Not to be confused with senior independent living
apartment communities
- Often house ALF’s
- Some offer continuum of care


What are the characteristics of Non-Institutional Living
Arrangements: Memory care Assisted Living Facility (ALF)?

Some in form of apartment communities or group residential homes


What are the characteristics of Non-Institutional Living
Arrangements: home?

• Usual residence in house– age-restricted communities w/high level of amenities and activities becoming popular
• Apartment/townhome– age-restricted apartments growing in popularity
• Alone, with significant other, or family


What patients qualify for medicare?

>/ 65 years old and some disabled


What are the characteristics of part A of medicare?

Hospital, SNF, Hospice, some HHC
• Automatic- pay into the system while working


What are the characteristics of part B of medicare?

Doctor’s services, OP care, some HHC, labs, x-rays, DME
• Premium, deductible, co-insurance, co-pay


What are the characteristics of part C of medicare?

Medicare Advantage Plans
• Provide both part A and B and other services
• Provided through private insurance companies
• Locked in for certain periods of time, not able to use Original Medicare


What are the characteristics of part D of medicare?

Prescription Drug Coverage
• Premium


What are the characteristics of medicaid?

• Low income coverage for those over age 65
- < $1025/month
• Provides coverage for premiums, out of pocket
expenses, nursing home care, prescription drugs
• Medicare pays first then Medicaid pays
• Administered by federal and state governments
• May have different names
• Must check eligibility often


What are the characteristics of Veterans Administration (VA) Healthcare?

• Free for veterans with service-connected condition
• Must apply and qualify
• Must receive services at a VA facility
• Co-pays for veterans with non-service connected
conditions and based on income


What are the payment options in an acute care setting?

Inpatient Perspective Payment System
• Diagnostic Related Group (DRG) Method
• Medicare Part A
• Lump sum based on diagnosis
• Severity of illness considered
• Co-morbidities considered


What are the considerations of care at an acute care facility?

Must be cost effective, productivity matters
• PT does not impact payment


What are the payment options in a long term acute care hospital?

• Medicare Part A
• PPS based on length of stay >/ 25 days
• # of days based on dx and co-morbidities
• Full payment received at 5/6th of stay
- Money made this way
- Money lost if patient stays past assigned length of stay


What are the considerations of care at a long term acute care hospital?

Must be cost effective, productivity matters
• PT does not impact payment


What are the payment options in an inpatient rehabilitation facility (IRF)?

• Medicare Part A
• Perspective Payment System (PPS)- predetermined fixed amount
• Payment based on Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) - FIM Scores
• Distinct groups based on clinical characteristics and expected needs


What are the considerations of care at an inpatient rehabilitation facility (IRF)?

If patient unable to be seen 3 hours a day on average 5-7 days a week, payment will be impacted
• Patient will need to DC to another location
• Therapy impacts payment


What are the payment options in a skilled nursing facilities (SNF)?

• Medicare Part A
- 100 days of coverage: Days1-20 paid in full, Days 21-100 copay up to $164.50/day
• Per Diem PPS
- Covers all cost (routine, ancillary, capital)
- Resource Utilization Groups III (RUG’s)
• Based on resident assessment and classification using MDS 3.0
• Number of therapy minutes and days impacts reimbursement


What are the payment options in home health care?

• Medicare Part A
• 60 day national episode payment (certification period)
- Outcome and Assessment Information Set (OASIS)-
assessment tool
- Health condition and Care needs
- In the past, therapy has impacted payment for HHC,
however this is changing


What are the payment options in outpatient?

• Medicare Part B – Outpatient Therapy
- 80% covered
• Cap- No more!!!
- $1980 PT and ST combined
- $1980 OT
- $3700 Manual Medical Review
• PT bills for services for reimbursement. Reimbursement is based on the Medicare Fee Schedule


What are the payment options in a nursing home?

• Insurance
• Private Pay
• Medicaid
• Note: Rehab services covered under Part B Medicare if the patient has it.


What are the payment options in assisted living?

• Insurance
• Private Pay
• Note: Rehab services covered under Part B Medicare if the patient has it


What are the intrinsic factors that impact motivation and compliance in the aging adult?

- Achieve goals (function, participation, etc.)
- To have control of their


What are the extrinsic factors that impact motivation and compliance in the aging adult?

- Please someone else
- Praise, attention
- Punishment (negativity)


What are the characteristics of aging and motivation?

• Greater self-regulatory capacity
• Focus on positive
- Immediate benefits of behavior
• Stronger adherence
• Positive self-concept
• Social supports
• Information-seeking behavior


What influences motivation? in patients

• Self-efficacy expectations
- Belief in capabilities
• Outcome expectations
- Belief personal action will produce certain consequence


What enhances motivation?

• Successful performance
• Verbal encouragement – “you are capable of this”
• Vicarious experience
• Physiologic and affective states


What are the keys to motivating the older adult?

• Caring and confidence
• Patient Centered
• Ensure success
• Attend to the setting
• Challenges: Overcoming Fear
- Graded exposure
- Building on baseline tolerance
• Apathy
- Medication may be necessary first step
- Focus on activities that can be done successfully


What are the characteristics of goals to set for patients?

Goals should be:
- Related to specific behavior
- Challenging, but realistically attainable
- Achievable in the near future


What are the characteristics of social support in the patient care?

• Need to investigate and understand what their social
support is
• Teach those involved in supporting patient
• Use social supports in goal setting


What are the characteristics of patient-centered goal setting?

• Patient-centered goal setting is primary way of enhancing patient centeredness
• Improves outcomes and satisfaction
• Recommended and/or required in practice
• Highly personal
• Can be critical for motivation


What does people-first language mean?

Emphasizes the person first not the disability by starting
the phrase with the words “person who” or “person with.”


What are the key aspects of Patient-Centered Care?

• Patient’s values and preferences guide plan of care
• Focus on the PERSON, not the illness
• Quality and value defined by respect for personal choices
• Goals driven by the patient and their functional desires
• Patient empowerment to take an active role in care plan


What is patient centered care?

Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical


What are the characteristics of individualized care?

• Recognizing individual needs and differences
• Using kindness and humor
• EMPOWERING to take active part
• Gentle verbal persuasion
• Positive reinforcement
• Be genuinely interested


What are the characteristics of self-efficacy beliefs in patients?

• Verbal encouragement of capability
• Expose to role models
• Decrease unpleasant sensations associated with
• Encourage actual PRACTICE
• Educate on benefits and reinforce those benefits


What is health literacy?

Limitation in the ability to obtain,
process, & understand basic health information & services necessary to make appropriate health decisions and follow treatment instructions


How does health literacy apply to the older adult?

• Older adults at especially high risk for misunderstanding
• Health literacy declines with age
• Independently associated with greater risk of hospital admission,
lower use of preventative health services, poor physical and mental health and higher all-cause mortality


Why do aging adults have difficulty understanding verbal and written health communication?

• Sensory deficits
• High stress and/or anxiety
• Language barrier
• Communication at TOO HIGH LEVEL
• Lower health literacy


What are some communication tips to use when interacting with an aging adult?

• Slow down, allow extra time
• Use plain, nonmedical language
• Show or draw pictures
• Limit amount of information and repeat it
• Use the teach-back technique
• Create shame-free environment; encourage questions
• Sit face to face, use eye contact
• Listen without interrupting
• Frequently summarize key points
• Frame conversation first
• Encourage older adult to bring a friend or family member
• Plain language info in writing
- What to do
- How to do it
- Why
• Give patient chance to ask questions
• Don’t assume the patient can’t hear you!


What are the characteristics of the content of information being given to an older adult?

• Accurate, up-to-date, LIMITED
• Focus on behavior


What are the characteristics of the assessment of learning in an older adult?

• Don’t assume learning occurred just because you taught!
• Must evaluate the effectiveness of your teaching
• Must document whether learning has occurred and to what extent
• How do we do this:
- Return demo
- Repeat back
- Checklists and diaries


What are the barriers to learning in an older adult?

• Our desire to exert control
• Cure model versus Care model
- Cure = Paternalism – we are acting in “best interest of patient”
- Care = Values autonomy and collaboration of /with pt
• Self perception of older adult
- Don’t really see themselves as learners
- Sensitive to failure
- Resistance to change and skepticism
• And, honestly, impatience on both parts!


What are the Considerations When Teaching New
Information or Skills to Older Adults?

• Accommodate for slower speed of mental processing
• Present one new item at a time, if possible, before moving to the next item
• Encourage “errorless” learning
• Incorporate compensatory strategies as needed
• Incorporate multimodal sensory inputs
• Encourage formation of a “habit”
• Have older adult verbalize new habit to encourage formation of intentions to be
completed in the future (prospective memory)
• Have older adult paraphrase the information or demonstrate the new skill


What are the teaching strategies for older adults (65+)?

• Teaching approach recognizing special needs of older adults related to learning
• Refers to need to fine-tune adult teaching & instructional styles for older adults
- Are post-career
- No longer raising families
- Are often frail
• Recognizes older adulthood as a developmental stage with key elements concerning age-related sensory, physical, psychological, cognitive, and
psychosocial changes


What are the characteristics of the appearance/appeal of information being given to an older adult?

• Attractive
• Easy to read
• Smallest font 14 point type (might even go higher)


What are the characteristics of the writing style of information being given to an older adult?

• Talk directly to reader
• Positive, friendly tone
• Short words common in spoken language
• Clearly explain any medical terms
• Short sentences
• Active voice
• Provide examples


What are the characteristics of the structure/organization of information being given to an older adult?

• Most important info first
• Create small chunks
• Clear action messages


Who are the senior athlete?

• Former Competitive Athletes
• Lifelong athletes
• Non-athletes


What are the CDC descriptions of a senior athlete?

• Sedentary
• Recreational
• Competitive
• Elite


Masters athletes are ___ older adults

Masters athletes are *not always* older adults


What are the MSK considerations of an older athlete?

• OA- common with normal age related changes
• Bone mineral density loss
- Less loss in the older athlete with weightbearing and resistance exercise
• Changes result in an athlete that looks a little different
- Muscle fiber changes, addition of fat
• Less force production secondary to less type II fibers, somewhat activity specific
- Weight lifters experience less strength decline
- Runners experience less of a decline in endurance


What are the cardiopulmonary considerations of an older athlete?

• Physically active show less decline in VO2 max
• Smaller changes in physiologic functional capacity are seen in those who exercise with increased volume and intensity


What are the characteristics of a macrotrauma (acute, traumatic) seen in an older athlete?

• Trauma occurs less frequently
- Participation in less contact sports
- Exceptions: cycling, hiking, climbing, skiing (falls and accidents common with these sports)
• More likely to sustain a fracture than rupture ligament
- Secondary to decreases in bmd
• More likely to tear or avulse muscle than strain muscle
- Increased collagenous stiffness
• Increased recovery time needed
- Deconditioning occurs faster secondary to normal age related changes


What are the characteristics of a microtrauma (acute, traumatic) seen in an older athlete?

• Muscles strains, bursitis, tendinopathies
• May be more prone to these injuries when compared to
younger athletes
- Stiffer, less flexible
- Arthritic changes
- Less shock absorption and protection
• Joint pain and edema more common in older athletes as
compared to their younger counterparts
- Structural changes


What are the characteristics of a OA seen in an older athlete?

• Common in the aging adult
- Equally common in the older athlete
• Strong flexible muscles act as shock absorbers
- Treatment should focus progressive resistance exercise, patient education
on functional activities that minimize compression and shear
- Cycling, rowing, swimming, walking, cross training
• Increase in total joint arthroplasties being seen with expectation of
return to sport
- Procedures at younger ages
- Associated with improved function, quality of life, and longer life
- Return to sport can take up to 6 months after surgery


What are assessments of the senior athlete?

• Norm Referenced Tests
- Senior Fitness Test
- YMCA Fitness Test
- ACSM Fitness Test
• Sport or movement specific examination
- Selective Functional Movement Assessment
- Whole body functional approach


What are the rehab considerations of a senior athlete?

• Recovery is slower; rate of tissue repairs slows with age.
• Treat the injury not the age
• Be aware of co-morbidities and screen/monitor/educate
• Don’t be too quick to blame OA as the cause of an older athlete’s
• Joint mobility and soft tissue restrictions can be addressed with
manual therapy as long as not contraindicated
- Once mobility is improved corrective exercises can be initiated
• Don’t forget stability
- Taping, supports, braces, stabilization techniques, functional corrective exercises


What are the important things to focus on during the rehab of a senior athlete?

• Proximal stability will facilitate distal mobility
- Don’t forget the core
• Generalized strengthening is important
- Don’t forget appropriate exercise prescription
• Stretching
- Warm up is imperative and may include some stretching
- Cool down stretching is better
- 60 seconds is better than 30 in the older adult


What are the definitions of abuse?

• “Intentional act, or failure to act, by a caregiver or another person in a relationship involving the expectation of trust that causes or creates a risk of harm to an older adult.”
• “Physical, sexual, or psychological abuse as well as neglect, abandonment, and financial exploitation of an older person by another person or entity that occurs in any setting either in a relationship where there is an expectation of trust or when an older person is targeted based on age or disability.”


What are the different types of abuse?

• Physical- bodily harm
• Emotional (psychological)- verbal: hurtful words, yelling, threatening, ignoring; isolation
• Neglect: caregiver fails to respond to needs
• Abandonment: left alone without plan for care
• Sexual: forcing to watch or partake
• Financial: money or belongings are stolen – forging checks, retirement or SS benefits, credit cards or bank accounts without consent, etc.


What are the signs of elder abuse?

• Physical: injuries/trauma, bruises, emaciation
- Challenging
• Behavioral: anger, helplessness, suicidal actions
• Psychological: fear, anxiety, depression
• Social: limited contacts, withdrawal
• Others: has trouble sleeping, messy look or unwashed
hair or dirty clothes, develops preventable conditions


What do you do when you suspect elder abuse?

Report it!
• Most states require mandatory reporting by healthcare workers
of suspected elder abuse to Adult Protective Services (APS).
• Immediate danger: 911
• Local APS
• Eldercare Locator


What are the characteristics of "good death"?

• Pain or discomfort free
• With those they love
• Location or environment of choice


What is the role of the PT in end of life?

Assist in pain reduction, optimizing function, and addressing quality of life remaining
• Safe mobility
• Energy efficiency
• Sleep quality
• Stress
• Respiratory function
• Reduction in medications needed for pain


What is death?

Decline or failure of all major organ systems


What are the physiologic signs of death?

• Confusion, delirium, disorientation
• Increased time sleeping
• Anxiety, restlessness
• Weakness, functional loss, fatigue
• Reduction in BP, variable irregular heart rate
• Rapid breathing with periods of apnea
• Cool distal extremities
• No interest in food
• Constipation, diarrhea, incontinence, reduced urine output


What are the components of planning for end of life?

Advance Directives
• Legal document
• States patients desires in the event of imminent death
• Appoints a medical power of attorney
- Decision maker on the patients behalf if the patient becomes incapacitated
• Optional element of orders for “Do not resuscitate” (DNR)- Note not required for hospice care
- Physical therapists need to be aware of the DNR
• Also known as a Living Will


What are the characteristics of a hospice care?

• Death is a physical, psychological, and spiritual event
• Covered by Medicare part A
- Terminal condition with 6 or less months to live
- No longer seeking cure
• Interdisciplinary team:
- Nurse
- Chaplain
- Social Worker
- Physical Therapist
- Volunteers (caregiver respite)


What are the characteristics of PT in a hospice care?

• Rehabilitation Light
- PT once a week or biweekly
- Slow, easy, strengthening exercises and functional activities
- Issue an HEP…very light, but essential to slow progression
• Rehabilitation in Reverse
- Assisting a patient and caregivers as their mobility declines. May include equipment recommendations, bed mobility for positioning and comfort, PRN visits may be indicated
• Skilled Maintenance
- Maintenance of quality of life unable to be performed safely by other caregivers Example: Ambulation and transfers that a caregiver can not manage secondary to severe weakness and balance limitation in conjunction with caregiver limitations