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Because the abilities and disabilities of older adults are so diverse, so are the environments in which these individuals live. PTs and PTAs may encounter older individuals in a wide variety of settings. People with acute medical conditions such as pneumonia, cardiovascular dysfunction, or hip fractures will be treated in hospitals. Older people with conditions such as cerebro vascular accident (stroke), Parkinson disease, or amputation may be seen for physical therapy in rehabilitation centers once they are medically stable. A variety of long-term care (LTC) centers (skilled nursing facilities [SNFs], extended care facilities [ECFs], and others) provide services to older people who are not acutely ill but who require nursing care or assistance with functional activities. PTs and PTAs in LTC settings generally provide two types of services: 1) rehabilitative services to improve skills so people may return to their own homes or allow less dependence on caregivers in the LTC facility, and 2) functional maintenance programs, often implemented by facility staff under the supervision of PTs, to assist older adults to maintain the skills they currently possess and prevent further limitations or disability.

Many older people with functional limitations are healthy enough to live at home independently or have family members who are able to care for them. Depending on the medical condition of the individual and availability of appropriate transportation, older people living at home who require physical therapy may receive those services at an adult day care facility, at an outpatient clinic, or through a home health care agency.

Healthy older people who want to maintain, regain, or improve their optimum physical status may attend exercise classes at senior centers or those sponsored by such groups as the Arthritis Foundation. Traditional or aquatic exercise programs, tai chi, or yoga may be conducted, supervised, or developed by PTs. These exercise programs may be aimed at general fitness and health promotion or at the prevention of specific conditions responsive to exercise, such as osteoporosis or poor balance.

Roles for Physical Therapists with Older Adults

It is easy to envision the PT as a clinician who provides hands-on services (direct intervention) to older adults. However, in each of the settings described earlier, PTs are also educators. With valuable knowledge of the physiologic aging process, PTs are the ideal professionals to educate patients, family members, and other professionals to prevent and minimize impairments, functional limitations, and disability. Armed with facts, older people will be better able to exercise appropriately and maintain or regain skills. For example, the woman in Figure 13-3 is being taught how to use her arms to more easily get up from a reclined position. The PT is in an excellent position to teach the older person that strength and endurance can be increased with properly designed programs.

PTs may act as consultants to individuals and programs. PTs are effective advocates for older people in developing appropriate activity programs and in ensuring accessibility to all environments. For an individual the PT provides the knowledge necessary to acquire appropriate adaptive equipment or assistive devices that provide for both safety and convenience. Adaptive equipment allows an individual to perform a functional task with increased ease or independence. An example is a grab bar secured to the wall in the bathroom near the shower or toilet so the individual can safety attend to ADL without assistance from a caretaker. An assistive device is one that provides the individual with assistance during periods of mobility. For example, a cane may assist an individual in climbing stairs safely. As a program consultant, the PT makes recommendations for group activities to maintain strength and endurance. The PT acts as a resource for other staff members to determine how to incorporate goals related to mobility into other components of the day program.

Other roles PTs may assume relating to the older adult are those of manager and researcher. PTs are prepared to assume such roles as managers of rehabilitation services or case managers. In each of these positions, the PT’s educational background in managing resources and leadership allows them to combine knowledge of the aging issues and management skills to take on additional responsibilities to serve clients. Research related to topics such as the aging process, prevention of disability related to aging, and effective intervention for older adults is a priority in the health care field. Discipline-specific studies of the cost effectiveness of particular interventions are essential in the determination of reimbursement policies for health care for older individuals. PTs are also essential team members in interdisciplinary studies that expand the knowledge of all health care professionals related to aging.

Aging-Related Changes

PTs and PTAs must be familiar with the changes that occur in “normal” aging in order to distinguish them from pathologic changes. Aging-related changes, which vary with each individual, are considered when conducting an examination, formulating an evaluation that includes a prognosis, designing a program with clinical interventions, and setting goals for people over 65 years of age. Although there are biologic changes associated with aging, many changes once thought to be an inevitable part of aging are now considered to be related to the reduced activity and sedentary lifestyle of many elders. The PT, with the health care team, has an important role in evaluating older adults to determine what impairments and functional limitations can be addressed or what disabilities can be minimized through physical therapy. Changes that are not amenable to improvement may be addressed through adaptation, accommodation, or compensation. For example, an elderly person who has experienced multiple falls may be evaluated by a PT to determine the need for an assistive device. The PT or PTA would then determine the appropriate height of the device and teach the patient how to use the device on a variety of surfaces (carpet, tile, stairs).

The physical changes observed in older adults that affect the musculoskeletal system (bones, muscles, and joints) often result in poor posture, changes in gait pattern, and decreased strength and flexibility. Decreased strength is often related to hypokinesis (decreased activity or movement) and the decreased muscle mass (sarcopenia) typically seen in older people. Muscle mass is reduced because of a decrease in the number of muscle fibers.⁵ The reduction in fibers is related to loss of motor neurons (nerves innervating muscles) and active motor units (a single motor neuron and all the muscle fibers it innervates).⁶

Changes in flexibility with age are related to both hypokinesis and biologic changes in connective tissue. Connective tissue tends to become less hydrated thus stiffer in older persons. With less activity the muscles are not required to lengthen as often and actually become shorter over time. As muscles shorten, individuals tend to assume more flexed positions, potentially leading to postural changes.

Bone also undergoes changes with age. In studies of vertebral bodies, bone mass was shown to decrease by 35% to 40% between the ages of 20 and 80 years.⁷ This finding suggests that bone is weaker in older people. This change may eventually advance to osteoporosis.

Weight-bearing joints such as hips or knees degenerate over time. Excessive wear and tear destroys articular cartilage (which covers the ends of bones) causing impairments such as pain, inflammation, and deformities. Obesity is a risk factor that causes additional stress to these joints, facilitating rapid deterioration⁸ (see the discussion of arthritis in the section on common conditions).

The central nervous system shows a reduction in conduction velocity associated with age.⁵ The reduction affects the ability of the nerve to transmit impulses. This change tends to make movement responses slower in older persons and may explain the reduced ability to respond rapidly to loss of balance or the slowed gait pattern often seen in later life.

Several of the sensory systems display changes that significantly affect mobility, specifically in the ability to move safely in the environment. The visual system is important in providing accurate information regarding the environment. In the older person the lens becomes less elastic, and the muscles around the lens decrease in their ability to accommodate rapidly from seeing far to near distance.⁹ Visual acuity is also reduced. These changes make lighting and contrasting colors important in offering the older person cues about objects or surfaces that might interfere with safe mobility. When the lens becomes cloudy it creates a condition known as cataracts, which also affects acuity. Macular degeneration is a condition that affects the retina, resulting in a central loss of vision. Visual changes can cause an increase in falls in the older population.¹⁰

Older people display a group of characteristics called presbycusis (“old people’s hearing”). This term refers to the decreased ability to perceive higher pitches and to distinguish between similar sounds.¹¹ Auditory acuity is also reduced. These changes must be considered and strategies need to be adopted (such as lowering of the voice, talking more slowly, or looking directly at the patient at all times) when instructions are given in a physical therapy session.

The tactile system is another sensory system whose changes may affect mobility. The tactile system provides important information regarding the texture and changes in the walking surface. Age-related changes reduce the amount of tactile information the individual receives regarding the environment. If an older person does not receive accurate information regarding the surface underfoot, ambulation may become altered or a loss of balance may occur.

Age-related changes in the cardiovascular system are complicated by the characteristic cardiovascular diseases of aging. For example, 67% of people over the age of 60 have hypertension (high blood pressure).¹² Non-Hispanic blacks (men and women) are more likely to be hypertensive than people of any other racial or ethnic group.¹³ It appears, however, that overall cardiac performance at rest is not altered by age in healthy people, although cardiac response to stress does differ. This is demonstrated by a decrease in maximum cardiopulmonary function and work capacity.¹⁴ Increased stiffness in the chest wall affects the respiratory system, which further reduces the effectiveness of cardiopulmonary function. These changes should be considered carefully in the design of exercise programs for individuals over 65 years of age.

Balance is a skill essential for safe and independent daily function. Limitation in balance and an increase in the risk of falling are common problems in older adults. Falls have been reported to occur in more than 35% of people over the age of 75.¹⁵ Static balance and dynamic balance are the result of a complex interaction of multiple systems subject to age-related changes mentioned previously. If any of these systems undergoes change, balance may be affected as well. A fall resulting from a loss of balance could expose the elder to a multitude of subsequent impairments, such as fracture or other trauma, pneumonia, decubitus ulcers, and loss of strength or range of motion. The psychosocial impact on the individual can also be disabling. Fear of falling and loss of confidence may cause the individual to become isolated or more sedentary. If the fall is serious enough to cause injury, the elder could lose the ability to safely live independently.

For many years one of the most common myths of aging was that cognitive function always significantly decreases with advanced age. In fact, people seemed to assume that dementia was inevitable. It is now known that deterioration of cognitive function characterized as dementia is related to Alzheimer’s disease or some other pathologic condition, not to aging itself. Reports indicate that 10% of the general population over 65 years of age, and 20% of people over age 85, display dementia.¹⁶ Health professionals serving older people are aware of how to recognize dementia and how to interact with people with dementia; however, the characteristics of dementia are not displayed universally by people over age 65 or even those over age 85.

Significant cognitive changes that do fall in the category of normal aging are in memory and conceptualization (tasks requiring abstract thinking).¹⁷ Specifically, the manner in which new information is stored (encoded) in the memory is altered. This leads to difficulty in retrieving newer information. Studies show that training in memory techniques, such as list organization, can improve recall in older persons.¹⁸

Psychosocial changes may affect people in older population groups. These vary widely based on the individual, family, environment, and presence of other changes or actual disease. What is important for the PT and PTA to remember is that understanding psychosocial issues is crucial to the success of any rehabilitation program. Social considerations such as adjustment to retirement, loss of lifetime roles (e.g., worker, parent, homeowner, athlete), living environment, and presence or absence of health insurance have a tremendous impact on the elder’s life. Older persons may be required to adjust to the loss of spouses, friends, and siblings. Psychiatric disorders such as depression, dysthymia (disorder of mood), and anxiety are more common among homebound older people than those who are able to be out in the community.¹⁹ The PT or PTA has a responsibility to bring signs of psychological problems to the attention of other members of the health care team.

Osteoarthritis

By far the most common problem for older people is one of the joint diseases described as arthritis. In 1995, 43 million people in the United States were affected by arthritis.²¹ African Americans have a higher rate of osteoarthritis (OA) than whites or Hispanics. OA most commonly affects the hands, spine, knees, and hips and occurs when the cartilage deteriorates owing to advancing age and/or obesity. Patients often complain of morning stiffness and pain on movement. This may alter a gait pattern or make simple tasks such as buttoning a blouse very difficult. It is important for the person with OA to maintain at least a moderate activity level while protecting the joints. PTs and PTAs can teach appropriate exercise routines (such as aquatic exercises) to maintain flexibility without excessively stressing the joints. For people who are excessively overweight, programs that address weight loss as well as exercise and joint protection are beneficial to reduce the stress on the joints. There are some facilities and therapists that specialize in treating such individuals. Their services may be referred to as bariatric programs.⁸ With an aging population and the escalation of obesity, the economic burden of arthritis is likely to continue to escalate.

Rheumatoid Arthritis

In contrast to OA, rheumatoid arthritis (RA) is a disease of the immune system that causes chronic inflammation of the joints. It is more common in women than in men, and the peak incidence occurs at 40 to 60 years of age.²² It is characterized by enlarged joints that are often reddened and warm to the touch. The affected joints are stiff and painful, usually more so in the morning or after extended periods of inactivity. This disease process leads to limited range of motion, joint deformity, and, eventually, progressive joint destruction. Typical physical therapy goals for the person with arthritis are pain relief, increased joint movement, assistive devices to facilitate independent function, and rehabilitation when joint surgery is required.

Pain relief may be provided by heat modalities such as hot packs or paraffin baths. The PT or PTA may teach the individual positioning principles for pain relief when in resting postures. Active range-of-motion exercises assist the individual in maintaining movement and flexibility necessary for function. Assistive devices such as canes or walkers may reduce pain in the affected joints during ambulation.

Total joint replacements of the hip and knee are common surgeries for older adults, undertaken to decrease the pain associated with arthritis and to improve function. When joint replacements are performed for a person with arthritis, the PT is involved with the patient or client before surgery as well as during the rehabilitation process. Before surgery the PT teaches the older person strengthening and flexibility exercises so the patient will go into surgery in the optimal condition. The therapist also teaches the individual important guidelines to follow after surgery, orders assistive devices, and reinforces the importance of exercise and rehabilitation after surgery. After joint replacements the PT and PTA provide interventions for maximizing muscle strength, joint motion, and ability to perform ADLs.