Physiotherapy and Older People

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

Top Contributors -

Bhanu Ramaswamy and Evan Thomas  

Contents

Introduction

‘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.’ Pickles 1995 [1]

Physiotherapy settings and onward referral

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

  • In health promotion and disability prevention programmes
  • In hospital – either acutely ill on the general wards or on a specialised older person's unit; or a specialised rehabilitation ward.
  • Ambulatory clinics or Day Assessment and Rehabilitation Units – where individuals classically require input from more than one profession and spend a day in a centre where rehabilitation is provided
  • Community – a term that encompasses settings such as:
    • Community physiotherapy in a person’s own home or at the doctor's clinic.
    • Regional and local outreach services, often for specific conditions, e.g. neurological or respiratory conditions to provide a monitoring service with rapid response capabilities should the therapist detect a decline in the person’s condition.
    • Intermediate Care, with the provision of jointly funded health and social services set up through a multi-disciplinary team for an average of 2–6 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 Care Home.
    • Community Rehabilitation Teams, with a longer remit of up to 12 weeks, historically funded to promote the early 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 looking into age-related conditions and issues

A physiotherapist working with older people can be considered a ‘Jack of all trades’. Far from being a term of belittlement, the phrase should be regarded with respected for the skills necessary to apply all aspects of the bio-psycho-social 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 on which physiotherapy with older people is based are:

  • 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.

Assessment and treatment

Assessment

The assessments and principles of therapy with older people should follow suggested national protocols and guidance. Where 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], 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 (Schkade and Schultz 1992 [6] & [7]) or The Illness Constellation model (Morse and Johnson 1991[8]). The one described here is the framework put forward by the World Health Organization (WHO), known as the International Classification of Functioning, Disability and Health (ICF) (WHO 2001[9]). The ICF offers a model enabling healthcare professionals to review multiple impairments and relate them to the ICF domains to guide assessment, goal setting and treatment planning.
Impairments often impact on activities of daily living and how the person can participate in societal roles in later life (Izaks and Westendorp 2003[10]). The ICF framework also considers issues in context, for example environmental (physical and attitudinal) and personal (medication, support) factors. 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. 

Image: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

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. You might still treat initially with 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 inform you whether the patient can sit comfortably for the duration of the treatment with their hips flexed to 90 degrees or more.

The concomitant medical / surgical history and supporting drug history is of importance as an older person can often be put on medication and left with no review until they reach toxic levels. The individual might not report a medical condition to you that you would otherwise be alerted to depending on the type of medication they are on (See section on Medication).
The social history also becomes vital in case the individual 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 etc.

Treatment

Assessment and treatment by nature of our profession tends to focus on the physical nature of a condition. 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. The physiotherapist identifies the underlying impairments such as strength and balance, or the psychological barriers such as a fear of falling. There are few techniques we 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.

Goals

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 prescribe analgesics to inhibit pain and allow participation, and the nurses or social care staff may ensure the person can walk an optimal amount to start to increase strength and confidence. Goals should be directed more towards the management and improvement of a condition rather than ‘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 (Squires and Hastings 2000[11]).
The therapist in this field 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 your idea of what might be safe; our task then is to highlight the risks and try and minimise them where possible rather than stopping a person functioning altogether.

Discharge planning and outcome measurement

Discharge Planning

Discharge planning requires 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; e.g. 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 (CSP 2005[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 (Bowling[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, SF 36
  • Quality of life scales - often disease specific like the 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.

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References

  1. Physiotherapy with Older People edited by Barrie Pickles, Ann Compton, Cheryl Cott, Janet Simpson and Anthony Vandervoort WB Saunders, London, 1995 (ISBN 0 7020 1931 3)
  2. Chartered Society of Physiotherapy (2002). Physiotherapy Consultant (NHS): Role, Attributes and Guidance for Establishing Posts. PA 56. London, CSP
  3. Chartered Society of Physiotherapy (2005). Core standards of physiotherapy practice. London, CSP
  4. AGILE (2008). Core standards of physiotherapy practice and Service standards of physiotherapy practice. AGILE supplementary paper. London, AGILE
  5. AGILE Thames (2002). Elder Rehabilitation: Core learning objectives for physiotherapy students during clinical placements. Physiotherapy; 88 (3); 158 - 166
  6. Schkade and Schultz (1992). Occupational adaptation: Towards a holistic approach for contemporary practice. Part 1. American Journal of OT; 46; 829- 837.
  7. Schkade and Schultz (1992) Occupational adaptation: Towards a holistic approach for contemporary practice. Part 2. American Journal of OT; 46; 917 - 925.
  8. Morse J, Johnson J (1991). Toward a theory of illness: The illness constellation model. In J M Morse and J L Johnson (Eds). The illness experience: Dimensions of suffering (p 315 - 342), California, Sage
  9. World Health Organisation (WHO) (2001) International Classification of Functioning, Disability and Health. Geneva: World Health Organisation
  10. Izaks G and Westendorp R (2003). Ill or just old? Towards a conceptual framework of the relation between ageing and disease. BMC Geriatrics, 3(7). www.biomedcentral.com/1471-2318/3/7
  11. Squires A and Hastings M (Eds) (2000). Rehabilitation of Older People: A handbook for the interdisciplinary team. 3rd edition. Nelson Thornes, Cheltenham
  12. Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub3.
  13. Chartered Society of Physiotherapy (2005). Core standards of physiotherapy practice. London, CSP
  14. Bowling A (2004). Measuring health: A review of quality of life Measurement Scales 3rd Edition. Maidenhead, Open University Press