International keynote speaker Jennifer Bottomley discusses the role of geriatric physiotherapy in promoting health in the ageing adult.
The world’s population is ageing rapidly and with age, an increase in co-morbidities and a decline in functional abilities is seen. Frailty is a term to indicate a higher risk to adverse health outcomes. This seems to be a simple concept; however, in daily practice it is awkward for physiotherapists to work with the term ‘frailty’. Frailty is complex and dynamic and is often not recognised by the patient themselves.
There are multiple dimensions of frailty that need to be addressed by physiotherapists. I propose that we shift our perspective to view frailty as a complex diagnostic syndrome rather than approaching it in a piecemeal fashion based on speciﬁc systems impacting function (eg, visual, posture, neuromuscular etc). Screening to identify and manage risks for frailty may be key. Education and self-managed care, home modiﬁcations and caring for the caregivers may also be warranted in influencing function and slowing the progression of frailty.
Though it is difﬁcult to concisely deﬁne the term frailty, the concept of frailty is well understood in geriatric rehabilitation. It conjures up a clear mental image for most clinicians. Compromises in cognition, sensorimotor input and integration, and polypharmacy are some components of frailty. Decline in muscle strength and mass, respiratory reserve and cardiovascular functioning, kyphotic postural changes, poorer eyesight, poor hydration and marginal nutritional intake, and many other physiological and physical changes are also associated with inactivity and ageing. Combined, these changes lead to frailty. In other words, any of these conditions, in isolation or in combination, can create frailty.
The presence of multi-diagnostic situations in the elderly leads to multiple drug and nutrient interactions and complex medical management, with the frequently resulting side-effects of progressive loss in functional reserve and physiological homeostasis. Concomitant diseases such as congestive heart failure, renal disease, osteoporosis, diabetes, chronic lung disease and arthritis, to name a few, add to the level of medical complexity and resulting frailty.
Impaired physical functioning is certainly observed in older patients in hospital. With any admission for acute illnesses or injury in an older person, there is signiﬁcant short-term deterioration in mobility and other functional domains. As physiotherapists, we are well aware of the functional consequences of even a short period of bedrest in older adults. Decline in physical function, while a negative outcome in itself, has also been associated with a number of other adverse costs such as falls, disability and mortality.
Muscle weakness, atrophy and fatigue are key elements in the clinical manifestation of frail elderly. Sarcopenia is a decrease of muscle mass and muscle strength often seen in older adults. Scientiﬁc research indicates that an increase of physical activities appears to be the most promising treatment strategy in the rehabilitation of frail elderly individuals. Speciﬁcally, the muscles show positive results with training. To adequately train frail elderly, knowledge of the speciﬁc biological changes in muscles that occur with exercise is essential.
Physiotherapists play a major role in health promotion and are under- utilised in many settings. It is the responsibility of physiotherapists to step up to the plate in contributing to the health and wellbeing in ageing populations in community and global healthcare settings. The burden of disease increases with increased inactivity—which leads to the cascading events of increased disability, functional loss and a decrease in the quality of life. Physiotherapists are the experts in activity and exercise prescription and also have the knowledge to make healthy lifestyle recommendations.
As gatekeepers in the healthcare system, we play a role in referrals to other disciplines for health-related issues and other important components of health such as nutrition, medication use, stress management and the like. We could play a larger role in health education and in the integration of physiotherapy into disease prevention and disease management.
In addition, my lecture will address healthcare disparities, the impact of climate change, and opportunities for working with community and global healthcare providers across the spectrum of care.
While dramatic gains have been made, we need to seek ways to prevent frailty. It may help physiotherapists to reset our lenses on frailty. Though it shares many key features with many long-term conditions, frailty is not routinely identiﬁed or coded as a diagnosis in primary or secondary care. As a result, frailty is not a visible condition for health service planning and delivery. I propose that we explore what this means in terms of a more proactive, preventative health and social care response. In physiotherapy, screening and early intervention may be the key to maintaining the highest maximal functional capabilities and quality of life. I look forward to sharing evidence from intervention studies that support the value of physical rehabilitation for improving mobility and physical function in the elderly in presentations at this year’s conference.
Dr Jennifer Bottomley has a doctoral degree in gerontology (University of Massachusetts) and a second PhD in health service administration, legislation, and policy management with a specialty in gerontology (Union Institute).
Q&A: National keynote speaker Steven McPhail discusses the benefits and challenges of older people undergoing rehabilitation.
What are the most pressing problems that older people face when undergoing rehabilitation?
There are two different types of pressing challenges that come to mind for people undergoing rehabilitation. First, I should say that I think rehabilitation services for older adults in Australia are among the best in the world. I believe the high-quality healthcare professionals working in rehabilitation settings in Australia—in which physiotherapists feature prominently—are the envy of the world. However, it concerns me that it can be difﬁcult for people to navigate rehabilitation services, which can seem complex and fragmented at times.
It seems unfortunate to me that we have this wealth of expertise and experience among our rehabilitation professionals, but timely access without notable out-of-pocket patient costs remains a challenge unless people present to a public hospital. This is a shame because successful bouts of rehabilitation therapies are typically associated with substantial gains in functional independence and health-related quality of life.
Another notable challenge that older people face is maintaining functional gains once rehabilitation therapies have ceased. This is perhaps underpinned by the ever-present risk of returning to predominantly sedentary living after the completion of a cycle of physical rehabilitation therapies.
What aspects of rehabilitation do you think physios do well with older people? Where could we improve?
There are loads of things physiotherapists do really well. We are great at motivating older people to engage with therapeutic exercise and customising therapies to achieve whatever goals are important to each person. We are also great at helping people to work hard during rehabilitation sessions to achieve their goals. Physiotherapists are also good at customising their interventions to patients’ circumstances and abilities.
There are a few things we could do better too. I think one area where physiotherapists could improve is understanding the influence of exercise intensity and facilitating patients to be able to continue to work at appropriate intensity levels independently. Another opportunity for improvement may be the way in which we work with patients to help them establish lifestyle patterns and physical activity behaviours that help them maintain the beneﬁts of rehabilitation long into the future.
What are some of your key findings you think should shape physios’ approach to working with the older population?
Some important ﬁndings were about simply highlighting the extent to which older adults who have been recently hospitalised are at great risk of further injury and illness requiring subsequent hospitalisation. This is particularly important as physiotherapists and other health professionals ought to have a key role in trying to mitigate this risk. Of particular concern is risk of serious fall-related injuries—something physiotherapists in the community may be able to help prevent. Another important ﬁnding, which is probably no surprise to physiotherapists, was the large extent to which older people participating in rehabilitation can improve their physical function even at very advanced ages.
Professor Steven McPhail is the academic director of the Australian Centre for Health Service Innovation (AusHSI). He also leads the Health Management Discipline at the Queensland University of Technology and is part of @PhysiosforPA.
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