Geriatric Rehabilitation Goals: Knee OA, Diabetes & Dementia

Introduction

Goal-setting in rehabilitation is defined as the establishment of intended future states for a patient that involve a change from their current situation (Smit, Bouwstra, Hertogh, Wattel, & van der Wouden, 2019). Our patient, Mrs. Vaz, has a history of osteoarthritis and is finding it difficult to kneel down. We will offer her therapeutic knee management to ensure she regains her knee function. She also suffers from type II diabetes mellitus; therefore, our goal will be lifestyle modification by encouraging physical activity and limiting sugary and fatty foods. The final rehabilitation goal will be cognitive rehabilitation to ensure she can maintain her activities of daily living (ADLs).

Management of Knee Osteoarthritis

The management of osteoarthritis requires conservative measures to be used initially, especially for the geriatric population, due to their increased risk of medication toxicity, comorbidities, and polypharmacy. According to the American College of Rheumatology (ACR), management of patients with osteoarthritis should begin with conservative measures such as self-management programs, weight loss, social support, and appropriate footwear (Mushtaq, Choudhary, & Scanzello, 2011). Using these methods, the patient is most likely to adopt the recommended practices and achieve a good quality of life. The main goal is to restore the patient to her normal routine of tending to her garden without difficulty kneeling or going down the stairs. This would also help ensure the patient maintains her physical activity while gardening. However, if the patient does not respond to non-pharmacological interventions, pharmacological measures can be introduced with a focus on functional improvement.

Specific footwear has been tested for use with patients who suffer from knee osteoarthritis. Lateral-wedged (LW) insoles are recommended for osteoarthritis (Mushtaq et al., 2011). These insoles decrease the degree of varus misalignment at the knee by causing ankle pronation, which reduces the medial joint load associated with osteoarthritis progression. According to Mushtaq et al. (2011), while LW orthotics do decrease a patient's consumption of oral analgesics in knee osteoarthritis, no functional or pain improvement has been clearly demonstrated, and their long-term effects remain unknown.

Weight loss appears to be a more favorable option, as even moderate weight loss may relieve joint pain, reduce the progression of osteoarthritis, and produce improvement in physical function. On average, a 10-pound weight loss reduces the risk of knee osteoarthritis by 50%, which should be encouraging for patients. To help the patient achieve weight loss, a dietary intervention to reduce her caloric intake will be recommended.

Prolonged inactivity can lead to deconditioned muscles, which contributes to the worsening of knee osteoarthritis symptoms (Kardez et al., 2019). Since the patient has been having difficulty kneeling and going up and down stairs, she may have been avoiding these movements, which could result in further loss of muscle activity. Therefore, improving her muscle function through targeted physical therapy and exercise is essential. Any exercises that strengthen her quadriceps are particularly important. Individualized strengthening programs developed by therapists will improve strength and function, leading to pain relief in the patient's knee (Kardez et al., 2019). Studies have shown it is possible to increase quadriceps strength using weights in elderly patients (Chen, 2007). Weight training equipment such as the leg extension machine can be beneficial, as the resistance can be controlled and progressed as the patient's strength improves. Patient education can also assist in relieving pain; providing informative discussions about the disease, therapeutic options, and the benefits and risks of various interventions will empower the patient and increase her understanding of her condition.

Pharmacological therapy may be introduced when needed, with the least toxic drug chosen for elderly patients to reduce the risk of adverse effects. Options include topical analgesics, acetaminophen, non-narcotic analgesics, intra-articular corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and disease-modifying osteoarthritis drugs (DMOADs). Pharmacological therapy should be employed only after non-pharmacological therapy has failed or has not produced sufficient pain relief (Ferreira, Duarte, & Gonçalves, 2018). In some cases, medications may be used in the initial stages of physical therapy when pain is limiting the patient's ability to exercise. Caution should be taken to ensure the patient does not become overly dependent on medications.

Management of Type II Diabetes Mellitus

Elderly individuals are prone to developing type II diabetes mellitus. This is due to several mechanisms, including genetic background, modification of environmental factors responsible for central obesity, and long life expectancy leading to decreased insulin secretion (Schlender et al., 2017). Central obesity is responsible for insulin resistance, which is the leading cause of type II diabetes mellitus in elderly individuals. Glucose intolerance increases with age, and postprandial hyperglycemia is a characteristic feature of diabetes in the elderly. As age advances, decreased beta-cell compensation capacity results in insulin resistance that manifests as postprandial hyperglycemia. While reduced physical activity could increase the likelihood of type II diabetes mellitus, this appears less relevant for our patient, who seems active through gardening and caring for her grandchildren.

There are limited clinical trials specific to persons above 65 years of age, making it difficult to apply standard recommendations for treating and managing type II diabetes mellitus in the elderly (Strain et al., 2018). While controlling hyperglycemia in older patients may be beneficial, the lack of strong supporting evidence means this approach is not the primary focus for our patient at this stage. Lifestyle modification therefore becomes the primary treatment recommendation. The patient will be counseled on nutrition, optimizing metabolic control, physical activity, and preventing complications. Weight reduction will also be recommended if needed and will be achieved through diet, exercise, and behavioral modification (Yakaryilmaz & Öztürk, 2017). It should be noted that medication is not ruled out over the course of treatment. As shown by Gómez-Huelgas et al. (2018), a majority of patients with type II diabetes mellitus will require medication at some point, especially older patients.

The patient should be encouraged to be as active as her functional status allows. Since she is functionally independent, she should be encouraged to perform at least 30 minutes of moderate-intensity aerobic activity, such as brisk walking, five days a week. Given that she will also be undergoing muscle-strengthening exercises to recover knee function, she is likely to develop the muscle strength needed for recommended aerobic activities. Since the patient loves gardening — which involves bending, kneeling, and walking — she should be actively encouraged to continue this activity as a meaningful form of exercise.

Metformin can be used as the initial drug therapy for the patient (Chentli, Azzoug, & Mahgoun, 2015). Because the patient has no kidney impairment, it is safe to use this drug. Metformin has been proven effective in lowering blood glucose, carries a relatively lower risk of hypoglycemia, and is low in cost (Chentli et al., 2015), making it favorable for older patients. However, its use should be monitored carefully given the risk of comorbid conditions such as heart failure and chronic renal insufficiency, which increase the risk of lactic acidosis. Metformin should not be given to women with serum creatinine ≥1.4 mg/dL. The drug also has frequent gastrointestinal side effects — nausea, diarrhea, vomiting, and flatulence — that may cause poor appetite, weight loss, and reduced caloric intake.

Insulin may also be used; however, due to concerns about hypoglycemia, insulin should only be used for a short period to counter glucose toxicity. The dose can be lowered or replaced once insulin sensitivity has been restored.

Conclusion

The main goal of rehabilitation is to ensure that the patient can be discharged and maintain her level of activity. For Mrs. Vaz, this means eliminating the difficulty she experiences when kneeling and walking up and down stairs. Through exercise and muscle-strength building, she can manage her knee osteoarthritis and continue active participation in gardening. This physical activity will also assist in controlling her type II diabetes mellitus, while dietary changes and lifestyle modifications provide additional metabolic benefits. Activity and dieting are the recommended foundational methods for managing diabetes in elderly patients. Finally, through activity planning and open communication, the patient can maintain her ADLs even in the presence of mild dementia, preserving her independence and quality of life.

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