Physiotherapy For The Elderly

Hello and welcome back again to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy related. As community physiotherapists seeing our patients in their homes or quite often their care homes we have a large amount of experience of working with elderly patients and I wanted in this blog to have a look at how physiotherapy for the elderly/ older person is different from other forms of physiotherapy.

So, before looking at how physiotherapy for the elderly is different from other forms of physiotherapy, I think it is probably important to know what a physiotherapist does and also what the term “elderly” means in a modern context. Possibly we should start with thinking about who is elderly and at what age someone becomes elderly.

What Do We Mean By Elderly?

I have been wanting to write an article for a while on this topic of the difference between physiotherapy for the elderly and other forms of physiotherapy such as for those with sporting injuries, but I have always found it very difficult to define what is meant by elderly. Traditionally in the UK, we have taken it to mean anyone over the age of 65 (the state retirement age) but given the large increase in life expectancy (and the fact that I personally am getting closer to that age group!) it doesn’t seem like a very useful way of defining “elderly”. Possibly it is better to consider frailty and general health as a better way of considering if someone is “elderly”. For example, as a physio I have personally seen many people in their 80s who were physically fit, very healthy and very active and I have not treated these patients as if they were “elderly”, instead I have treated them as a patient for whom age is just another factor to consider when deciding what is best to do. However, I have also seen many patients in their 60s and early 70s for whom their frailty and poor health is a massive factor and quite clearly these people were “elderly”. This makes being clear who it is I am talking about when I use the term “elderly” quite difficult and as such we need to have some form of definition:

For the purposes of the rest of this article when using the term “elderly” I will be meaning someone who is over the age of 65 and is quite frail and may also be in poor health. At some points we may well talk about people who are quite old (over 75yrs etc) but are not elderly in that sense and how as a physiotherapist my treatment and advice may vary.

What is Physiotherapy?

It is probably best before we look at what a physiotherapist is, to have a look at what the profession of physiotherapy involves as it encompasses a huge amount. Physiotherapy is a wide ranging profession and is hard to define in one single sentence but the Chartered Society of Physiotherapy (Professional body of Physios) defines it as: 

"a healthcare profession that works with people to identify and maximise their ability to move and function." 

Physiotherapy plays a key part in enabling people to improve their health, wellbeing and quality of life in a variety of ways including by the use of soft tissue massage, spinal manipulation, exercises and rehabilitation. Physiotherapy is involved with recovery after operations such as a knee replacement and also after a person has had a stroke. Physiotherapy is an autonomous profession. This means that physiotherapists can accept referrals for assessment from a range of sources: from an individual themselves (self-referral) or from other people involved with that individual. There are a large range of interventions, treatment options and benefits that physiotherapy can offer and also a range of different types of physiotherapy including neurological physiotherapy, paediatric physiotherapy, sports physio and post-operative physiotherapy to name but a few!

What Is A Physiotherapist?

Fortunately unlike what physiotherapy is, the answer to this question is relatively simple. A physiotherapist is anyone who is registered with the HCPC (Health & Care Professions Council) as a physiotherapist. To be registered with the HCPC you need to have a passed an approved physiotherapy course (usually a degree). As discussed above the scope of physiotherapy is very broad and as a physiotherapist you could be treating children all the way through to the very elderly with an enormous range of problems.

Why Does Being Elderly Make A Difference To Physiotherapy

Before considering how physiotherapy might be different for an elderly person we need to look at the factors that make being elderly different to someone in their 30s. It seems obvious that there would be differences between a 30 year old and a 90 year old but what actually might these differences be?

1. Sarcopaenia: this simply means muscle loss and is something that happens in old age. After a certain age (this is debated but 75yrs would seem a reasonable number) people struggle to maintain the muscle mass that they have and will start to lose it unless they actively work to preserve it. This has the side effect of making older people weaker and making it harder for them to walk and get up out of a chair for example.
2. Osteoporosis/Osteopaenia: this describes the loss in bone density that commonly happens as people age and makes them vulnerable to fractures if they have a fall.
3. More Medical Conditions: as we age we tend to develop more medical conditions such as diabetes, underactive thyroids, heart disease etc
4. More Medicines: alongside having more medical conditions, as people age the number of medicines that they take slowly increases.
5. Neurological Conditions: most of the common neurological conditions such as strokes and Parkinson’s Disease are strongly linked to aging and are much more likely the older one gets.
6. Falls: as our previous blog highlighted as people age there is a tendency for them to have falls and often break bones or injure themselves.
7. Dementia: unfortunately age is very much linked to the likelihood of having dementia or Alzheimer’s.
8. Needing Care: the likelihood of needing care increases substantially as people age and many elderly people will have carers visiting their home several times a day.
9. Living in a Care Home: although many people may choose to have care at home, others may choose to move into a care or nursing home.
10. Relatives Organising Physiotherapy: it is very common for a relative to be the person organising physio as often the elderly patient may be unwell or lack sufficient capacity.

I think from reading the factors above that you should be able to see that there are likely to a wide range of differences between a patient in their 30s and one in their 90s and the physiotherapist seeing them will need to consider this and adapt their assessment and treatment to the individual situation.

What Is The Difference Between Physiotherapy For The Elderly & The Young/Fit & Healthy?

To answer this question it might be helpful to have a look at a typical home visit physiotherapy session for a patient in their 30s and a typical session for a person in their 90s and then we can look afterwards in more detail at the adaptations that a physio will need to make when seeing an elderly patient.

Male 30s Session at Home:

In this case our patient emailed to ask for an appointment because he had low back pain that had flared up and wasn’t going away. We booked a session via email for later that week and our physio attended with a plinth/massage table. The patient answered the door himself and the session took place in the lounge. Initially a conversation took place between the physio and the patient to establish the problem and in this section the physiotherapist found that the patient had no relevant medical history and the only medication was some painkillers. The physical assessment took place with the physio watching the patient move and then the patient moved onto the plinth where the physio physically assessed his back by palpating (touching) at various levels. Treatment of massage and some manipulation was given and then the physio prescribed some exercises and gave advice which the patient made a note of. A follow up session was booked and the patient made a note of this themselves and paid via card machine. Now, I can imagine anyone that has seen a physio in the past will be reading this and thinking this is all very obvious stuff but if you bear with me and read the section about our 90yr old patient you will see some stark differences in the session despite the complaint being the same (low back pain).

Male 90s Session At Home:

This session was booked by the patient’s daughter and was done via email with the daughter disclosing all relevant information and requesting to be there for at least the first session. Due to availability of the patient’s daughter it took a week or so to book the session and we also needed to avoid care visits (patient had 4 care visits a day which meant that timing the session between these was important). The physiotherapist attended the home and was let in by the patient’s daughter, although the physiotherapist had a plinth in the car this was not brought in at this stage.  The patient himself was in the lounge in a large “rise and recline” style chair with a zimmer frame in front of him and had a catheter in-situ. The initial discussion took place with the patient’s daughter being present and she answered the majority of the past medical history questions and general background questions. Although, the patient had capacity his hearing and memory was poor and clearly the daughter had most of the key information. The physical assessment showed that the patient struggled to move from sit to stand, that he was generally very weak and deconditioned and that his back pain was secondary to weakness and lack of movement. The assessment also showed that he was quite unsteady and at a high risk of falls. As such, a programme of exercises was prescribed and initially twice weekly sessions were recommended in order to improve his general strength and balance. The daughter of the patient paid for this initial assessment via card but then agreed to pay for any future sessions via bank transfer as she had power of attorney for her father.

I think it is clear from the 2 sessions that even though both patients had a physio visit them at home there are significant differences between the sessions and that the physiotherapist needed to make a significant number of adaptations to the sessions. Below I have listed what are in my opinion some of the key differences between physiotherapy for the fit and healthy and for the elderly:

1. Relatives: many elderly patients will have the bookings made by their relative and during the session the relative will often be present (at least for the initial assessment). This means that the physiotherapist will often need to discuss progress, goals and best management with the relative.
2. Care: often our elderly patients have substantial amounts of care entering the home in order to support them. This presents a challenge for the physiotherapist (and us as a practice) in terms of arranging our sessions so that we are not there at the same time as the carers. Care visits often vary daily in their timings and the physio will need to work around this.
3. Long-Term Rehab: many of our elderly patient need a much more long-term approach to physiotherapy and maintaining their mobility and strength. In the initial period the patient may be seen several times a week in order to get them to improve as quickly as possible but after that it is often necessary for the physiotherapist to continue visiting the patient weekly in order to maintain the gains that they have made.
4. Larger Medical History: seeing elderly patients as a physio means being comfortable with and knowledgeable about a much wider range if medical conditions than with younger patients. As a physiotherapist seeing elderly patient you need to have a good working knowledge of medications and their likely side effects and also the range of conditions that elderly patients are likely to have and how these may affect them in a particular session.
5. Slower Pace of Session: many of our more elderly patients need much more rest and recovery in their physiotherapy session than our younger and fitter patients and as such we always schedule a one hour session. This allows a relaxed pace of activity and work in the session and gives the patient time to recover and chat about any issues.
6. Falls: often mobility and balance is reduced in the elderly and any physiotherapist seeing an elderly patient needs to be much more cautious about the potential for that patient to have a fall and injure themselves.
7. Dementia: some form of cognitive decline is much more likely in elderly patients and as such the physiotherapist will need to adjust the session and how they communicate. It is often also unrealistic to expect the patient to remember to do any exercises in between sessions.
8. Poor Hearing: this can make communication much harder and many elderly patients with poor hearing rely upon seeing a person's lips move and as such the physiotherapist will need to work on ensuring that they communicate clearly to the patient.

Conclusion

So, what can we learn from the above information? Well, simply put physiotherapy for the elderly and frail requires a different approach and a different set of skills from the physio. Seeing elderly patients requires the physiotherapist to make a significant number of adjustments and adaptations to the sessions and have a much wider knowledge of medical conditions and medicines. Okay, I hope that you have found this article about physiotherapy for the elderly helpful. Should anyone you know need be elderly and frail and need help with physiotherapy please get in touch and one of our physios would be happy to help. Just to remind you we are a home visit physiotherapy service and our physios are mobile and will come out to you at home.