CHAPTER 1 Geriatric Physical Therapy in the 21st Century Physical therapists who find geriatrics particularly rewarding and exciting tend to be practitioners who dislike a clinical world of "routine ,and patients with n es,can provide a more c ers enjoy ng creative mance relative to similarly aged oder adu servings highest level of optimal aging and enjoy making common language and as a baseline for measuring prog personal impact on the care of their patients.Navigating tminute wall eent an effective solution in the mids test (175 m). en 01 rovides a more ate des tion than“an older ma who requires mod assistance of two to transfer,walks a walker,and whose strength is WFL. Need for Physical Therapists in Geriatrics tests,appropriate The year 2011 marks a critical date for the Americar he of the baby-boomer generation ued 65 years.This group,born post-World War II,is mucl RED on,both in terms of ON numb er c ing this era( f th 946o1965j Physical therapists working with older adults must ingly although health services rchers have lon be prepared to serve as autonomous primary care casted the substantial impact of this demographi re searchers utors adequate prepar ion has bee tes,in to m et the Although none of these roles is unique to geriatric group of older adults.The 2008 landmark report of ical erapy,what is unique is the remarkable s and the regularity provides physic le ide all le health care workforce (professional,technical,unskilled direct care worker,and family caregiver).These short- them to n L short physica the the apy status and may be simultaneously dealing with signifi- health care practitioners and the depth of preparation cant psychosocial stresses such as loss of a spouse,loss of these practitioners.The goal of this textbook is to of an important aspect of indepen or a change in tosupport physical thera- us,cogr epressio d size ble eload of physical aspects and provide an additive challenge to the physical therapy practices is the older adult. physical therapist.The physical therapist must be cre- clues about un the c r acc 88 ated acros s,are pa epresents mutually ed-ongoa ptions,the majority of the caseload of the aver physical therapist will soon consist of older adults making the Despite this,physical therapists still tend to think about therapist ethe tha geriatrics only as care pr in a nur sing home or geriatric physical ther- apy,physical therapists must recognize and be ready to vide effective services for the high volume of older ed cation to patient adult patients across all practice settings.Every physica CHAPTER 1 Geriatric Physical Therapy in the 21st Century 5 triathlon. Dissimilarities cannot be attributed to age alone and can challenge the therapist to set appropriate goals and expectations. Functional markers are useful to avoid inappropriate stereotyping and undershooting of an older adult’s functional potential. Functional tests, especially those with normative values, can provide a more objective and universally understood description of actual perfor￾mance relative to similarly aged older adults, serving as a common language and as a baseline for measuring prog￾ress. For example, describing an 82-year-old gentleman in terms of gait speed (0.65 m/s), 6-minute walk test (175 m), Berg balance test (26/56), and Timed 5-repetition chair rise (0) provides a more accurate description than “an older man who requires mod assistance of two to transfer, walks 75 feet with a walker, and whose strength is WFL.” Reli￾able, valid, and responsive tests, appropriate for a wide range of abilities, enhance practice and provide valuable information for our patients and referral sources. THE PATIENT-CENTERED PHYSICAL THERAPIST ON THE GERIATRIC TEAM Physical therapists working with older adults must be prepared to serve as autonomous primary care practitioners, and as consultants, educators (patient and community), clinical researchers (contributors and critical assessors), case managers, patient advocates, in￾terdisciplinary team members, and practice managers.11 Although none of these roles is unique to geriatric phys￾ical therapy, what is unique is the remarkable variability among older adult patients and the regularity with which the geriatric physical therapist encounters patients with particularly complex needs. Unlike the typical younger individual, older adults are likely to have several complicating comorbid conditions in addition to the condition that has brought them to physical therapy. Patients with similar medical diagnoses often demonstrate great variability in baseline functional status and may be simultaneously dealing with signifi￾cant psychosocial stresses such as loss of a spouse, loss of an important aspect of independence, or a change in residence. Thus, cognitive issues such as depression, fear, reaction to change, and family issues can compound the physical aspects and provide an additive challenge to the physical therapist. The physical therapist must be cre￾ative, pay close attention to functional clues about un￾derlying modifiable or accommodative impairments, and listen carefully to the patient to assure goal setting truly represents mutually agreed-upon goals. In addition, the older patient is likely to be followed by multiple health care providers, thus making the physical therapist a member of a team (whether that team is informally or formally identified). As such, the physical therapist must share information and consult with other team members; recognize signs and symp￾toms that suggest a need to refer out to other practitio￾ners; coordinate services; provide education to patient and caretaker/family; and advocate for the needs of patients and their families. Physical therapists who find geriatrics particularly rewarding and exciting tend to be practitioners who dislike a clinical world of “routine” patients. These prac￾titioners enjoy being creative and being challenged to guide patients through a complex maze to achieve their highest level of optimal aging; and enjoy making a more personal impact on the care of their patients. Navigating an effective solution in the midst of a complex set of patient issues is professionally affirming and rarely dull or routine. Need for Physical Therapists in Geriatrics The year 2011 marks a critical date for the American population age structure, representing the date when the first wave of the baby-boomer generation turned age 65 years. This group, born post–World War II, is much larger than its preceding generation, both in terms of number of children born during this era (1946 to 1965) and increased longevity of those in that cohort. Interest￾ingly, although health services researchers have long forecasted the substantial impact of this demographic shift on the health care system and encouraged coordi￾nated planning efforts, inadequate preparation has been made to assure sufficient numbers of well-prepared health care practitioners to meet the needs of this large group of older adults. The 2008 landmark report of the Institute of Medicine (IOM) Retooling for an Aging America12 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 short￾ages include shortages of physical therapists and physical therapist assistants. The report provides numer￾ous 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 thera￾pists who work with older adults. A sizeable proportion of the caseload of most physical therapy practices is the older adult. A recent large-scale physical therapist practice analysis1 reported that 40% to 43% of the caseload of physical therapists, aggregated across clinical practice settings, are patients age 66 years or older. Undoubtedly, with very few ex￾ceptions, 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 only as care provided in a nursing home or, perhaps, in home care. Although these are major and important practice settings for geriatric physical ther￾apy, physical therapists must recognize and be ready to provide effective services for the high volume of older adult patients across all practice settings. Every physical