Introduction to Geriatric Physiotherapy1

Geriatric Physiotherapy is a branch of health care system that deals with elderly care. It provides the knowledge regarding the health problems which are particularly experienced by a group of elderly. This knowledge can assist physical therapists in understanding the principles and perspectives that come into play when caring for the aged and even sometimes altering outcomes through preventive measures. It also provides the useful information regarding the prevalence of a particular condition and its incidence in elderly. Physical therapists can use this information to establish the goals of health care with older patients.

By convention, elderly is defined as being 65 years of age or older.¹

As patients age, there is a transition in the health care, from primary prevention and curative interventions to secondary prevention and chronic disease management. To understand the complexity of the problems of aging patients and help them enjoy optimal quality of life, they are classified into smaller age ranges. In part this classification arose because the objectives of patient care change with advancing age.

Three groups have been identified:

Young-old: This group consists of the populations between 65 and 75 years of age. The young-old are somewhat similar to middle-aged patients. They have minimum level of disability. Hence the research studies pertaining to exercise physiology are mostly carried out in this particular group. With the average life expectancy of about 15 to 20 years, physical therapy is aimed at primary prevention of diseases. For example, by participating in a weight loss program, the obese patients can reduce their risk for cardiovascular disease. Similarly an appropriate combination of endurance and strengthening exercises can slow down the rate of decline in neuromuscular functions.

Middle-old: The populations between 75 and 85 years of age are included in this group. They exhibit the occurrence of chronic diseases. Physical therapist should exert the aggressive efforts to deal with the problems like osteoporosis, diabetic neuropathy, falls, etc. There is a decline in additional years of life expectancy. Physiotherapy is directed at the improvement of functional status in the finite remaining years.

Old-old: This group comprises of the populations older than 85 years of age. With the average additional life expectancy of 5 to 6 years, the old-old have the limited survival benefits from screening tests or therapeutic interventions. Taking this into account, physical therapist should concentrate on achieving human comfort. For example, passive movements, including trunk turning, positioning in bed or chair, warmth, attention and eye-to-eye contact have the great significance for the happiness of patients.

In the 20th century the elderly population has represented the fastest growing segment of total world population. However, these demographic changes were high-flying in developed countries. For example, in United Kingdom the population of people over 65 years has increased from 5 percent to 16 percent in this period. Figure 1.1 shows the increases in elderly population of America over the last hundred years.

This is in contrast to America where currently 13 percent of elderly population will approach 22 percent by 2030 (Figs 1.2 and 1.3).

Following factors contributed in the demographic changes occurred in the last century:

The changing scenario of the demography of elderly has a major impact on the health and social services. Life expectancy today is 74 years for men and 80 years for women, a remarkable rise in longevity from 100 years ago, when men lived an average of 48 years and women an average of 51 years¹. While gains in average life expectancy is the indicator of nation's well being, it does not imply that these additional years of life are the quality years. Rather, it has been postulated that there is an exponential increase in disability, and mental and physical morbidity, in individuals over the age of 75 years. In the UK, the estimated prevalence of those with severe disability is less than 1 percent in those aged 50–59, but 13 percent in those aged over 80 years.² Olshansky and others have also argued that there will be an expansion of morbidity as medical technology improves the likelihood of survival from previously fatal diseases without improving overall quality of life for these individuals.³ Hence it is imperative to evaluate the status of elderly in detail so as to understand the role of Geriatric Physiotherapy in modifying and upgrading the quality of life in old age.

There are 77 million older persons in India according to 2001 census, of which 37 million are males and 40 million are females. This shows significant probability of older women for living longer than their spouses. There is also a significant chance of women living alone. This is largely because of widowhood, creating a lot many problems for them. At present, 19 million elderly women are widows, 80 percent of them live in villages, a majority in the unorganized sector with no pension plans, provident fund, gratuity or medical cover as security in trying times.

Financial and emotional support is of utmost importance for elderly as poverty and dependency increases with age. Loss of spouse and distance of family often results into loneliness. In India, 12 percent of elderly population is living alone in villages and 10 percent in cities. The reasons as to why poverty increases with age may be that the cost of medications, professional services and personal help increases with age, whereas incomes do not. 40 percent of Indian elderly population is living below the poverty line.5

Interdependent relationships between disease, disability and death in elderly are well known (Fig. 1.4). As individual ages, there is a gradual but definite reduction in physiological capacity of various systems like musculoskeletal, cardiovascular, neuropsychiatry and immune. This makes the elderly predisposed to certain diseases like arthritis, hypertension, stroke, dementia and infections. As an outcome, there is a decrease in functional capacity of elderly causing social isolation, depression, chronic disability and ultimately death. The three most common causes of death in elderly are coronary heart disease, cancer and stroke.⁴ Over last three decades, the mortality rate from CHD has come down; still it remains the leading cause of death in elderly population throughout the world. In 1988, arthritis was the most prevalent self-reported condition of elderly, followed by high blood pressure, hearing impairments and heart disease. These conditions are even more prevalent among elders who are alone and poor.⁹

With the outburst in the number of elderly in our society, it has become a challenging job for the physiotherapists to promote health and prevent disability in individuals over 65 years of age. Unfortunately, at present the physiotherapists specialized in geriatric physiotherapy are few in number. Hence, it is need of the hour to enhance the existing knowledge and skills for the management of continually growing patient's physiotherapeutic needs while maintaining high quality care and services.6