Physiotherapy and Older People

Original Editor - Bhanu Ramaswamy as part of the AGILE Project.

Top Contributors - Bhanu Ramaswamy, Lauren Lopez and Evan Thomas  

Introduction

Providing physiotherapy to older people is a challenge, perhaps best described by the following: "Working with older people can present the physiotherapist with a set of challenges unparalleled in other areas of practice. The caseload is very mixed; patients with musculoskeletal, neurological, and cardiovascular problems may all be found in a single caseload and often in the same patient. Interlinking between medical, psychological, rehabilitative, economic and social problems that all need attention is the norm, rather than the exception. Add to these the differences in presentation of disease, the unique pattern of ageing in each individual, and the varying responses that older people may demonstrate, and the complexity of the challenge is obvious."[1]

A physiotherapist working with older people can be considered a ‘Jack of all trades’. Far from being a term of belittlement, the phrase is a term of respect for all of the skills a physiotherapist needs to apply to their patients in light of the biopsychosocial model to ensure a holistic, patient-centred approach. All over the UK advanced practice posts like Clinical Specialist and Consultant posts [2]are emerging for physiotherapists in this clinical field. Knowledge, therefore, in respiratory care, orthopaedics, neurology, medicine together with awareness of psycho-social aspects are essential.

The Fundamental Principles of Physiotherapy for Older People
Disability is generally regarded as being due to a pathological process, or injury, not prima facie ‘old age’
The effects of biological ageing reduce the efficiency of the body’s systems, but throughout life, optimum function is maintained in each individual by continuing to use these systems to their maximum capacity
Physiotherapists have a key role in enabling older people to use a number of the body’s systems fully to enhance mobility and independence
When neither improvement nor even maintenance of functional mobility is a reasonable goal, physiotherapists can contribute to helping older people to remain comfortable and pain free
Prevention of the development of problems in later life through health promotion
This Physiopedia article describes common settings of physiotherapy for older adults, assessment and treatment of older adults and subsequent discharge planning and measuring of outcomes.

Physiotherapy Settings

In the UK, many initiatives have been set up to provide better systems of health and social services for older people. Mmost of these involve physiotherapy with the more common areas of work for physiotherapists with older people listed below: 

  • Health promotion and disability prevention programmes
  • Hospital: either acutely ill on the general wards or on a specialised older person's unit, or specialised rehabilitation ward.
  • Outpatient ambulatory clinics or day assessment and rehabilitation units: where individuals usually require input from more than one profession and spend a day in a centre where rehabilitation is provided
  • Community:
    • Community physiotherapy in a person’s own home or at a doctor's clinic. This could be provided by either a private physiotherapy company or by government-funded healthcare services.
    • Regional and local outreach services, often for specific conditions. For example, a monitoring service for neurological or respiratory conditions with rapid response capabilities should the therapist detect a decline in the person’s condition.
    • Intermediate care where care is jointly funded by health and social services. Such care is set up through a multidisciplinary team and runs for an average of two to six weeks to prevent (re)admission of older people into hospital. This can take place either in the person’s own home or in beds set aside for rehabilitation at a residential care facility.
    • Community rehabilitation teams where with a longer time frame of up to 12 weeks. Historically such teams were funded to promote the early hospital discharge of people post-stroke, but who now take those with orthopaedic and general rehabilitation needs
  • Physiotherapists in mental health teams, who can be called upon for specialist advice.
  • In research institutes where research into age-related conditions and issues is conducted.

Assessment and Treatment

Assessment

The assessments and principles of therapy with older people should follow suggested national protocols and guidance. The assessment of older people differs from that of younger people is in taking into account the differences in the body that occur with age. AGILE, the clinical interest group of the Chartered Society of Physiotherapy comprised of physiotherapists who work with older people, have reviewed the CSP’s Core Standards (2005) [3][3][3][3][3][3][3][3][3][3], identifying which core standards and service standards have key additions of relevance to therapists working with older people [4]. Members of AGILE (Thames region) also published a scholarly paper providing objectives for physiotherapy students working with older people[5]

There are different models of rehabilitation such as the Occupational Adaptation framework[6] [7] or The Illness Constellation model[8]. Perhaps the most universal and inclusive model is the World Health Organization's (WHO) International Classification of Functioning, Disability and Health[9]. More commonly known as the ICF, the framework offers a model whereby healthcare professionals can review multiple impairments and relate them to the relevant domains of an individual's life in order to guide assessment, goal setting and treatment planning.

WHO ICF model.gif
Permission granted by WHO. Source: Short version booklet of the International Classification of Functioning, Independence and Health (WHO 2001) page 26. http://www.who.int/classifications/icf/en/; ISBN / WHO Reference Number 92 4 154544 5

The ICF is valuable to clinicians because it can guide a thorough assessment of the older person. The ICF helps clinicians assess impairments often impact on activities of daily living and how the person can participate in societal roles in later life[10]. The ICF also considers the person in context. For example: environmental factors (physical location and attitudes of society) and personal factors (medication factors, social supports). These can act either as barriers or facilitators in the analysis and the subsequent planning of appropriate nursing interventions and support. As a point of interest, many hospitals in the UK now use the related International Classification of Diseases & Related Health Problems (ICD-10) to code patients’ problems on admission, which compliments the ICF. 

Obtaining a thorough medical / surgical history and supporting drug history is of importance, especially in a community setting where medical information may not be as ready available as in hospital. In particular, medications can have a significant impact on the older adult and can contribute to poor mobility and falls. Or, the individual might not report a significant medical condition (e.g. a cardiovascular condition) to you that you would otherwise be alerted to depending on the type of medication they are on (see Medication).


Taking a thorough social history is vital in the case of the older adult as they often rely on supports, either formal or informal (family and friends). For example, how can a physiotherapist (and other allied health disciplines ) guide rehabilitation in the case of the older person who is to be discharged home alone, but is unable to stand safely to cook a meal, or to walk to the shops to buy food.

The ICF can guide clinicians through assessment and act as a checklist to make sure all relevant history and assessment is included.

Treatment

The nature of physiotherapy means that assessment and treatment tend to focus on the physical nature of a person's condition. For older adults, the physical tasks of daily life are an important starting point for treatments. Intervention should include (re)assessment of a person's abilities and difficulties in performing functional tasks such as transfers on/off a chair or the bed and general mobility. Having assessed the older adult performing a task like chair transfers, the physiotherapist then identifies the underlying impairments impacting on the task. For example, strength and balance deficits, or psychological barriers such as a fear of falling. There are few techniques physiotherapists use that differ from those taught for all age groups, whether manual techniques are used in a clinic setting (although the mechanical changes to a person's skeleton may require us to modify a position of treatment), or functional intervention in the person's home.

Appropriate care must be taken with some treatment techniques, and more time allowed for learning and practice of skills and exercises. For example, with an acute sprain, the history taking would be no different, but the treatment would take into account much more of the past medical history and pre-injury status. Treatment might still initially include rest, ice, compression and elevation, but the therapist would also have to assess the condition of the skin to allow for the safe use of ice, or the effects of compression. For example, if a treatment of ice, elevation and rest was for an already oedematous ankle, you must think about assessing the length of the hamstring muscles to make sure the person has sufficient length in them. This will confirm whether the patient can sit comfortably for the duration of the treatment with their hips flexed to 90 degrees or more.

Exercise older person.jpg


Goals

Goals are important for keeping therapy person-centred and co-ordinating treatments. The therapist should be aware of the difference between therapy goals and person-centred goals, the latter often being achieved through the intervention of a team. For example, the goals of the individual may be to walk independently at home with a Zimmer frame. The physiotherapy goal might be to increase quads strength for safe transfers to standing, improve balance and endurance. The occupational therapist (OT) may provide equipment to enable a safe transfer. The doctor prescribes analgesics to inhibit pain and allow participation in therapy while nurses or care staff may assist or supervise the person to go for regular walks to increase strength and confidence.

Goals should be directed more towards the management and improvement of a condition rather than passive ‘care’ towards the older person. At times, it is appropriate to work together with another team member whether in a hospital or community setting, not only to learn from one another, but also to ensure you are working toward the same goals for the benefit of the individual[11].


Goals may be to improve the older person's function or to maintain current function and prevent decline. To plan appropriate goals, the therapist working with older adults must learn how to identify rehabilitation potential by deciding which of the presenting features are related to deskilling, deconditioning, pathology or ageing and, therefore, which are reversible and manageable. To this end, the therapist must have knowledge of what is an acceptable ‘norm’ for this age group, e.g. age related changes in gait and posture. At times, there may be conflict between the person's goals and the therapist's idea of what might be safe. The physiotherapist's task is then to highlight the risks and try and minimise them where possible rather than stopping a person functioning altogether.

Discharge Planning and Measuring Outcomes

Discharge Planning

Discharge planning requires considerable consideration[12]. A basic idea of what the patient is expecting at the end of the intervention will help you focus and modify your input. For example, do they wish to return to their own home, be re-housed, or go into care? Each decision will require communication with different members of the interdisciplinary or multidisciplinary team to ensure that the necessary assessments are carried out, e.g. stair assessment, ensuring the patient is capable of catching a bus to town in order to collect their pension.

In many countries, step-up/step-down facilities have been established specifically to help older people with frailty that are medically stable, but not fit enough to go home to receive additional rehabilitation. These facilities are classically in a community hospital or a care home, and act as a half-way house allowing the build up of confidence to carry out the necessary skills required to return home safely, plus usually combine the skills of health and social care services.

Outcome Measures

An outcome measure is a measure of change (usually from before to after an intervention). Universally, the evaluation of healthcare practice has become a priority as health organisations have a statutory duty to provide clinical quality and measurement of the outcome to prove effectiveness. Outcomes Measurement is a standard required for competent physiotherapy practice[13] and the CSP have dedicated a section of their website to this area. When measuring ‘outcome’ it is important to be clear from whose perspective we are measuring it. What is measured depends on your definition of ‘the outcome of interest’, on who wants the data and for what purpose. Physiotherapists may be interested in how a person’s function has changed; managers and purchasers in the cost of delivering this change; and the individual in how well they can function in everyday life. 

Care should be taken to avoid using a tool devised to measure outcome as an assessment form, and vice versa. This detracts from our assessment skills of specific impairments underlying the patient’s needs, but also negates the choice of the correct tool to measure the outcome of our intervention. Measures include those on pathology or function[14] as seen in the examples below.

  • Global measures, e.g. Barthel scale, the Functional Independence Measure (FIM) or the Therapy Outcome Measures (TOMs) done by the multi/ interdisciplinary team
  • Age specific measures, e.g. Elderly Mobility Scale
  • Disease specific scales, e.g. scales for Parkinson’s disease, scales for arthritis, stroke etc.
  • Function specific tools, e.g. Timed up and go test, measures of balance and gait
  • Patient specific measures, e.g. Treatment Evaluation by the Le Roux method (TELER), Goal Attainment Scoring (GAS)
  • Emotional status of the patient or carer, e.g. Carer Strain Index,
  • Quality of life scales - often disease specific like the SF 36 or PDQ-39.
  • Health status e.g. EQ 5D

The tool must be valid, sensitive and specific to the person's need. Use outcome measures to record intervention effect and / or to record the baseline ability of the person. An outcome measure to one profession may be an assessment tool for another; e.g. the Mini Mental State Exam used by doctors as a medication outcome measure, but as an assessment of mental state for a physiotherapist dictating whether they can comply with treatment.

Previous Page - Medication and Older People   ||   Next Page - Physical Activity and Older Adults

References

  1. Pickles B, Compton A, Cott C, Simpson J, Vandervoort A, editors. Physiotherapy with Older People. London: WB Saunders London,1995 (ISBN 0 7020 1931 3).
  2. Chartered Society of Physiotherapy. Physiotherapy Consultant (NHS): Role, Attributes and Guidance for Establishing Posts. PA 56. London: CSP, 2002.
  3. Chartered Society of Physiotherapy. Core standards of physiotherapy practice. London: CSP, 2005.
  4. AGILE. Core standards of physiotherapy practice and Service standards of physiotherapy practice. AGILE supplementary paper. London: AGILE, 2008.
  5. AGILE Thames. Elder Rehabilitation: Core learning objectives for physiotherapy students during clinical placements. Physiotherapy. 2002; 88 (3);158-166.
  6. Schkade JK, Schultz S. Occupational adaptation: towards a holistic approach for contemporary practice. Part 1. Am J Occup Ther. 1992; 46: 829- 837.
  7. Schkade JK, Schultz S. Occupational adaptation: towards a holistic approach for contemporary practice. Part 2. Am J Occup Ther. 1992; 46; 917-925.
  8. Morse J, Johnson J. Toward a theory of illness: The illness constellation model. In Morse, JM and Johnson, JL eds. The illness experience: Dimensions of suffering. California: Sage, 1991. p315-342.
  9. World Health Organisation. International Classification of Functioning, Disability and Health. Geneva: World Health Organisation, 2001.
  10. Izaks G, Westendorp R. Ill or just old? Towards a conceptual framework of the relation between ageing and disease. BMC Geriatr. 2003; 3(7). Accessed 30 August 2018.
  11. Squires A, Hastings M, editors. Rehabilitation of Older People: A handbook for the interdisciplinary team. 3rd ed. Cheltenham: Nelson Thornes 2000.
  12. Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home (Cochrane review). Cochrane Database Syst Rev 2010; (1): CD000313.
  13. Chartered Society of Physiotherapy. Core standards of physiotherapy practice. London: CSP, 2005.
  14. Bowling A. Measuring health: A review of quality of life Measurement Scales. 3rd ed. Maidenhead: Open University Press, 2004.