CHAPTER 1 Geriatric Physical Therapy in the 21st Century ciples of optimal agin nd Asking an Answerable Question adults if given the opportunity to fully participate in Converting a need for information into a searchable rehabilitation. clinical question is the first step of an evidence-based beli rgy people who firmly Taking a few mome ts to formulate a clear eve in ther n the challe ds t n patient who ne rustration as thousands of sible pie related to the real ques odel clinica ma0。a the that shou are essential n in o atr Th or diagn osis)th int nd (diagnos sis),and the outco e.Some commo recognize the positive cha f mastering the man- compl group of patients are as technical making comp 1.The Patient.This nent should n y the seareh during which the learner starts with uncomplicated stan to an applicable subgro oup of older adults.For exam- esses to complex and ariable ple,a clinician working with two differen ones. varia stenosis.Or typically mastered after the lower levels.Part of thetr and generally healthy senior athlete The best evidence tion from novice to expert is the increasing ease with proach to the frail older adult and complex situation, tly)ana Dest thlete Con e ns.Because the atien includ pa aplex and variable than the typical younger natient such as community-dwelling or nursing home resident (institutional); well-older adult,generally healthy,or apists shoul seek rail older adu 85 85 2.Intervention:This portion of the answerable question NALYZING,AND APPLYING represents the patient management focus of a ques ion(therapy ostic tool prognost evidence into clinical dec factors,che the miting the making is the second maior anchor of evidence-based considerations of the older adult practice.We live in an information age.For almost any 3.Comparison intervention:A question about the ef- fectiveness of a given intervention or diagnostic pro ogy. re is o commonly accepted usual care?"or ()"Does a new credible,clinically important,and applicable to the ve a better outcome than no interven specifc patient sit ation Whe an un miliar clinical situ on,a cli h erventions are typi identify missing evidence needed to guide 4.Outcomes:Carefully considering the specific out- making.A fou step process is typically used to locate and comes of interest is a good way of focusing the nce:(1)asking a search that is most useful in guid searching the able clinical ques re an evidenc ing the nd (4)de e of care improve functional mobility,increase the patient's ability to participate process and provides insights into applying these principles or improve overall in geriatric physical therapy. essing specih CHAPTER 1 Geriatric Physical Therapy in the 21st Century 7 firm believers in the principles of optimal aging and had a genuine high regard for the capabilities of older adults if given the opportunity to fully participate in rehabilitation. Geriatric experts are high-energy people who firmly believe in their role and responsibility as a patient advo￾cate, and they thrive on the challenge of the complex patient who needs creativity and individualization of ap￾proach, good interpersonal skills, and deep knowledge of the specialty content. These specialists model clinical excellence by not set￾tling for less than what the patient is capable of. Physical therapists are essential practitioners in geriatrics. The physical therapist must embrace this essential role—and recognize the positive challenge—of mastering the man￾agement of a complex and variable group of patients. Skill acquisition in any specialty area consists of technical, perceptual, and decision-making components during which the learner starts with uncomplicated stan￾dard situations and progresses to complex and variable ones. Performing in a highly complex and variable envi￾ronment requires the highest level of decision making— typically mastered after the lower levels. Part of the transi￾tion from novice to expert is the increasing ease with which a person can enter a new and complex situation, quickly (and increasingly implicitly) analyze the various components, and then make effective and efficient deci￾sions. Because the typical older adult patient is more complex and variable than the typical younger patient, the level of expertise required is particularly high. Less experienced physical therapists should seek mentorship and residency opportunities and engage in active and fre￾quent reflection with peers to develop these skills. FINDING, ANALYZING, AND APPLYING BEST EVIDENCE Incorporation of best evidence into clinical decision making is the second major anchor of evidence-based practice. We live in an information age. For almost any topic, an overwhelming amount of information can be accessed in seconds using computer technology. The challenge, as evidence-based practitioners, is to quickly identify and apply best evidence. The best evidence is credible, clinically important, and applicable to the specific patient situation. When faced with an unfamiliar clinical situation, a cli￾nician reflects on past knowledge and experience, and may identify missing evidence needed to guide their decision making. A four-step process is typically used to locate and apply best evidence: (1) asking a searchable clinical ques￾tion, (2) searching the literature and locating evidence, (3) critically assessing the evidence, and (4) determining the applicability of the evidence to a specific patient situa￾tion. The following section describes each step in this process and provides insights into applying these principles in geriatric physical therapy. Asking an Answerable Question Converting a need for information into a searchable clinical question is the first step of an evidence-based approach. Taking a few moments to formulate a clear search question can considerably facilitate the search process. A poorly formulated question often leads to frustration as thousands of possible pieces of evidence may be identified, most of which are only tangentially related to the real question. Strauss et al.2 identify four major components of a clinical question that should guide a search for evidence: the patient, the intervention (or diagnosis/prognosis), the comparison intervention (diagnosis, prognosis), and the outcome. Some common themes when considering an answerable question related to older adults are as follows: 1. The Patient. This component should narrow the search to an applicable subgroup of older adults. For exam￾ple, a clinician may be working with two different patients, each with a diagnosis of spinal stenosis. One patient is 92 years old and frail; the other is a very fit and generally healthy senior athlete. The best evidence to guide the clinical approach to the frail older adult with spinal stenosis is likely to be different from the best evidence for the senior athlete. Consider a more complete description of the patient beyond spinal ste￾nosis. For example, include modifiers as appropriate such as community-dwelling or nursing home resident (institutional); well-older adult, generally healthy, or frail older adult; independently functioning or depen￾dent; young-old (age 60 to 75 years), old (age 75 to 85 years), old-old (older than age 85 years). 2. Intervention: This portion of the answerable question represents the patient management focus of a ques￾tion (therapy, diagnosis or diagnostic tool, prognostic factors, etc.). The information delimiting the patient section will help to focus the evidence on the unique considerations of the older adult. 3. Comparison intervention: A question about the ef￾fectiveness of a given intervention or diagnostic pro￾cedure is often asking one of two questions: (a) “Does a new intervention have better outcomes than the commonly accepted usual care?” or (b) “Does a new intervention have a better outcome than no interven￾tion at all?” Either question may be important given the likelihood that alternative interventions are typi￾cally available and recommended. 4. Outcomes: Carefully considering the specific out￾comes of interest is a good way of focusing the search for the evidence that is most useful in guid￾ing the specific episode of care. For example, does the primary question relate to the best approach to remediate a key impairment, improve functional mobility, increase the patient’s ability to participate in activities, or improve overall quality of life? Typically, there are more studies addressing specific