15.3 Geriatric Cardiorespiratory and Neurological Considerations

Quick Answer: Fight hospital deconditioning with early graded mobility when stable. After pneumonia, monitor RR/SpO2/fatigue and progress carefully. In HF, titrate to symptoms and fluid status—stop for decompensation. Treat new fluctuating confusion as delirium until proven otherwise, not ‘just dementia’. Discharge only when home tasks, carers, aids, and escalation plans match real life.

Older adults rarely present with a single-system problem. Cardiorespiratory disease, neurological change, and deconditioning interact with falls risk and musculoskeletal limitation. On the APC Written Assessment, gerontology-embedded cardiorespiratory and neurological reasoning appears in acute, subacute, community, and residential aged-care vignettes. This section covers deconditioning, pneumonia risk, heart failure considerations in older adults, delirium versus dementia awareness for physiotherapy sessions, and safe discharge planning with carer education.

Deconditioning: The Silent Multiplier

Hospital-associated deconditioning develops quickly. Bed rest reduces muscle protein synthesis, blood volume, orthostatic tolerance, and aerobic capacity. An older adult may lose meaningful lower-limb strength within days of immobility—enough to turn independent toileting into a high falls-risk transfer. Physiotherapy’s core contribution in acute and subacute settings is early, graded, medically appropriate mobilisation and progressive activity, not heroic gym workouts on day one of critical illness.

Assessment cues for deconditioning: prolonged bed time, new dependence for sit-to-stand, orthostatic dizziness, tachycardia with mild effort, reduced gait distance, and fear of moving. Differentiate pure deconditioning from unresolved medical instability (sepsis, ACS, PE, severe anaemia, uncontrolled heart failure). If vital signs and medical status prohibit mobilisation, treat that as a temporary constraint, reassess frequently, and use in-bed/in-chair strategies (positioning, circulatory exercises, sitting balance) within orders.

Document response: SpO2, heart rate, blood pressure, symptoms (dyspnoea, dizziness, pain), and recovery time. Teach energy conservation for those with limited reserve, without defaulting to permanent inactivity.

Pneumonia Risk and Respiratory Considerations

Older adults have higher risk of community-acquired and hospital-acquired pneumonia, and recovery is often slower. Reduced cough effectiveness, aspiration risk (stroke, Parkinson’s, dementia, polypharmacy sedation), chest wall stiffness, and immobility all contribute. Physiotherapy roles vary by setting and medical plan: early mobilisation, positioning to optimise ventilation/perfusion as appropriate, airway clearance techniques when indicated and tolerated, and education on activity pacing during recovery.

Session safety cues: rising respiratory rate, new or worsening dyspnoea, SpO2 drop below team parameters, cyanosis, new confusion (possible infection or hypoxia), haemoptysis, chest pain of cardiac/PE concern, and exhaustion that does not recover. Do not ‘complete the walking goal’ if the person is deteriorating. Escalate. After pneumonia, rebuild endurance gradually; post-infectious fatigue is real, especially in frail people.

Aspiration risk contexts require careful seating posture for oral intake (often with speech pathology collaboration), upright positioning after meals when advised, and awareness that aggressive dual-task walking immediately after meals may not be wise in high-risk dysphagia cases. Stay within scope: you do not independently prescribe thickened fluids, but you do coordinate and observe.

Heart Failure in Older Adults

Heart failure (HF) is common with age and frequently coexists with renal disease, anaemia, COPD, and frailty. Typical physiotherapy-relevant features: exertional dyspnoea, fatigue, peripheral oedema, orthopnoea, reduced exercise tolerance, and sometimes cognitive fog with low output or polypharmacy. Acute decompensation may show rapid weight gain, worsening oedema, marked dyspnoea at rest, hypoxia, and inability to lie flat. HFpEF is particularly common in older adults with hypertension and multimorbidity—breathlessness still demands careful titration even when ejection fraction language in the notes is ‘preserved’.

Activity principles:

• Confirm medical stability and team parameters before loading
• Use symptoms, RPE, HR/BP/SpO2 response, and oedema/fluid status to titrate
• Prefer frequent short bouts over single exhausting sessions when severely limited
• Include lower-limb strength when safe—HF rehabilitation benefits function, but entry-level care focuses on safe mobilisation and referral into structured programs when available
• Stop and escalate for chest pain suggestive of ischaemia, severe dyspnoea at rest, syncope, SpO2 collapse, new productive pink frothy sputum context, or marked hypotension/hypertension outside parameters

Orthostatic hypotension from diuretics and vasodilators complicates first stands after bed rest. Rise in stages, ankle pumps, and adequate supervision reduce syncope risk. Coordinate timing of sessions with nursing around diuretic schedules when relevant (toileting urgency vs exercise window).

Cor pulmonale and advanced lung disease overlap in older adults: watch for signs of right-heart strain context (oedema, elevated JVP if noted in notes) and severe exertional desaturation. Your decision framework remains: stable enough to mobilise? response acceptable? when to stop?

Delirium Versus Dementia: Why Physiotherapy Sessions Change

Dementia is a chronic progressive decline in cognition interfering with function. Subtypes (Alzheimer’s, vascular, Lewy body, frontotemporal, mixed) influence behaviour, motor features, and fluctuating attention patterns, but the physio constants are: person-centred communication, simple instructions, consistent routines, falls risk, and carer partnership.

Delirium is an acute, fluctuating disturbance of attention and awareness, often triggered by infection, medications, hypoxia, metabolic disturbance, pain, constipation, urinary retention, surgery, or environmental change. Delirium is a medical emergency flag until the cause is addressed. Superimposed delirium on dementia is common in hospitalised older adults.

How to tell them apart in practice (working guide):

Physiotherapy implications for delirium:

• Prioritise safety, orientation cues, familiar carers, adequate lighting, and hearing/vision aids
• Avoid overstimulation and complex dual-task circuits
• Mobilise when medically appropriate—immobility worsens outcomes—but with higher supervision
• Escalate new acute confusion rather than labelling it as ‘just dementia’ and continuing aggressive unfamiliar gym tasks
• Reassess capacity for informed choices session-to-session; involve substitute decision-makers as required by local law and policy

Physiotherapy implications for dementia (stable baseline):

• Use short, concrete instructions; demonstrate; reduce choices overload
• Leverage procedural memory and familiar functional tasks (walking to bathroom, sit-to-stand for meals)
• Maintain mobility and strength to reduce falls and contractures
• Plan for wandering risk, sundowning, and behavioural change without punitive approaches
• Educate carers on safe assistance, not dragging or under-arm lifts that injure shoulders

Never assume that cognitive impairment means ‘no rehab potential’. Many people with dementia improve transfers and walking safety with skilled, consistent practice—especially after an acute reversible insult resolves.

Neurological geriatric themes also include Parkinsonian gait and freezing (cueing, dual-task caution), post-stroke residual deficits with later-life deconditioning, peripheral neuropathy with sensory ataxia, and vestibular hypofunction after infection or medication effects. Map these back to falls risk + function + setting, and escalate acute stroke/TIA signs immediately.

Safe Discharge Planning and Carer Education

Discharge failures often come from mismatch between ward performance and real-world demand. An older adult who walks 30 metres with a frame on a flat corridor may still fail at home with steps, a narrow bathroom, night toileting, and no carer at 2 a.m.

Discharge planning checklist for physio input:

1. Transfers and toileting at the level required at destination
2. Gait aid fitted, practised, and available at home
3. Stairs/steps practised if essential for home entry
4. Carer education: hand placement, pace, when to stop, how to help from the floor only if trained and appropriate, and when to call emergency services
5. Home hazards flagged; OT referral for modifications when needed
6. Follow-up: community physio, transition care, falls group, or outpatient rehab
7. Medical red flags education: chest pain, sudden dyspnoea, new confusion, inability to weight-bear after a fall, neurological change
8. Medication and orthostatic advice in plain language (rise slowly, sit if dizzy)
9. Equipment delivery timing—do not discharge ‘pending rail’ with no interim plan if risk is high
10. Residential care transition: communicate mobility status, supervision level, and behavioural strategies to facility staff

Carer education should be practical and respectful. Demonstrate, then watch the carer practise. Written simple cues help when cognition or stress is high. Cultural safety matters: family structures, language, and decision-making norms vary across Australian communities—use interpreters when needed and avoid assuming one ‘standard’ family model. Aboriginal and Torres Strait Islander older people and culturally diverse families may prioritise different care locations and decision-makers; collaborate rather than impose a single discharge template.

Integrating Systems in One Session

Example: an 88-year-old admitted with pneumonia on a background of HFpEF and mild dementia develops fluctuating confusion on day two (delirium). Physiotherapy priorities: medical liaison, SpO2 and RR monitoring, short assisted sits and stands when stable, pressure-care mobility, reorientation, and no ambitious outdoor dual-task walk. As delirium clears and oxygen requirements fall, progress gait and strength, then plan discharge with carer training and community follow-up. That arc—safety, graded recovery, system integration, exit plan—is the APC-ready model.

APC Exam Lens

Wrong answers often include exercising through acute respiratory deterioration, ignoring new fluctuating confusion, treating all cognitive change as irreversible dementia, discharging without carer/home readiness, or enforcing bed rest long after medical stability returns. Right answers show monitoring, graded mobilisation, delirium urgency, HF symptom titration, and functional discharge planning matched to Australian care settings.

Closing Exam Anchor

Deconditioning is prevented by early graded mobility; pneumonia and HF demand monitoring and stop rules; delirium is acute and urgent; dementia needs person-centred strategies without therapeutic nihilism; discharge equals home-task competence plus carer and equipment plans.