The American Physical Therapy Association’s (APTA) Guide to Physical Therapist Practice provides the following definition: ‘Physical therapy is a dynamic profession with an established theoretical base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function’ (APTA, 2003). The World Confederation for Physical Therapy (WCPT), which is a non-profit organization comprising 106 member organizations, states that it is the sole international organization representing over 350 000 physical therapists worldwide and that it is dedicated to furthering the physical therapy profession and improving global health (WCPT, 2012).

The primary goal of geriatric physical therapy is to prevent, maintain or rehabilitate impairments, improve activity limitations and decrease participation restrictions that are accomplished with the application of evidence-based scientific principles. Prevention of functional loss should be of primary concern for all healthcare providers. Preventative care and education are much less costly to provide to avert injury or illness as opposed to treating the sequelae of a health-related problem. The rehabilitative process should be geared to assist the older person to achieve the highest level of function possible within their environment. Physical therapy focuses on functional mobility while maintaining safety, enabling the older adult to enjoy a longer life by living it more independently and with less pain. The Academy of Geriatric Physical Therapy (AGPT, 2014) section of the APTA mission is to ‘further our members ability to provide best practice physical therapy and to advocate for optimal aging’ (AGPT, 2014). This includes being ‘advocates for the health, wellness, fitness, and physical function needs of the aging adult’ (AGPT, 2014). The WCPT has a subgroup called the International Association of Physical Therapists Working with Older People (IPTOP, 2012), whose goal is to serve as the international resource for physical therapists working with the elderly. IPTOP states that ‘The prime purpose of physical therapists working with older people is to maintain and/or restore function, activity and independence. This requires a person-centered, collaborative, inter-professional approach to a wide range of conditions affecting this population’ (IPTOP, 2012).

Physical therapists are healthcare professionals involved in the examination and evaluation of individuals with neuromuscular, musculoskeletal, cardiopulmonary and integumentary disorders. The physical therapist can then determine a physical therapy diagnosis and develop an individualized intervention plan to achieve short- and long-term goals for improved function. Physical therapists do not limit their skills to treating people who are ill. A significant portion of time is spent working on health promotion and prevention of primary and secondary problems to avert an initial injury or secondary impairment that would lead to subsequent loss of movement and function.

A physical therapist in the United States of America is a graduate of a college or university accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), and has passed a licensing examination that is conducted by the Federation of State Boards of Physical Therapy (FSBPT) and is regulated by each state. The physical therapist assistant holds an Associates Degree from a college program also accredited by CAPTE. Physical therapist assistants are licensed in most US states through examination. They are not permitted to perform evaluations, but can perform many of the treatment activities under the supervision of a physical therapist. Supervision requirements vary from state to state.

As the world’s older population grows, the US and other nations will require a well-trained workforce of healthcare providers with expert knowledge in geriatric care. Compared with younger adults, older Americans use a disproportionately larger share of healthcare services. Longer life spans and greater prevalence of chronic illnesses, such as diabetes, arthritis, hypertension and kidney disease, in older adults has placed a greater demand on the healthcare system (Thorpe et al., 2010). The average healthcare expense in 2002 was $11 089 per year for elderly people but only $3352 per year for working-age people (ages 19–64) (Agency for Healthcare Research and Quality, 2010). The Kaiser Family Foundation (2012) estimated that healthcare costs for chronic disease treatment account for more than 75% of US national health expenditures. Healthcare professionals who are trained in geriatric care can help to maintain the health and quality of life of older adults. The complex needs of older patients often require a team of healthcare providers with aging-related expertise to work together to assess the patient’s physical and mental wellbeing and to coordinate care in a variety of environments. These teams need to work cooperatively with informal caregivers, such as family and friends, who play a crucial role in helping the older patient maintain health and independence.

Older patients who receive specialized geriatric care tend to do better than those who receive usual care. Cohen et al. (2002) found that patients who received inpatient and outpatient care in geriatric units experienced large reductions in functional decline and improvements in mental health at no additional cost. In another study, older patients cared for by nurses trained in geriatrics had fewer readmissions to the hospital and were less likely to be transferred from nursing facilities to a hospital for inappropriate reasons (Kovner et al., 2002). Bardach and Rowles (2012) found that this need for trained geriatric specialists remains substantiated. This need should provide incentive for physical therapists to enter the geriatric field to assist in filling this gap.

There are many reasons to seek out the knowledge and skills of a physical therapist. Box 83.1 is a useful, but not an entirely inclusive, list of possible indications for a physical therapy referral. Physical therapists understand a vast array of problems that affect physical function and general health. They utilize screening to enable them to refer to other appropriate healthcare practioners if the therapist is serving as a portal to the healthcare system. Physical therapy is a rapidly evolving profession. In most US states an individual can have direct access to a physical therapist for evaluation and treatment without first seeing a physician for a referral. The APTA (2013) has the vision statement: ‘Transforming society by optimizing movement to improve the human experience’. One of the guiding principles in this new vision statement is identity, for which:

Many older people do seek out a physician as the traditional first stop in the healthcare process, with subsequent referral for physical therapy, although this may be underutilized. Johnson et al. (1994) determined that almost one-half of the patients that were hospitalized and found to be deficient in ambulatory or transfer skills compared to status at admission did not receive physical therapy services. Interestingly, those patients who received physical therapy in the hospital were significantly more likely to receive it in the post-acute period. It is possible to infer that elderly medical patients develop functional disabilities during hospitalization that are not appropriately recognized. Routine physical screening of all elderly patients should be performed by nursing staff to determine if there has been any loss in physical performance. Freburger et al. (2003) found that even after controlling for diagnosis, illness severity and physical therapy supply, referrals to physical therapy were much less likely from primary care physicians in comparison to orthopedic surgeons. This lack of referrals affects the quality of care received and may eventually result in an increased cost if a treatable condition worsens. Delays in care can also lead to decreased functional outcomes and frustration for clients and patients.

In a hospital, the physician is traditionally in charge of the patient as he/she has admitting privileges. The therapist may very well be an employee who is assigned the case through a scheduling rotation or based on their specific skills (e.g. GCS) and does not usually have the authority to seek older persons in need of services without a referral from the physician. The physician has traditionally served as the ‘gatekeeper’ to the healthcare system.

Outside the hospital, a great number of states do allow direct access, although the majority of therapists still receive referrals from a physician, physician’s assistant or nurse practioner. Direct access varies considerably in terms of legal, practice and reimbursement models. Some limitations or barriers to receiving physical therapy services are due to legal issues, but other reasons include such factors as lack of public and healthcare provider education. Additionally, most secondary payers such as the federal government and private insurance carriers limit reimbursement without a physician referral.

Interestingly, Miller et al. (2005) found that more than 66% of physician orders or referrals to physical therapy for geriatric clientele specified only ‘evaluate and treat’, or ‘P.T. Consult’. This finding does indicate some degree of confidence from physicians in the expertise and decision-making skills of physical therapists.

A physical therapist has a great deal to consider when assessing the geriatric client. Conditions of normal aging such as loss of eyesight and hearing can make assessment and intervention more difficult. Decline in physical reserve (homeostasis) may transform mild problems into those that are life-threatening. More than 50% of older adults have three or more comorbidities, including chronic diseases (Anderson, 2010). Older adults with multiple health problems have higher rates of death, disability, adverse effects, institutionalization, use of resources and a poorer quality of life (Boyd & Fortin, 2011). A comprehensive review of systems and a biopsychosocial or patient-centered approach must be utilized when assessing and planning intervention for these clients. Health is best understood in terms of a combination of biological, psychological and social factors rather than purely in biological terms. This concept was first put forth by Dr George Engel (1977). Physical therapists must not only understand internal factors such as physical abilities, cognition and pharmacological interaction, but also how external factors such as environment, financial resources and social support will affect the therapeutic relationship and eventual outcome.

Not all older adults’ problems can be classified into specific disease categories. The term ‘geriatric syndrome’ (Inouye et al., 2007) has been utilized to categorize many of the most common health interrelated problems in older adults. Geriatric syndromes include falls, incontinence, delirium and functional decline, and represent a state of impaired health (Inouye et al., 2007). These complex syndromes are multifactorial and associated with poor outcomes, frailty, dependence and significant morbidity. A change in health status may be precipitated by one of the inter-related conditions. For instance, a urinary tract infection may lead to delirium which may then cause a fall that results in a fractured hip which will affect physical function for weeks, months or the remainder of one’s life. We can explore this inter-relatedness in considering a specific case (see Case Study), which to the professional who lacks specific geriatric training may appear as a ‘simple’ case.