Geriatric Rehabilitation Manual - 2nd Edition

496 SOCIAL AND GOVERNMENT IMPLICATIONS, ETHICS AND DYING obligations. Therefore, an underlying motivation in effecting the dis- Ethics and long-term care charge or transfer of a patient from an institution may be the adminis- trative obligation to insure that the institution remains viable. This Long-term care, in current health services delivery, refers to a broad obligation may be seen to supersede the obligations of the institution to range of services that are available to assist an individual who has the community, the medical staff, and even the patient. As a result, the functional impairments. These services can include personal care, needs of individual patients may playa relatively minor role in ethical social support and health-related services. Settings for the provision frameworks espoused by some administrators. Rather, in this context, of long-term care include an individual's home as well as a variety of a patient's needs are balanced against the needs and interests of others. institutional setting. The same ethical issues described above arise in the care of any older person receiving long-term care. This may pose an ethical dilemma for those caregivers directly As noted previously, a primary ethical concern in decisions about involved in effecting an appropriate discharge plan for an individual long-term care involves the admission process itself. Frequently, patient (Spielman 1988). decisions are made with little respect for patient autonomy. An indi- vidual may be denied the right to choose what is perceived as a risk- Discharge plans that involve placement in long-term care are often laden choice (to remain at home), and that may be a violation of his among the most difficult. The health delivery system provides the or her autonomy. In order to preserve autonomy and allow a patient older individual with little opportunity to choose either the site of care to return home, he or she must understand the risks and conse- or its details. Such decisions are often made by discharge planners or quences and must also understand that the decision should not have social workers who have little opportunity to consult with the individ- an adverse impact on the rights of others. ual patient. Frequently, the discharge plan is determined without dis- cussing the circwnstances with the patient, family or caregiver, and is Another consideration in long-term care is the issue of privacy and based on the physician's judgment that the older patient 'needs dignity. Providers of geriatric rehabilitation services must be cog- 24-hour care'. Additionally, the patient is rarely informed that the pri- nizant of individual dignity when assisting with personal care ser- mary purpose of the discharge planner is to facilitate prompt discharge vices such as bathing and toileting. In institutional settings, sensitivity while automatically following rules for referral to postacute care set- to issues of privacy and dignity must be heightened, as the environ- tings. The older individual is expected to make a critical life decision ment, by its nature, is not conducive to either. Examples of situations with inadequate time and information and may be being advised by that may lead to violation of these rights include multiple occupancy professionals who have not fully disclosed the constraints imposed on rooms, responsiveness to call buttons, and the use of first names with- them by their jobs. Furthermore, little consideration is given to the indi- out permission from the patient. vidual's right to make an informed, autonomous decision to return home when that decision is considered risky or hazardous by the Rehabilitation in long-term care may evoke ethical dilemmas physician or healthcare team. This is often the result not only of the unique to that setting. By definition, rehabilitation implies fostering healthcare professionals' desire to do what they know is best for maximum patient independence in functional tasks. Geriatric patients the patient, but also of the fear of litigation resulting from the adverse seek long-term care precisely because they are dependent to some outcome of a risky discharge decision (Kane 1994). degree. An ethical challenge exists between respecting a patient's autonomy and complying with his or her request for help and encour- Recurrent ethical conflicts may revolve around discharge orders aging independence. In a broader sense, a similar challenge may exist that violate the conscience of those caring for the patient but do not in decisions related to protecting a patient from risky situations such as necessarily violate the law. An example of a recurring theme seen in falls or adverse health events. Healthcare providers must determine geriatric care would be situations in which discharge is planned for when a person needing care should be allowed to consciously choose a patients who are medically ready, but a discharge location that meets course that professionals consider risky in order to maximize values vs, the patient's and family's need is not available. In these situations, the allowing a patient to be unattended and potentially unsafe. therapist and discharge planner recognize that the geriatric patient's needs may be in conflict with the discharge order. In this case, it may be The lack of patient autonomy in long-term care living environ- argued that hospitals are held to a higher standard than a patient's ments may be the result of the caregivers' and administrators' roles, medical status alone. Discharge must not be effected until there is ade- their job descriptions, the physical environment, and the regulations quate care and support in the home or an appropriate healthcare facil- that govern these institutions. Administrators and staff may be trained ity. The institution must not discharge a patient under adverse to be task oriented, which provides little opportunity to consider conditions, whether of medical status or social support. On the other autonomy or even clients' involvement in daily decisions about their hand, patients have no right to prolong their stay simply because they own care. The physical environment is often one of little space for stor- are comfortable or the desired discharge destination is not available. age of clothing and personal possessions, minimal security for per- Patient autonomy is not absolute in this example, and questions of dis- sonal items, and limited privacy. Care plans and routines dominate tributive justice must be considered, and patient's rights must be bal- the timing and the content of daily activities. Regulations, although anced against institutional policies. The institution might argue that designed to protect the welfare and safety of residents, frequently dis- the patient is entitled to be discharged to a facility as long as it meets courage residents' participation in decision-making and often allow for minimally acceptable criteria, and has no right to demand discharge to little freedom of choice. Examples include restrictions on what residents the best possible facility. Such a discharge would serve the principle of can keep in their rooms, requirements about supervision and the chart- justice as this same standard would apply to all patients. On the other ing of patient activity, and safety requirements. Conversely, some regu- hand, consistency offers only a minimal standard of justice. It does not lations may enhance patient autonomy, such as those that mandate the take into consideration the impersonality of the institution in enforcing availability of consumer information, enforce privacy regulations, and its own regulations. In attempting to do the right thing in these cases, place limits on the use of restraints (Kane 1994). the therapist and discharge planner are continually presented with a hopeless choice and an unfair set of circumstances. There are no easy The Center for Advocacy for the Rights and Interests of the answers at the individual case level. In these types of situations, practi- Elderly (CARIE) developed a curriculum for guiding and improving tioners may look to preventive ethics, which focuses on the overall ethical decision-making in long-term care. The program is based on problem rather than the individual case. The right thing to do, then, the premise that long-term care involves the overall well-being of the becomes the mandate to change conditions so that a more equitable, resident, including the emotional, spiritual, psychological and social ethical solution may be effected for future cases (Moody 2004). well-being, as well as the physical health of the resident. It takes into account the relationships that exist with family members, friends,

Ethics 497 and staff that may be supported and strengthened by including them It should be noted that the use of restraints without the patient's in the resident's care. The program recognizes that long-term care informed consent may be legally restricted. The Omnibus Budget residents have physical dependencies and often suffer from dement- Reconciliation Act (OBRA) of 1987 strongly implies that nursing facil- ing illnesses, and recognizes that the experience of dependency is ities must obtain informed consent for whatever approach is takeri to magnified by the variety of ways in which a resident relies upon effect resident safety. Also, the Fourteenth Amendment to the US facility staff. The Center's model recognizes that traditional bioethics Constitution guarantees freedom from harm and unnecessary is inadequate to address the ethical issues confronting staff and resi- restraints (Moss & LaPuma 1991). dents in long-term care. The resulting curriculum, 'Promises to Keep: Creating an Ethical Culture in Long-Term Care', represents an ethics It may be ethically permissible to override the refusal of a compe- education curriculum that proposes commitment to the resident as tent patient to apply a mechanical restraint if that individual is jeop- the ethical basis of the long-term care admission. The program iden- ardizing the safety and welfare of others. In such cases, the ethical tified five themes: health, safety, pain and suffering, respect for per- principle of preventing harm to others supersedes the patient's right sonhood, and life story. These themes are coupled to commitments to to refuse, and the negative rights of an individual to be free from preserve and promote the resident's health, protect the resident's interference ends as the autonomy of others is violated. In this case, safety, palliate the pain and suffering, practice respect and care for the the professional must balance professional responsibility to an indi- attributes of personhood, and provide opportunity and support for vidual patient with societal and legal obligations to protect public the continuation and completion of the resident's life story. In this health (Moss & LaPuma 1991). model, health is concerned with maximizing functional ability rather than curing disease, and safety addresses the resident's interaction If restraints are used as a punitive measure, there is no ethical jus- with the external environment. Spiritual and emotional pain is tification for their application. Such a practice would be defined as deemed to be as important as physical pain. Life story is viewed as a abusive. continuation of that person's being, and involves honoring, encour- aging and supporting in the resident the qualities that are associated When the use of restraints is consistent with treatment goals, their with personhood including self-awareness, intentionality, decision- application may be ethically indicated. One example is when a making, agency, emotions, relationships and creativity. CARIE devel- restraint such as wrist cuffs is applied to prevent interference with a oped a five-step process called IDEAS, which provides a framework life-sustaining treatment such as a nasogastric tube. In such cases, it for working through care dilemmas to reach ethical solutions. The should be emphasized, the treatment goal is to restore the patient to steps are: (i) identify the ultimate issues, stakeholders, and other deci- health (Moss & LaPuma 1991). sion points; (ii) develop a resident narrative; (iii) explore all conceiv- able responses to the issue; (iv) assess each response in light of the Managed care provider's commitments to the residents; and (v) select a course of action and create an implementation plan. This program contributes Part of the tradition of health professionals' service toward society's to care providers' ability to identify ethical dilemmas and provides a common good is based on the notion of altruism, or selfless concern process for examining and sensitively resolving problems that are for the welfare of the patient. Patients are viewed not as customers, unique to long-term care (Mathes et aI2004). but as individuals who are vulnerable and require the intervention of the healthcare provider. In tum, physical therapists promise to meet Restraints the health needs of the patient under the ethical principles of do no harm and provide benefit, while fostering autonomy and justice. In The use of restraints in the care of the elderly poses several ethical and essence, the healthcare professional is a trustee who works for the legal questions that must be addressed by healthcare providers. A good of the client and knows the limits of his or her expertise. restraint is defined as any device that restricts freedom of movement. However, in the current healthcare delivery system that embraces The rationale for restraint use with the elderly is frequently cited as managed care principles, this concept may be challenged, especially prevention of injury to self or others, but often the underlying motiva- when treating older patients who come to us with complex medical tion is fear of institutional liability. and social problems that require our professional expertise and inter- ventions (Nalette 2001). As such, managed healthcare poses special When considering the use of restraints to control a patient for challenges in geriatric rehabilitation and ethics. One consideration is safety or because of behavior, the rehabilitation professional must be the managed care organization, structure and function itself. In the cognizant of the fact that the literature reports little scientific basis to managed care structure, there are multiple actors with incompatible support the efficacy of restraints in safeguarding patients from harm interests. For example, the rehabilitation provider has a fiduciary (Hieleman 1991, Moss & LaPuma 1991). In fact, adverse effects cited responsibility to patients, but may also be an employee of or contractor in relation to restraint use include such consequences as reduced with the organization. The organization itself may have legal and finan- functional capacity secondary to immobilization, as well as physio- cial obligations to shareholders to maintain low cost, yet an ethical obli- logical changes including contractures, decreased muscle mass and gation to patients to provide quality care. strength, loss of bone integrity, decubitus ulcers, and adverse psycho- logical response to stress. It should also be noted that, with respect to Another current source of ethical conflict is the morality of geriatric rehabilitation, the use of restraints is inconsistent with and market-driven healthcare, which has the potential to threaten profes- frequently in conflict with the goals of rehabilitation (Hieleman 1991). sionalism. The introduction of market-driven practices into health- care may divide professional loyalties between providing the best Hieleman (1991) identifies several issues that must be addressed treatments in order to improve the patient's quality of life and keep- when weighing the option of using restraints: ing expenses to a min-imum by limiting services, increasing effi- ciency, and lesse-ning the amount of time spent with each patient. • informed consent; The result may be that the professional must choose between the best • risk vs. benefit analysis; interests of the patient and economic survival. Frequently, reimburse- • determination of competency; ment drives the care. • the resident's rights and empowerment; and • risk reduction. The integrity of the patient-provider relationship may also be threatened in the current healthcare delivery climate. Focus on the patient is the primary concern of healthcare. Managed care, however, may threaten this relationship through policies that deny access to care,

498 SOCIAL AND GOVERNMENT IMPLICATIONS, ETHICS AND DYING restrict the professional's ability to perform tests, and withhold or limit appropriate stewardship of healthcare resources. One tenet of this treatment. Such policies create conflicting loyalties and undermine the principle is that a clinician's first and primary duty is to promote the trust between provider and patient. The provider may be in the dual good of the patient while honoring the responsibility to practice effec- and potentially conflicting positions of being guardian of society's tive and efficient healthcare that utilizes healthcare resources respon- resources and being a primary advocate for the individual patient sibly. It also states that health plans should engage purchasers in (AMA 1995, Kassirer 1995, Rodwin 1995). With respect to geriatric discussions about the health coverage that can reasonably be met, and patients, it can be stated that, ethically, the profession may not be able that health plans should work with purchasers to insure that benefit to afford to rehabilitate someone who is about to die, in which case packages are consistent with the healthcare needs and cultural norms rehabilitation would not be effective anyway. On the other hand, it is of the purchasers' constituents. Contracts must not only contain costs, imperative that the professional never withholds treatment just but should enhance efforts to improve quality care. Principle III states because a person is old. The difficulty lies in detennining who is ready that all parties should foster an ethical environment for the delivery of to die and who may benefit, and how much, from rehabilitation efforts. effective and efficient quality healthcare. Financial incentives should enhance the provision of quality care and support professional ethical Managed care may impact on the ethical principle of patient obligations. Principle IV states that patients should be well informed autonomy, and it potentially threatens the patient's freedom of about care and treatment options and the financial and benefit issues choice. When healthcare coverage is provided as an employee or that affect the provision of care (Povar et al20(4). retirement benefit, the employee's choice may be even more restricted. In order to take advantage of healthcare coverage as a Elder abuse benefit, the employee or retiree is often forced to accept a plan that limits service access and does not meet healthcare needs. A person Abuse of the elderly may take many forms, from causing actual phys- has the responsibility of understanding the terms of his or her own ical harm or mental anguish to denial of needed medical and social healthcare plan (AMA 1995,Emmanuel & Dubler 1995). services to financial exploitation. Abusive behavior toward the elderly may come from family members, caregivers or healthcare One more factor related to patient autonomy is the perceived providers themselves. Often, the abuse may not be overt or inten- right to have all treatment choices funded. It is paramount to tional, but may stem from personal and professional values, includ- acknowledge that autonomy does not guarantee funding. Rather, ing the desire to protect the elderly patient at the expense of his or her some balance must be achieved between conserving society's health- right to make autonomous choices. care dollars and paying for ind-ividual healthcare needs. Providers and elderly patients must recognize that autonomy also entails One ethical consideration that must be acknowledged when health- responsibility. It obliges individuals to use resources wisely, to assist care providers become aware of actual abuse is the need to maintain a in conserving resources, and to live a healthy lifestyle. balance between sensitivity to patient trust and the need to abide by regulatory statutes that mandate reporting. This is especially important In 2000 and 2001, the American College of Physicians, with the if knowledge of the abusive situation was gained through confidential Harvard Pilgrim Health Care Ethics Program, convened a group of disclosure of information (Guccione & Shefrln 1993). patients, physicians, managed care representatives and medical ethi- cists. The purpose of the meeting was to develop a statement of ethics As recognized previously, components of elder abuse must be for managed care. The statement that they developed offers guidance acknowledged in discharge planning, use of restraints and denial of on preserving the patient--elient relationship, patient rights and services enforced through regulations and managed care. responsibilities, confidentiality and privacy, resource allocation and stewardship, the obligation of health plans to foster an ethical envi- CONCLUSION ronment for the delivery of care, and the clinician's responsibility to individual patients, the community and public health. The statement Ethical concerns and sources of conflict abound in regard to the reha- identifies four ethical principles to address the ethical challenges bilitation of the geriatric patient. It is imperative that the healthcare posed by limitations realized in association with managed care and practitioner who works with elders should be sensitive to these that recognize that healthcare resources should be distributed justly. issues, understand the underlying ethical principles, acknowledge Principle I addresses the relationships that are critical in the delivery the legal basis of these principles and incorporate moral values into of health services. It states that health plans, purchasers, clinicians the decision-making process. and patients should be characterized by respect, truthfulness, consis- tency, fairness and compassion. Principle II states that health plans, purchasers, clinicians and the public share responsibility for the References Available: http://www.apta.org/ AM/Template.cfm?Section= Ethics_and_Legal_Issues1&CONTENTID=23729&TEPLATE= / American MedicalAssociation(AMA) 1995Council on Ethical and CMM/ContentDisplay.cfm. Accessed April 6, 2006 Judicial Affairs, Ethicalissues in managed care. JAMA273:338-339 Brindle N, Holmes J 2005Capacity and coercion:dilemmas in the discharge of older people with dementia from general hospital American PhysicalTherapy Association (APTA) 2003, Professionalism settings. Age Ageing 34:16-20 in PhysicalTherapy.Available: http://www.apta.org/AM/ Dubler NN 1988Improving the discharge planning process: Template.cfm?Section=Professionalism/&TEMPLATE=/CM/ distinguishing between coercion and choice.Gerontologist ContentDisplay.cfm&CONTENTID=21299. AccessedApril 6, 2006 28:76-81 ElliottC 1992Where ethics comes from and what to do about it. American PhysicalTherapy Association(APTA) 2006a, AMA Code of Hastings Cent Rep 22:28-35 Ethics.Available: Emmanuel EJ, Dubler NN 1995Preserving the physician-patient http://www.apta.org/ AM/Template.cfm?Section= Ethics_and_Legal relationship in the era of managed care. JAMA273:338-339 _Issues1&CONTENTlD=21760&TEMPLATE= /CM/Content Display.cfm. AccessedApril 30, 2006 American PhysicalTherapy Association (APTA) 2006b, APTA Standards of EthicalConduct for the PhysicalTherapist Assistant

Ethics 499 Guccione AA, Shefrin DH 1993 Ethical and legal issues in geriatric Purtilo R 2005 Ethical Dimensions in the Health Professions, 4th edn. Elsevier Saunders, Philadelphia, PA physical therapy. In: Guccione AA (ed.) Geriatric Physical Therapy. Ries E 2003 The art and architecture of caring. PT Mag 11(4):36-43 Mosby-Year Book, St Louis, MO Rodwin MA 1995 Conflicts in managed care. N Engl J Med 332:604-607 Scott RW 1997 Informed consent. In: Scott RW (ed.) Promoting Legal Haddad A 2000Acute care decisions. Ethics in action. RN 63:21-22, 24 Awareness in Physical and Occupational Therapy. Mosby, Henderson ML, McConnell ES 1997 Ethical considerations. In: Matteson StLouis, MO Spielman BJ1988 Financially motivated transfers and discharges: MA, McConnell ES, Linton AD (eds) Gerontological Nursing administrators' ethics and public expectations. J Med Humanities Concepts and Practice, 2nd edn. WB Saunders, Philadelphia, PA Bioeth 9:32-43 Swisher LL 2005 Ethics in geriatric physical therapy. An independent Hieleman F 1991 Restraint reduction in nursing facilities: the issues home study course for individual continuing education. Section on Geriatrics, APTA involved in decision-making. Geri-topics 14:26-27 Torrens PR 2002 Overview of the organization of health services in the United States. In: Williams SJ,Torrens PR (eds) Introduction to Kane RA 1994 Ethics and long-term care. Clin Geriatr Med 10:489-499 Health Services, 6th edn. Delmar Publishers, Albany, NY WCPT 2006 World Confederation for Physical Therapy. Declarations of Kassirer JP 1995Managed care and the morality of the marketplace. Principle, Appendix to WCPT Ethical Principles. Available: N Engl J Med 33:50-52 http://www.wcpt.org/policies/principles/appendixethical.php. Accessed April 6, 2006 Mathes M, Reifsnyder J, Gibney M 2004 Commitment, relationship, Weiss GB 1985 Paternalism modernized. J Med Ethics 11:184-187 Wong RA, Barr JO, Farina N et a12000 Evidence-based practice: voice: cornerstones for an ethics of long-term care. Ethics, Law, a resource for physical therapists. Issues Aging 23(3):19-26 Aging Rev 10:3-24 Moody HR 2004 Hospital discharge planning: carrying out orders? JGerontol Social Work 43:107-118 Moss R], LaPuma J 1991The ethics of mechanical restraints. Hastings Cent Rep 21:22-25 Nalette E 2001 Physical therapy: ethics and the geriatric patient. JCeriatr Phys Ther 24(3):3-7 Povar Gj, Blumen H, Daniel J et al 2004 Academia and clinic. Ethics in practice: managed care and the changing health care environment: Medicine as a Profession Managed Care Ethics Working Group Statement. Ann Intern Med 141:131-136

501 Chapter 76 Physical therapy and the generational conflict Timothy L. Kauffman and Megan Laughlin CHAPTER CONTENTS being 'warm-hearted') to our children and grandchildren. This sim- plistic either/ or verbiage is the source of an increasingly intense gen- • Introduction erational conflict that pits one generation against another. • Partisan politics A similar perspective was promoted by a World Bank economist concerning the aging population in the former Soviet bloc countries of • Demographics Eastern Europe. 'I tell people in Eastern Europe that pensions policy is impoverishing their children. The demands of pensioners are taking • Political Decisions food out of the mouths of working people's children' (Kohli 1996). • Former soviet bloc Dollars, euros, yen, and the other monetary units drive this con- flict, aided by partisan politics, abuse of elders by the media (Cohen • Paradigm shift 1994) and in health delivery (Commission for Healthcare Audit and Inspection, CHAI, 2006) and sensationalism. Political concerns about i • The role of healthcare providers healthcare costs are heard around the world, especially in countries with aging populations. , • Noeasy answers The generational conflict can also be seen in the workforce as mid- I • Conclusion dle-aged and older people hold the highest paid and most authorita- tive jobs. Because those positions are occupied, younger people cannot L_ move up the business ladder as easily. In the US, there are approxi- mately 77 million people who were born between 1945 and 1963, the INTRODUCTION 'baby boomers'. Beneath them in age is 'generation X, born between 1964 and 1983, which is about 48 million strong (Karp & Sirias 2(01). The conflict between the older generation and the younger genera- This is part of the demographic that is manipulated in the conflict of 'us tion is an age-old problem. The issue is particularly poignant in soci- against them', especially because older people use more healthcare and eties and nations that do not venerate their seniors. Physical therapy social security/pensioner dollars/euros (Vladeck 2(05). care in an aging world population was the subject of an editorial 19 years ago in which T. F. Williams, former Director of the National DEMOGRAPHICS Institute of Aging in the United States, was quoted as saying, 'Of all human beings who have ever lived on the earth and have reached According to World Health Organization data, in 2000 there were age 65 years, the majority are alive today' (Williams 1987). 'This 600 million people living in the world who were aged 60 years and statement holds significant implications for the society in general older. It is projected that there will be 1.2 billion people over this age and especially for healthcare providers and their aged patients' by 2025 and 2 billion by the year 2050. This is a worldwide phenom- (Kauffman 1988). By now, everyone has heard the demographic enon. By 2025, 75% of the aging persons will be living in the devel- litany about the increasingly aging population and the rising costs of oping world. The fastest growing cohort in the developed world is caring for the elderly. The problem that we, as a civilization, face is that group of old-old people over the age of 80 years (WHO 2(06). how to handle this growing dilemma, both fiscally and ethically. Europe was the first region in the world in which the demographic PARTISAN POLITICS transformation resulting from increased life expectancy was mani- fested. It has the highest proportion of old people in the world. Of 11 A member of the US House of Representatives addressed a group of European countries, Italy has the highest population of people aged 65 physical therapists at the 1996 Combined Sections Meeting of the years and older (18.6%), followed by Sweden (17%) and Germany American Physical Therapy Association. He presented a scenario in (16.6%) (Carpenter 2(05). Italy, with a low birth rate and rapidly aging which a family had a choice between healthcare for a terminally ill society, now has the oldest population of all the European countries. mother or more money for the discretionary use of the younger fam- They have relatively underdeveloped community care services, and ily members through tax savings derived from reduced healthcare many are supported at home by extended families with minimal for- benefits for Medicare patients and pensioners. The Congressman mal care (Carpenter 2(05). Despite the various languages, cultural insisted that we must cut the healthcare benefits, even though it is heritages and political histories, Europe is considered a homogeneous cold-hearted, because we must offer hope and a future (which is

502 SOCIAL AND GOVERNMENT IMPLICATIONS, ETHICS AND DYING society. Nevertheless, European countries have diverse healthcare and shortly thereafter. The impasse resulted because of partisan political social care structures, and this has created a unique opportunity to maneuvering by a Congress that wanted to cut costs and to eliminate study different models of care (Carpenter 2(05). the US federal debt in order to save something for future generations. Blocking this move was President Clinton, who wanted to protect the The European Observatory on Health Care Systems recently stud- healthcare benefits for the elderly. ied health delivery systems in eight different countries, all of which provide some type of universal healthcare financed through public In November 2005, the administrator of the Centers for Medicare funding (Dixon & Mossialos 2002). It is interesting to note that and Medicaid Services (CMS) released an updated physician fee sched- Australians have bipartisan support for improving access and equity ule, indicating that payment rates per service for physicians' services for its Medicare system, which is a more comprehensive program will be reduced by 4.4% for 2006. 'The existing law calls for a decrease than it is in the US. However, the impact of the aging population and in payment rates for physicians in response to continued rapid how to provide care were acknowledged challenges for health sys- increases in use of services and spending growth, and Medicare does tems in New Zealand and the European Union, especially Denmark, not have the authority to change this', said CMS Administrator Mark France and Sweden. B. McClellan. Similar changes in fee schedules have also affected rehabilitation services, with reimbursement for physical therapy The European Union recently funded the Aged in Home Care services decreasing. This presents a challenge to healthcare providers project, which included the development of the inter Resident who are dedicated to providing the best quality of care, but with Assessment Instrument (interRAI), which assesses the needs of older diminishing financial resources (CMS 2(05). people. It is now in use in over 30 countries and has the potential to improve the understanding and measurement of effectiveness, effi- In the UK, the demographic reality has also had an impact on ciency and quality of care of healthcare services provided to people access to universal healthcare. Shortages of primary care providers of various ages in different settings (Carpenter 2005). are a factor (Dixon & Mossialos 2(02). Young (1996) indicated that the pressure for shorter lengths of stay has reduced rehabilitation Living Well in Later Life, A review of progress against the National services for the elderly. A projected deficit of nearly £800 million has Framework for Older People (Commission for Healthcare Audit and worsened the care especially for the elderly (Laurance 2006). Inspection, CHAI, 2006) was an effort to look at social and health serv- ices for the elderly in the UK. In its framework, data are presented that It is a profound truth that democratic governments built on con- can be interpreted from generational differences. People 65 years old sensus and compromise must painfully allocate limited resources to and older account for 16% of the population in the UK, but they use numerous mandated, needy and exigent programs and projects. almost two-thirds of general and acute hospital beds. In 2003/4, 43% or £16 billion, of the National Health Service's (NHS) budget was con- FORMER SOVIET BLOC sumed by the same age group. Similarly, 44% or f:7 billion of the social services budget was spent for this same age group. This official govern- The difficulty of developing workable and ethical solutions to prob- ment report was met with criticism because of the '... \"patronising and lems of healthcare and aging may be greater in the countries of the for- thoughtless\" manner in which NHS hospitals and care institutions treat mer Soviet bloc. The paternalistic system of government provided older patients'. It was noted that the ruling Labour party featured bet- many social supports for retirees, including freehealthcare and med- ter care for the elderly and that may not be happening (Laurance 2006). ications, which improved life expectancy in the 1980s. However, many societal changes took place after the fall of the Communist system. In The need to grapple with these demographic and financial issues Russia, life expectancy for males dropped to 57.6 years during the is very real. Across the European Union, 80% of social protection 7 years between 1987 and 1994. This was attributed to a variety of rea- expenditures are for old-age pensioners (Watson 1995). sons including environmental degradation, accidents, excessive alco- hol use, poor diet and deterioration in health services (Kinsella 2005). A similar trend is occurring in the US, where the over-85 age group In the present period of transition, the rehabilitation possibilities in is growing the fastest. Currently, in the US, there are 36 million people Hungary, for example, are limited by few resources and few health- aged 65 years and over, and 4.5 million over 85 years. By the year 2050, care specialists, which may account for the extensive use of medica- both these populations will have increased significantly with 80 mil- tion there (Blasszauer 1994). In Georgia (in the former Soviet Union), lion people aged 65 years and older and 20 million people over the age only 0.59% of the gross domestic product (GOP) was spent on health- of 85 (Louria 2(05). Researchers in Europe have found that, in industri- care in 1999, and only 22% of healthcare expenses were covered by alized countries, the population of centenarians has doubled each state or municipal budgets or insurance. decade since 1950 (Kinsella 2(05). Adding to the Medicare problem is the looming postwar baby boom cohort, which reaches retirement age PARADIGM SHIFT beginning in 2010. Someone retiring today can anticipate spending 25-29% of their adult life in retirement but, with increasing longevity to The drawing here (Fig. 76.1), by the German artist Bernd Stolz, illus- 95 years, this percentage increases to 40% (Louria 2(05), Compounding trates the problem by depicting the weight (or burden) of the young the problem further is the fact that the US birth rate reached unprece- and the old resting upon the shoulders of healthy, young, working dented lows in the mid-1970s (Yeas 1994), which means that the tax- adults. The question to be answered is, must the generational difference paying workforce will be smaller when the mandated social costs are be viewed as an either/or situation? The answer is no. What if the head- likely to be the highest ever. If current retirement trends continue, there lines in the newspapers reported that nearly 100% of education costs go will be a shortage of workers by 2025 (Vladeck 2005). to persons under the age of 19 years? Should pensioners in the UK stop paying community charges and other taxes that benefit younger per- POLITICAL DECISIONS sons? Public education in the US is funded largely by real estate taxes on property owners. Some fixed-income Medicare retirees must sell The zenith of the generational conflict in the US occurred in November their homes because they can no longer afford their real estate taxes. 1995.That was when the American people suffered through the deba- cle of the closing down of the US government. The closure occurred In the US, the federal government spends about 40% of its budget because it was announced by some that Medicare, the American old- on services that go mostly to older people for the benefits of social age healthcare system, would be bankrupt by the year 2000 or

Physical therapy and the generational conflict 503 Figure 76.1 Bernd Stolz, 1996. return to work out of financial necessity, many may return as healthy, involved, active and productive members of society, thereby helping to counteract the shrinking workforce and the financial burden on this workforce (Louria 2005). Lubitz et al (1995) took a sample of actual 1990 Medicare costs and simulated lifetime costs for people who became Medicare beneficiaries in that year and for people who will enter the system in 2020. These writers suggested that the effect of increased longevity on Medicare cost per individual may be minimal, even though the overall costs will, of course, increase because of the greater number of enrollees. Physical therapy, both rehabilitative and preventive, is integral to the compres- sion of morbidity and, thus, to the control of costs. The trend toward home healthcare (Dall1994), which should clearly involve rehabilitation care, may help to reduce costs to the system and possibly to preserve individual dignity and family integrity (Allert et aI 1994).However, the trend is not without problems. It shifts the costs to families, which already provide the majority of care for the elderly (Topinkova 1994),and it may increase stress on the caregivers. Over the past 20 years, the population of people aged 75 years and older has increased by two-thirds, but the use of nursing homes has only increased minimally. This can be attributed to the increase in commu- nity-based alternatives to long-term care as well as the improved health of old people. Despite the current trend toward less frequent and later child-bearing, growing longevity is leading toward families with three and four surviving generations. As baby boomers age, there is now a large population of older people with surviving adult chil- dren. Baby boomers are moving quickly between childcare responsi- bilities and caring for aging parents. What will happen as the baby boom generation, who outnumber their children, continues to age (Vladeck 2(05)? Recognizing these increased burdens on families, a plan was designed in Germany to help families to offset these addi- tional costs, but the demand exceeded what the system could manage (Karcher 1995). Also, family structures are changing as more women enter the workforce, and social and international mobility is increasing (McCormick & Rubenstein 1995). Better screening of individuals through the use of a geriatric intermediate-care facility may help to pre- dict those who are likely to be discharged home and, thus, to prevent institutionalization. However, this study conducted in Japan did not deal with the changing structure of the family and workforce (lshizaki et aI 1995). security, Medicare, Medicaid and veterans. In contrast, state and THE ROLE OF HEALTHCARE PROVIDERS local governments spend about 37% of their budgets on benefits to the younger population in the form of education at all levels and Healthcare providers are very much involved in the entire process. criminal justice (VIadeck 2005).When the debate about the costs for We are involved as caregivers with our patients and our families. We healthcare and social care for the elderly are couched in terms of gen- are involved as researchers hoping to find better ways of providing erational conflict, these data on spending levels are not included. the best possible care within the social structures and financial con- straints of each country, and we share that information through this Harbingers of doom aside, not all the information is catastrophic. text and many others. We are involved as citizens, hoping that our First, although the population of the world is aging, the morbidity of governments will listen to our needs and the needs of our patients. the aging population is being compressed into a shorter time period We, as healthcare providers, are the future elderly ourselves. We can (Mor 2005). Of persons in the USover the age of 85 years, 80% are not look forward to living longer and healthier lives than past genera- living in nursing homes, and half of the over-85-year-old patients in tions. For these reasons, it is crucial that we voice our concerns, nursing homes are there because of chronic conditions that have needs, and ideas for our future. We are seeking the wisdom and abil- definable and modifiable antecedent risk factors (Lubitz et al 1995). ity to amalgamate our personal interests with our professional inter- Although studies in the nineteenth century demonstrated that the ests and the interests of our societies. However, Binstock (1986),past death rate increased exponentially with age, more recent studies president of the Gerontological Society of America, reminds us of an have found a decline in mortality at age 80 years and older, and the enduring and universal truth: 'Politics, not research, will resolve value age of mortality deceleration is rising. This creates a society of older conflicts regarding the nature and extent of hardship and what actions, people with healthy attributes (Kinsella 2005).This means that peo- if any, governments should undertake to alleviate hardships'. Maybe ple are living longer and healthier lives. This, it is hoped, will reduce we need to remind our politicians that 'When, due to financial restric- the per capita cost. That is, adding years to life does not automati- tions, resources are allocated in a hard and pitiless manner, society's cally mean adding excessive cost to the system. This presents a promising scenario for counteracting the costs of an aging society for future decades and centuries. Although old and very old people may

504 SOCIAL AND GOVERNMENT IMPLICATIONS, ETHICS AND DYING response to its vulnerable old and ill members becomes an even greater patient of medical means to cause self-death). Civilization must con- sign of its humaneness' (Allert et al1994). tinue to wrestle with these issues, especially as we enter this age of aging. NO EASY ANSWERS CONCLUSION The determination to remain independent despite the travails of age- The issues of generational conflict are not new, and they need not be related pathology and the fear of becoming a burden on family and magnified. The biblical story of Abraham and Isaac serves as a con- society is an attitude that correlates with the compression of morbid- cluding comment. Abraham, a centenarian, was tempted by God to ity. This phenomenon of aging has forced society to consider issues sacrifice his only son, Isaac, who was then only a lad. Abraham such as advance directives or living wills and do-not-resuscitate instructed his servants to wait for him and Isaac and stated, 'We will orders. Hesse (1995) reported that, in persons 85 years old and older, return: Seeing the wood, fire and knife, Isaac asked, 'Where is the during terminal hospitalizations, there have been significant declines lamb?' Abraham answered, 'God will provide himself a lamb' in high-intensity medical interventions such as cardiopulmonary [Genesis 22:1-13, Authorized (King James) version]. The important resuscitation, invasive tests and minor surgery. Requiring consent message is that Abraham never lost sight of what he needed to do, to treatment may reduce undesired and costly medical and surgical which was to obey God and sacrifice his son, the next generation. In interventions. Palliative care must be maintained out of human this story, a desirable solution to Abraham's dilemma was reached. decency, and this requires physical therapy for comfort and for As this world ages, the solution will be found by young people and pain control. At this time, there is very little support for the old people working together for the common good. We, as health- highly emotional subjects of euthanasia, (deliberate acts that lead care providers, must be participants in that solution. directly to death) or assisted suicide (the provision to a knowing References Kinsella K 2005 Future longevity - demographic concerns and consequences. J Am Geriatr Soc53:299-303 Allert G, Sponholz C, Baitsch H 1994Chronic disease and the meaning of old age. Hastings Cent Rep 24:11-13 Kohli M 1996 The problem of generations: family, economy, politics. Public Lectures No. 14, delivered at Collegium Budapest Binstock R 1986Perspectives on measuring hardship: concepts, dimensions, and implications. Gerontologist 26:60 Laurance J 2006 The great betrayal: how the NHS fails the elderly. Available: http://news.independent.co.uk/ uk/health_medical / Blasszauer B 1994Institutional care of the elderly. Hastings Cent Rep article353861.ece. Accessed March 27, 2006 24:14-17 Louria D 2005 Extraordinary longevity: individual and societal issues. Carpenter G 2005Aging in the United Kingdom and Europe - a JAm Geriatr Soc 53:317-319 snapshot of the future? J Am Geriatr Soc 53:310-313 Lubitz J, Beebe J, Baker C 1995 Longevity and Medicare expenditures. Centers for Medicare and Medicaid Services (CMS) 2005CMS announces payment update and policy changes for Medicare N Engl JMed 332:999-1003 physician fee schedule. Available: http://www.cms. hhs.gov / apps/media/press/release.asp?Counter +1709. McCormick We, Rubenstein LZ 1995International common Accessed November 3, 2005 denominators in geriatric rehabilitation and long-term care. JAm Commission for Healthcare Audit and Inspection (CHAI), 2006 Living Well in Later Life, London. Available: http://www.healthcare Geriatr Soc 43:714-715 commission.org.uk/assetRoot/04/02/ 46/42/04024642.pdf. Accessed 18 April, 2006 Mor V 2005The compression of morbidity hypothesis: a review of research and prospects for the future. J Am Geriatr Soc 53:308-309 Cohen GD 1994Journalistic elder abuse: it's time to get rid of fictions, get down to facts. Gerontologist 34:399-401 Topinkova E 1994 Care for elders with chronic disease and disability. Hastings Cent Rep 24:18-20 Dall J 1994The greying of Europe. Br Med J 309:1282-1285 Dixon A, Mossialos E 2002 Health Care Systems in Eight Countries: V1adeckB 2005 Economic and policy implications of improving longevity. J Am Geriatr Soc 53:304-307 Trends and Challenges. The London School of Economics & Political Science, London, p 1-129 Watson R 1995Making the most of ageing populations. Br Med Hesse KA 1995Changes in the way we die. Arch Intern Med J 310:554 155:1513-1518 Ishizaki T, Kai 1,Hisata T et a11995 Factors influencing users' return World Health Organization (WHO) 2006The world is fast ageing - have home on discharge from a geriatric intermediate care facility in we noticed? Available: www.who.int/ageing/en/.Accessed 16 Japan. J Am Geriatr Soc 43:623-626 February, 2006 Karcher H 1995Germany's home care scheme faces problems. Br Med J 310:1025 Williams TF 1987 The future of aging. Arch Phys Med Rehabil Karp HB, Sirias D 2001Generational conflict - a new paradigm for 68:335-338 teams of the 21st century. Gestalt Rev 5(2):71-87 Kauffman T 1988Physiotherapy as the world ages. Physio Theory Pract Yeas MA 1994 The challenge of the 21st century: innovating and 4:61-62 adapting social security systems to economic, social, and demographic changes in the English-speaking Americas. Soc Seeur Bull 57:3-9 Young J1996Caring for older people: rehabilitation and older people. Br Med J313:677-681

505 Chapter 77 Medicare Timothy L. Kauffman CHAPTER CONTENTS to changes in the health insurance system (Keehan et a12004) or pos- sibly improved lifestyle habits which compress morbidity (Hubert • Introduction et aI2oo2). • History • The key players The bad news is that the system is mired in a political debate about • Social security trust funds the future based on demographics. At this time, the population of • Criteria for medicare reimbursement Americans who are 65 years old or older is just under 13% of the • Medicare parts A and B:The confusion total. The percentage is projected to increase to 15.7% by 2019 and to • Home health services 21.3% by 2049 (Keehan et aI2004). Unfortunately, the political rheto- • The Medicaid system ric offers solutions of cutting costs, stopping fraud, more choices/ • The Older Americans Act options and reducing (rationing) services. Because there will be • Conclusion more Medicare beneficiaries, this does not mean there will be more services. This debate and failure to solve this demographic impera- tive have been ongoing for decades (see Binstock & Post 1991). INTRODUCTION HISTORY In the United States, the rehabilitation of geriatric patients takes The bill that initiated the Medicare program was signed into law by place largely within the Medicare and Medicaid systems. As the President Lyndon Johnson on July 3 1965. Symbolically, he signed population ages, the systems have become an increasingly partisan the bill at the Truman Library in Independence, Missouri, because political battleground with a moderate to high level of distrust, frus- President Harry Truman had publicly endorsed and fought for gov- tration and confusion among the various players on the field, includ- ernrnent health insurance in the 1940s and 1950s. Interestingly, at ing the beneficiaries and their advocates, lobbyists and families; the that time, then Senator Lyndon Johnson was only one of several care providers, both individuals and institutions: the insurance com- southern Democratic senators who supported President Truman's panies; and the politicians and regulatory bureaucrats. legislative effort. Truman's ideas were not new, as they were based on European hospital insurance models that were shaped at the turn There is some justification for this sociopolitical quagmire because of the century. Truman's proposals were defeated by Congress in the Medicare and Medicaid systems are large, changing and expen- 1951,but the tenets were debated and reworked during the Eisenhower sive. Over 42 million people are covered by the Medicare system, administrations, which offered scaled-down alternatives under the and Medicaid enrollees amount to over 44 million beneficiaries, of name'medicare'. whom almost half are children (Centers for Medicare & Medicaid Services (CMS) 2(05). Medicare accounts for about one-third of all As President, John Kennedy determined that hospital healthcare for payments to hospitals and one-fifth of payments to physicians. In the aged was 'must have' legislation. Introduced by Representative 1999, over $387 billion were spent on personal healthcare by people Cecil King (Democrat, California) and Senator Clinton Anderson aged 65 years and older (Keehan et al 2004). The Medicare system (Democrat, New Mexico), the bill was blocked by opponents, includ- paid 46% and Medicaid 15% of these costs. Including all healthcare ing Senator Wilbur Mills (Democrat, Arizona). Kennedy's death and programs directed by the CMS, the cost in 2004 to the federal govern- Johnson's landslide victory in 1964 led to a new makeup of Congress. ment was $449.9 billion or 19.6%of the federal budget (CMS 2005). By then, Mills not only supported the Anderson-King Bill (hospital insurance, now known as Medicare Part A), he also expanded it to The alarm about Medicare costs and expenditures has been ring- outpatient services (now known as Medicare Part B).Thus, Title XVIII ing for almost two decades because of the looming demographic of the Social Security Act became the law of the land, and the Medicare shift of the initial wave of postwar baby boomers reaching Medicare system went into effect 11 months later on 1 July 1966. age in the year 2011. The good news is that the average rise in Medicare costs started to decline in 1996 (Keehan et a12004) and con- The Medicaid legislation was also enacted in 1965 as Title XIX to tinued to decline through 2004 (CMS News 2006). This may be due provide for a combined federal and state program for poor families. Medicaid covers children and some long-term care service, but it varies with the state (Moon 1995, Poen 1996).

506 SOCIAL AND GOVERNMENT IMPLICATIONS, EITHICS AND DYING Figure 77.1 The key players in the Medicare system are in all CMS is not designed as an insurance company, so it contracts with three branches of the federal government. private insurance companies to administer the Medicare regulations and to handle the reimbursement and healthcare delivery processes. THE KEY PLAYERS These fiscal intermediaries, or insurance companies, also reinterpret and implement the Medicare regulations that come from the The American government is based on a system of checks and bal- Department of Health and Human Services and from CSM. The ances, so it should be no surprise that this comes into play within the intermediaries will, at times, release guidelines for implementing the Medicare system too. The key players are in all three branches of the regulations. government, as shown in Fig. 77.1. First of all, Congress enacted the legislation that authorized the Medicare system. Congress can and There is no single fiscalintermediary for theentire Medicare system. does alter the system by passing new laws; indeed, the Balanced Thus, the interpretation of the regulations is not uniform. This Budget Act (BBA) of 1997has had a strong impact on geriatric reha- causes some confusion among care providers and patients, espe- bilitation. Prior to passage of the BBA, there were almost 11 000home cially as they move from one location to another in the United States. health agencies and, by 2004, the number was reduced to 7519 (Keehan Further confounding the situation is the tendency toward larger and et al 2004). Likewise, the Medicare Modernization Act of 2003 larger business organizations for healthcare delivery; thus, one may expanded the Medicare program to a new option called Medicare be providing rehabilitation services in Massachusetts when the Part D for drug coverage. This also carries a premium projected to be Medicare intermediary is located in Tennessee. Also, the healthcare an average of $32.20,per month depending upon the choice of cover- provider companies may further refine and make declarations in age. This new elective program is administered by the Supplemental writing concerning what is coverable or allowable according to their Medical Insurance Trust (Hoffman et al 2005). interpretations of the intermediary guidelines or CMS regulations. A second and equal player is the Chief Executive, or President, Several other government agencies are involved in overseeing the who signs the legislative bills into law. The President is responsible implementation of the Medicare system too. They are the US General for executing the law. This is done by asking the appropriate execu- Accounting Office (GAO), which is occasionally funded to review tive branch department to implement the wishes of Congress. In the system to determine its appropriateness. For example, the GAO 1965, it was John Gardner, the Secretary of Health, Education and released a report (GAOl HRD-87-91) in July 1987that has had a pro- Welfare, who was responsible for promulgating the regulations found effect upon geriatric rehabilitation. It said that rehabilitation to implement the grand idea of providing healthcare to elderly services were being paid for by the Medicare system without receipt Americans. In 1980, during the Jimmy Carter administration, the of adequate information. This was the major justification for the Department of Health, Education and Welfare was dismantled, and tightening of requirements for documentation. Another very impor- the new Health and Human Services Department emerged. Thus, tant report (GAOl PEMD-93-97) was released by the GAO in August the law comes from the Congress and the regulations come from the 1993;it found that the methods being used by four Medicare carriers Department of Health and Human Services (HHS). Most changes in to pay claims under the supplemental medical insurance program, the Medicare system now take place through the regulatory process. or Medicare Part B, were not effective in determining whether the medical care was appropriate or not. Thus, since this report, greater Shortly after the inception of the Medicare system, the Department emphasis has been placed on establishing medical necessity. of Health, Education and Welfare recognized that it did not have expertise in administering the financial aspect of federally mandated Also, the Office of the Inspector General of the Department of healthcare programs. Thus, the Health Care Financing Administration Health and Human Services is at times called upon to review the (HCFA) became a new federal agency, and it oversaw all the finan- implementation of the Medicare system. Additionally, the Office of cial aspects of the Medicare and Medicaid systems and the regula- Management and Budget and the Congressional Budget Office are tory process. In 2001,HHS Secretary Tommy Thompson reorganized involved in auditing the Medicare programs and forecasting future the system and changed the name to Centers for Medicare & expenses. Medicaid Services (CMS). In today's healthcare arena, it appears at times that CMS's purpose is to control costs, not to assist in the deliv- A third equal player in the Medicare system is the judiciary branch, ery of care. as lawsuits are brought by Medicare beneficiaries or plaintiffs against the Medicare system. A major case was the Foxv. Bowen deci- sion in 1986,which had a profound impact upon outpatient geriatric rehabilitation by implementing screens or edits that delimited the length and number of treatments allowable according to diagnosis. SOCIAL SECURITY TRUST FUNDS As mentioned above, during the historic debate over the Medicare legislation, the initial thrust was to provide hospital insurance, with acute care benefits in mind. This is administered under the Hospital Insurance Trust Fund (HI) and is best recognized as Medicare Part A. Currently, Medicare beneficiaries are required to pay $952 (up from $764in 1998)as a deductible for the first day in the hospital. After 61 days, a co-payment is implemented at $238 (up from $191.00in 1998) until day 90, after which the co-payment increases to $476 (up from $382 in 1998). HI, or Medicare Part A, also pays for 'inpatient' care and services provided in a patient's home if there is reasonable reha- bilitation potential and the patient is currently housebound. This will be discussed in further detail later. Hospice care is usually Part Aas well.

Medicare 507 As mentioned above, in its historic context, the Medicare Part B Figure 77.2 The delineation between Part A and Part B of system, or Supplemental Medical Insurance (SMI), was added to the Medicare should not bebased on the skilled natureof the services, legislative effort late in the process. It provided for outpatient ser- but should be based on sociomedical decisions that determine the vices. In addition to these two social security trust funds, there are place of care. SNF, skilled nursing facility; LTC, long-term care; ICF, the Old Age and Survivors Insurance (OASI) and Disability intermediate care facility. Insurance. The most well-recognized social security payment system falls under the OASI program. This is the program to which employ- MEDICARE PARTS A AND B: THE CONFUSION ers and employees contribute and, upon retirement or if the worker dies, payment is made to the employee or to his or her survivors As stated above, Medicare Part A is a hospital insurance; however, respectively. At the present time, one can retire at age 65 years and services under the HI trust fund may be rendered in a hospital, reha- receive full social security benefits; the age will rise to 67 years by the bilitation unit, hospice system, skilled nursing facility or home year 2027. The OASI, or social security fund, currently brings in healthcare situation. In contrast, coverage under Medicare Part B more money through payroll deduction taxes than it spends. This may take place in an outpatient setting in the hospital, a patient's payroll deduction tax is 6.2%, which is deducted from employees' home, an extended care facility,rehabilitation agency, comprehensive wages, plus an additional 6.2%, which is contributed by employers. outpatient rehabilitation facility (CORF) or other outpatient treat- This amounts to a payroll deduction tax of 12.4% to support the ment center. Additionally, it may be rendered to an Individual who is OAS!. Further, the Medicare Hospital Insurance Trust Fund is sup- living in a skilled nursing facility in a long-term care setting. Thus, ported by an additional payroll deduction tax amounting to 2.9%, the strict nomenclature of inpatient vs. outpatient care is not fully which is split evenly between the employee and the employer, com- appropriate. This continuum of healthcare under the Medicare sys- ing to a contribution of 1.45% from each. At this time, the Hospital tem is shown in Fig. 77.2. From the rehabilitation perspective, there Insurance Trust Fund for Medicare Part A is also solvent but is the should be no difference in the sophistication of the level of care ren- focus of major political and public discussion. dered to a patient, whether it falls under Part A or Part B.The differ- entiation arises only from the sociomedical factors that necessitate The Medicare Part Bsystem, or SMI trust fund, is supported by the inpatient rather than outpatient care. payment of premiums by beneficiaries. Typically, when an individ- ual turns 65 years of age, he or she is able to receive retirement HOME HEALTH SERVICES benefits under the OASI system. At that time, the Medicare retiree receives the Hospital Insurance Part A protection without any Geriatric rehabilitation taking place in the home is largely a result of further financial outlay. However, the Medicare Part B system is legislative and regulatory decisions made in the 198Os. At that time, financed by a deduction from the social security retirement amount the prospective payment system (PPS) with diagnosis-related groups as a premium payment for the SMI or Part B insurance. In 1966, this (ORGs) was enacted, which encouraged hospitals to discharge people SMI premium amounted to $3.00 per month and, by 1996, this as quickly as possible. The concept behind this PPS was that the effi- premium amount had increased to $42.50. In 1997/8, the amount cient hospitals would benefit and the inefficient hospitals would suf- rose to $43.80 and is now $88.50 in 2006. The increased monthly fer financial demise. However, as the late Senator John Heinz reported, Part B premiums are projected to bring improved outpatient the ORG system encouraged patients to leave hospitals 'sicker and care, especially for mammograms, pap smears, prostate and colorec- quicker'. tal cancer screening, some bone mass measurements and diabetes self-management. There is a great deal of discussion about this As a result, the home healthcare industry grew so rapidly that, by changing amount and possibly attaching it to a means test or allow- the late 19905, it had become a major concern for budget watchers ing people to opt out of the system. At the present time, Medicare Part Bpays for 80% of allowable expenses and carries a $124 annual deductible. CRITERIA FOR MEDICARE REIMBURSEMENT Geriatric rehabilitation services are covered by the Medicare system when there is an expectation of restoring the patient's level of function if it has been compromised by an injury or illness. Repetitive care to maintain a level of function is not eligible for reimbursement. It is crucial to have an appropriate diagnosis, with specific treatment goals, both short term and long term. The frequency of treatment should be enumerated and, for Part A, there is a minimum of 5 days per week. In most rehabilitation units, treatment takes place twice daily for a minimum of 4 hours at least 5 days a week, sometimes 7 days a week. For Medicare Part B,rehabilitation services are supposed to take place at least three times per week; however, this regulatory perspective has become very difficult to achieve in the outpatient setting as Congress and HHS have established a cap or limit on Part B services of $1740starting in 2006.Obviously, both these guidelines may have to be modified in order to meet the individual patient's ill- nesses, schedules, and other confounding factors in the delivery of healthcare. These confounding situations should be recorded in the patient's chart.

508 SOCIAL AND GOVERNMENT IMPLICATIONS, EITHICS AND DYING because of the increase in home healthcare costs. Home health services discrepancy concerning who and what is covered by the program. are usually covered under Medicare Part A, provided certain criteria Basically, Medicaid is a safety net for poor families with dependent are met. As stated above, the patient must have an appropriate diag- children, disabled and blind adults, and the elderly. In 2005, the nosis, and there should be a reasonable expectation that the patient poverty guide was $9570 for a single person and $12 830 for a couple will recover from the condition. Obviously, in the geriatric setting, the (Federal Register 2(05). The respective numbers in 1996 were $7740 functional declines are not always clearly attributable to an acute and $10300. episode, and this creates some ambiguity about medical necessity. For people aged 65 years and over, Medicaid financed 15% of A person who requires skilled rehabilitative services must be deter- healthcare in 1999 (Keehan et aI2004). In 2002,17.9% of the US pop- mined to be confined to home in order to receive home healthcare. ulation was enrolled in the Medicaid program. The total cost includ- Also, the physician must certify that the patient is confined to home. ing contributions from federal and state Medicaid programs was If the patient is able to leave home, it should be achievable only with $297.5billion in 2004 (CMS 2(05). considerable and taxing effort. The patient may leave home for short durations to obtain medical care such as outpatient dialysis, An important feature of the Medicaid program is the coverage of chemotherapy, radiation or for an occasional trip to a barber or a long-term care, which amounted to $39.3 billion for 1.8 million ben- walk or drive around the block. eficiaries in 2002 (Hoffman et aI2oo5). Further, the patient is considered housebound if he or she has a con- THE OLDER AMERICANS ACT dition or illness that restricts the ability to leave home except with assis- tance from another person or requires special transportation, or leaving Like the Medicare and Medicaid legislation, the Older Americans home is contraindicated. Any condition such as a stroke that may cause Act (OAA) was passed in 1965. It established the Administration on the loss of the use of the upper extremities so that the patient is unable Aging, which organizes and directs the delivery of community- to open doors or use handrails will fit the criteria of being housebound. based services at the state level and represents a federal grant pro- Posthospital care with resultant asthenia or weakness, pain or other gram. The OAA supports education, research and training. It has medical conditions that restrict activities also qualify the patient for been the impetus for states to establish local agencies concerned with home healthcare. For example, a person with atherosclerotic cardiovas- aging. These programs are often involved in establishing social ser- cular disease may have cardiac risk with physical activity and should vices, nutritional services and senior center programs. not be leaving home. Additionally, a psychiatric problem in which a patient refuses to leave home or a circumstance in which it is unsafe to CONCLUSION leave a person unattended may qualify the person as housebound. From its inception, Medicare has been surrounded with controversy The patient is not confined to home if he or she has the ability to over costs, paperwork, fraud and types of services rendered. The obtain healthcare in an outpatient setting. The aged person who does great achievement of this mammoth system is that many, many not often travel from home because of feebleness and insecurity patients have received quality healthcare services that may not have brought on by advanced age would not be considered to be house- been available to them in the past. The changing demographics of bound for the purposes of receiving home health services unless he the aging population, including the increasing wealth of a large per- or she meets one of the above conditions. centage of Medicare recipients, are likely to be considerations in determining the services to be rendered to the postwar baby boomers THE MEDICAID SYSTEM when they reach retirement and Medicare age. The Medicaid system is a federally mandated program under Title XIX, which is administered by the individual states, so there is References of the Actuary, Centers for Medicare & Medicaid Services, Department of Health and Human Services,Baltimore,MD Binstock R,Post S 1991 TooOld For Health Care? Controversies in Hubert H, BlochD, Oehlert et al 2002Lifestylehabits and compression Medicine,Law Economicsand Ethics.The Johns Hopkins University of morbidity. J Gerontol 57A:347-351 Press, Baltimore, MD Keehan S, Lazenby H, Zezza M et al 2004Health Care Financing Review/Web Exclusive; Age Estimates in the National Health Centers for Medicare & Medicaid Services(CMS) 2005Statistics. US Accounts, Vol. 1, No.1 Centers for Medicare & Medicaid Services, Department of Health and Human Services.Available: Department of Health and Human Services,Baltimore, MD http://www.cms.hhs.gov /MedicareMedicaidStatSupp/ downloads/ Moon M 1995Medicare Now and in the Future. Urban Institute Press, 200S_CMS_Statistics.pdf. Accessed4 March, 2006 Washington, IX Poen MM 1996Harry S Truman versus the Medical Lobby:The Genesis Centers for Medicare & Medicaid Services (CMS) News 2006Healthcare of Medicare. University of Missouri Press, Columbia, MO Spending Growth Rate Continues to Decline in 2004. Available: http://www.cms.hhs.gov / apps/media/press/release.asp? Counter= 1750. Accessed 19January, 2006 Federal Register 2005 Vol. 70, No. 33,P 8373-8375. Available: http:/ / aspe.hhs.gov/poverty /05poverty.shtml. AccessedMarch 4 2006 Hoffman E, KleesB,Curtis C 2005BriefSummaries of Medicare & Medicaid,TItleXVIII and TitleXIX of the SocialSecurity Act. Office

509 Chapter 78 The end of life Timothy L. Kauffman CHAPTER CONTENTS Death is ourgreatest victory propelling us to a peace beyond ourown understanding. • Introduction • The end of life Dyingis thevehicle thattransports us, notalways a smooth • Palliative care and tranquil ride but at journey's end remains the • The role of rehabilitation promise ofa safe arrival. • Emotions Lynn Phillippi, written at Linen & Lace B&B, June 26, 1997 • Hospice • Impending death These words were composed by Lynn Phillippi who wrote Chapter • Conclusion 65 in the first edition of this book. Struggling with her own medical problems and shortly before her own death, Lynn Phillippi com- -- --- - - - - - - - - - - - - - - - - - - posed these words as well as her other contribution to the first edi- tion, which was revised for Chapter 63 of this edition. As Lynn INTRODUCTION noted, death is but a finite moment, and each person's death is dif- ferent and unique. As healthcare providers to geriatric patients, we Death and Dying are faced with the reality of patients dying, but the process and tim- Death is afinite moment ing of that moment are not always simple or clearly delineated. Therein lies a difficult and ethical problem, especially with the acute known onlyto God care model dictated by the US Medicare system. That is, when Dying isa process that should rehabilitation services be stopped? This question does not concern medical or nursing services because Medicare requirements Everyone does differently and uniquely. are not the same as rehabilitation, which is '...performed with the Death is a victory expectation of restoring the patient's level of function which has been lost or reduced by injury or illness'. But the dying process is A giftfrom Jesus on thecross often protracted, filled with repetitive losses and rebounds as the Dying isa plethora ofemotions progressive decline and downward spiral transpire, so rehabilitation should be refined to meet the changing needs of increasingly frail frustration and debilitated patients. In these commonly occurring cases, the inconsistent days purposes of rehabilitation are to assist the patient and other care- givers with quality of life issues such as pain control, positioning, some joyful mobility, handling, and toileting, and to provide dignity to a human some angry being and his or her family. some, maybe many, in pain or some days when youjust sense THE END OF LIFE an overall loss of wellness Death is thefinal goodbye to lifeon earth When does the end of life start - after the second stroke or when a aswe know it terminal illness is diagnosed, or when a person is admitted to an Dyingis thegoodbyes to people, events, yes,even things close to extended care facility or when a doctor says so...? In an abstract you. way, the end of life may start at the time of birth, and luck, choice, The hardest andmostoverwhelming goodbye to meis leaving and genetics determine how long the involution will be. Most my children healthcare providers in the field of geriatrics recognize when a Their careers I'll not see develop andflourish patient is approaching the end of life; but most also realize that some Their weddings I'll never participate in patients will 'hang on' for days, months or even years. Therefore, to The grandchildren I'll never hold or spoil andof course withdraw rehabilitation services too early or to deny those services may approach neglect or abuse, especially if rehabilitation specialists other immediate family, friends, colleagues, places are not consulted. I've traveled, forests, waterfalls, lakes, flowers, mountains, rustic roads, parks, oceans, my cats, Tabitha and Magnum, my stuffed animals, and more andmore.

510 SOCIAL AND GOVERNMENT IMPLICATIONS, ETHICS AND DYING Admittedly, constraints such as patient potential exist, but the deci- comfort and moderating the intensity of pain lying at the other, when sion should be arrived at by the family, care providers, physicians and restoration is unlikely or impossible. rehabilitation specialists with due consideration given to pathology, family and patient desires, availability of services and financial reali- This concept of the continuum of rehabilitation/ palliation fits well ties. Included among the family's and patient's desires are sociological within the parameters of the Guide to Physical Therapist Practice differences, for the end of life is surrounded by a variety of habits, (1997),especially with the roles of the physical therapist in consulta- beliefs, customs and values. Culture and religion are crucial consider- tion and communication. The interventions of coordination and ations that influence the provision of healthcare to people as they communication are particularly pertinent, as they can be used to approach death. coordinate care of the patient with family, significant others, care- givers and other professionals. This involves instruction in proper PALLIATIVE CARE procedures and techniques but holds quality of life issues and palli- ation as the focus. The American Physical Therapy Association When a patient has little or no potential or refuses rehabilitative care, (APTA 2005) recently released an Emerging PT Practice: No. 13, then respect, dignity and physical as well as emotional comfort must be which validates the purpose of physical therapy care at the end of given freely by all ethical people who come into contact with this life in the hospice setting. human being. At such a time, rehabilitation for the purpose of restoring or recovering function is obviously not appropriate; however, pallia- THE ROLE OF REHABILITATION tive care is. Palliation simply means moderating the intensity of pain or offering care or services that will allow for a better quality of life at Because each individual patient and family approaches the dying the time when life is ending. Often, care is directed toward the dying process with a different set of medical, spiritual and physical needs, patient's family as much as it is given to the patient. For example, the the role of rehabilitation must be varied. In the early stages, mobility family might need help in accepting the harsh and sad reality of the is an important treatment consideration, and thus typical gait, bal- impending expiration. ance and therapeutic strengthening exercises may be appropriate. The use of assistive devices for balance, safety, pain reduction In palliative care, an interdisciplinary team including nurses, and joint protection may enable the patient to maintain a sense of social workers, physical therapists, pastoral counselors, family ther- independence and involvement in life's activities. Joint protection apists and physicians usually provides the better services. Family with the use of an orthotic or splint may enhance functional capacity members are crucial members of this team. The desired outcome is a and, as a patient becomes more confined to bed, it may be used to pre- 'good death', which is defined as '...one that is free from avoidable vent painful and disfiguring contractures, swelling or pressure areas. distress and suffering for the patients, families and caregivers: in general accord with the patients' and families' wishes; and reason- Therapeutic exercise to maintain breathing capacity and exercise ably consistent with clinical, cultural and ethical standards' (Field & tolerance is useful. The inability to breathe is frightening and can Cassel 1997). usually be controlled until the very last days or hours of life. Exercise tolerance should be aimed at sitting up on the bedside or in an easy Emanuel and associates (2001)developed the needs at the end-of- chair or wheelchair. The world looks better from an upright posture, life screening tool (NEST), which is concerned with four areas: (i) and the patient may be able to eat or at least sit at a meal with family needs that are social, financial, caregiving and access to care; (ii) exis- and friends. Breathing and eating may be easier in the upright tential needs that are spiritual, purpose, distress and settledness; (iii) position. symptoms that are physical and mental; and (iv) therapeutic needs that are relationship, information and goals of care (Emanuel et al Adaptive equipment for eating, dressing and bathing may help to 2001).These categories of care may be helpful for all members of the maintain independence and a sense of self-worth. A wheelchair is most team and may enable a 'good death' (Della-Santina & Bernstein useful for transport and to conserve energy; however, it can cause 2004).Emanuel et al (2004) reported that talking in a structured inter- injury or at least pain and fatigue if it is ill-fitted. Pressure areas can view with terminally ill patients and their caregivers caused little or occur, and edema may result in dependent extremities. A poorly fitted no stress in nearly 90% of their subjects and that nearly 50% found it wheelchair or prolonged sitting encourages kyphosis of the spine, to be helpful. These researchers found the interview to be helpful, which can cause back pain, reduce chest expansion for breathing and especially for ethnic minorities and persons who were anxious. Over compress the abdomen, making eating more difficult. 50% of dying patients who were having difficulty in coming to closure with family and friends reported that the discussion was Pain management for the terminally ill patient usually involves helpful. medication, especially narcotics. Some patients and their families choose not to use these types of medications because of their beliefs or Appropriate services from a physical or occupational therapist because of the lightheadedness or drowsiness that results. The physi- may help with proper positioning or mobility in bed, with sitting, cal modalities of the various heat or cold applications and electrical and with assisting to toilet. Speech therapy may be helpful for teach- stimulation are beneficial, although realistic expectations are requisite. ing swallowing, mouth care and communication modifications. The effects of the portable and easily used transcutaneous electrical Perhaps at this stage of life, the end, the ability to communicate at nerve stimulator (TENS)are less potent and not identical to the effects any level is a most crucial need, especially for the sake of family and of a dose of morphine, but they are of value. The physical modalities intimate friends. are described in more detail in Chapter 68, Conservative Interventions for Pain Control. Palliative care is not something that is done only at the end of life. Efforts to moderate the intensity of pain and minimize functional lim- Range of motion exercises help to control pain and to prevent con- itations and impairment would have been made prior to clinical tractures, stiffness and pressure areas. These can often be taught to recognition that the patient has poor rehabilitative potential and is family members; that way, they have an opportunity to participate in approaching the end of life.So rehabilitative and palliative care are not the care of their loved one rather than being just bystanders. Further, mutually exclusive but are on a continuum, with the emphasis on cur- these exercises require physical contact, which is an important ative recovery of function lost lying at one end of the spectrum and on human need that may be lost to the dying patient because of medical interventions or simply because family members do not know

The end of lif~ 511 whether or not handling will cause harm. Gentle massage is thera- CONCLUSION peutic too, both physically and emotionally. As LynnPhillippi wrote, 'Death is the final goodbye to life on earth'. It EMOTIONS is an individual experience inherent in life. Knowing what stops life allows a better understanding of what life is. Healthcare providers to When providing medical care, be it curative or palliative, it is vital to aging and dying patients participate in this universal college fre- remember that patients and their families have real emotions that quently. Rehabilitative services, curative and palliative, enhance the must be considered. Bereavement is a process that starts before death quality of life for the dying patient and for the patient's family. and continues after it. The family and intimate friends are facing a loss, sometimes one that they are not ready to accept, and denial is a The following words were written as I sat at the funeral of a common coping mechanism. Denial may be used by the patient, too, patient I had treated, off and on, for 8 years, both curatively and and that can impede the more important acts of completing one's life palliatively. work, settling one's affairs and saying goodbyes. When working with a patient and family members at a time when all of them may be in The Meaning of Life various stages of denial, it is necessary to be honest, but not brutally What is themeaning of life? so. Empathy and honesty help, especially when they come from all The answer is unclear; members of the healthcare team and from clergy (Faulkner 1995). And it is not thesame forall. Part of theanswer is in death Anger and frustration are also commonly encountered in a dying When it is not. patient and may be directed at family members, at God, or at some Death begets life or all of the medical care providers. Fear and guilt may also be pres- For it is theaging, thepassage ent, for death is an unknown. Several of the world's major religions have taught the concept of sin, and the dying person may have a oftimethat nourishes theyoung; sense of guilt about the commissions or omissions of life, and may Without someone before us, regret the inability to do something about them in the last remaining days. Again, empathy, honesty and dignity are important. At the end there can benone behind us. of life, a person should feel that he or she is okay and is valued by the medical providers as a human being until death and then as a Life is noteasy. memory. It isfilled with problems, Many patients and families are most appreciative of anything that heartaches, sadness, Yet can be done to provide additional comfort, dignity and worth. Therein there isjoyabundant. lies the inner strength to continue to work with patients and their fam- Sometimes it is hard tofind. Accept ilies as life completes its journey. thebad, for it is life, too. Butsearch andfocus on thegood, HOSPICE thebeauty. It passes every day. The hospice concept developed in the 19605 in the UK; in the US, it is now a Medicare Part A program, which usually starts when a patient is Those who precede us andthose determined by a physician to have less than 6 months left to live. A who pass through life with us wide variety of physical capabilities and needs are found among hos- are ALWAYS present. pice patients. In the early stages of hospice care, rehabilitation services may indeed be curative and, in the end, only palliative. The blending of They livewith usforever one phase into the other is usually gradual, but the consultation and in ourthoughts, care provided by rehabilitation specialists as members of the hospice ouractions, team will maintain the quality of life at its optimal level (Della- our lives. Santina & Bernstein 2004, APTA 2005). In life, there is noabsolute beginning IMPENDING DEATH andnoabsolute ending; there is onlyconception andthere is death Certain signs indicate that death will occur soon. In the final days, the which mark these times. patient may become increasingly somnolent and diaphoretic, and intake of fluids and food may nearly cease. Parenteral nutrition is not But what preceded andfollowed these events, advocated at this time; however, oral care and the use of lip salve and both conception anddeath? ice chips is palliative (Merck 2000). The toes and fingers as well as the nose and ears may become cyanotic as the circulation and oxygen per- Arethelives ofloved ones fusion decline. The death rattle, a frequent cause of distress for family both givingand receiving love; members, results from bronchial congestion or palatal relaxation. U sharing learning andliving. desired, clergy should be consulted, and the family can be present and hold hands or touch or rub the loved one to say final goodbyes. Peace, Weare ourparents, ourspouses, dignity and respect must prevail. ourchildren, ourgrandparents, and grandchildren, andothers whoenter ourlives sharing, learning, living, loving. The meaning of lifeis thehere andnow, which are built upon what preceded and provide for whatfollows; The meaning oflifeis to experience it, thegood andthebad, But most important is tofocus on thebeauty ofits experiences. TIm Kauffman, March, 1993

512 SOCIAL AND GOVERNMENT IMPLICATIONS, ETHICS AND DYING References Faulkner A 1995 Working with Bereaved People. Churchill Livingstone, London American Physical Therapy Association (APTA) 2005 Hospice Care: Emerging PT Practice, No. 13, Rehabilitation. Oncology 23(2):24-26 Field M, Cassel C 1997 Approaching Death: Improving Care at the End of Life. National Academy Press, Washington, DC Della-Santina C, Bernstein R 2004 Whole patient assessment, goal planning, and inflection points: their role in achieving quality Guide to Physical Therapist Practice. Phys Ther 1997:77(11). end-of-life care. Coo Geriatr Moo 20:595-2004 Merck 2000 Manual of Geriatrics, 3rd edn. Merck Research Laboratories, Emanuel L, Alpert H, Emanuel E 2001 Concise screening questions for Whitehouse Station, N}, p 115-127 clinical assessments of terminal care: the needs near the end-of-life screening tool. J Palliat Moo 4:465--474 Emanuel E, Fairclough D, Wolfe Pet a12004 Talking with terminally ill patients and their caregivers about death, dying, and bereavement. Arch Intern Med 164:1999-2004

515 Chapter 79 Caregivers: the sustaining force Cheryl Anderson CHAPTER CONTENTS out their caregivers and begin to outlive their own assets. Such is the testament for many admissions to skilled nursing facilities. • Informal networks • Societal viewpoints As part of the clinical team treating frail elders, therapists must • Clinician viewpoint develop a broader perspective of whom and what supports each • Cognition as the decision driver patient. Given the multiple demands and stresses that equate with • The many roles of the caregiver caregiving, therapists should monitor and assess the well-being of the • The stages of caregiving caregivers for older patients. Often, the overwhelming burden of care- • Caregiver recognition giving places a risk on the caregiver becoming a patient too. The focus of most medical care and concern in dealing with frail elderly It is well documented that caregivers are at a high risk of develop- patients is on the elder and their medical treatments. However, this is a ing disorders such as depression and anxiety, which may contribute small fraction of the overall care provision for most chronically ill to hostility toward, and even abuse of, the difficult or demented elders. Well over 90% of all care to the elderly and disabled is provided elder. Furthermore, the risk of caregivers developing depression and by an informal network of family, friends, and faith (Family Caregiver their own physically debilitating symptoms increases with increased Alliance 2004). This invisible network of support and help sustains caregiver burden (Schultz et al 1995). most elders through their aging years. SOCIETAL VIEWPOINTS INFORMAL NETWORKS Societal pressures and the stigma of skilled nursing facilities place Dissecting the major realms of this invisible caregiver network, family pressure on informal caregivers to provide care to the elder in home is usually primary. Family includes the spouse, children and siblings. and community settings. There is a general belief that all senior citi- Generally, the family is faced with determining the type of living zens desire to grow old and eventually die in their lifelong home. This, arrangements and has the responsibility of most formal decisions. like most stereotypes, is false for many. However, this belief is perva- Friends may be lifelong acquaintances or neighbors who may find sive, influencing public policy in multiple modes. their simple acts of kindness tum into an ongoing, often reluctant role. Shoveling a heavy snowfall may gradually tum into routine home Families are increasingly faced with caregiver concerns for their maintenance, to transportation, to medical advocate and some form of elderly relatives. Although about 3.4% of the American public reside communication conduit with the family. It is difficult for these good in a skilled nursing facility at anyone time, another 3% reside in Samaritans to say they wish to decrease or terminate their services. assisted living facilities, while another 5-8% receive care through The third variable, faith, is generally a more distant role than family home- and community-based services (HCBS) (University of and friends. However, the rise of parish nursing programs is a method Maryland 2(05). Many HCBS are actually provided by the same for faith communities to acknowledge their own important role in informal network that already existed. caregiving. The landmark 1999 passage of the National Family Caregiver The informal caregiver network is faced with multiple, conflicting Support Program acknowledged the prominent public policy issue issues. In the case of spouses, friends and some faith providers, the associated with aging and long-term care and the factors associated caregiver is often at least as old as the person requiring help. These pe0- with informal caregivers (US Department of Health and Human ple are often ill equipped to deal with comorbid conditions of aging Services 2(03). This legislation laid the groundwork for HCBS pro- elders. This informal network begins to fail when chronic illnesses grams that focused funding needs on frail elders while continuing to progress and difficult behaviors arise, causing a frail elder to wear ignore the actual needs of the caregivers who provide that care. HCB5-type systems put a face on the invisible caregiver network. The mission of HCBS is to keep the elderly in their own homes and community for as long as possible. HCBS are driven to decrease insti- tutionalization. This legislative policy is the main force credited with the closure of nursing home beds in lieu of community alternatives. On the face of public policy, this is what the public wanted. However, the silent burdens actually increased for the caregivers. Given that

516 THE REHABILITATION TEAM society was pressuring toward no institutionalization, the family or not necessary. They may rush to do things that the frail elder may was left to grapple with the questions of 'then what?' and 'how?'. actually be able to do independently. For thehealthcare provider, this situation may create an ethical dilemma because the caregiver rejected A positive outcome of HCB5-type care is monetary. Funding is now the care. In this case, the healthcare provider must offer the appro- available to pay people who provide care, including the family. There priate services and also respect the caregiver with one exception, are restrictions on who may be paid for what services, e.g. a spouse which is that no abuse is taking place. cannot be paid for providing activities of daily living (ADL) support but a daughter may be reimbursed. Many caregivers question these The roles that the caregiver may assume run a gamut. The follow- policy changes, as they would provide care whether paid or not. HCBS ing sections describe several of these roles. funding is provided through a combination of federal and state dollars by formulas generally managed through state Medicaid programs. Medical advocate Families face difficult pressures. With child-bearing occurring later The route to being a caregiver is insidious, creeping into one's life in a in life,many dual-income, middle-aged couples have school-aged chil- slow or innocuous fashion. Advocating for appropriate medical care is dren at home. Further, these couples often have their own 70+ aged one of the first formal steps an informal caregiver may begin assum- parents and their 90+ aged grandparents to worry about. The stress of ing. As the physical presence, caregivers play an integral role in caregiving for the aged is falling squarely on the busiest people in treatment decisions and their implementation. Caregivers begin the American society. processes through their role as transporter and information source. This includes bringing frail elderly to appointments, assisting with CLINICIAN VIEWPOINT diagnosis, providing the oral history and accurately conveying the current abilities of their loved one. Caregivers bear the burden for Surprisingly to many clinicians, families provide the vast majority of final decisions including what treatments may be implemented, long-term care needed by frail elderly. Clinicians generally recognize when to begin or end treatments and end of life issues. Caregivers families as decision-makers and short-term caregivers following become increasingly responsible for making medical decisions as the acute incidents. However, the rise in elders living longer with multi- elder's physical and cognitive status deteriorates. For these reasons, ple comorbidities increases familial responsibilities beyond most it is very important for caregivers to fully understand the nature of expectations. The rehabilitation team should acknowledge this fac- each chronic or debilitating condition and the possible treatment tor. Treatment that focuses on a frail elder being discharged to their approaches, benefits, limitations and potential side effects. As care- home or a community source will be dependent on others, most giving may last anything from 2 to 20 years, this is a long-term part- probably a family member, for care. nership that requires respect of the caregivers' abilities. Minnesota (MN) has long studied this phenomenon. The 2005 Difficulties and disagreements often arise as different people may report to the legislature completed by the MN Department of Human assume this role at varying times. Distant living children may hold Services found that one in four adults in MN was involved in some legal title to Power of Attorney or Health Care Guardian; however, level of caregiving for older relatives. The dollar value of informal others may make the daily small decisions. care far outweighed the other sources of funds spent caring for MN elders. This longitudinal study found that $6.84 billion was spent in Clinical partner 2004 for all care provided for MN seniors. The cost breakdown found that Medicare accounted for 7%, Medicaid and other state programs For a frail elder to reach maximal rehabilitation potential, the care- for 13%,out-of-pocket 11%, private insurance 1%, with 67% provided giver needs to be seen as a clinical partner. Caregivers need to have through informal care (MN Department of Human Services 2005). realistic expectations about what benefits can be realized and how they may be a part of the success or failure. U the caregiver does not COGNITION AS THE DECISION DRIVER fully understand and support the treatment plan, the elder's care may suffer. The therapist needs to be able to effectively communicate The most debilitating factor for caregivers is cognitive decline. with each caregiver and insure that the regime may fit into the sched- Notably, the majority of patients with Alzheimer's disease live out- ule of daily life for both the elder and their caregiver. Overzealous side institutions, creating considerable serious psychological mor- treatment programs, multiple exercises and lengthy care plans will bidity among their caregivers. Research continues to focus on methods certainly meet with failure for all involved. The focus on function, of dealing with cognitive decline. However, the day-to-day challenges mobility, movement and recognition of what life is like in the home are far outside the researchers' microscope. Families find themselves setting will help each therapist to be realistic in assisting the care- forced to understand a dizzying array of services and placements giver to be a clinical partner. provided by mismatched incentives and awkward systems. Personal care attendant THE MANY ROLES OF THE CAREGIVER One of the most difficult tasks for caregivers is providing ADL support. Caregivers have many roles to perform in the care of an aging per- Bathing and grooming may fall to those ill equipped to deal with son. Some people are natural-born caregivers requiring little instruc- another's personal needs. Incontinence problems are disdainful to tion, while others have no idea how to help or where to begin. deal with and are often a leading driver toward institutionalization. Furthermore, the more helpful of these caregivers may also be the Feeding assistance and specific meal preparations become burden- most disabling. In the effort to ensure that the elder does not have to some and time-consuming tasks for many caregivers. exert too much physically or have increased pain, a softhearted care- giver may not allow the elder to reach maximal rehabilitation potential. Guardian The caregiver may view the exercises as too hard, too time consuming Caregivers are burdened with the responsibility of preventing harm from befalling a frail elder. Parenting the parent is a term that is often

Caregivers: the sustaining force 517 heard. One expects to parent their child for about 20 years. One rarely Table 79.1 The stages of caregiving expects to do the same for their own mother or father (or grandparent). Guardian duty is certainly a graded responsibility depending on the Stage' Coping with the initial impact cognitive and physical abilities of the elder. Stage 2 Deciding whether a family member can take on the caregiver role Guardians insure that the physical environment inside and out- Stage 3 The long stretch of at-home caregiving provision side the home remains safe. It may begin as yard work and snow Stage 4 Considering residential placement shoveling, and progress to the laundry and housework. Soon meal Stage 5 Caregiving during residential placement preparation, inside safety and sleep routines require attention. Stage 6 Death of the patient- griefand relief Stage 7 Resuming life - healing and renewal While therapists may make treatment recommendations, the day-to- day quality of life is the responsibility of the caregiver. The caregivers' efforts may be focused on continuity, dignity, pleasure, social interac- tion and a stable environment, while the therapist's are toward increased functional ability. Activities and social director Stage 2: Deciding who will be the caregiver. This may be a lengthy stage with multiple versions of caregivers. This stage seems to The family is often faced with being the main social interaction for the meld into Stage 3. frail elder. The weekly visit, grocery shopping and medical appoint- ments often progress to becoming their confidante and friend. It is a Stage 3: The long stretch of at-home caregiving. This is the strength of difficult role that seems to creep in slowly until a family realizes that the invisible caregiver network formed by family, friends and faith. the burdens of providing social outlets have fallen solely on their Multiple incidents may occur during this phase. The ebbs and shoulders. flows of chronic illnesses will be found. It is the stage when care- givers grow weary and are at risk of becoming patients themselves. The wise therapist will assist families in determining other sources of care and respite. Community resources may be accessed to relieve Stage 4: Considering residential placement. Stage 4, a watershed some of this burden, and elder visiting networks may also provide the decision, may be viewed tragically by society and welcomed by needed companionship for housebound elders. caregivers. Nursing home placement is a relief to many. The care- giver is allowed to rest, to resume activities and to be assured that Chiefcook and bottle washer others can provide 24/7 care. Handing the baton of care from overwrought caregivers to a formal system is difficult even when A sudden, acute illness causes most to rush to the aid of the ill or injured. welcomed. Although it may appear that this is the end of the The first steps home often find many willing secondary-type caregivers informal network, it is not. The network changes and adapts to including friends or faith-based! parish nursing people who are not the newer, often lesser demands and provides more nurturing usually involved in day-to-day caregiving. These caregivers bring in and care vs. meeting physical needs. food and offer household help. Unfortunately, the rush quickly turns to a trickle with a few or one left to fill in the gaps of services required Stage 5: Caregiving during residential placement. This stage recog- to run a home. For a married couple, it is the spouse who takes on nizes the caregiving changes following placement. Daily or most of the duties the two previously shared. In the case of a widow weekly routines will develop for caregivers and the elder. or widower, children step in as long as possible supported by lifelong family friends including the faith community. Recognizing the long- Stage 6: The eventual death of the elder that brings grief and relief. term nature of this role early may help caregivers to talk and plan Most deaths are grieved even when expected. A sense of guilt may how this role will be filled. Most communities do have formal ser- pervade those who have borne the brunt of care provision and now vices that may be accessed for meals, house maintenance and yard find the relief they desired. This is the stage where the faith com- work. Relinquishing these tasks to formal, paid providers may assist munity may provide the most support to the informal caregivers. in decreasing the caregiver burden. Stage 7: Resuming life. Stage 7 is intertwined with Stage 6. Finding a THE STAGES OF CAREGIVING sense of renewal in one's own life and healing from the long bout of burdens from caregiving. Caregiving may be viewed as a linear process beginning from the insidious start to heavy involvement to death of the elder. Seminal Staging systems are helpful methods of describing processes and work by Pfeiffer (2005) has been done in the stages of caregiving. His emotions that may be in place for caregivers of elders. However, not research describes seven distinct states of caregiving. Table 79.1 out- aU people will progress neatly through stages and staging systems lines each stage. will not always accurately describe the process for all. The seven stages described by Pfeiffer are important for therapists CAREGIVER RECOGNITION and for caregivers to understand. Although he applied much of his research to Alzheimer's patients, it is an applicable model for most Caregivers need to be recognized as an integral component in suc- caregivers. Each stage describes a new responsibility for caregivers and cessful rehabilitation. Therapists need to fully understand the legitimizes the multiple, conflicting emotions felt at each stage. breadth and depth of the care delivery system, noting particularly that most care is not found in the medical arena. Therapists need to Stage 1: Coping - the stage of disbelief. The diagnosis is given; the analyze each patient and their networks before determining how to incident happened; a hospitalization occurred. All create an acute integrate rehabilitation programs. awareness that life for this elder and their networks will never be the same. Internalizing Stage 1 leads to Stage 2. Each patient is an individual, as are his or her caregivers. No system, no matter how well developed or planned, can adequately address all individual needs. In the drive to do the right thing, empathy toward the caregivers needs to become a prerequisite characteristic.

518 THE REHABILITATION TEAM References Schultz R, O'Brien AT, Bookwala J,Fleissner K 1995 Psychiatric and Family Caregiver Alliance 2004The State of the States in Family physical morbidity effects of dementia caregiving: prevalence, Caregiver Support: A 50-State Survey. Family Caregiver Alliance, correlates, and causes. Gerontologist 35(6):771-791 Washington, IX: University of Maryland 2005 Partnership for long-term care. Available: http://www.hhp.umd.edu/AGING/index.html. Accessed December MN Department of Human Services 2005 Financing long-term care for 152005 Minnesota's baby boomers. A report to the Minnesota Legislature. US Department of Health and Human Services 2003 The Older Available: http://www.dhs.state.mn.us/main/groups/aging/ Americans Act, National Family Caregiver Support Pro- documents/pub/dhs_id_025734.hcsp. Accessed December 15 2005 gram: Compassion in Action. US Administration on Aging, Washington, IX: Pfeiffer EA 2005 Caring for the caregiver. Available: http:// www.medscape.com/viewartide/465785_22. Accessed December 152005

519 Chapter 80 Interdisciplinary geriatric assessment Michael Moran. David C. Martin. Margaret Basiliadis and Timothy L. Kauffman CHAPTER CONTENTS credibility from cross-species studies that related longevity to the number of cell doubJings that could occur in cell culture. The number • Introduction of cell doublings proved to be species-specific and varied directly with • Philosopical underpinnings of geriatric assessment the longevity of the species. (See Chapter 1 for additional information • The process of geriatric assessment about theories of aging.) • Directions for future research • Conclusion An exciting finding could further elucidate the exact nature of this biological clock. This finding is the discovery that repeating basepairs _.~--_._---------------- at the ends of strands of DNA, called telomeres, prevent unraveling of the DNA strands and preserve the genetic integrity through their INTRODUCTION repeated replication. The telomeres 'harden' the DNA strand in a fash- ion similar to the way in which the plastic caps on the ends of shoelaces Many approaches to the care of the geriatric patient have been lumped prevent the shoestring from unraveling. The length and stability of under the rubric of 'geriatric assessment'. Indeed, in terms of process telomeres could be the physiological basis of the biological clock. and outcome, geriatric assessment is one of the most widely studied aspects of geriatric healthcare. By 2006, there were thousands of pub- Secondary aging involves those decrements in function that can be lished reports on geriatric assessment, and numerous meta-analyses ascribed to disease processes. Primary and secondary aging are some- had been performed or were under way. times difficult to distinguish from each other. For example, it was once thought that there was a substantive decline in cardiac output that The American Geriatrics Society (AGS) Core Writing Group of the was age related and due to primary aging. However, Pugh & Wei Task Force on the Future of Geriatric Medicine hasoutlined a series of (2001) reported that cardiac output is actually well preserved into core attributes and competencies for geriatric medicine. These include advanced age. 'coordinated care that includes communication among providers' and 'interdisciplinary team care with shared responsibility for patient care Likewise, in the era before autopsy studies had been done upon processes and outcomes' (Besdine et aI2(05). The goal of this chapter people with dementia, it was believed that dementia was simply a is to examine the philosophical underpinnings of the interdisciplinary primary process of the senium rather than secondary aging. Autopsy approach to geriatric medicine, to examine some of the models of how series later disclosed that cognitive losses could be explained by spe- geriatric assessment hasbeen operationalized and to point out some cific pathologies such as multiple strokes or the senile plaques and of the weaknesses and future directions of research for this model of neurofibrillary tangles of Alzheimer's disease. It is now known that, healthcare. even though speed of effortful mental processing slows with aging, in the absence of disease, cognition remains well preserved (Weaver PHILOSOPHICAL UNDERPINNINGS OF et aI2oo6). GERIATRIC ASSESSMENT How do these principles relate to geriatric assessment? It is the Secondary aging must be distinguished from role of geriatric assessment to tease out the effects of secondary primary aging aging and to reverse them through specific treatments, to ameliorate them through interventions that may improve, although not cure, Physiologists often divide the problems of aging into two categories- the underlying condition or to assist the patient to function better by primary aging and secondary aging. Primary aging includes those marshaling support services or altering the patient's environment to physiological changes that can be ascribed solely to the passage of make that environment more conducive to the patient's needs. time. Several theories have been set forth to explain the changes caused only by aging. These include denaturation of proteins through Coexistence of multiple diseases and the cross-linking, cumulative damage from free radicals and an internal cascade of illness biological clock that is genetically determined. This last theory gained When clinicians are first trained in medicine, they are commonly taught to think in terms of the 'chief complaint'. This approach proves to be much too restrictive in the practice of geriatric medicine. Here, the most common scenario is one of multiple, coexisting pathologies that are all conspiring to harm the patient's functional ability. Many

520 THE REHABILITATION TEAM patients presenting for geriatric assessment may have more than four These issues are especially important in geriatric rehabilitation. A significant medical problems that need to be addressed. common scenario is the elderly patient who has suffered a hip fracture An example of the cascade effect of multiple problems might be and requires surgical repair. With postoperative pain and analgesia, the the patient who presents with delirium. Such a change in mental sta- tus is a final common pathway for many medical and psychiatric patient often suffers such setbacks as postoperative delirium, fever, ane- conditions. In this example, the pathology might be traced back as mia from blood loss, atelectasis and hypoxemia. Thus, the rehabilitation follows: the patient has some moderate renal insufficiency and pro- measures may be delayed for several days by intercurrent illness. While static hypertrophy. The prostatic hypertrophy leads to urinary reten- at bedrest, the patient may be losing in the order of 2-5% of muscle tion, which further worsens renal function, which leads to azotemia strength (Gillis 2005) and 1-2% of aerobic capacity daily. Whereas and anorexia, which leads to reduced fluid and nutritional intake, younger people may surmount these losses, in the geriatric patient who which leads to even further worsening of renal function and a relent- is already marginally compensated, these losses become highly sig- less downward spiral. This interrelationship of organ system func- nificant and make rehabilitation and recovery all the more difficult. tion causes a cascade of illness that affects many organs. In this setting, the patient might not cope well physically or psycho- A challenge of geriatric assessment is to trace the cascade of events logically with the arduous exercise demands of rehabilitation. The back to find key points in each patient's unique pathophysiology twice-daily treatments of up to 4 hours imposed by government regu- where treatment may halt or reverse the downward spiral. Because lations may be too rigorous for some of these more frail individuals. of the complexity of this process, an interdisciplinary approach is Sometimes, rehabilitation must occur at a more gradual pace and in the often most successful. Also, there is no substitute for seasoned and long-term care setting. experienced clinicians making expert diagnoses. The challenges of treating the frail elderly led Franklin Williams, a past director of the Diseases present in an atypical fashion National Institutes on Aging, to coin the phrase 'the fruition of the clinician' in respect of the practice of geriatric medicine. Among geriatric patients, the common presentations of illness are often replaced by the less specific and more global findings of As any cohort ages, variability increases increased confusion, weakness, anorexia and tendency to fall. One sees such phenomena as 'silent myocardial infarction', 'afebrile pneu- As noted earlier, it is often impossible to predict the specific decline monia' and 'depression without sadness'. The first manifestation of of any particular organ system on the basis of aging alone. Likewise, urosepsis might be falling, or the presenting symptom of a myocar- it is impossible to predict the physiological function of any individ- dial infarction might be increased agitation. In geriatric assessment, ual based on age alone. One may speak of chronological age vs. the clinician must cast a wider net in attempting to make diagnoses. physiological age. To speak of a young 80-year-old or an old 65-year- old does not sound like an oxymoron to the geriatric practitioner. Other diseases typically present only in the elderly or much more fre- quently in the elderly, and the index of suspicion for these problems What can be predicted is that, as people age, they become less and must remain higher. These disorders include such entities as polymyal- less like each other. (Anyone who has attended a 25-year class reunion gia rheurnatica, Parkinson's disease and hypothyroidism. has probably experienced this first hand.) No two persons age identi- cally. Some encounter diseases, others suffer traumatic injuries and Diseases are underreported others cope with both. Lifetime habits, choices and fortune add to the genetic variability of aging individuals. Geriatric patients commonly underreport their problems (Doughty 2003, Tariq et al 2003). Sometimes, cognitive impairment gets in the The increasing diversity that comes with age has a direct effect on way of an accurate relating of historical information. At other times, the geriatric assessment. For geriatric assessment to work well, it is crucial patient is embarrassed to bring up certain problems. This may account that both diagnostic and therapeutic approaches be individualized for for the fact that incontinence is so underreported. At other times, each patient. Attempting a 'cookbook' approach to the solution of clin- depression may lead to a sense of hopelessness about the possibility of ical problems in such a diverse group could easily lead to iatrogenic getting help; or patients may have acquired some of the ageist bias harm. The recent trend toward the creation and application of clinical from the society in which they live and may feel that their problems are pathways or clinical guidelines in the treatment of specific conditions to be expected at their time of life and they should not complain. must proceed carefully and contain greater flexibility when dealing with issues in geriatric medicine. The process of geriatric assessment strives for accurate and reliable historical information by collecting data through collateral interviews Again, the interdisciplinary approach, because of its greater clinical with caregivers and loved ones as well as with the patient himself or diversity, can better account for the pluralism of this unique population. herself. The patient is also typically interviewed by several profession- als. A patient might relate something to a nurse or social worker that Diminished homeostatic reserve blocks recovery would not have been mentioned to a doctor. Perhaps the best definition of aging is 'increasing susceptibility to the Self-report questionnaires and structured assessment tools to mea- forces of mortality due to decreased homeostatic reserve'. Homeostasis sure cognition, affect and morale can yield quite useful information if concerns the body's ability to maintain itself in a steady state and to get they are administered carefully and in a nonthreatening manner. These itself back on track whenever there is perturbation from that steady tools add additional important information to the historical database. state. Ability to maintain a constant temperature, constant blood pres- sure, and constant blood glucose level are all examples of homeostasis. THE PROCESS OF GERIATRIC ASSESSMENT When homeostatic reserves are constrained, there is diminished The process of geriatric assessment typically involves an interdisci- likelihood of survival with any extreme stress. A key principle in plinary approach. The most consistent team members to have formed geriatric assessment is to recognize that homeostatic reserves are the traditional core of this assessment process have included the geri- diminished and that patients are more sensitive to both the disease atrician or geriatric nurse practitioner, nurse and social worker. processes and the iatrogenic effects of intervention. This should lead Ancillary team members have included the occupational therapist, to a more conservative and individualized approach in the applica- tion of therapeutic maneuvers and drug therapies.

Interdisciplinary geriatric assessment 521 physical therapist, psychiatrist, nutritionist, speech therapist, exercise was pointed out that hercognitive loss might not be due physiologist, recreational therapist and respiratory therapist. One of to Alzheimer's disease, as she had been told previously, and the very first outpatient assessment programs even employed an that the prognosis was uncertain. It was decided to architect because of the frequency with which changes in the patient's continue to monitorthe patient's mood for another month home environment were being recommended. and to consider treating her with one of the newer selective serotonin uptake inhibitors if her mood remained In the following case study, an example of the geriatric team in action depressed. The patient was referred to an adult daycare may help to illustrate many of the principles of geriatric assessment: program. She began to attend 3 days per week. Case study Six months later, the patient was being maintained on 5 mg of prednisone daily. Her mobility remained good and Mrs A was an 85-year-old widowed woman who was living the sedimentation rate was 26 mm\"'. The patient had been with and being cared for by her 54-year-old daughter. She started on sertraline 50mg daily, and her mood had improved. was referred byherdaughter for outpatient geriatric The hemoglobin had risen to 13.0 g,tlLShe was still assessment. The patient had been suffering from gradual and occasionally delusional and the score on the Mini-Mental progressive memory loss for the preceding 3 years. Three examination had not improved. The patient's daughter, weeks previously, she had become more apathetic and however, was feeling greatly relieved, and she perceived her withdrawn, and had ceased to be able to climb the stairs mother to be functioning at a much higher level of cognition, because of arthritic complaints. On intake, she was being even though this could not be objectively demonstrated. treated with amitriptyline 25mg at nightfor depression. The daughter was planning to have hermother enter a 1-week respite program while the family went on a week- On further questioning, it was learned that the patient long vacation. was becoming delusional, believing that people on the television screen were real. Her functional status a month This case illustrates several key principles of geriatric assessment. earlier had been much betterand her incontinence was This patient was suffering primarily from an illness (polymyalgia new. She complained of a feeling of profound weakness. rheumatica) that is found exclusively in the elderly population. In the The social worker learned that the daughter was extremely absence of any symptoms suggesting cranial arteritis, many clinicians resentful that the caregiving burden had fallen to herand would institute an empiric trial of corticosteroid therapy without doing was not being shared by hertwo siblings. She felt guilty a temporal artery biopsy and gauge the response to therapy. A dra- about herresentment, and this made hercaregiving even matic response, as was seen in this case, helps to confirm the diagnosis. more difficult. The next most important problems, those of the cognitive impair- Medical workup disclosed moderate degenerative joint ment and dysphoria, reveal how multiple coexisting pathologies can changes, moderate hearing loss and dysphoric mood. The conspire to create dysfunction. The suddenness of the onset of the patient made seven depressive responses on the Geriatric patient's delusions and cognitive decline suggested either a vascular Depression Scale and scored 2Q'J0 on the Folstein Mini- process or a reaction to the anticholinergic effects of the amitriptyline. Mental Examination. She remembered zero out of three The low cobalamin level is also a not uncommon finding and could objects on early recall. Mobility testing showed profound also be contributing to the cognitive loss. The use of oral rather than weakness, with difficulty arising from the examination parenteral replacement therapy for a low cobalamin level is debatable, chair and broadening of the support base. Screening but the decision was made to institute parenteral replacement just in laboratory tests showed a mild anemia with a hemoglobin case the patient could not adequately absorb the vitamin. of 11.3 gJlL and a mean corpuscular volume (Mev) of 81. The serum cobalamin level was low normal at 200pg,mL In many instances of geriatric assessment, the caregiver becomes The sedimentation rate was markedly elevated at as much a client as the patient. Predictable respite is one effective 110 mm/h. Other blood parameters were normal. A means of reducing caregiver stress, and referral to an adult daycare magnetic resonance imaging (MRI) scan showed program is an ideal way to provide predictable respite. When allevi- periventricular hyperintensity and multiple lacunae. Soon ated of some of the caregiving burden, the daughter could once afterthe initial assessment, the patient was begun on again enjoy her relationship with her mother. 15mg of prednisone dailyfor a presumptive diagnosis of polymyalgia rheumatica. In addition, she was begun on The perception on the part of family members that the patient was cobalamin injections. The amitriptyline was discontinued. functioning much better cognitively even though objective improve- When the patient was returned to the clinic for a family ment could not be measured represents another phenomenon conference, her mobility had improved dramatically, as deserving of mention. Significant disparity between 'perceived' and had herpain symptoms. The incontinence had resolved 'measured' improvement often exists. because the patient was now mobile enough to get to the bathroom. The delusions had also disappeared, but the In order to coordinate and implement the various recommendations patient remained dysphoric. The family was educated and of the separate professionals involved in the interdisciplinary approach, counseled about the spectrum of the patient's problems. It a team conference is typically held after the assessment. The care plan is crafted with input from the various team members. Often, a family conference is held with the patient and all involved family members and caregivers. The purpose of this conference is to educate the patient and caregivers, to make official recommendations, and to answer ques- tions. It also provides yet another opportunity to assess for caregiver burden and to move to alleviate it if it is clinically Significant.

522 THE REHABILITATION TEAM The interdisciplinary model of geriatric assessment has been an effort to standardize care and reduce costs. As healthcare systems applied to a variety of settings (Phillips 2005). The most common become globalized to include the entire continuum, these pathways have been adult medical-surgical hospital wards, outpatient clinics, must become more extended. They will cease to be disease- or organ- inpatient geropsychiatry units, nursing homes, rehabilitation hospi- specific and, rather, will evolve into a 'syndromic' approach. To tals, patient homes and hospital-based consulting services. There are work effectively, these pathways must take into account the various also more complex models that involve many team members and are principles of geriatric assessment that have been under discussion. found in the inpatient and consultation models. The effects of the application of such pathways on outcomes have been positive (Smyth 2001, Endo et al 2004). From many outcome studies (Barnes 2006, Covinsky 2006, Jacobs 2006) that have been performed on the various manifestations of Many other important questions about the approach to treating geriatric assessment, one can make several generalizations. First, the geriatric patient must be addressed. Some of these are the fol- and perhaps most important, is that assessment without implemen- lowing: What is the value of treating dysphoric mood that falls short tation is of almost no value. The programs with the most robust out- of full-blown depression? Some data suggest that patients with dys- comes have been those with direct links to rehabilitation services phoria may be inappropriately high uti1izers of healthcare resources. and those in which the geriatric team had direct responsibility for the How stable are people's advance directives? Do they change when implementation of care plans. Second, not all geriatric patients can patients are more immediately confronted with life-threatening situ- be expected to benefit from geriatric assessment. Patients who have ations and the issues are more immediate and less abstract than relatively high function and those who are hopelessly ill are less when the directive was originally formulated? How valuable are likely to derive benefit, so many programs attempt to target those exercise prescriptions in later life? What are some of the long-term who would be most likely to benefit. On the other hand, one would effects of nutrition on health? Higher folate intakes may have an also not wish to be too quick to judge a patient as hopelessly ill, antiatherogenic effect mediated through homocysteine levels. Are because geriatric assessment has scored some of its greatest suc- there ways to ameliorate the effects of bedrest deconditioning and cesses in patients who had previously been written off by the tradi- the development of delirium that so often add to the morbidity of tional healthcare system. hospitalization of geriatric patients? Is there a role for anticipatory conditioning prior to elective hospitalizations or procedures (so- In terms of traditionally measured outcomes (such as mortality, called prehabilitation)? functional status, frequencies of hospitalization and nursing home placement), research study results are mixed. Because of the mixed CONCLUSION models of geriatric assessment and differing sites of practice, meta- analyses and generalizations about the value of geriatric assessment It remains for the upcoming generation of researchers and practitioners are difficult. Nevertheless, some reviewers Oouanny 2005) have felt to improve the knowledge base and give good health and meaning to that the data are convincing in terms of reduction in mortality, low- the later stages of peoples' lives. Not enough students are entering this ered rates of nursing home placement and lowered levels of care- important field, yet it can be among the most rewarding and challeng- giver burden. ing of endeavors. DIRECTIONS FOR FUTURE RESEARCH To recapitulate the previous clinical scenario of the 85-year-old woman with both physical and cognitive impairments, recall that The technology of geriatric assessment has been under attack the patient's subjective improvement vastly surpassed what could because it is viewed as labor intensive and inadequately reimbursed. be measured objectively. When a patient is marginally compensated Were the data of research studies more conclusive with regard to and just barely able to get by, then slight improvements in condition outcomes, it would be easier to advocate the widespread application are often perceived as dramatic, even when the degree of improve- of interdisciplinary geriatric assessment. The main challenge in the ment can scarcely be measured by our crude assessment tools. This light of what has been learned seems to be selective application of magnified effect of intervention on the patient's and family's per- this interdisciplinary approach, targeting those subjects and con- ceptions of health and well-being can be one of the most gratifying texts in which geriatric assessment is determined to be cost effective. aspects of serving a frail geriatric population. Other areas of active research in this field include investigation It is hoped that the information in this book will help to enable into the optimal place to perform geriatric assessment. Some intrigu- accomplishment of the AGS Task Force goals for geriatric medicine. ing studies suggest that the optimal site may be in the patient's own They include: (i) 'continuity and seamlessness across all sites and home (Nikolaus & Bach 2003).Other important questions also have providers' and (ii) 'appropriateness of care within the context of the to be answered. Do data that have been collected largely through goals of the individual patient and the values of society'. But to interview reflect what the patient is actually able to perform? Do achieve this, new models must be developed for healthcare delivery data on functional status, which are often garnered by physical ther- especially in the United States, which is largely determined by the apy and occupational therapy in a laboratory setting, correlate well Medicare system. In this system, benefits are not uniform and obsta- with what the patient can do in his or her own home? cles exist within the fee-for-service model that encourages payment for units of care but not for case/disease management (Besdine et al The development of critical pathways, or clinical algorithms, is a 2005). process that is being repeated at virtually every acute care hospital in References Covinsky KE2006Development and validation of an index to predict activity of daily living dependence in community dwelling elders. BarnesDE 2006 Depressive symptoms, vascular disease, and mild Med Care 44(2):149-157 cognitive impairment: findings from the cardiovascular health study. Arch Gen Psychiat63(3):273-279 Doughty DB2003Promoting continence: simple strategies with major impact. Ostomy/Wound Manage 49(12):46-52 Besdine R, BoultC, Brangrnanet al 2005 Caring for older Americans:the future of geriatric medicine.JAm Geriatr Soc53 (suppI6):S245-S256

Interdisciplinary geriatric assessment 523 Endo H, Nippon R, Igakkai Z 2004 Comprehensive geriatric medicine. Phillips SL 2005 Pain management in a long term care setting: an [ap J Geriatr 41(4):375-377 interdisciplinary approach. Ann Long Term Care 13(6):34-36 Gillis A 2005 Deconditioning in the hospitalized elderly. Can Nursing Pugh KG, Wei JY 2001 Clinical implications of physiological changes in 101(6):16-20 the aging heart. Drugs Aging 18(4):263-276 Jacobs LG 2006 Warfarin pharmacology, clinical management, and Smyth C 2001 Creating order out of chaos: models of GNP practice with evaluation of hemorrhagic risk for the elderly. Clin Geriatr Med 22(1):17-32 hospitalized older adults. CIin Excellence Nurse Pract: lnt J NPACE 5(2):88-95 Jouanny P 2005 Pharmacological treatment in severe dementia. Psychol Tariq SH, Morley IE, Prather CM 2003 Fecal incontinence in the elderly Neuropsychiat VieiIl3(suppll):S51-S55 patient. Am J Med 115(3):217 Nikolaus T, Bach M 2003 Preventing falls in community dwelling frail Weaver q, Maruff P, Collie A, Masters C 2006 Mild memory older people using a home intervention team (HIT): results from the impairment in healthy older adults is distinct from normal aging. randomized falls-HIT trial. JAm Geriatr Soc51(3):300-305 Brain Cognition 60(2):146-155

525 Chapter 81 Gerontological and geriatric nursing Brenda Hage CHAPTER CONTENTS area are known as geriatric nurse practitioners or geriatric clinical specialists. • Introduction • Direct patient care An overall goal for gerontological and geriatric nursing is to pro- • The four steps of nursing vide humanistic healthcare to older adults and their families by pay- • Case management ing careful attention to individual circumstances, needs and goals. • Health education and counseling for patients and Preventing impairment, restoring function and maintaining an enduring state of health and well-being and quality of life are families embedded in these goals. A key strategy that is used to meet these • Administration goals is the application of the nursing process that consists of assess- • Advocacy and public policy development ment, planning, intervention and evaluation within the context of • Education and research healthcare issues presented by the elder and their family. • Conclusion As a discipline, nursing has agreed to a social contract to make its INTRODUCTION services available 24 hours a day. Thus, gerontological and geriatric nurses have critical roles in the collaboration of the healthcare team, as The nursing profession has a long history of providing healthcare to they must be involved in planning, implementing and evaluating sick older people. Initially, geriatric nursing focused on physical care, patient care. The nurses' roles and functions include nursing manage- comfort measures and palliation. The care was often given almost ment and other therapeutic activities for direct patient care, case man- entirely by nurses and their assistants in nursing homes or in people's agement, patient and family health education and counseling, admin- own homes. As knowledge, technology, public policy, and societal istration, advocacy, public policy development, and education and expectations changed, the scope, types of geriatric services and quality research. of nursing care also changed. The establishment of the first formal stan- dards for nursing care for older adults, adopted in 1970 by the DIRECT PATIENT CARE American Nurses Association (ANA), was a landmark initiative for nurses in geriatrics. It provided a link to nursing science, which is To ensure seamless care, continuous leadership and accountability defined by the ANA as the deliberate problem-solving process, are requisite. Professional nurses act on these responsibilities in acute grounded in the biopsychosocial sciences, of diagnosing and treat- care units, ambulatory care clinics, long-term care facilities, homecare ing actual or potential health problems. agencies and other sites where the need for geriatric care can be fulfilled. As these practice standards were reviewed and modified over time, patient-eentered care, family participation and nursing services related At least three different types of nursing expertise, using different lev- to the prevention of disease and disability and the promotion of good els of critical thinking and clinical decision-making skills, are available health for older adults were articulated more explicitly as major com- to older patients to assist them in meeting their healthcare needs: ponents of geriatric nursing practice. This paved the way for the use of the term'gerontological nursing' to refer to a domain in the continuum 1. Staff nurses have clinical, technical and humanistic skill in one- of the science and practice of nursing that is devoted to the complex to-one interaction so they can strengthen and support the care of older adults and their families and to balancing the effects biopsychosocial processes of recovery, rehabilitation, healing, of normal aging and pathology. Today, the term 'geriatric nursing' preventing disease and disability, and dying with dignity. Nurses indicates specialized clinical care for the medical problems of the functioning in this role practice in acute care settings, skilled sick and chronically ill elderly in various interdisciplinary patient nursing facilities, home health settings and hospices, and a care settings. Nurses with advanced training who practice in this smaller number practice in ambulatory care clinics or doctors' offices. 2. Advanced practice nursing roles in gerontological nursing pri- marily include clinical specialists and nurse practitioners. These master's degree or doctorally prepared nurses function in a vari- ety of roles to support this challenging patient population.

526 THE REHABILITATION TEAM (i) Geriatric clinical nurse specialists have expertise in working It is important for members of healthcare teams to be aware that with complex nursing care problems and draw from their some problem areas that demand priority nursing interventions may advanced skills in hands-on clinical care, critical analysis and not always be parallel to or target directly the 'curing' goals of a decision-making, teaching, counseling, and coordination and medical plan. follow-up of interdisciplinary care plans. They practice in acute and long-term care settings and may be consultants to Step 2: Planning community clinics and home-based geriatric care programs. They may also conduct research, evaluate program outcomes, The nursing care plan incorporates specific nursing interventions and and coordinate quality improvement activities. activities to treat specific nursing diagnoses or deal with problem areas such as changes in food intake, impaired capacity for personal care, (ii) Geriatric nurse practitioners have expertise in performing com- risk of accidental injuries due to general weakness and mild dementia, prehensive physical assessments, interpreting symptoms and grief unrelated to the health problem, and other needs of the geriatric physiological abnormalities, and developing treatment, man- patient and the caregiver. Included in the plan are nursing actions to agement and follow-up plans for medical problems, in partner- insure the continuity of all prescribed medical treatments and other ship with the primary care physician and other team members. intervention modalities for the geriatric patient. Clinical judgment is an Their practice is closely linked with primary care services in important nursing skill in this process because it enables an accurate ambulatory clinics, although a growing number of these nurses identification of the nursing diagnosis. are providing services to elderly patients in long-term care facil- ities, adult day health programs, and physicians' officesas well Step 3: Implementation as inpatient settings. The process of implementation utilizes the collective efforts of mem- THE FOUR STEPS OF NURSING bers of the nursing staff, including auxiliary nursing personnel, and directs them so that the nursing care plan can be carried out. Safe The four-step nursing process guides the nurse to individualize, con- and compassionate approaches that are clinically and technically textualize and prioritize problem areas. The steps consist of assess- appropriate are used to achieve the desired clinical outcomes. ment, planning, intervention and evaluation. Nursing actions may include activities such as checking vital signs, changing the position of an immobilized elderly patient, orienting Step 1: Assessment an elder with a memory deficit to time, place, and activity, inter- viewing a family caregiver prior to homecare, consulting other Biopsychosocial data about geriatric patients are collected by means of healthcare professionals, advocating for an elder to obtain a local interviews, record reviews, direct observations and other approaches, community resource, and other actions aimed at resolving a nursing as time allows, to build a composite picture of the multiple and often problem or reducing the impact of a nursing diagnosis. competing needs of the geriatric patient and the informal caregiver. For example, the federally mandated multidisciplinary assessment Step 4: Evaluation called the Minimum Data Set (Burke & Walsh 1997)is usedin nursing homes by long-term care nurses to record assessment data as part of A patient's physical, verbal and behavioral responses, informal care- the team approach to care planning and treatment. givers' reports and observations by healthcare providers from other disciplines are important aspects of the feedback mechanism that helps Data from nursing assessments are necessary to identify problems in the nursing staff to maintain a dynamic, flexible care plan. Critical the order of clinical significance at a Specifictime and according to the analysis of information obtained while nursing interventions are in urgent need for nursing interventions. The information may include progress may be usedto modify nursing interventions, redirect patient general and specific data on the presenting problems as defined by the and family participation in the overall treatment and management patient and the caregiver, medical diagnoses, prescribed medical treat- plan, re-examine the healthcare team's understanding of the clinical ments, status of physical and mental functions, alternate healthcare problem, determine cost benefits, realign leadership and support the resources, patient goals and expectations, safety risks, self-care abilities standards of quality patient care. for recovery, including the ability to perform activities of daily living, and other information that a nurse considers clinically relevant to the CASE MANAGEMENT case or situation. Identifying nursing diagnoses and prioritizing these problem areas are the major intended process outcomes. The nurse case manager looks after a group of elderly patients and informal caregivers. As a rule, frailty, multiple chronic illnesses, unsta- Since 1973, the North American Nursing Diagnosis Association ble functional status, complex psychosocial and financial situations, (NANDA) has continued to develop a taxonomy of nursing diagnoses, and other multilayered clinical issues trigger the need for this type of and currently there are approximately 130 approved classifications of professional nurse. Advanced skills in clinical decision-making, com- patient care problems in nine categories. In 1987, the Center for munication, resource identification, referral, management, systems Nursing Classification and Clinical Effectiveness at the College of analysis and cost analysis are essential for effective case management. Nursing, University of Iowa, developed taxonomies for classifying and The role of a nurse case manager involves consulting with healthcare organizing nursing interventions and nursing outcomes through the providers; meeting with patients, family members and other support use of the Nursing Intervention Classification (NIC). This was followed systems; advocating for need-specific health and social services; plan- by the development of Nursing Outcomes Classification (NOC) coding ning for discharge; insuring safe termination of services; facilitating systems in 1992.The NIC/NOC codes are linkedto the NANDA diag- shared decision-making; and recording appropriate documentation. noses and serve to document the effectiveness of nursing interventions Case managers may also negotiate a change in health benefit with and outcomes (McCloskey et a12004,Moorhead et al2(04). Refinement of the NIC/NOC classification systems has been ongoing. The use of nursing taxonomies facilitates the capture of nursing data useful for evaluation, quality improvement, and research activities.

Gerontological and geriatric nursing 527 third-party payers to insure that the older patient's needs are being expertise in the legislative process and their analyses of public poli- optimally addressed. As healthcare delivery systems change, the num- cies may be applied to issues related to healthcare access for the ber of nurse case managers for older people is expected to increase, aging population and other relevant concerns. They find employ- particularly in community-based programs such as home-based ser- ment in governmental agencies, in the offices of public officials, with vices, adult day health programs, and respite and hospice services. advocacy organizations, or with other entities oriented toward pub- For example, in the home health arena, the nurse is the ideal team lic policy issues and aging. leader; in that role, the nurse can coordinate the case and facilitate the completion of required documentation by interdisciplinary care EDUCATION AND RESEARCH providers, institutions, physicians in group or private practice and payers. With the growing trend toward managed care, the nurse in With the increasing number of education programs in gerontological such a role might be called a case manager. Other administrative func- and geriatric nursing being taught in colleges and universities, the tions may also be part of the geriatric nurse case manager's responsi- need for faculty members with doctoral and master's degrees in bility in the practice sites mentioned earlier. gerontology and geriatrics will continue to grow. Clinical specialists, nurse practitioners and nursing administrators predominate in the HEALTH EDUCATION AND COUNSELING FOR faculties of many nursing schools across the country. Gerontological PATIENTS AND FAMILIES and geriatric nurses with doctoral degrees have teaching and research responsibilities. They are prepared to function as principal A major focus of the teaching and counseling done by gerontological investigators in research projects and clinical trials and to establish and geriatric nurses relates to the implementation of treatment and research programs in gerontological and geriatric nursing science. management prescribed by healthcare providers in acute care, home- Generating evidence-based nursing practice is an important com- care, or community care. Teaching patients before they are dis- mitment of these nurse researchers. Some of the domains of nursing charged home or to another site of care helps to prepare the patient research are sleep disturbances, agitation, pet therapy, family care- and the family. Education in ways of preventing disease, disability, giving, falling behavior, sensory disabilities, use of technology to and complications of existing chronic health conditions becomes support aging in place and self-care deficits. The body of knowledge increasingly necessary as the shift to community care expands. produced by their studies contributes to improving healthcare for Teaching and counseling by these nurses take place across the contin- older people and to advancing the science of aging. In addition, uum of care of the elderly. This function may be combined with direct these researchers create opportunities for other nurses to experience patient care and case management functions. the research process as assistants, graduate students or participants in the study. ADMINISTRATION CONCLUSION Professional roles for administrative nurses include director of nursing Gerontological and geriatric nurses have a variety of roles and func- services in a skilled nursing facility and administrator in a variety of tions. With the trend toward downsizing and the shift to managed settings, such as homecare, adult day health, respite care, hospice, and care programs, these roles and functions are being fused and struc- other community care programs for older adults. Some nurse entrepre- tured in different ways. New personnel who deliver direct bedside neurs take on the challenge of administering small board-and-care (i.e. care but have limited formal education and training are being intro- personal care) homes. The legislative mandates of Medicare and duced into the clinical arena. The challenge to nursing, in particular to Medicaid, regulations, and the standards of care, to name a few, are nurses in gerontology and geriatrics, is to maintain the standards of complex bodies of information that the geriatric nurse administrator is healthcare for older adults, especially those who are disempowered able to translate into practice in order to support quality standards of by chronic disability, socioeconomic status, racial or cultural factors, care and insure fiscal responsibility. environmental situations, low health literacy or technological illiter- acy, and lack of technology access. Also, the aging of the baby ADVOCACY AND PUBLIC POLICY boomers, a social and historical phenomenon, is already shifting the DEVELOPMENT focus of healthcare from the cure model to the prevention model. The high incidence of chronic disease in this population requires new Although nurse activism is found among all types of practitioners of approaches to assisting older adults in the development of self- nursing, some nurses in gerontology and geriatrics build careers in management skills needed to deal effectively with these problems. It is advocacy dedicated to shaping and changing public policy. Their clear that new expertise and more advanced practice nurses will be needed in this specialty. References Moorhead 5, Johnson M, Maas M (eds) 2004 Nursing Outcomes Classification (NOC), 3rd edn. Mosby, Philadelphia, PA Burke M, Walsh M (eds) 1997Gerontologic Nursing: Holistic Care of the Older Adult. Mosby YearBook,St Louis, MO McCloskeyDochterman J, BulacheckGM (eds) 2004Nursing Intervention Classification (NIC), 4th edn. Mosby, Philadelphia, PA

529 Chapter 82 Geriatric occupational therapy Molly Mika CHAPTER CONTENTS Additionally, the occupational therapy clinician conducts an analysis of the client's occupational performance (AOTA2002, Boyt • Introduction Schell et al2003b). He or she observes the older adult engaging in • Occupational therapy assessment a valued occupation, such as eating, dressing, moving in bed or • Occupational therapy intervention preparing a meal, to identify the client's functional strengths and • Conclusion limitations. The clinician then performs standardized and/or non- standardized tests to specifically pinpoint the client factors, such as INTRODUCTION decreased strength or decreased ability to initiate a task, contributing to any functional limitations. Occupation may be defined as any meaningful and purposeful activ- ity or series of activities in which an individual engages. According Occupational therapists and the interdisciplinary team members to the occupational therapy practice framework of the American share their assessment findings with one another in order to develop a Occupational Therapy Association (AOTA), areas of occupation comprehensive treatment plan. In some settings, such as hospitals include activities of daily living (eating, dressing, toileting, etc.), and home healthcare, interdisciplinary team members contribute instrumental activities of daily living (homemaking, meal prepara- their findings to a joint team evaluation. Using the Functional tion, money management, etc.), education, work, play, leisure, and Independence Measure (FIM),in hospitals across the United States for social participation (AOTA 2(02). Disease, dysfunction and loss example, enables healthcare providers to establish a baseline level of associated with advanced age threaten the older adult's satisfactory performance for each client and provides all team members with a engagement in occupations. Occupational therapy (O'I') practition- method of tracking a client's progress in primary areas of daily func- ers, consisting of both occupational therapists and occupational ther- tioning (Uniform Data System for Medical Rehabilitation 1993). While apy assistants, therapeutically use meaningful and purposeful the FIM tool may be entirely conducted by any treatment team mem- activities to insure and enhance an individual's participation in cho- ber, occupational therapists are often responsible for completing the sen occupations. self-care and transfers portion of the assessment. OT practitioners serve older adults in various settings including a Through joint and discipline-specific evaluation, the occupational variety of inpatient settings such as acute care hospitals, rehabilitation therapist and the treatment team members, in collaboration with the centers, skilled nursing facilities and psychiatric centers. Community- older adult, prepare for the client's discharge either home or to the based occupational therapy may be provided in outpatient settings, next level of service. clients' homes or in adult daycare and senior centers (Boy! Schell et al 2003a). Occupationaltherapy professionalsmay fulfill the roles of direct OCCUPATIONAL THERAPY INTERVENTION service provider, administrator, consultant, educator and researcher. Upon completion of the OT assessment, the OT practitioner begins OCCUPATIONAL THERAPY ASSESSMENT intervention planning and implementation. Practitioners may employ a combination of interventions including the therapeutic use ,f '. :. of self, the therapeutic use of occupations and activities, education and consultation with either individuals or groups (AOTA2(02). In order to provide effective, efficient therapeutic intervention, occu- pational therapists conduct a thorough twofold assessment of their Additionally, based on the etiology of the client's deficits, practi- clients. The therapist conducts an occupational profile (a client- tioners use a combination of the following treatment approaches: centered interview) designed to gather pertinent information regard- create/promote, establish/restore, maintain, modify and prevent. ing the individual's occupational history and preferences, the various (This approach is used when a client's pathological condition, contexts in which the client engages in occupation, and the client's Alzheimer's or Parkinson's disease for example, is progressive in values, beliefs and goals regarding his or her current functional per- nature. In these situations, the absence of OT intervention would formance (AOTA2002, Boyt Schell et aI2003b). result in significant decline in a client's functional performance, thereby increasing his or her burden of care.) The following case illustrates how occupational therapy might be applied in geriatrics.

530 THE REHABILITATION TEAM Case study Arlene's physician referred herto home healthcare services Arlene to engage in the tasks) with transfers and moderate including nursing, physical therapy, and occupational therapy. assistance (a helper contributed approximately 50% of the The physician's orders for occupational therapy included effort necessary for Arlene to engage in the tasks) with most training in activities of dailyliving, transfers, instrumental self-care tasks. The therapist also assessed Arlene's left upper activities of daily living (homemaking), increasing left upper extremity status and function, including pain and edema extremity active range of motion (ROM) and left upper (excess swelling that had accumulated in Arlene's hand as a extremity strengthening. result of sustained immobilization and now interfered with her mobility) evaluation, active/passive ROM and muscle strength Arlene, an 83-year-old female, recently fractured herleft measurement. Moderate edema of Arlene's left hand and wrist distal humerus, herdominant extremity, when she fell trying was noted. She experienced moderate pain during gentle passive to get to the bathroom one night. While the doctor performed ROM of hershoulder and elbow and had significant active and no surgery or casting to Arlene's left arm, he had immobilized passive ROM and strength limitationsthroughout her left upper it with a simple sling for 6 weeks. He has removed the sling extremity. Additionally, the therapist assessed Arlene's home in and has ordered therapeutic services through a home health order to make recommendations to insure the client's safety and agency. Arlene has diabetes and experiences atrial fibrillation. to optimize herfuture occupational performance. The Her right middle finger was surgically amputated 1 year ago. occupational therapist noted obstacles such as clear oxygen Arlene has type II diabetes and undergoes kidney dialysis three tubing strewn on the floor in multiple rooms. times per week. The occupational therapist, in collaboration with Arlene, set Occupational profile the following long-term goals: Arlene resides in a two-story home with herhusband and 1. Arlene will perform all self-care with supervision only within adult son. Her husband uses compressed oxygen 24 hours 5 weeks. per day and herson works full time in a warehouse. Prior to herfall and subsequent left humeral fracture Arlene slept in 2. Arlene will prepare a simple lunch for her husband herbedroom and used the bathroom on the second floor of her independently within 5 weeks. home. Arlene currently does not access hersecond story because she cannot use the single handrail when descending The occupational therapist set corresponding short-term the stairs because of left upper extremity pain and ROM goals for each long-term goal. For example. in order to meet limitations. She sleeps in a rented hospital bed on the first long-term goal number one, Arlene would first meet the floor. As there is no bathroom on the first floor, Arlene toilets following short-term goal: using a portable commode and sponge bathes in the kitchen. She relies on herson to empty the commode and for Arlene will comb her hair using her left hand with minimal assistance with bathing and dressing. Arlene reports assistance within 2 weeks. significant limitations when attempting herfavorite occupations, cooking and baking. Occupational therapy intervention Arlene reports that she longs to sleep in herbed upstairs as Arlene's occupational therapist used a variety of intervention well as use the second-story bathroom. She also wishes to approaches to insure Arlene's goal accomplishment. prepare a simple lunch for herself and her husband without the assistance of herson. Prevention: As Arlene's humeral fracture resulted from a fall, the occupational therapist educated herand herfamily in fall Arlene uses a straight cane when ambulating throughout prevention. To increase visibility, yellow duct tape was applied her home and requires supervision to do so as her to the clear oxygen tubing at 6-inch intervals. Additional lighting compromised endurance and dynamic standing balance put in hallways, especially for night use, was also recommended. herat risk of future falls. Restoration: The occupational therapist instructed Arlene in Analysis of occupational performance left upper extremity active assistive ROM exercises. Additionally, she engaged Arlene in therapeutic activities and occupations The occupational therapist observed Arlene's performance in designed to increase shoulder, elbow, wrist and finger strength functional mobility (transferring to and from the bed, the and ROM. For example, Arlene used her right hand to assist the commode, a kitchen chair and a reclining chair) and in self- left hand in pressing out a graham cracker pie crust and later care (item retrieval required for grooming in the kitchen and cleaned the table using her left upper extremity, stretching to hand washing). Arlene required minimal assistance (a helper reach a bit further with each swipe of the dishcloth. contributed approximately 25% of the effort necessary for Modify: The occupational therapist introduced Arlene to adaptive dressing equipment, a sock aid and shoe horn to assist herwith lowerextremity dressing. Arlene is not expected to fully regain the function of her left upper extremity, but would still like to don hersocks and shoes independently.

G~riatric occupational therapy 531 An Of consultant, hired by the manager of a high-rise apartment performance. For example, an OT practitioner would recommend building for independent seniors, uses the createlpromote approach showering while seated on a tub bench for an older adult who has when instituting a work simplification and energy conservation pro- sustained bilateral lower extremity amputations. gram in the setting so that seniors might not become overly fatigued when shopping or preparing meals. The createlpromote approach Finally, OT practitioners concern themselves with preventing fur- targets the well population with the aim of enhancing quality of life ther disability among their clients. Older adults recovering from through participation in occupation. lower extremity joint replacement, for instance, would benefit from a fall prevention program. An Of practitioner uses the establishlrestore approach to inter- vention when he/she facilitates a patient's functional skills that were CONCLUSION lost as a result of a particular condition. An O'I' practitioner teaching a stroke survivor how to use a spoon again uses the establish/restore Occupational therapy practitioners work closely with a number of approach to intervention. different healthcare professionals in caring for geriatric clients. They use therapeutic occupation and activities as their primary modality Occupational therapists often work with families whose loved ones in meeting their patients' needs. Finally, regardless of the setting, have dementia. As a client with dementia is forgetful and will pro- occupational therapists and assistants, upon completion of a thor- gressively decline in functional performance, the occupational thera- ough assessment, insure clients participate as fully as possible by pist uses the maintain approach to intervention when he/she suggests employing a variety of treatment approaches including creation/pro- ways in which the family could structure the home environment to motion, restoration/establishment, maintenance, modification and support or preserve the client's current abilities. For example, to main- prevention. tain an older adult's independence with dressing himself, an occupa- tional therapist might post signs with pictures of simple sequences to remind the client to put on his socks before putting on his shoes. When using the modify approach to treatment, OT practitioners alter tasks or environments to insure the client's success in functional References BoytSchellBA,Cohn ES,Neistadt ME 2003b Introduction to evaluation and interviewing: section one: overview of evaluation. In: Neistadt ME, American Occupational Therapy Association (AOTA)2002 Crepeau EB(eds) Willard and Spackman's Occupational Therapy, 10th Occupational therapy practice framework: domain and process. edn. J.B. Lippincott, Philadelphia, PA Am J Occup Ther 56:609-639 Uniform Data System for Medical Rehabilitation 1993Guide for the Boyt Schell BA,Cohn ES,Crepeau EB2003aOccupational therapy Uniform Data Set for Medical Rehabilitation (Adult FIM). UB practice today. In: Neistadt ME, Crepeau EB(eds) Willard and Foundation Activities, Buffalo, NY Spackman's Occupational Therapy, 10th edn. J.B.Lippincott, Philadelphia, PA

533 Chapter 83 Geriatric physical therapy William H. Staples CHAPTER CONTENTS and develop an individualized intervention plan to achieve short- and long-term goals for improved function. Physical therapists do not • Introduction limit their skills to treating people who are ill. A Significant portion of • Referrals to physical therapy time is spent working on health promotion and prevention of primary • Assessment of the geriatric patient and secondary problems to avert an initial injury or secondary impair- • Goal setting and interventions ment that would lead to subsequent loss of movement and function. • Conclusion The physical therapist is a graduate of a college or university INTRODUCTION physical therapist education program, which in the US is accredited by the Commission on Accreditation in Physical Therapy Education This chapter is designed to introduce the reader to current physical (CAPTE), and has passed a licensing examination that is regulated therapy practice and its importance in the rehabilitation process. by each state. The physical therapist assistant holds an Associate's Physical therapy is an integral part of the rehabilitation process of Degree from a college program also accredited by CAPTE. The WCPT the older adult. As the population ages, physical therapists will play currently recommends a minimum of 4 years of university-level a pivotal role in the recovery of geriatric clients who have experi- studies to achieve professional recognition. Physical therapist assis- enced disease or illness. tants are licensed in most states through examination. They are not per- mitted to perform evaluations, but can perform many of the treatment The American Physical Therapy Association (APTA)'s Guide to activities under the supervision of a physical therapist. Supervision Physical Therapist Practice provides the following definition: 'Physical requirements vary from state to state. therapy is a dynamic profession with an established theoretical base and widespread clinical applications in the restoration, maintenance, The APTA has set forth a goal that, by the year 2020, physical ther- and promotion of optimal physical function' (APTA2003).The World apy will be provided by physical therapists who are doctors of phys- Confederation for Physical Therapy (WCPI), a nonprofit organization ical therapy (APTA 2005). As of 2006, 78% of 209 CAPTE accredited comprising 92 member organizations representing over 250()()() physi- physical therapist education programs offered the Doctor of Physical cal therapists worldwide, states that 'the aim of physical therapists is to Therapy (OPT) degree. It is anticipated that, by the year 2008,95%of US identify and maximize human movement potential within the spheres physical therapy programs will be offering the DPT degree. of promotion, prevention, treatment, and rehabilitation, in partnership with their clients' (World Confederation for Physical Therapy 2005). Geriatric physical therapy can be practiced in a variety of settings including acute care hospitals, rehabilitation centers, skilled nursing The primary goal of geriatric physical therapy is to prevent, main- facilities,continuing care communities, home healthcare agencies and tain or rehabilitate an impairment or functional limitation, which is outpatient clinics.Geriatric physical therapy is committed to combating accomplished with the application of evidence-based scientific princi- and minimizing the accumulative disabling effects of physical illness in ples. The rehabilitative process should be geared to assist the older association with the aging process. This is performed by hastening con- person to achieve the highest level of function possible within their valescence and reducing institutionalization, education of the patient environment. Physical therapy tries to focus on functional mobility and caregivers, contributing to the comfort and well-being of the while maintaining safety, enabling the older adult to enjoy a longer life patient, and assisting the individual to return to optimal living within by living it more independently and with less pain. The WCPT has a their capabilities. Geriatric physical therapy has beenrecognized as an subgroup called the International Association of Physical Therapists area of specialization that requires a specific set of advanced skills and working with Older People, whose goal is to serve as the international knowledge that addresses the aging process. Specialists in geriatric resource for physical therapists working with the elderly. physical therapy understand the differences between 'normal' aging and pathological changes that commonly occur in the older adult. Physical therapists are healthcare professionals involved in the Assisting the geriatric client can be an arduous task because of multi- examination and evaluation of individuals with neuromuscular, system involvement and multiple comorbidities. Special considerations musculoskeletal, cardiopulmonary and integumentary disorders. The such as psychosocial issues, reimbursement, environmental, frailty, physical therapist can then determine a physical therapy diagnosis nutritional, pharmacological and cultural factors must be accounted for in a successful rehabilitation process. The American Boardof Physical Therapy Specialties first recognized individuals as board-eertified geri- atric clinical specialists (GCSs) in 1992 Tobecome a GCS, one must be a licensed physical therapist, spend a prescribed number of hours in

534 THE REHABILITATION TEAM direct patient care with the elderly, and pass a rigorous written exami- based on their specific skills (e.g. GCS), and does not usually have the nation. The WCPT (2005)supports the specialization process. authority to seek older persons in need of services without a referral from the physician. The physician has traditionally served as the REFERRALS TO PHYSICAL THERAPY 'gatekeeper' to the healthcare system. There are many reasons to seek out the knowledge and skills of a Outside the hospital, a great number of states do allow direct physical therapist. Box 83.1 is a useful, but not entirely inclusive, list access, although the majority of therapists still receive referrals from a physician, physician's assistant or nurse practitioner. Direct access Box 83.1 Possible indications for geriatric physical varies considerably in terms of legal, practice and reimbursement therapy referral models. Some limitations or barriers to receiving physical therapy services result from legal issues, but other reasons include lack of .. Recent fall or history of falls public and healthcare provider education. Additionally, most sec- .. Deficits in strength or range of motion ondary payers such as the federal government and private insurance • Loss of mobility or ambulation requiring an assistive device carriers limit reimbursement without a physician referral. '\" Musculoskeletal pain \" Difficulty with transfers Interestingly, Miller et al (2005) found that over 66% of physician • Orthotic or prosthetic needs orders or referrals to physical therapy for geriatric clientele specified \" Open wound only 'evaluate and treat' or 'PT consult'. This finding does indicate '. Neurological disorder some degree of physician confidence in the expertise and decision- making skills of physical therapists. Balance deficits Decreased endurance for ADLs ASSESSMENT OF THE GERIATRIC PATIENT • Bed bound status • Need foradaptive equipment to enhance safety and function Evaluation of clients, whether referred or by direct access, should include a history as well as a physical examination using various tests of possible indications for a physical therapy referral. Physical thera- and measures (see Box 83.2). The examination should also include a pists understand a vast array of problems that affect physical func- tion and general health. They utilize screening to enable them to Box 83.2 Tests and measures provided by physical refer to other appropriate healthcare practitioners if the therapist is therapists (APrA 2003) serving as a portal to the healthcare system. Physical therapy is a rap- idly evolving profession. In most states, an individual can have direct • Aerobic capacity/endurance access to a physical therapist for evaluation and treatment without • Anthropometric characteristics first seeing a physician for a referral. The APTA's Vision Sentence • Arousal, attention, and cognition states that physical therapists will be 'recognized by consumers and • Assistive and adaptive devices other health care professionals as the practitioners of choice to whom • Circulation (arterial, venous, lymphatic) consumers have direct access for the diagnosis of, interventions for, • Cranial and peripheral nerve integrity and prevention of impairments, functional limitations, and disabilities • Environmental, home, and work ijob/school/play) barriers related to movement, function, and health' (APTA2oo5). • Ergonomics and body mechanics • Gait, locomotion, and balance Many older people do seek out a physician as the traditional first • Integumentary integrity stop in the healthcare process, with subsequent referral for physical • Joint integrity and mobility therapy, although thismay be underutilized. Johnson et al (1994)deter- • Motor function (motor control and motor learning) mined that almost half 'the patients who were hospitalized and found • Muscle performance (including strength, power, and to be deficient in ambulatory or transfer skills compared with status at admission did not receive physical therapy services. Interestingly, endurance) those patients who received physical therapy in the hospital were sig- • Neuromotor development and sensory integration nificantly more likely to receive it in the postacute period. It is possible • Orthotic. protective, and supportive devices to infer that elderly medical patients develop functional disabilities during hospitalization that are not appropriately recognized. Routine • Pain physical screening of aU elderly patients should be performed by nurs- • Posture ing staff to determine if there has been any loss of physical perform- • Prosthetic requirements ance. Freburger et al (2003) found that, even after controlling for • Range of motion (including muscle length) diagnosis, illness severity, and physical therapy supply, referrals to • Reflex integrity physical therapy were much less likely from primary care physicians in • Self-care and home management (including activities of comparison with orthopedic surgeons. This lack of referrals affects the quality of care received and may eventually result in an increased cost daily living and instrumental activities of daily living) if a treatable condition worsens. Delays in care can also lead to • Sensory integrity decreased functional outcomes and frustration for clients and patients. • Ventilation and respiration/gas exchange • Work ijob/school/play), community, and leisure integra- In a hospital, the physician is traditionally in charge of the patient as he or she has admitting privileges. The therapist may very well be tion or reintegration (including instrumental activities of an employee who is assigned the case through a scheduling rotation or daily living)

Geriatric physical therapy 535 systems review for screening purposes to rule out any pathological GOAL SETTING AND INTERVENTIONS conditions that need to be referred to other health professionals. The therapist then evaluates the data collected and makes clinical judg- Improved function must be the priority focus of interventions pro- ments based on this information to establish a physical therapy diag- vided by the geriatric physical therapist. Functional goals are estab- nosis. The geriatric physical therapist is able to interpret the data lished with the patient, and sometimes with family or caregiver, in gathered into categories, syndromes or clusters to determine the order to determine the appropriate treatment interventions. The skills appropriate intervention strategies. This can be quite a challenge in of the therapist are utilized to provide appropriate treatment strategies older adults because they present with more complex problems. The and techniques. For this case study, the long-term goal of return to aging process has taken some toll on the body, and multiple patholo- being an independent functioning, cornmunity-dwelling individual gies may exist that may exaggerate, or hide, underlying conditions. was determined. To meet this long-term goal, several short-term goals The experienced therapist will attempt to determine, where possible, were set. These included: which problems are age related and which are due to pathology. • Safe and independent gait, with full weight bearing left lower The examination of Mrs S (see Case study) reveals that she has had extremity with a walker, progressing to a cane and stair climbing several recent falls, history of osteoarthritis, hypertension and athero- as appropriate. sclerotic heart disease. She was taking Lasix, acetaminophen (parae- etamol) and Evista prior to the hospitalization and she has begun to • Increase lower extremity strength to 4/5 to enable progression take them again. She is unsure of what medications she was given in to cane. the hospital. Tests and measures reveal overall left hip strength of 3+ /5; a mild kyphosis; independent gait with a standard walker, • Increase Tinetti score to 24/28 to decrease risk of falls. weight-bearing as tolerated at approximately 75%, limited due to • Independent with ADLs to decrease outside care and expense. pain rated at 3/10; difficulty with activities of daily living (ADLs); • Increase endurance and ambulatory velocity to 100 feet (30.48m) decreased balance (Tinetti score of 20/28); limited endurance as she is only able to ambulate 80 feet in 2 minutes before requiring a rest in 1 minute with a perceived exertion level not to exceed '5' on a period; and she is hard of hearing. Vital signs at rest: blood pressure 0/10 scale or '13' on the 0/20 Borg Rating of Perceived Exertion (BP) 140/82, heart rate (HR) 74, respiration rate (RR) 20. Vital signs Scale. after gait: BP 150/86, HR 110, RR 28. She has not been on a regular exercise program. Table 83.1 TheTinetti assessment tool The physical therapist must now analyze these data. There is a Gaittests Maximum score is 12 myriad of factors that will need to be considered before progressing to the next steps of goal setting and selection of interventions. The Balance tests Maximum score is 16 geriatric therapist has to screen for a possible lower extremity blood clot because of recent surgery and recognize that Evista has a ten- Totals Maximum score is 28 dency to promote clots. The physician will need to be contacted regarding medications. Knowing that the best predictor of a fall is a Score 19or below = high risk of falls previous fall, the therapist must try to determine the underlying cause of her falls. The Performance-Oriented Assessment of Mobility, Score 20-24 = moderate risk of falls commonly called the Tmetti assessment, was chosen by the therapist because of the patient's ability to use an assistive device. Addition- Score 25 and above = low risk of falls ally, the therapist felt that the Berg Balance Scale would be too diffi- ------------------------ cult for the patient to perform safely. The Tinetti score (see Table 83.1) indicates that she remains at a moderate risk of falling. Is the cause Table 83.2 Case study evaluation and interventions external (environmental, such as loose carpeting) or internal (possi- bly orthostatic hypotension caused by taking Lasix as an antihyper- Evaluation findings Interventions tensive medication)? Is she able to get in and out of her apartment independently in case of emergency or able to shop for food? Will she Decreased hip strength Progressive resistance exercise require a call alert, home health aide, Meals on Wheels or other serv- ices? These factors must be accounted for in order to insure a suc- 80% 1 rep max, 8-12 repeats withoutpain cessful rehabilitation process. Decreased balance Balance exercise at kitchen counter or heavy Casestucly chair, progress with less upper extremity support Mrs S is an 82-year-old retired school teacher who lives alone in a two-storey walk-up apartment. She had fallen History of falls External: loose rugs, cords, pets at home, fracturing the left femoral head. After a 5-day hospitalization for a left hemiarthroplasty, followed by a Internal: check BP sit to stand and provide 2-week stay at a skilled nursing facility, she was referred education to a home health agency. The physical therapist is scheduled to open this case the day after her return Diminished gait status Gaittraining with appropriate assistive home. device including stair climbing. Mayneed to order cane or quad cane Decreased endurance Increased ambulatory distance, while monitoring vital signs, home exercise program. Monitorthrough use of target heart rate or perceived exertion Other needs Raised toilet seat, grab bars for bathroom, are banisters adequate in stairwell?

536 THE REHABILITATION TEAM The therapist must monitor and continually assess the client's CONCLUSION progress in the short-term goals in order to update them and progress toward the long-term goal. Modification of the interven- The geriatric population is a unique group to work with because of tions must be made if outcomes are not being successfully achieved. the aging and disease processes that interact to produce a wide vari- Additionally, the therapist must provide preventative and wellness ation in each individual. Physical therapists, as healthcare providers, education to this client regarding the importance of regular exercise, are also health educators and health promoters, and will continue to osteoporosis and posture. play an ever more important role in the provision of healthcare services. Time should be spent to teach, counsel and modify the In order to achieve the long-term functional goal, interventions behaviors of individuals that, if left unattended, would lead to dys- are planned to improve Mrs S's impairments. These interventions function. Some of the concerns that can affect the older adult, such as will be tailored to meet this individual's needs and tolerance (see nutritional concerns, psychosocial problems, and limited finances, Table 83.2). may fall outside the immediate practice of physical therapists, but must be addressed in order to maximize therapeutic outcomes. The In addition to the above noted interventions, the physical thera- geriatric practitioner must also understand reimbursement issues to pist may identify the need for additional services. Referrals were better serve their clientele. Rather than working in a vacuum, com- made to occupational therapy for ADL training and to social services munication and teamwork must be utilized for the best overall care in order to arrange Meals on Wheels. Geriatric patients, i n particu- of the patient or client. Geriatric rehabilitation offers a huge chal- lar, benefit from a team approach. The elderly are commonly affected lenge to the talent and creativity of each therapist. As the geriatric by a variety of interacting problems that can be better solved with population continues to grow, so will the challenges. input from several points of view. It is essential that members of the team communicate with each other in order to achieve a positive outcome. References Johnson JH, Sager MA, Hom G et all994 Referral patterns to physical therapy in elderly hospitalized for acute medical illness. Phys Occup American Physical Therapy Association (APTA) 2003Guide to physical Ther Geriatr 12:1-12 therapist practice, 2nd edn. APTA, Alexandria, VA Miller EW,Ross K, Grant S et al200S Geriatric referral patterns American Physical Therapy Association (APTA) 2005Vision Sentence for physical therapy: a descriptive analysis. J Geriatr Phys Ther for Physical Therapy 2020and APTAVisionStatement for Physical 28:20-27 Therapy 2020. Available:http://www.apta.org. Accessed 15 September 2005 World Confederation for Physical Therapy. Available: http://www.wcpt.org/ . Accessed 16 September 2005 Freburger JK Holmes GM, Carey TS 2003Physician referrals to physical therapy for the treatment of musculoskeletal conditions. Arch Phys Med Rehabil84:1839-1849

537 Chapter 84 Providing social services to the older client James Siberski CHAPTER CONTENTS issues, can either assist or detract from the success of the rehabilitative process. • Introduction Goal incongruence • Additional considerations • The geriatric care manager In the rehabilitative process, the team often determines that the • Durable medical equipment appropriate placement is a structured living arrangement, whe~as t~e • Placement older client believes that the appropriate living arrangement IS their • Conclusion home. This goal incongruence between team and client is not • Resources restricted to just placement but can include driving, employment, financial management and other issues of autonomy. Unresolved INTRODUCTION goal incongruence hinders the rehabilitative process. In addressing this issue, the social worker should capitalize on the client's motiva- Internationally, older adults are confronted with numerous chal- tion to go home by communicating that several steps are necessary to lenges as they age (Lemme 2006). In addition to normal age-related attain this goal. By graphically demonstrating the intervening steps changes, there are frequently disease states that must also be toward the goal (see Fig. 84.1), the social worker utilizes the client's addressed in order to age successfully. The social service provider motivation to achieve the rehabilitative team's goal as well as his or plays an important role in assisting older adults to adjust to age- her own personal goal. In Figure 84.1,several possible steps are identi- related changes through adaptive changes and devices, and to adjust fied in a rehabilitation process to capitalize on a patient's motivation to to the disease state when required, through the rehabilitative process. return to their own home. Step one is attending therapy until X% of It is recognized that not all elderly people will require rehabilitation. function is gained. Step two is learning to use adaptive devices. Step Some will need treatment, time and perhaps education to return to three is discussing the required supports and home adaptations with their previously healthy state. The social service provider can con- the social worker and family. Step four is placement in a personal care tribute to positive outcomes. home for a period of 6 months in order to demonstrate the ability to do X.Step five is to return home. While returning home may not even As a member of the rehabilitative team, the social service provider be an attainable goal, the social worker should avoid making it an issue performs a key role. In order to succeed, the team needs specific infor- in order not to detract from the rehabilitative process. mation from the social worker or geriatric care manager. Initially, this individual completes a comprehensive social work assessment and Cure vs, care social history providing important data that will be incorporated into the rehabilitative care plan and enable theolder client to achieve his The social service assessment should address the older client's desire for or her goals. While various forms are available (see Form 84.1) for care or for cure. Many clients will want a cure. Other clients will want a completing this task, in many settings, the format is dictated by the purpose in their lives and that purpose may be the caregiver~ent agency or department. As a result of education and training, profes- interaction. The rehabilitative team needs to be aware that older clients sional social service providers are efficient at completing an assess- need care to achieve cure. Care is also the opportunity for such thingsas ment, taking a social history, determining needs and strengths, and intimate touch by the physical therapist, occupational therapist, nurse developing discipline-specific goals. In assessing the elderly, addi- or physician. Care also gives purpose to the day. The older client needs tional considerations must be entertained in order to facilitate opti- to go to the outpatient clinic on Monday; to cardiac rehabilitation on mal care/services placement. Tuesday; to the pharmacy on Wednesday, etc. Theolder client's regular interaction with the social worker or home health aide is an opportunity . . . . Nll:LF to socializeand to feel valued by the provider. In contrast, cure, by elim- inating therapy or treatment, creates a loss of the caregiver-client inter- Additional considerations, which include goal incongruence, cure vs, actions. Recognizing thissituation, the rehabilitative team can then plan care, client and family perceptions, personality, activities and diversity around the loss if, indeed, care is the focal issue, so that the client will not be excessively concerned.

538 THE REHABILITATION TEAM ~----~----------------------------------------- Form 84.1 Social work assessment form ~---- - ~~--- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Room #: Admission date: _ Name: _ Age: DOB Address: _ Hospital admitted from: Insurance info.: _ Phone: _ Physician: _ Rehab. DX: _ Other DX: _ Employment status: _ Employer: Income sourcelsl: _ Work phone: FAMILY/CAREGIVER Spouse name: _ Empl. Marital status: M S D W Sep. Age: _ Phone: Others in household: Name: _ Other contact: Name: _ Address: _ Phone: Name: HOME/ENVIRONMENT Rent: No. of floors: No. of steps: _ Type of home: Own: Handrails: _ _ Primary entry: No. of steps: Handrails: ~ Bedroom location: Bath location: Depressed? Anticipated equipment needs: _ Mental status and emotional reaction: Other community services? _ _ Alert? Oriented? Comments: Date: _ Equipment at home: _ _ Home health agency? Patient family goals: Plan: Social worker: Figure 84.1 Steps in rehabilitation to consider when a patient is Client. family and others' views of rehabilitation motivated to return home. The social service provider needs to assess both the client's and the family's view of the expected outcomes of rehabilitation. If the pre- vailing view is that the rehabilitative plan will not help or that the client is doomed to fail, the client's potential for success is seriously impaired. The social worker must provide education, appropriate for reading and comprehension level, and perhaps even involve other team members in the education process. Personality Knowledge of the client's personality in their youth is beneficial in determining possible issues and appropriate team approaches prior to therapy (Hoyer & Roodin 2003).Someone who was guarded at age 40 tends to be more guarded, if not suspicious, as they age, especially when under stress. As an overly friendly approach would increase suspicion and hinder therapy, the social worker should employ a pas- sive friendly approach. This would entail briefly discussing the reha- bilitation process and then pulling back and letting the client ponder the information. Next, could be one or two more short visits by the social worker, asking if there are any questions or concerns, followed by gently asking the client what are their thoughts and when might

Providing social services to the older client 539 they be ready to start the rehabilitation process? This process can take The home a bit more time but yields more positive results. U someone had always demanded perfection, and with therapy, could not expect A home visit by members of the rehabilitation team allows family mem- 100% return to function, the social worker would also need to bers to be interviewed in a familiar, nonthreatening setting. It allows address this in therapy. therapists to evaluate the home for barriers and adaptations that may be needed. Occasionally, a home may be dangerous or inappropriate for a Activities patient's return. Extreme clutter, filth, lack of utilities or disrepair may require community intervention. The social worker will have to refer An assessment of the older individual's activities and activity style these rare situations to the Protective Service Unit of the Area Agency enables one to get a good understanding of the severity of the client's on Aging or some other appropriate agency. A first-hand view of the condition and its impact on the client's life. The passionate reader, home environment helps the social worker to prepare the family for who after completing therapy has 50% mobility, may be satisfied, the patient's return and also helps to coordinate community services whereas the passionate walker would be upset. The social worker for the patient's return home. needs to address this situation by first discovering the needs met by walking, e.g. stress reduction, and then by providing either alterna- 't. _DURABLE..... tive methods to meet the needs or by modifying the walking pattern, . .4...1 MEDICI AL EQUIPMENT._.... . _. . . . . . . ..-\".~~:oio~ . ,. .... e.g. a slower pace, a shorter distance or a different frequency. This might require the involvement of other members of the rehabilita- Most rehabilitation patients require the use of assistive devices, if only tion team. A bright light at the end of the rehabilitation tunnel will for a short time. Ordering durable medical equipment (DME) in a motivate the older person to work harder and ultimately experience managed care climate requires knowledge of preferred provider rela- better results from rehabilitation. tions and limits of coverage. Patients and families rely on social workers for this knowledge. Diversity Basic items such as canes, walkers and wheelchairs are covered by Social service providers need to be cognizant of ethnic diversity and most insurance carriers for appropriate patients. Larger items such cultures. African-Americans, Pacific Asian Americans, American as lifts, continuous passive motion units and even hospital beds are Indians and Hispanic Americans all have different belief systems. The less readily available and may not be covered at all. Items such as lift older American Indian will approach rehabilitation differently from chairs or stair glides are rarely, if ever, covered by insurance. Some the African-American. The manner in which the team approaches, DME suppliers have previously used lift chairs and stair glides, as addresses, and instructs the client is important to the outcome of ther- well as other items available at reduced cost. apy (Quadagno 2005).The social worker should educate the team as to how to address diverse populations as well as their cultural beliefs in Those patients injured under workers' compensation or automobile terms of medical care and, in fact, if they are even accepting of tradi- plans may be covered for special items. Each individual has to be tional medical care. reviewed separately. THE GERIATRIC CARE MANAGER Some rehabilitation facilities or agencies for the disabled may employ an equipment adaptor. This professional person modifies A geriatric care manager (GCM), as defined by the National Associa- and customizes medical equipment to individual needs. This can be tion of Professional Geriatric Care Managers, is a health and human a very helpful service for the geriatric patient. services professional, such as a gerontologist, social worker, coun- selor or nurse, with a specialized body of knowledge and experience Home health related to aging and elder care issues. The GCM assists older adults and persons with disabilities in attaining their maximum functional Medicare and most major insurance plans cover rehabilitative and potential. They strive to respect the autonomy of the individual and nursing services in the home after the patient has been discharged to deliver care coordination and support services with sensitivity, in from a facility if a skilled service (a physical therapist or a registered order to preserve the dignity and the respect of the individual. In nurse) is ordered by a physician. In some cases, a nurse's aide may addition, the GCM is an experienced guide and resource for families be covered for personal care, such as bathing. As with DME, many of older adults and others with chronic needs. As time progresses and carriers are now requiring the use of preferred providers for home as baby boomers age, the rehabilitative team will work hand in hand health services. with this newly emerging professional. Clinical journals, business publications and weekly news magazines frequently discuss the cur- It should be noted that rural areas are often underserved by home rent concept of care management for older individuals. The GCM can health rehabilitative services. This can delay the initiation of care in be quite helpful to the social worker in terms of assessment and the home. understanding of the older person in need of rehabilitation. The role of the GCM will develop internationally as the older population Many people are under the impression that Medicare or other grows. The title of GCM could vary from country to country as the insurance companies provide for private nurses or aides in a patient's profession matures. At present, no international organization exists. home. Medicare has never covered this service, and most other plans have long since discontinued such benefits. There are many agencies When discharge approaches, the social worker and the rehabilita- that offer this help for a fee. tion team need to consider the post rehabilitation requirements and needs of the client and family. Those requirements and needs include Community services the home, durable medical equipment, home health and community services. The following are useful community services that have traditionally helped older people to remain at home; however, as public funds for these programs have dwindled, agencies have initiated fee-for-service arrangements. This has resulted in shorter waiting lists and faster start-up for services. Of course, it has also resulted in increased costs to the older consumer.

540 THE REHABILITATION TEAM Area Agency on Aging (AAA) CONCLUSION This is a local, public agency funded by federal and state monies; the While the social assessment and history provide a good basis for the agencies were created to provide support for older people in their rehabilitative process, it is important to be cognizant of the older per- homes. Some of the services offered include homemakers, personal son's special needs. Assessing and evaluating these additional consid- care aides, friendly visitors, Meals on Wheels (MOW), and so forth. erations enhances the social worker's or social service provider's A means test determines eligibility, and the services are generally opportunity for positive outcomes from the rehabilitative effort. The limited to 1 or 2 hours a week. Some AAA offer personal attendant social worker's counseling skills, knowledge of community resources care or TItle XX (Lamp II or Options) programs designed to help the and ability to provide education throughout the rehabilitation process most physically challenged individuals stay at home. Agencies on help the client and family cope with the process and reach their reha- Aging are generally run by county governments. Phone numbers and bili tation goa Is. addresses can be found in the blue pages of the telephone book. Chore RESOURCES Chore services may be available through AAA or another public National (USA): http://nihseniorhealth.gov/ agency. This useful program can help to build ramps, attach (National senior health net) handrails, or provide other minor adaptations. All materials are pur- chased by the individual receiving the service. National Alliance for Caregiving Suite 642 Meals on Wheels 4720 Montgomery Lane Bethesda, MD 20814 This is perhaps the best known service. MOW provides a full meal (301) 718-8444 for the homebound individualS days a week or more. A fee is gener- http://www.caregiving.org ally charged for this service. This agency is also listed in the blue pages of the telephone book. National Family Caregivers Association Suite 500 Transportation 10400 Connecticut Avenue Kensington, MD 20895 Adequate transportation services are the most common need of the (BOO) 896-3650 elderly, especially for the geriatric rehabilitation patient. Most commu- http://www.nfacares.org nities offer some type of subsidized transportation for eligible indi- viduals. These programs function as a cross between a bus and a National Association for Home Care taxi. The vehicles, usually modified vans, travel specified routes but 228 7th Street, NE require advance notification of appointments. Vans equipped with Washington, DC 20003 wheelchair lifts are available, but extra notice may have to be given. (202) 547-7424 Ambulance transport for routine medical appointments is rarely http://www.nahc.org covered by insurance and is very expensive. Many ambulance pro- http://www.caremanager.org/(geriatric care managers) viders offer wheelchair van service at more reasonable rates. National Council on the Aging PLACEMENT Suite 200 409 3rd Street, SW Despite the best efforts and the fervent hopes of all, the goal Washington, DC 20024 of returning home may not be possible for all patients. Inadequate (202) 479-1200 progress in therapy or insufficient support at home may make nursing http://www.ncoa.org home, assistive living or other appropriate placement the only appro- priate course of action. The social worker has to be sensitive to feelings International: of guilt, abandonment and hopelessness as he or she guides the patient and family through the application process. Furthermore, if the realities International Society for Aging and Physical Activity: of modem healthcare make the first choice of a facility unachievable, www.isapa.org the social worker must be frank and straightforward in dealing with International Council on Active Aging® (ICAA): www.icaa.cc placement issues. At all times, lines of communication must be kept International Conference on Aging, Disability and Independence open to make the patient's transition as smooth as possible. (ICADI): www.ittatc.org References --------------------------- ------------------------ Hoyer]W, Roodin P 2003 Adult Development and Aging, 5th edn. Quadagno J2005 Aging and the Life Course: An Introduction to Social McGraw Hill, Boston Gerontology, 3rd edn. McGraw Hill, Lemme BH 2005Development in Adulthood, 4th edn. Allyn & Bacon, Boston

541 Index Note: Page numbers in italics refer to figures, Age Discrimination in Employment Act diabetic foot ulcers 312 tables and boxes. (1967) 489 dressings 316-317 early care 316-317 A aging 3,5-6 exercise 317 markers 5 mobility 316,317 abciximab 288 population 503 prostheses 316,317 abstracttltin!ing 185 primary 519 rehabilitation 316,317-318 acarbose 309 secondary 519 related conditions 315-316 Achilles tendon reflex loss 214 skin temperature 6, 7 self-care 317 Acorn Corcap procedure 293 theories 6-7 sensory tests 316 acoustic immittance testing 371 variability 520 therapeutic interventions 316-318 actinic purpura 352 transtibial 315, 316 action tremor 208 agitation 176-177 wheelchairs 317,469 activities of daily living 54-55 agoraphobia 405 see also prostheses air pollutants 298 Amsler grid 360,361 brain tumors 231 akathisia 207,211 amyotrophy 333 CABG patients 291 albumin serum levels 69 analgesics caregivers 516 albuterol 299 osteoarthritis 130 cognitive impairment/dementia 185, alcohol abuse, peripheral neuropathy 215 thoracic spine compression fractures alcohol consumption 187-188, 189 163 dizziness 404,405 cataract risk 364 anemia 70 macular degeneration 364 menopause management 400 pain 444 osteoporosis association 124 gastrectomy 239-240 visual loss impact 362-363 stroke risk 181 heart failure 276 Activities-specific Balance Confidence thermoregulation 56 iron deficiency 110 alendronate 418 anger 511 Scale 411 Alexander technique in Parkinson's angina pectoris 260-261 activity levels management 261, 263 disease 201 transmyocardial revascularization 293 contractures 115-116 alkaline phosphatase, serum 69 unstable 260 social services assessment 539 allergic alveolitis, external 300 variant 260 activity theory 6 allergic contact dermatitis 349 anginal threshold 261 acute respiratory distress syndrome alveolar disease, diffuse 300-301 angioplasty 288 alveoli 38 angiotensin-converting enzyme (ACE) (ARDS) 300-301 Alzheimer's disease 66,185, 186 acyclovir 346 inhibitors 66 adaptation, orthopedic trauma 168 exercise 189 congestive heart failure 67-68 adaptive equipment 510 amantadine 202 heart failure 277 adherence 373 ambulation see gait; mobility; walking ankle adiposity 439 American Physical Therapy Association mobility 427-428 administrative nurses 527 neoprene sleeve 466 advance directives 489,504 (APTA) 491,494 stiffness 428 adverse drug reactions 63,391, American Spinal Injury Association (ASIA) ankle brachial pressure 312, 320-324, 324 diabetes 322 392-393 Impairment Scale 178 procedure 321-322 advocacy Americans with Disabilities Act (1990) venous ulcers 323 ankle orthoses 466 healthcare 516 489 peripheral neuropathies 216 nursing role 527 amitriptyline 65 age, physiological 3 amputations 315-318 circumferential measurements 316, 338,472 classification 315

542 INDEX ankle-foot orthoses 465-466 gait training 462 assessment 155,410-412,418 multiple sclerosis 198 low-vision 363 assistive devices 462 peripheral neuropathy 216 multiple sclerosis 197-198 definitions 409 sciatic neuropathy 224 pain control 449-450 dynamic 461 spinal cord injury 179 pneumonia 381,383 environmental factors 410 assistive living 540 exercise use 412,421 ankylosing spondylitis 154 asterixis 207 gait training 457-462 cervical spine myelopathy 160 asthenia 111 peripheral neuropathies 213,216 asthma 297 physiology 409-410 ankylosis, fibrotic 130 astrocytomas 229-230 responses 410 antianxiety drugs 64 atherectomy 288-289 self-report 410,411 antibiotics 61 atherosclerosis 78, 259-260 static 461 lesion removal 289 strategies 409,410,412 erysipelas 347-348 plaques 259,289 training 201,412 folliculitis 347 athetosis 207 balance impairment 28 mycobacterial tuberculosis 304 atopic dermatitis 350 assessment 410-412 pneumonia 303 atrial arrhythmias 266-270, 273 dizziness 404, 405 anticholinergic drugs 299 atrial contractions, premature 268 treatment 412,413 anticoagulation therapy 293 atrial fibrillation 262, 268, 269 Balanced Budget Act (1997) 506 immobility 395 heart failure 276 ballismus 207 pulmonary embolism 302 Maze procedure 289,293 balloon valvuloplasty 292 pulmonary hypertension 302 pacemakers 281 bariatric surgery 440 anticonvulsant hypersensitivity syndrome stroke risk 181 Barnes method of myofascial release (MFR) atrial flutter 269 351 atrial tachycardia, paroxysmal 268 479 anticonvulsants atrioventricular block baroreceptor activity 50 first-degree 271 barrel chest 38 chorea 211 pacemakers 281 Barthel Index 444 diabetic neuropathy 225 second-degree 271-272 basal cell carcinoma 241,242 antidepressants 64--65 third-degree 272, 273 diabetic neuropathy 225 atrioventricular valves 277 treatment 243 extrapyramidal dysfunction 211 atrovent 299 basal ganglia 23 peripheral neuropathies 217 attribution model 3-4 antidizziness medication 404-405 audiometry, pure-tone 370-371 stereotactic surgery 202 antihypertensive drugs 67 auditory nerve compression 166 bedrest 393, 394 antiinflammatory medications 64 auscultation 155 see also non-steroidal antiinflammatory pulmonary embolism 302 neurological system effects 396 sites 156 strategies for minimizing negative drugs (NSAIDs) autoimmune diseases 153-154 antinuclear antibodies 131 multiple sclerosis 191 consequences 396 antipsychotic drugs 65 automated perimeters 360 vertebral compression fractures 124 autonomic dysreflexia 179 beds, hospital 539 tardive dyskinesia 392 autonomic nervous system 50 behavior therapy in obesity 440 u1-antitrypsin deficiency 297 sweat glands 55 benzodiazepines 64 anxiety autonomic neuropathy bereavement 511 diabetes 312-313 beta2-agonists 299 caregivers 515 ulceration 326 beta blockers defibrillator patients 284 autonomy, patient 488,492 heart failure 277 drug treatment 64 discharge planning 495,496 thermoregulation 55-56 aortic regurgitation 278 healthcare providers 495 biceps tendon rupture imaging 91 aortic stenosis 278,279 long-term care 496 bioelectrical impedance 439 aphasia 376 managed care 498 bioelectromagnets 478 aquatic therapy 481-482 axillary nerve injury 179 bioenergetic techniques 479 Area Agency on Aging (AAA) 540 azathioprine 131, 301 biofeedback techniques 183 arterial insufficiency 325 Parkinson's disease 201 arterial system 47, 48 B urinary incontinence 390 stiffness 49 biological time clock 7 arterial ulcers 324, 325 B lymphocytes 59 223 biomicroelectropotentials 479 arteriosclerosis 259 back pain, lumbar (LS)radiculopathy bisphosphonates arthralgias 392 baclofen 179 after vertebroplasty 127 arthritis bacterial infections, skin 347-348 fracture healing 418 psoriatic 350-351 bacterial overgrowth, intestinal 45 osteoporosis prevention 400 stiffness 426 balance vertebral compression fractures 125 see also osteoarthritis; rheumatoid bladder dysfunction, multiple sclerosis 195 blepharoptosis 362 arthritis blindness 365 arthroplasty 130 definition 359,366 prevalence 366 shoulder 137-138 blisters, treatment 351-352 arthroscopy 130 articular gelling 426 aspiration 382, 383 assistive devices brain tumors 231

INDEX 543 blood chemistry 69 brain calcium pyrophosphate dihydrate crystal exercise 110 frontal lobe 23 deposition 132 hand action mapping 436 blood clots, hormone replacement therapy imaging 80, 84, 85 calcium-ehannel blockers 66, 67 399,400 motor maps 436 calf claudication 312 multiple sclerosis 193 blood pressure 49,50 seealso traumatic brain injury intermittent 315, 325 exercise 108 cancer seemalignancy; metastases; named brain tumors 229-231 blood vessels, fragility 352 rehabilitation 230--231 diseases blue-yellow defects 362 treatment 230 Candida albicans 347 Bobath approach in stroke 183 visual field loss 360 canes 449,539 body mass index 251,311,439-440,481 capillaries 47, 48 body tissues, heating/cooling 56,57 brain-derived neurotrophic factor (BDNF) body-weight supported treadmill training 109 density 50 capsaicin 225 (BWS-TI) 183 brainstem 23 capsulotomy, YAG laser 364 bone break test 107-108 carbamazepine 217,351 breast carbidopa 65, 202 abnormal 14 carbohydrates, dietary 43-44 aging 13-15 neoplasms 233-235 carcinoembryonic antigen 238 cancellous 416 reconstruction 234 carcinogens, chemical 241,243 cell types 14 breast carcinoma 233-235 cardiac afterload 32 cortical 13,14,415 hormone replacement therapy 399,400 cardiac arrhythmias 262, 265-271, 281 ectopic formation 179 metastases 234 hand 436 therapeutic intervention 234-235 heart failure 276 metastases 246 breath sounds, mycobacterial tuberculosis pacemakers 281-283 Paget's disease 165-166 rehabilitation 273 pain 165-166 303,304 cardiac autonomic neuropathy 312-313 remodeling 14,81,416,417 breathing cardiac catheterization 287-288 strength 394-395 cardiac conduction disturbances 271-273 structure 13-14 dysfunction 155 cardiac defibrillators, implantable 277, tensile strength 415 techniques 156 trabecular 13-14,415 work of 38 283-284 turnover in osteomalacia 165 seealsodyspnea cardiac denervation syndrome 312 see also fractures bromocriptine 202 cardiac output 32,48, 251 bone cement 126, 127, 142 bronchitis, chronic 297-300 bone grafts 417 clinical manifestation 298-299 exercise 50 bone mass 13 treatment 299-300 cardiac preload 48 immobility effects 394-395 bronchodilators 299 cardiac procedures, invasive 287-294 bone mineral density 122,415,416 bronchogenic carcinoma 301 cardiac resynchronization therapy 282 improvement 421 budget spending 502-503 cardiac rhythm disturbances 266 testing 168 Buerger-Allen exercise protocol 342-343 cardiac wall rupture 262-263 bone morphogenetic proteins (BMPs) 15, Buerger-Allen vascular assessment 334, cardiogenic shock 262 cardiopulmonary bypass 289 416,417 335-338,338,339-341 cardiopulmonary reflexes 50 bone remodeling units (BRUs) 14 bullous eruptions 351,352 cardiovascular disease 34 bony trabeculae, microfractures 416 bullous pemphigoid 352 Borg's rating of perceived exertion bundle branch block 273 clinical development 259-263 diabetes 311-312 253-254 pacemakers 281 drug therapy 34, 66-68 botulinum toxin injections, shoulder pain buoyancy 481,482 progression 259-263 burns 320,351-352 waist circumference 439-440 139 bursitis 133 cardiovascular system bowel control, normal 387 buspirone 64 age-related changes 33-34, 35 bowel dysfunction aquatic therapy 482 c deconditioning 395 incontinence 387-388 diabetes mellitus 311-312 multiple sclerosis 195 calcipotriene 351 125 immobility effects 395 bowel management/training 388 calcitonin physiology 32-33 brachial plexopathies 179,221-222 structure 31-32 brachytherapy 289 osteoporosis prevention 400 carditis, acute 278 bracing vertebral compression fractures care contractures 117 calcium ethics of 492-493 knee 450 after vertebroplasty 126, 127 vs cure 537 osteoporosis 125 bone cells 14 seealso healthcare; long-term care prostate cancer 247 deposition in tendonitis 133 caregivers 515-517 vertebral compression fractures 124, immobility effects 396 advocacy 516 osteoporosis prevention 124 affective disorders 515 125 regulation 110 clinical partners 516 Braden scale 327, 328-329 supplementation 168 cognitive decline issues 516 bradycardia 266,281 calcium phosphate 417 dementia patients 186, 187, 188-189 bradykinin 49,63 brady-tachy syndrome 269,281

544 INDEX caregivers (Contd) stenosis 222 patient empowerment 186-187 funding 516 symptom treatment 160 self-eare enhancement 187-190 geriatric assessment 521 cervicalgia 159 short-term 375-376 guardianship 516-517 cervical-thoracic orthoses 467 cognitive processing 22 hostility 515 Charcot's foot 326,334 colchicines 132 uuormalnenvorks 515 Charcot's fracture 334,342 cold-related emergencies 57 long-term care 517 Charles Bonnet syndrome 364 collagen 425-426 patient autonomy 492 chemical carcinogens 241,243 Colles' fracture 168-169 personal care attendants 516 chemotherapy colon, therapeutic intervention 239 recognition 517 brain tumors 230 colon cancer 82 social interaction 517 colon cancer 239 clinical relevance 238 societal pressures 515-516 muscle effects 110,111 incidence 237 see also family prostate cancer 247 metastases 239 skin cancer 243 treatment 239 caregiving stages 517 chest wall color vision 361-362 carotid artery compliance 51 compliance 38,40 colostomy 239 carotid sinus compression 109 excursion 154 coma 176 carpal tunnel chest X-rays 74,75 communication 373-377 Chinese medicine, traditional 478 cognitive dysfunction 375-376 pressure release 220 chlorpropamide 309 cultural considerations 373-374 syndrome 219,221 chondroblasts 426 dementia patients 186, 187 carpopedal spasm 110 chondroitin sulfate 426 executive dysfunction 373 cartilage 17-18,426 chorea 206-207,210 hearing impairment 375, 376 case management 526-527 drug-induced 211 hearing loss 371 casting choreoathetosis 210 literacy 374 contact 331 choroidal neovascularization 365 visual impairment 375, 376 contractures 117 chronic obstructive pulmonary disease world view 374-375 plantar ulcers 342 community services 539-540 cataracts 362, 363-364 (COPD) 41, 154,297-300 comorbidities 4 causal chain model 4 clinical manifestation 298-299 complement 59 celecoxib 64 peripheral neuropathy 215 complementary therapies 477-482 celiac disease 45 pulmonary rehabilitation 300 acceptance level 477-478 osteoporosis 122 thoracic assessment 154 benefits 479 cellulitis 348 treatment 299-300 types 478-479 cement, bone 126,127,142 cic1osporin 301 compliance 373 Center for Advocacy for the Rights and ciliary body 358 stiffness prevention 426 circulation, neuropathic foot 334, compresses 346 Interests of the Elderly (CARIE) compression neuropathies 396 496-497 335-338,338,339-341 compression therapy for wounds 327, Centers for Medicare &: Medicaid Services circulatory response 55 (CMS) 506 claudication 312 330,331 central nervous system (CNS) 21-30 computed tomography (CT) 75-76, 77-7, changes with aging 21-23 intermittent 315,325 demyelination 191 clinical algorithms 522 80 exercise effects 109 clinical partners 516 advantages/disadvantages 87, 89 hand motor control 436 clinical practice guidelines 4-5 brain imaging 80,84 interactions 27-28 Clinical Test of Sensory Interaction and brain tumors 230 learning 23, 29 cervical spine 160 plasticity 23,29,436 Balance (CTSIB) 411 neck pain 88 rehabilitation 27-28 clinician perspective on caregiving 516 Parkinson's disease 199 models 23-25 cochlea 369 radiation dose 86 sensory changes 21-22 stroke 86,181-182 ceramic composites 417 hair-eell function deterioration 370 computed tomography arteriography cerebellurnn 23,410 cochlear implantation 371 cerebral artery, middle 182 cognitive function (CTA) 89 cerebrovascular accident see stroke computer fatigue, visual 358 cerebrovascular disease, amputations 315 assessment for prostheses 469 conduction disturbances 271-273 cervical disk disease 160 executive 376-377 confidentiality 492 cervical orthoses 467 loss 28 cervical radiculopathy 222 progressive recovery 177-178 elder abuse 498 cervical spine 159-160 Rancho Los Amigos levels 176-178 conflicts in geriatric rehabilitation 494 differential diagnosis 160 cognitive impairment 185-190 history taking 159 caregiver role\" 516 discharge plans 495-496 imaging 160 communication 375-376 confusion 6, 376 myelopathy 160 exercise 189-190 conjunctiva 362 physical examination 159-160 fecal incontinence 388 connective tissue 426-427 sepsis 160 long-term 376 multiple sclerosis 194 biomechanical changes 425-426 pain assessment 445, 446 elastic component 426 Parkinson's disease 203 elongation 426-427, 428

INDEX 545 stress 427 creatinine phosphokinase-myocardial dizziness 405 stretching 427 band (CK-MB) 262 multiple sclerosis 192,194 viscous component 426 Parkinson's disease 203 consciousness, altered levels 70 critical pathways 522 without sadness 520 consent, patient 488,492 cross-linkage theory 7 dermatitis safety actions 497 cruciform anterior spinal hyperextension atopic 350 constipation 46,396 contact 352 constraint-induced therapy (CIT) 183 (CASH) orthosis 450 stasis 350 contact dermatitis 352 cryotherapy 453 treatment 349-350 continuous passive range of motion cultural factors in communication 373-374 dermatological agents 345-346 cure vs care 537 dermatomyositis 154 machines (CPMs) 117 Cushing's disease 110 diabetes mellitus 69,70,307-313 provision 539 cyclo-oxygenase 2 (COX-2) inhibitors 64 ankle brachial pressure index 312,322 supracondylar fractures of distal femur cyclophosphamide 131, 301 autonomic neuropathy 312-313 cyclosporin 301 cardiovascular function 311-312 170 cytokines 11 classification 307,308 contraction, maximal voluntary 119-120 complications 311-313 contractures 115-117,426 D diagnosis 307-308 exercise 310 activity levels 115-116 dantrolene sodium 179 foot infections 89,92 arthrogenic 116 dark adaptation 362 hyperglycemia 310 mechanisms 115 death, impending 506 hypoglycemia 309-310 myostatic 115 DeBakey assist device 294 insulin therapy 308-309 neuromuscular techniques 117 decision-making macrovascular complications 310,311 pathology 116 medical treatment 308-309 prevention 116 by patients 492 microvascular complications 310,311 pseudomyostatic 115 discharge plans 496 newly diagnosed 308 treatment 116-117 ethical 494-495 peripheral neuropathy 215,312 contrast agents 75, 81, 83 political 502 peripheral vascular disease 312,316 intravenous 81, 83 deconditioning 50 Pityrosporum folliculitis 347 contrast sensitivity 361 decubitus ulcers 395 prevalence 307 conversion disorder 209-210 deep pharyngeal neuromuscular racial groups 307 coordination, orthopedic trauma 168 renal failure 313,392 coronary arteries stimulation 383 stroke risk 181 atherosclerosis 259 deep vein thrombosis 276, 302 therapeutic intervention 308-310 changes 32 defecation 387 type 1 308-309,310 spasm 260 defibrillators 283-284 type 2 308,309,392 coronary artery bypass surgery (CABG) vascular complications 312 implantable cardiac 277, 283-284 wound healing 312 259,289-291,292 therapeutic intervention 284 diabetic ketoacidosis 308 grafts 259,289 degenerative joint disease 99 diabetic nephropathy 313, 392 minimally invasive 290 prostate cancer 247 diabetic neuropathy 224-225 therapeutic intervention 290-292 deglutition process 381-382 diabetic retinopathy 313, 365 coronary artery disease 34, 259 dehydration 34,44 diaphragm 38 heart failure 275 aquatic therapy 482 diarrhea 387 risk 251-252 diuretics 55 diastolic dysfunction 34 corticosteroids exercise 110 diathermy, short-wave 453 bone metabolism 122 delirium 185 diazepam 64,179 COPD 299 multiple problem presentation 520 diet injections 220 dementia 185-190 cultural issues 373-374 intraarticular 130 adverse drug reactions 392 diabetes mellitus 308,309 systemic lupus erythematosus 131 Alzheimer's disease 66, 185, 186, 189 dysphagia 383 see also steroids discharge planning 495 fracture prevention 418 cortisone 64 executive dyscontrol 376-377 macular degeneration risk 364 costal expansion, lateral 156 exercise 189-190 modifications in gout 132 costochondritis 154 hormone replacement therapy 400 obesity 440 cough occupational therapy 531 osteoporosis prevention 124 defibrillator patients 284 Parkinson's disease 203 thermoregulation 55 efficacy 38, 40 patient empowerment 186-187 see also nutrition mycobacterium tuberculosis self-eare enhancement 187-190 differential diagnosis 160,164 demographics 357,501-502,505 diffuse idiopathic skeletal hypertrophy 303-304 demyelination 191 counseling depersonalization 375-376 (DISH) depolarization, cardiac 265, 266, 293 cervical spine myelopathy 160 family 188 depression thoracic spine 163 nursing role 527 caregivers 515 osteoporosis 124 defibrillator patients 284 C-reactive protein (CRP) 260 dementia 189 creams 345-346 creatinine, serum levels 70,392

546 INDEX diffusing capacity of the lung for carbon dying 509-511 paraseptal 297 monoxide (DLeO) test 301 emotions 511 treatment 299-300 role of caregiver 517 employment digestive system 43-46 role of rehabilitation 510 gag clauses 488 digital rectal exam 245 protection for older workers 489 digitalis 302 Dynamic Gait Index 412 empowerment model 25 dignity issues 496 dynamometers 108 emulsions 345-346 digoxin 34, 67 dyskinesias 205-212 end of life care 509-511 direct access to physical therapy 489 endothelial dysfunction 48,49 disability classification 210-211 endothelium 47,48 rehabilitation 211-212 endothelium-dependent vasodilation evaluation in visual impairment 358 dysphagia 45,421-425 prevention of progression 531 assessment 423 (EDV) 51 Disability Insurance 507 brain tumors 231-233 endothelium-derived constricting factors discharge planning 495-496 conditions affecting 422 disease-modifying antirheumatic drugs etiology 421 (EDCF) 49 Parkinson's disease 232-233 endothelium-derived relaxing factors (DMARDs) 131 prevalence 421 diseases treatment 424-425 (EDRF) 49 dyspnea endurance 108 multiple coexistence 519-520 assessment 254,255 presentation 76,84-86,88-89,520 emphysema 299 assessment 155 underreporting 520 heart failure 276, 277 training 462, 471 disengagement theory 6 dystonia 206 energy diskitis 89 expenditure in amputees 471 lumbosacral spine 164 E flow 479 disuse, functional loss 28 requirements 43 diuretics ear, functional changes 369-371 environmental adaptation 188 congestive heart failure 67 echocardiography 262 gait training 462 heart failure 277 Ecological Framework 374 occupational therapists 531 hypertension 67 ectropion 362 environmental factors, balance 410 potassium deficiency 110 eczema, asteatotic 350 Epley maneuver 404 pulmonary hypertension 302 education eptifibatide 288 thermoregulation 55 equipment diversity issues 539 nursing 527 adaptive 510 diverticular disease 46 see also patient education durable medical 539 dizziness 369-370,403-408 elastic recoil loss 38,49,298 see also assistive devices activities of daily living 405 elastic stocking 395 equipment adaptor 539 balance impairment 405 elder abuse 488-489, 515 ergonomic devices 437 causes 404 ethics 498 error catastrophe theory 7 diagnosis 403--405 electrical stimulation erysipelas 347-348 exercise 406-408 dysphagia 383 erythema multiforme major 351 functional loss 405 fracture healing 417 erythrocyte sedimentation rate (ESR) 70 history 404--405 functional 139, 183 erythroderma, exfoliative 351 imbalance 404 inferential current 452 esophagus 45 presentation 403-405 neuromuscular 183 essential tremor 208-209 walking program 408 pain control 451-452 estrogen Dizziness Handicap Inventory 404, wound healing 330-331 osteoporosis prevention 418 electrocardiography (ECG) 265-266 replacement therapy 399 406 myocardial infarction 262 vascular changes 49-50 donepczil 66 electromyographic feedback, glenohumeral vertebral compression fractures 125 dopamine 199 ETDRS eye chart 359 dowager's hump see kyphosis, thoracic subluxation 139 ethics 491-498 driving, prosthetic rehabilitation 318 electromyography of care 492-493 drug eruptions 351 codes of 493-494 drug therapy 63-68 glenohumeral subluxation 139 conflicts in geriatric rehabilitation tremor 207 balance effects 410 emollients 349,351 494 cardiovascular disease 34 emotional pain 497 decision-making 494-495 fracture healing 418 emotional processing 22 discharge planning 495-496 movement disorders 210-211 emotional status, visual loss impact education curriculum 497 multiple sclerosis 198 elder abuse 498 Parkinson's disease 202 362-363 legal obligations 495 thermoregulation 55-56 emotions, palliative care 511 long-term care 496-497 vertebral compression fractures 125 empathy 511 managed care 497-498 drusen 364-365 emphysema 297-300 morality 491 duloxetine 217 principles 491-492,493-494 dumping syndrome 239 clinical manifestation 298-299 restraint use 497 durable medical equipment 539 contributing factors 298 virtue 492-493 durable power of attorney 489,495 panacinar 297

INDEX 547 ethics committees 494 pregait 461 social services outcomes 538 ethnic diversity 539 prescription 253-254 societal pressures 516 Europe, population 501-502 progressive resistance 168 structure changes 503 evaporative loss 50,54,55 prostate cancer 247 see also caregivers executive dysfunction 375 pulmonary hypertension 302 Family and Medical Leave Act (1993) 489 pulmonary system changes 40-41 family support groups 188 communication 373 relaxation 201 fascicular block 273 executive function 375 resistive 130 fasciculation 205-206 screening for 252 fat, dietary 43 disordered 376-377 session components 255, 256 fatigue 431-434 exercise(s) ~ strengthening 138, 156, 168 associated conditions 431 concepts 431,432 active-assistive motion 136 spinal cord injuries 179 definition 431 activity log 256 stretching 130, 179 heart failure 276,277 aerobic 51,291,454 termination guidelines 254, 255 instruments 432,433,434 after myocardial infarction 262, 263 tolerance 283 interventions 434 aging adults 251-257 training 40, 50-51 measurement 432, 433, 434 ambient temperature 56 valvular heart disease 279 multiple sclerosis 192, 194, 197 amputation 317 vascular system response 50-51 older people 432 autonomic neuropathy 312 vertebral compression fractures 124 fear 511 balance training 412,413,421 vestibular dysfunction 406-408 fecal impaction 387, 396 balance treatment 412,413 water 421 feed-forward automatic task 29 blood chemistry imbalance 110 weight-bearing 421 Feldenkrais technique in Parkinson's blood pressure 108 wound care 331-332 breast surgery 235 exercise machines 109 disease 201 CABG patients 290, 291 exercise testing 252 femoral neuropathy 224, 225 cancer risk ~,109 extrapyramidal dysfunction, drug-induced femur cardiac output 50 Chairbound box 109 210-211 distal, supracondylar fractures 170 CNS effects 109 eye neck fractures 169 cognitive impairment 189-190 fetal tissue transplantation 203 cool-down 255, 256 physiological changes 362 fever 53,54 dehydration 110 structural changes 362 fibrinous adhesions 425, 426 dementia 189-190 structure 358 fibroblast growth factor (FGF) 417 diabetes mellitus 308, 309, 310 eye charts 359, 363 fibromyalgia, lung involvement 154 dizziness 406-408 eye disease prevalence 357 Fick equation 251 duration 254 eyelids, changes 362 fidelity 492 dysphagia 383 fingers eccentric elevation 138 F mechanosensory receptors 436 effectiveness of water therapy 482 see also nails frequency 254 Faces Pain Scale 445,446 fitness 5 function 5 faith communities 515 Five Steps to Safer Healthcare 391-392 glenohumeral subluxation 139 falls 28,409 Flexicurve ruler tracings 419,420 glucose blood levels 310 flovent 299 heart failure 277 dizziness 404 fluconazole 347 iatrogenic conditions 397 drug-induced 392 fluid requirements 44 immobility management 395-396 multiple sclerosis 197 fluoroscopy 75 immune system 61 peripheral neuropathy 215, 216 fluoxetine 65 intensity 253-254 prevention 412,418,471 folliculitis 347 intolerance in heart failure 276, 277 risk 410,411,412 foot isometric submaximal 136 Falls EfficacyScale 411 autonomic neuropathy 326 maximal oxygen consumption 33 familial adenomatous polyposis 237 bony destruction 334 mode 253 familial choreoathetosis 210 care after amputation of opposite limb neuropathic foot 342-343 family nonaerobic 454 aphasic patients 376 315 nutritional status 110 brain tumors 231 Charcot's 326,334 obesity 440 caregivers 515 circumferential measurement 338 osteoarthritis 130, 454 dementia patients 188 deformities 333 oxygen requirement 50 discharge plans 495 heel ulceration 327 pain control 453--454 long-term care 517 imaging 89,92 palliative care 510 obligations 495 infection 92 Parkinson's disease 201 occupational therapist support 531 neuropathic 334,335-338,338,339-341 peripheral neuropathies 216 palliative care 511 physical activity progression 254-255 patient autonomy 492 changes 333 post-stroke 109 perceptions 521 exercise protocol 342-343 postural 171 rights 495 neurological involvement 334 precautions 454 social interaction 517 sensation evaluation 334 therapeutic interventions 342-343

548 INDEX foot (Contd) functional assessment 6 geriatric assessment orthoses 465 functional capacity, baseline 252 interdisciplinary 519-522 peripheral neuropathy 213,214,216, functional electrical stimulation 183 occupational therapy 529 326 optimal site 522 plantar ulcers 342 glenohumeral subluxation 139 physical therapy 534-535 pressure ulcers 327 Functional Gait Assessment 412 process 520-522 prosthetic 317,474 functional incontinence 389 social services 537, 538 re-ulceration prevention 338,342 functional independence 4 sensation loss 334 Functional Independence Measure (FIM) geriatric care manager (GCM) 539 tinea 346 geriatric nursing 525-527 ulceration 333,338,342 529 gerontological nursing 525-527 diabetic 312 functional loss gestational diabetes 307 wound status evaluation 338 giant cell arteritis 133 disuse 28 glare sensitivity 361 foot posture index 103 dizziness 405 Glasgow Coma Scale 176,177 foot-drop 222-224 Functional Reach test 411 glatiramer acetate 198 footwear functional residual capacity (FRC) 38 glaucoma 363,364,365 functional training in spinal cord injury glenohumeral joint, osteoarthritis 137 diabetes 312 glenohumeral subluxation 139, 183 gait 462 178-179 glioblastoma multiforme 229-230 pain control 449-450 funding of treatment choices 498 glipizide 309 peripheral neuropathy 216,312 fungal infections 346--347 glomerular filtration rate (GFR) 392 force platform systems 461 glucagon, intramuscular 310 forced expiratory volume in 1 sec (FEVt ) G glucose, intravenous 310 glucose blood levels 69,307-308 298-299 gabapentin 217 forced vital capacity 298-299 gadolinium 83 exercise 310 gagging 382-383 fasting in diabetes 308 vertebral compression fracture effects gait hypoglycemia 309-310 121 gluteus medius muscle tear imaging 95 assessment 412,457,458-460 glyburide 309 fracture orthoses 466 deviations 460, 462 glycemic control 308, 309 fractures 415-422 evaluation in neuropathic foot 334 glycoprotein lIb/IlIa inhibitors 288 footwear 462 goal incongruence 537 care 167 intervention strategies 460 goal setting 535-536 Charcot's 334,342 normal 458 goblet cells 297, 299 . distal radius 168-169 outcome measures 458-460 Goldmann perimeter 360 femoral neck 169 pathological 458 Goldmann tonometer 365 further injury prevention 418-420 peripheral neuropathy 215,216 gout 132, 392 healing 416,417 postpolio syndrome 119,120 Graphic Rating Scale (GRS) 445 restoration of functional 169 grasping 436,437 pharmacological interventions 418 velocity 462 grip strength 108 hip 415,416 gait pattern 29 griseofulvin 347 intertrochanteric 169 assessment 155 growth factors occult 416 multiple sclerosis 192,197 fracture repair 416-417 operative reduction and internal Trendelenburg 169 topical application 331 gait training 457-462 guardianship 495 fixation 136--137 environmental adaptation 462 caregivers 516--517 osteoporotic bone 168,415 mobility 457,461 guilt 511 Parkinson's disease 201 hormone replacement therapy 400 prosthetic rehabilitation 317-318 H therapeutic interventions 417-418 transfer activities 457,461 pain management 418 gangrene, peripheral vascular disease Haemophilus influenzae 59 pathological 416 hair follicles, infections 347 proximal humerus 136--137,168 325 hamstrings, flexibility 179 repair in elderly 416 gastric cancer hand skull 177 spine 415 clinical relevance 237-238 aging 435-438 stress 416 hematogenous dissemination 238,239 clinical assessment of function 437 supracondylar of distal femur 170 incidence 237 deformities in rheumatoid arthritis 131 tibial plateau 170-171 metastases 239 development of function 437 wrist 168-169,415 presentation 238 evaluation 435 see also vertebral compression fractures therapeutic intervention 238-239 grasp 436, 437 frailty 111 gastritis, atrophic 45, 237 grip strength 436 Frank-Starling law 32 gastroesophageal reflux disease 45 motor control 436-437 free radical theory 7 gastrointestinal tract 44-45 numbness 219-222 friction massage immobility effects 396 deep 117 general adaptive syndrome (GAS) 22 transverse 134 generational conflict 501-504 frustration 511 paradigm shift 502-503 function exercise 5 recovery 29

INDEX 549 orientation 437 heart valvular disease 277-279 hospitalization 391 therapeutic training 437 causes 278 hostility, caregivers 515 tinea 346 clinical manifestations 278-279 human immunodeficiency virus (HIV) transport 436 procedures 292-293 tremor 436 therapeutic interventions 279 infection 303 see also nails humerus, fracture of proximal 136-137, 168 hand-arm position 437 HeartMate ventricular assist device 294 humoral immunity 60 hand--eye system 435, 437 heat application, contractures 116 Huntington's chorea 210 hands-on treatment 188-189 heat exhaustion 55 hyaluronic acid 426 happiness, authentic 375 heat intolerance, multiple sclerosis 192,194 hydrodynamics 481 head heat stroke 55 hydrogel-impregnated gauze 330 injury 175-178 heat-related emergencies 57 hydrostatic pressure 481 mobility 428 hematological assessment 70 hydrotherapy 327, 330, 331 healers' hands, energy flow 479 hemiballism 207 hyperglycemia 308 healing process 319 hemiparesis, amputations 315 Health Care Financing Administration hemiplegia with shoulder pain 138-140 diabetes mellitus 310 hemoglobin levels 70 hyperkyphosis 102-103 (HCFA) 506 hemostasis, disorders of 352 hyperlipidemia 68 health education 527 herpes simplex 346 hyperpolarizing factor 49 Health Insurance Portability and herpes zoster 346 hypertension heterotopic ossificans 179 Accountability Act (HIPAA) (1996) high density lipoprotein (HDL) 69 atrial fibrillation 268 489 diabetes 308 healthcare diabetes 308 drug therapy 67 advocacy 516 hip macular degeneration risk 364 continuum 507,510 stroke risk 181 European services 502 abduction 143 hyperthermia 54 hOnle 503,507-508,530 abductor strengthening 169 avoidance 58 nursing 539 extension 112 hyperuricentia 132 social services 539 flexion contracture 116 hypoglycemia, diabetes 309-310 market-driven 497 fractures 415,416 hypokinesis 426 vision-related costs 357, 358 imaging 94-95 hypotension healthcare providers mobility 427 orthostatic 179,395 discharge planning 495 stiffness 428 postexercise 108-109 role 503-504 strengthening 143 hypothalamus 54 hearing, measures 370--371 hip arthroplasty, total 141-143,144-146 hypothermia 55 hearing aids 371 cement techniques 142 avoidance 58 hearing impairment function changes 144-145 surgical patients 56 communication 375, 376 home-healthcare rehabilitation hysterical tremor 209-210 evaluation 370--371 hearing loss 22, 370 142-143 iatrogenesis 391-397 Paget's disease 166 indications 141 adverse drug reactions 392-393 remediation 371 noncement techniques 142 immobility 393-394 heart block 271-272 outcomes 143 interventions 392, 394, 395-397 heart disease outpatients 142-143 clinical development 259-263 postoperative considerations 143 ileostomy 239 hormone replacement therapy questionnaires 144-145 illness cascade 519-520 399 rehabilitation 142-143 illness diagnosis models 3-4 ischemic 268,281 surgical approaches 141-142 imaging 73-96 progression 259-263 hip orthoses 466 risk modification 400 hip-knee-ankle-foot orthoses 466 choice of modality 86-87, 89 heart failure 33, 275-277 holistic therapies 477,478, 479 contrast agents 75, 81, 83 clinical manifestations 276, 277 home- and community-based services modalities 73-86 congestive 60,67-68,275,277 screening 81 contributing factors 276 (HCBS) 515-516 spine 88,89,159-160 exercise in prevention 34 home healthcare 503,507-508 imbalance 404 ventricular 275-276 multiple sclerosis 192,197 heart hugger 291-292 occupational therapy 530 immobility 391, 393-394 heart rate 32, 251 social services 539 interventions 396-397 aquatic therapy 482 homeostasis negative effects 466 exercise intensity 253-254 diminished reserves 520 organ system effects 394-396 heart sounds, pulmonary hypertension physiological range 6 immune system 59-61 302 homeothermy 53 dysfunction 6Q--61 heart valves homonymous hemianopia 360 exercise 61 congenital deformities 278 honesty 511 function 59-60 replacement 292 hormonal imbalance 110 therapeutic interventions 61 hormone replacement therapy 399-400 fracture healing 418 hospice care 506, 511 Hospital Insurance Trust Fund 506

550 INDEX immune theory 7 Iowa Pain Thermometer (IPT) 444 L immunity, acquired/innate 59 iridotomy 365 immunosuppressants 198 irritant contact dermatitis 349-350 laboratory studies 69-71 impaired glucose tolerance 308 ischemic mononeuropathy 333 aging effects 71 impetigo 347 isoniazid 304 indications for 7G-71 itraconazole 347 normal values 70 bullous 352 implantable cardiac defibrillators 277, J lactase deficiency 45 large intestine 46 283-284 Jewett hyperextension orthosis 450 laser therapy incontinence joint capsules 18 joints 17-18 atherectomy 289 bowel 387-388 Maze procedure 289,293 urinary 388--390 bursitis 133 laxatives, misuse 56 independence 504 cartilaginous 17 learned helplessness 375 independent functional ability 4 deformities in rheumatoid arthritis 131 learning, CNS 23, 29 infections degenerative disease 99 left heart catheterization (LHT) 287, 288 foot 90,92 fibrous 17 leg nosocomial 61,391 hand 436 circumferential measurement 316, 338, prevention 61 immobility effects 394 respiratory 298,302-304 mobility assessment 155 472 risks 59-60 mobility loss 425-428 condition of remaining 472 skin 346-348 mobilization 117,156 volume containment 471-472 therapeutic interventions 61 synovial 17 see also amputations; ankle; foot; hip; inferior vena cava filters, pulmonary see also contractures; range of motion knee embolism 302 (ROM) legal disclosure requirements 492 infestations 348--349 junctional rhythm 269-270 legal issues 487-490 inflammation 11 K decision-making 495 drug treatment 63-64 ethical obligations 495 inflammatory bowel disease 46 Karvonen method, heart rate range 444 Medicare 506 influenza, vaccination 61 253-254 lens 358 information disclosure, elder abuse 498 changes 362 informed consent 488, 492 Katz Index of activities of daily living intraocular implant 364 key questions 187 lethargy 70 safety actions 497 knee levodopa 65-66, 202, 211 inner ear 369 lichen simplex chronicus 350 instrumental active daily living apparatus extension 112 lidoderm transdermal patches 217 flexion contracture 116 life expectancy 501 (IADLs) 437 imaging 91 lifestyle changes, menopause 400 insulin mobility 427 lifts 539 osteoarthritis 450 ligaments 19-21 hyperglycemia 310 pain 449-450 limb see amputations; leg; prostheses resistance 69 stiffness 428 limbic system 22 therapy 308--309 knee arthroplasty, total 147-148,149 lindane 348, 349 insulin-like growth factor 1 (IGF-1) 11 clinical rating 149 lipids 69 exercise effects 109 implants 147-148 diabetes 308 insurance regulations 492 rehabilitation 148 literacy 374 intention tremor 208,209 surgical fixation 147-148 litigation 487 inter Resident Assessment Instrument knee brace 450 liver 45 knee immobilizers 466 living wills 489,504 (interRAI) 502 knee orthosis 466 long-term care 496 interdisciplinary teams 494-495 knee prostheses 474 caregivers 517 knee-ankle-foot orthosis 120,466 ethics 496-497 case conferences 521 Koebner's phenomenon 350 Medicaid funded 508 geriatric assessment 519-522 Kellner's law 362 lotions 346 occupational therapists 529 kyphoplasty 125-126,127,421-422 louse infestation 349 pallia tiVI' care 510 kyphoscoliosis 154 low-density lipoprotein (LOL) 69 interferon 198 physical examination 122 diabetes 308 interleukin 6 (IL-6) 11 kyphosis 102 low vision intermittent claudication 315,325 postural stresses 151-152 definition 366 International Classification of Diseases spinal osteoporosis 450 evaluation 362-363 thoracic 38,154,163 prevalence 366 (ICD) 3,457 thoracic arthroplasty 138 Lower Limb Prosthetics Medical Review International Classification of Function Policy (Medicare) 472,472-473 (lCF) model 25 lumbar (LS) radiculopathy 223 International Classification of Impairments, lumbar radiculopathy, upper 224 Disabilities and Handicaps (ICIDH) model 24 intertrigo 350 intertrochanteric fractures 169 intraocular lens (IOL) implant 364 intraocular pressure 365 intrinsic muscles 436

INDEX 551 lumbosacral orthoses 467 235 pathological fractures 416 metastases lumbosacral plexopathy 224 thoracic spine 163 brachial plexopathies 221-222 lumbosacral spine 164 malignant melanoma 243 brain tumors 230 malnutrition 61 cervical spine 160 stenosis 164,214-215 dietary management 46 lung cancer 304 lung(s) malpractice malignant melanoma 243 claims 487 prostate cancer 246, 247 breast cancer metastases 235 legal bases 487-488 thoracic spine 163 elastic recoil loss 38, 298 negligence 487 function 38, 40 managed care metformin 83,309 obstructive disease 152 ethics 497-498 methotrexate 131 occupational disease 298, 300 gag clauses 488 Mexican-American elders 373,374 restrictive disease 152-154 manual muscle test (MMT) 107, 108 microalbuminuria 313 structure 38 manual skills 435 microfractures 416 volume changes 38, 40 manual therapies 478 mind/body interventions 478-479 see also pulmonary diseases manubrium 151 minerals lung cancer 304 market-driven healthcare 497 bronchogenic carcinoma 301 massage 450-451 deficiencies 436 metastases 304 contractures 116-117 dietary requirements 44 lung capacity, total 301 deep friction 117 Mini-Mental State Examination 187, 375 lymphedema therapy, breast surgery palliative care 511 minute ventilation 299 transverse friction 134 mitral regurgitation 278 M mastectomy 234 mitral stenosis 278 Maze procedure 289,293 mitral valve 277 McGill Pain Questionnaire (MPQ) 445 meals on wheels 540 mobility macrophages 59 mean arterial pressure (MAP) 49 amputation 316,317,469 macular degeneration 361-362,363 mechanistic therapies 478 ankle 427-428 mechanosensory receptors, fingers 436 assistive devices 462 age-related 364-365 median nerve compression 219-220 gait training 457,461,462 macular holes 365 Medicaid 505,508 head 428 magnesium medical advocacy 516 hip 427 Medicare 505-508 knee 427 deficiency 110 costs 503, 505 neck 428 serum levels 69 expenditure 505 pelvic 427 magnetic resonance arteriography (MRA) healthcare continuum 507 quality of life 391 history 505 ribs 428 89 hospice care 506, 511 shoulder 428 magnetic resonance imaging (MRI) 76, key players 506 skills 202, 203 lawsuits 506 stiffness 427-428 79-80,81 legislation 505 thermoregulation 54-55 advantages/disadvantages 87,89 Part A 506, 507 trunk 427 brain imaging 80, 84, 85 Part B 507 well-being 391 brain tumors 230 political decisions 502 wheelchair 178 cervical spine 160 regulations 492 models of healthcare 3-4, 23-25 diskitis 89 reimbursement criteria 507 morality 491 foot infections 92 service implementation 506 morphine 63,64 hip 94-95 social security trust funds 506-507 palliative care 510 multiple sclerosis 193 Medicare Modernization Act (2003) 506 motor control 28 neck pain 88 memory loss 28 orthopedic trauma 168 nerve sheath tumor 92 meningiomas 230 theories 25, 26, 27 Parkinson's disease 199 menopause management 400 motor learning 28,29 safety 86 mental state theories 25,26, 27 shoulder 93-94 brain tumors 230 motor performance, functional assessment spine imaging 88, 89 dehydration 110 stroke 181-182 Mini-Mental State Examination 187, 108 vertebral compression fractures 90, 123 motor planning, Parkinson's disease 201 magnetic resonance imaging, functional 375 motor relearning program 183 meperidine 63,64 motor skills loss 28 (fMRI) 182 meralgia paresthetica 224 motor system 22-23 magnetic resonance imaging (MRI) metabolic acidosis 310 motor units 9 metabolic equivalents (METs) 252 movement spectroscopy 182 Majocchi's granuloma 347 activity level 255 awareness techniques 478 malabsorption 45 metabolic function, immobility effects impairment 27 malignancy 60 movement disorders 205-212 396 classification 210-212 brachial plexopathies 221-222 metabolic syndrome 307, 308 drug-induced 210-211 brain tumors 230 rehabilitation 211-212 exercise influence 5, 109 lumbar radiculopathy 224 lumbosacral plexopathy 224 lungs 304