CHAPTER 1 Geriatric Physical Therapy in the 21st Century PATIENT-CLIENT PREFERENCES AND MOTIVATIONS f en moi s physical appea Patient-client preference and motivation is the third A80 information stream making up evidence-based(evidence- aho not be described as old by those around her,whereas The the expertis ms hared and b als and in likely to be perceived and tions.Patient autonomy is grounded in the principle that Age bias,a negative perception of older adults based their re. ency for he set in a met provi be oward ol of 43 than younger adults to make decisions about their health toward younger people.The subtle negative attitudes and rehabilitation.The reality of clinical practice is that inte wid ty of c more obvious and ir atient a (and familv/caretakers.as appr poo ropriate)have all pertinent make therapy-related health care t rm: on s share 0 racteristics in a study ld the nd th nch tial risks.benefits.and harms amount of effort and tient receiving rehabilitation postamputation.Howeve compliance associated with the various options;and the multiple variations of this core scenario were presented likely prognosis. The uld ha d patient to expres or fe 11 has heard them accurarely and without bias.Thegoals (2)depressed,or (3)nor and preferences of the older adult patient may be very rom what physical therapis csaia eve t physical therapy is creatively addressing the tient' the scenario describing an old patient demonstra using appropriate evidence,clinical skills,and more negative attitudes than those responding to the available resources. scenario d n th care setting. THE INFLUENCE OF AGEISM 06e and less The perception of someone as being old or geriatric is making a human connection with the patient.2 Age been identified as a reason for undertreating older ent rew bas nd tha groups lation h which a as old.However,the age of the survey Typically,physical therapists are drawn to the profes Kespondents un by a strong desire to help peopl n a very tangib <n ine low potential for imp beginning of old age;and those older than age 64 years Stereotypes about older adults inaccurately he e typic age ed and perma noncompl ant an identified by medical n others Many interactions with physical thera ing individuals as old. at very vulnerable points in an older adult's life.For14 CHAPTER 1 Geriatric Physical Therapy in the 21st Century PATIENT-CLIENT PREFERENCES AND MOTIVATIONS Patient-client preference and motivation is the third information stream making up evidence-based (evidence￾informed) practice. The scientific evidence and the expertise of the practitioner are combined with the preferences and motivations of the patient to reach a shared and informed decision about goals and interven￾tions. Patient autonomy is grounded in the principle that patients have the right to make their own decisions about their health care. There is a tendency for health care providers to behave paternalistically toward older adult patients, assuming these patients are less capable than younger adults to make decisions about their health and rehabilitation. The reality of clinical practice is that physical therapists encounter a wide variety of decision￾making capabilities in their older adult patients. Physical therapists have a responsibility to ensure their patients (and family/caretakers, as appropriate) have all pertinent information needed to make therapy-related health care decisions, and that this information is shared in a manner that is understandable to the patient and free of clinician bias. The patient should understand the poten￾tial risks, benefits, and harms; amount of effort and compliance associated with the various options; and the likely prognosis. Patients should have the opportunity to express their preferences and be satisfied that the practitioner has heard them accurately and without bias. The goals and preferences of the older adult patient may be very different from what the physical therapist assumes (or believe they would want for themselves under similar circumstances). Part of the “art” of physical therapy is creatively addressing the patient’s goals using appropriate evidence, clinical skills, and available resources. THE INFLUENCE OF AGEISM The perception of someone as being old or geriatric is a social construct that can differ greatly among cultures and social groups. A recent Pew Foundation survey23 found that, on average, a representative sample of the U.S. population perceives age 68 years as the age at which a person crosses the threshold to be classified as old. However, the age of the survey respondent influenced perceptions: Respondents under the age of 30 years identified old age as starting at 60 years; those between 30 and 64 years indicated 70 years as the beginning of old age; and those older than age 64 years indicated that old age starts at 74 years. The age of 65 years, which is the typical age when individuals in the United States become eligible for Medicare, is probably the most common age identified by medical researchers and social policy advocates when categoriz￾ing individuals as old. In reality, perceiving a specific individual as old is often more associated with the person’s physical appear￾ance and health status than his or her chronological age. An 80-year-old who is independent, fit, and healthy may not be described as old by those around her, whereas a 60-year-old who is unfit, has multiple chronic health problems, and needs help with daily activities that are physically challenging is likely to be perceived and described as old. Age bias, a negative perception of older adults based on their age alone, is endemic in Western culture, includ￾ing health care settings.24 Kite and Johnson,25 in a meta￾analysis of 43 studies on age bias, concluded that atti￾tudes toward older people are more negative than toward younger people. The subtle negative attitudes toward older adults that are often identified among health care practitioners become more obvious and in￾fluential when old age is combined with a perception of the patient as having low motivation, poor compliance, or poor prognosis. Rybarczyk et al25a considered age plus other patient characteristics in a study of bias in nearly 1000 rehabili￾tation professionals, including physical therapists. One core clinical scenario was developed representing a pa￾tient receiving rehabilitation postamputation. However, multiple variations of this core scenario were presented. The identically involved patient was either young or old and further divided into male or female. The young or old patient was (1) ideally motivated and cooperative with rehabilitation, (2) depressed, or (3) noncompliant. The study found little age bias when the ideally moti￾vated old patient was compared to the ideally motivated young patient. However, when two noncompliant or depressed patients were compared, those responding to the scenario describing an old patient demonstrated more negative attitudes than those responding to the scenario describing a young patient. In the hectic and often stressful acute care setting, nurses admit that older patients are often marginalized with their needs given lower priority, and less time spent making a human connection with the patient.26 Age bias has been identified as a reason for undertreating older adults with cancer based on unsupported assumptions that treatments are unsafe for the older adult, or at times, despite evidence supporting the use of the inter￾vention for older adults.24,27,28 Typically, physical therapists are drawn to the profes￾sion by a strong desire to help people in a very tangible and interactive way, often expressing low interest in pa￾tients they perceive as having low potential for improve￾ment.29,30 Stereotypes about older adults inaccurately suggest that, as a group, older adults have low potential for improvement, are unmotivated, noncompliant and set in their ways, confused, and permanently dependent on others. Many interactions with physical therapists occur at very vulnerable points in an older adult’s life. For