Guccione’s Geriatric Physical Therapy

Dale Avers, Rita Wong

• Publisher: Mosby
• Year: 2020
• ISBN:
  9780323610155
• Edition: 4
• Topic: Medizin
• Subtopic: Geriatrie

Offering a comprehensive look at physical therapy science and practice, Guccione's Geriatric Physical Therapy, 4th Edition is a perfect resource for both students and practitioners alike. Year after year, this text is recommended as the primary preparatory resource for the Geriatric Physical Therapy Specialization exam. And this new fourth edition only gets better. Content is thoroughly revised to keep you up to date on the latest geriatric physical therapy protocols and conditions. Five new chapters are added to this edition to help you learn how to better manage common orthopedic, cardiopulmonary, and neurologic conditions; become familiar with functional outcomes and assessments; and better understand the psychosocial aspects of aging. In all, you can rely on Guccione's Geriatric Physical Therapy to help you effectively care for today's aging patient population.

• Comprehensive coverage of geriatric physical therapy prepares students and clinicians to provide thoughtful, evidence-based care for aging patients.
• Combination of foundational knowledge and clinically relevant information provides a meaningful background in how to effectively manage geriatric disorders
• Updated information reflects the most recent and relevant information on the Geriatric Clinical Specialty Exam.
• Standard APTA terminology prepares students for terms they will hear in practice.
• Expert authorship ensures all information is authoritative, current, and clinically accurate.

• NEW! Thoroughly revised and updated content across all chapters keeps students up to date with the latest geriatric physical therapy protocols and conditions.
• NEW! References located at the end of each chapter point students toward credible external sources for further information.
• NEW! Treatment chapters guide students in managing common conditions in orthopedics, cardiopulmonary, and neurology.
• NEW! Chapter on functional outcomes and assessment lists relevant scores for the most frequently used tests.
• NEW! Chapter on psychosocial aspects of aging provides a well-rounded view of the social and mental conditions commonly affecting geriatric patients.
• NEW! Chapter on frailty covers a wide variety of interventions to optimize treatment.
• NEW! Enhanced eBook version is included with print purchase, allowing students to access all of the text, figures, and references from the book on a variety of devices.

Chapter 1

Geriatric Physical Therapy in the 21st Century: Overarching Principles and Approaches to Practice

Cathy Elrod

Outline

• Introduction
• Aging
• Health, Function, and Disablement
  • International Classification of Functioning, Disability, and Health
    • Health Condition
    • Impairment of Body Structure or Function
    • Activity Limitation
    • Participation Restriction
• Key Principles in Geriatric Physical Therapy
  • Role of Physical Activity and Exercise in Maximizing Optimal Aging
  • Slippery Slope of Aging
  • Ageism
  • Objectivity in Use of Outcome Tools
  • Evidence-Based Practice
    • Sources of Evidence
    • Finding Evidence
    • Evidence Translation Sources
  • Patient Autonomy
• The Physical Therapist in Geriatrics
  • Geriatric Care Team
  • Geriatric Competencies
  • Expert Practice
  • Clinical Decision Making
    • Examination
    • Evaluation and Diagnosis
    • Prognosis and Plan of Care
• Summary
• References

Introduction

All physical therapists, not just those working in settings traditionally identified as “geriatric,” should possess strong foundational knowledge about geriatrics and be able to apply this knowledge to a variety of older adults. Although the fundamental principles of patient management are similar regardless of patient age, there are unique features and considerations in the management of older adults that can greatly improve outcomes.

The first wave of the baby-boomer generation turned 65 years old in 2011. This group, born post–World War II, is much larger than its preceding generation, in terms of both the number of children born during this era (1946 to 1965) and increased longevity of those in that cohort. The 2008 landmark report of the Institute of Medicine (IOM) Retooling for an Aging America¹ provides a compelling argument for wide-ranging shortages of both formal and informal health care providers for older adults across all levels of the health care workforce (professional, technical, unskilled direct care worker, and family caregiver). These shortages include shortages of physical therapists and physical therapist assistants. The report provides numerous recommendations for enhancing the number of health care practitioners and the depth of preparation of these practitioners. The goal of this textbook is to provide a strong foundation to support physical therapists who work with older adults.

The U.S. Census Bureau reports that in 2016, 15% of the population was age 65 years or older; by 2030, one in five Americans is projected to be an older adult.² Undoubtedly, with very few exceptions, the majority of the caseload of the average physical therapist will soon consist of older adults. Despite this, physical therapists still tend to think about “geriatrics” in terms of care provided to frail individuals in a nursing home, hospital, or home care setting. Although these are important practice settings for geriatric physical therapy, physical therapists must recognize and be ready to provide effective services for the high volume of older adult patients who range from the very fit to the very frail, across inpatient and outpatient settings.

Aging

When working with the older adult, it is important to understand the concept of aging and the rationale behind the high variability and differences among older adults in the aging process. Usual aging, or typical changes in physiological functioning observed in older adults, represents a combination of normal (unavoidable) aging-related decline and modifiable factors associated with lifestyle such as physical activity, nutrition, and stress management. For many older adults, a substantial proportion of “usual” age-related decline in functional ability represents “deconditioning” as most older adults do not engage in sufficient physical activity and exercise to derive health benefits. This decline can be partially reversible with lifestyle modification.

Aging trajectories that go beyond typical aging have been described by a variety of terms such as healthy aging, optimal aging, successful aging, active aging, and aging well.³ In 1997, Rowe and Kahn⁴ provided a model of successful aging that includes the following components: (1) absence of disease and disability, (2) high cognitive and physical functioning, and (3) active engagement with life. Although helping older adults avoid disease and disease-related disability is a central consideration for all health care practitioners, the reality is that the majority of older adults do have at least one chronic health condition, and many, particularly among the very old, live with functional limitations and disabilities associated with the sequelae of one or more chronic health conditions. Brummel-Smith expanded the concepts of Rowe and Kahn in the depiction of optimal aging as a more inclusive term than successful aging. Brummel-Smith defines optimal aging as “the capacity to function across many domains—physical, functional, cognitive, emotional, social, and spiritual—to one’s satisfaction and in spite of one’s medical conditions.”⁵ This conceptualization recognizes the importance of optimizing functional capacity in older adults regardless of the presence or absence of a chronic health condition. Recently, the American Geriatrics Society published a White Paper on Healthy Aging in which they recommend that the definition of healthy aging include “concepts central to geriatrics, such as culture, function, engagement, resilience, meaning, dignity and autonomy, in addition to minimizing disease.”⁶

Health, function, and disablement

The World Health Organization (WHO) defines health as a “state of complete physical, psychological, and social well-being, and not merely the absence of disease or infirmity.”⁷ According to this definition, “health” is best understood as an end point in the major domains of human existence: physical, psychological, and social. In contrast to assuming “complete health” as the expected end point of an episode of care, physical therapists work across the spectrum, from wellness to the end of life, to ensure outcomes associated with achieving the highest level of function possible wherever someone may be placed on that spectrum.

There have been several attempts to construct a model of health status that describes the relationship between health and function or, more precisely, describes the process of how individuals come to be disabled (disablement) and identifies factors, including therapeutic interventions, that can mitigate disablement (enablement process). The traditional medical model of disablement assumes a causal relationship between disease and illness. In this narrow perspective, disablement is primarily dependent on the characteristics of the individual (i.e., his or her pathology) that require an intervention to alleviate that can only be provided by a health care professional. The social model of disability fundamentally broadens the focus away from an exclusive concentration on the disease-related physical impairments of the individual to also include the individual’s physical and social environments that can impose both disabling limitations and enabling mitigation of limitations.⁸ Subsequent models of the twin processes of disablement and enablement have further explored the relationship of the environment to functional independence. In the 1960s, sociologist Saad Nagi characterized disablement as having four distinct components that evolve sequentially as an individual loses well-being: disease or pathology, impairments, functional limitations, and disability.^9,10 His work is associated with the biopsychosocial model, which recognizes the importance of psychological and social factors on the patient’s experience of illness. In the late 1980s and early 1990s, Jette, Verbrugge, and Guccione began exploring the process of disablement as a framework to assist physical therapists to clarify the domains of practice.^11–15 They proposed a multifactorial disablement framework that included the influence of environmental demand and individual capabilities on disability (Fig. 1.1).

Fig. 1.1 An expanded disablement model. (Adapted with permission from Guccione AA. Arthritis and the process of disablement. Phys Ther. 1994;74:410.)

A further elaboration of Nagi’s model was presented by Brandt and Pope in a 1997 report from the IOM.¹⁶ This revised model introduced the concept of enablement that explicated the balance between inevitable and reversible disablement depending on the confluence of disabling and enabling factors at the interface of a person with the environment. If ramps were introduced to allow access to the home or therapeutic exercises implemented that improved functional performance, then the individual with a neuromuscular condition precluding his or her ability to negotiate stairs has experienced a “disabling–enabling process.” The IOM model has three dimensions: the person, the environment, and the interaction between the person and the environment. Their conceptualization allows us to understand how two older adults presenting with similar impairments associated with a right cerebrovascular accident can have different levels of disability according to the uniqueness of each individual and the environment in which they live. Physical therapists can use this information to promote optimal aging in the older adult.

International Classification of Functioning, Disability, and Health

The WHO also independently took on the task of developing a conceptual framework for describing and classifying the consequences of diseases. In 1980, they presented the International Classification of Impairments, Disabilities, and Handicaps (ICIDH).¹⁷ In response...