4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century lifestyle factors and illness that influence physiological funioning ation that must be brought to bear on a inica er amew s are pre this ally the into model is grounded in the patient-client management can have a large imp model the Guide to Physica Therapist Practice part an em zes th al ro fra erapy nt disablement concept of the World Health Organiza in work, home. leisure activities nationa nto function continues ICF)m ty'are als and of di restrict leisure activities (fun)because of declining physi- substantial emphasis on describing and explaining per- ological capacity.Mov medic environmenta fact rs likely to en- managing Crucial Role of Physical Activity and Exercise in Maximizing Optimal Aging into wo whe ndiv nde concern across age groups th BADl The concept of functional thresholds and the down- ward mo fun to exercise sustainabil o regain physi ical reser appareof rved between t hat physi menrs)and chan ofcare for their older adult patients r as par for a person who is teetering between the thresholds of Exercise may well be the most important tool on and f physical erapist has to positively affect function and “frailt aging.De with its associated functional limitations.Once a per optimal intensity. duration and mode of exercise r moves to a lower functional level (down the curve of the scription,physical therapists often underutilize exercise. optimal negative on the potent to up to a high of tim cise activities may enhance efforts for an up ions may be ciated with such fa ment along the slippery slope.Moreove the furth that lower expe ctations for high levels of function.ack reshold. th of awareness of age-based functional norms hat can b more physi ava P A goa ure ot d h d pe ve role of phy cal the r the of in prevention)that are covered and reimbursed tients/c to und person's insurance benefit.Physica t physiological reserve should every opport nity to apply evi Clinical Decision Making in Geriatric ams that encourage p ositive lifestyle changes and, Physical Therapy thus.maximize optimal aging. eof physical therapy practice sth Objectivity in Use of Outcome Tools ovement and health.Providing a fram rk for clini Older adults be me increasingly dissimilar with increa cal decision making in geriatric physical therapy 1 ing age.A similarly aged person can be frail and reside in particularly important because of the sheer volume of a nursing home or be a senior athlete participating in a4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century lifestyle factors and illness that influence physiological functioning. Schwartz has embedded functional status thresholds at various points along this slope. Conceptually, these thresholds represent key impact points where small changes in physiological ability can have a large impact on function, participation, and disability. These four distinctive functional levels are descriptively labeled fun, function, frailty, and failure. Fun, the highest level, repre￾sents a physiological state that allows unrestricted par￾ticipation in work, home, and leisure activities. The person who crosses the threshold into function continues to accomplish most work and home activities but may need to modify performance and will substantially self￾restrict leisure activities (fun) because of declining physi￾ological capacity. Moving from function into frailty oc￾curs when managing basic activities of daily living (BADLs; walking, bathing, toileting, eating, etc.) con￾sumes a substantial portion of physiological capacity, with substantial limitations in ability to participate in community activities and requiring outside assistance to accomplish many home or work activities. The final threshold into failure is reached when an individual re￾quires assistance with BADLs as well as instrumental daily activities and may be completely bedridden. The concept of functional thresholds and the down￾ward movement from fun to frailty helps explain the apparent disconnect that is often observed between the extent of change of physiological functions (impair￾ments) and changes in functional status. For example, for a person who is teetering between the thresholds of function and frailty, a relatively small physiological chal￾lenge (a bout of influenza or a short hospitalization) is likely to drop them squarely into the level of “frailty,” with its associated functional limitations. Once a person moves to a lower functional level (down the curve of the y-axis) it requires substantial effort to build physiologi￾cal capacity to move back up to a higher level (back up the y-axis). Lifestyle changes including increased exer￾cise activities may enhance efforts for an upward move￾ment along the slippery slope. Moreover, the further the person is able to move above a key threshold, the more physiological reserve is available for protection from an acute decline in a physiological system. A major role of physical therapy is to maximize the movement￾related physiological ability (vigor) of older adult pa￾tients/clients to keep them at their optimal functional level and with highest physiological reserve. Clinical Decision Making in Geriatric Physical Therapy The primary purpose of physical therapy practice is the enhancement of human performance as it pertains to movement and health. Providing a framework for clini￾cal decision making in geriatric physical therapy is particularly important because of the sheer volume of information that must be brought to bear on a clinical decision. Several conceptual frameworks are presented in Chapter 6 and integrated into a model to guide phys￾ical therapy clinical decision making in geriatrics. The model is grounded in the patient-client management model of the Guide to Physical Therapist Practice8 and emphasizes the central role of functional movement task analysis in establishing a physical therapy diagnosis and guiding choice of interventions. The enablement– disablement concepts of the World Health Organiza￾tion’s International Classification of Functioning, Dis￾ability and Health (ICF) model of disability9 are also incorporated into this model, using ICF language to communicate the process of disablement and placing a substantial emphasis on describing and explaining per￾sonal, medical, and environmental factors likely to en￾able functional ability or increase disability. Crucial Role of Physical Activity and Exercise in Maximizing Optimal Aging Lack of physical activity (sedentary lifestyle) is a major public health concern across age groups. Only 22% of older adults report engaging in regular leisure-time physical activity.10 Sedentary lifestyle increases the rate of age-related functional decline and reduces capacity for exercise sustainability to regain physiological reserve following an injury or illness. It is critical that physical therapists overtly address sedentary behavior as part of the plan of care for their older adult patients. Exercise may well be the most important tool a physical therapist has to positively affect function and increase physical activity toward optimal aging. Despite a well-defined body of evidence to guide decisions about optimal intensity, duration, and mode of exercise pre￾scription, physical therapists often underutilize exercise, with a negative impact on the potential to achieve optimal outcomes in the least amount of time. Underuti￾lization of appropriately constructed exercise prescrip￾tions may be associated with such factors as age biases that lower expectations for high levels of function, lack of awareness of age-based functional norms that can be used to set goals and measure outcomes, and perceived as well as real restrictions imposed by third-party payers regarding number of visits or the types of interventions (e.g., prevention) that are covered and reimbursed under a person’s insurance benefit. Physical therapists should take every opportunity to apply evidence-based recommendations for physical activity and exercise programs that encourage positive lifestyle changes and, thus, maximize optimal aging. Objectivity in Use of Outcome Tools Older adults become increasingly dissimilar with increas￾ing age. A similarly aged person can be frail and reside in a nursing home or be a senior athlete participating in a