Introduction
Working with older people can present the physiotherapist with a set of challenges unparalleled in other areas of practice. The caseload is very mixed; patients with musculoskeletal, neurological, and cardiovascular problems may all be found in a single caseload and often in the same patient. Interlinking between medical, psychological, rehabilitative, economic and social problems that all need attention is the norm, rather than the exception. Add to these the differences in presentation of disease, the unique pattern of ageing in each individual, and the varying responses that older people may demonstrate, and the complexity of the challenge is obvious.
Physiotherapy settings and onward referral
Many initiatives have been set up to provide better systems of health and social services for older people. In the UK, most of these involve physiotherapy with the more common areas of work for physiotherapists with older people listed below: In health promotion and disability prevention programmes In hospital – either acutely ill on the general wards or on a specialised older person's unit; or a specialised rehabilitation ward.Ambulatory clinics or Day Assessment and Rehabilitation Units – where individuals classically require input from more than one profession and spend a day in a centre where rehabilitation is providedCommunity – a term that encompasses settings such as:Community physiotherapy in a person’s own home or at the doctor's clinic.Regional and local outreach services, often for specific conditions, e.g. neurological or respiratory conditions to provide a monitoring service with rapid response capabilities should the therapist detect a decline in the person’s condition.
Intermediate Care, with the provision of jointly funded health and social services set up through a multi-disciplinary team for an average of 2–6 weeks to prevent (re)admission of older people into hospital. This can take place either in the person’s own home or in beds set aside for rehabilitation at a Care Home.Community Rehabilitation Teams, with a longer remit of up to 12 weeks, historically funded to promote the early discharge of people post-stroke, but who now take those with orthopaedic and general rehabilitation needsPhysiotherapists in mental health teams, who can be called upon for specialist advice.In research institutes looking into age-related conditions and issuesA physiotherapist working with older people can be considered a ‘Jack of all trades’. Far from being a term of belittlement, the phrase should be regarded with respected for the skills necessary to apply all aspects of the bio-psycho-social model to ensure a holistic, patient-centred approach. All over the UK advanced practice posts like Clinical Specialist and Consultant posts are emerging for physiotherapists in this clinical field. Knowledge, therefore, in respiratory care, orthopaedics, neurology, medicine together with awareness of psycho-social aspects are essential.The fundamental principles on which physiotherapy with older people is based are:Disability is generally regarded as being due to a pathological process, or injury, not prima facie ‘old age’.The effects of biological ageing reduce the efficiency of the body’s systems, but throughout life, optimum function is maintained in each individual by continuing to use these systems to their maximum capacity.Physiotherapists have a key role in enabling older people to use a number of the body’s systems fully to enhance mobility and independence.When neither improvement nor even maintenance of functional mobility is a reasonable goal, physiotherapists can contribute to helping older people to remain comfortable and pain free.
Prevention of the development of problems in later life through health promotion.The therapist should be aware of the difference between therapy goals and person-centred goals, the latter often being achieved through the intervention of a team. For example, the goals of the individual may be to walk independently at home with a Zimmer frame. The physiotherapy goal might be to increase quads strength for safe transfers to standing, improve balance and endurance.
Physiotherapist may provide equipment to enable a safe transfer, the doctor prescribe analgesics to inhibit pain and allow participation, and the nurses or social care staff may ensure the person can walk an optimal amount to start to increase strength and confidence. Goals should be directed more towards the management and improvement of a condition rather than ‘care’ towards the older person. At times, it is appropriate to work together with another team member whether in a hospital or community setting, not only to learn from one another, but also to ensure you are working toward the same goals for the benefit of the individual.The therapist in this field must learn how to identify rehabilitation potential by deciding which of the presenting features are related to deskilling, deconditioning, pathology or ageing, and therefore, which are reversible and manageable. To this end, the therapist must have knowledge of what is an acceptable ‘norm’ for this age group, e.g. age related changes in gait and posture. At times, there may be conflict between the person's goals and your idea of what might be safe; our task then is to highlight the risks and try and minimise them where possible rather than stopping a person functioning altogether.