Physiotherapy Practice in Residential Aged Care

375 Pages·2004·7.97 MB·English

by  Jennifer C. Nitz

BUTTERWORTH-HEINEMANN
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Contributors
Susan R. Hourigan BPhty(Hons) BScApp(HMS-Ex Man)
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
Venerina Johnston BPhty(Hons)
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
Diane L. Josephson DipPhysio GradCertPhty(Geriatics)
Private Practitioner,Brisbane,Australia
Nancy Low Choy BPhty(Hons) MPhty
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
Jennifer C. Nitz BPhty MPhty PhD
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
Ann Rahmann BPhty GradCertPhty(Geriatrics)
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
Ruth Sapsford AUA DipPhty
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
Tina Souvlis BPhty(Hons) PhD
Division of Physiotherapy,School of Health and Rehabilitation Sciences,
The University of Queensland,St Lucia,Australia
vii
Introduction
Jennifer C. Nitz and
Susan R. Hourigan
In 2002 there were 2.5 million older people (aged 65(cid:2)) in Australia,rep-
resenting 12.7% of the total Australian population. In 2031 older people
will represent 22.3% of the total population (or 5.4 million people)
and by 2051 they will represent over one-quarter of our population
(Australian Bureau Statistics 2003). The increase in the older old (those
85 years(cid:2)) is even more pronounced,rising from 9.1% of those aged 65
years and over in 1996 to 20.1% by 2051.The average age of people living
in residential care homes in Australia is 83 years (AIHW 2002).
In Australia, at the latest census in June 2001, there were 136608
people accommodated in 2977 residential aged care facilities (RACFs).Two
per cent of these places were devoted to respite care but this accounted
for 43606 admissions during the financial year ending June 2001.In that
time there were 46545 admissions for permanent care. Most of the peo-
ple admitted to RACFs were women (72%) and just over half of all people
admitted were aged over 85 years. Only 6094 (4.5%) people admitted
were less than 65 years of age. Twenty-three per cent of these younger
people were admitted to high care compared to 63% of all older people
admitted.The remaining admissions were to low care (AIHW 2002).
Prior to admission,41% lived alone in a house or flat,21% with a spouse
and 12% with family members.Thus most people admitted to RACFs enter
from the community. When in the community, many would have been
the recipients of Community Aged Care Packages that were designed to
enable older people to live independently in the community with assis-
tance from community agencies such as meals on wheels,home help or
community nursing (AIHW 2002).
Where does the physiotherapist fit into the residential aged care scene?
This book was conceived to enable physiotherapists to define their role
in this area of practice and to educate physiotherapy students (both
undergraduate and postgraduate).It should assist our co-workers in aged
care regarding the skills we bring to the workplace and how collectively
we might offer best practice procedures that enable residents and carers
to attain a quality living environment.
From here on in we will refer to residential aged care facilities even
though young people are also cared for in these communities. In other
countries the RACFs will be known as nursing homes,rest homes,hostels
and retirement homes.
People entering RACFs often do so after losing the ability to manage
independently in the community.It is often a culmination of events such
1
2 Introduction
as the loss of a partner or parental carer who made life at large in the
community possible, or in other circumstances a catastrophic life event
that has led to physical dependency.In many cases this ultimate loss fol-
lows a series of losses including driver’s licence, home, friends through
death and pets.To many individuals,entering a care facility means giving
up self-determination,dignity and quality of life but this need not be the
case with good management in a well-organized facility. Irrespective of
whether the resident will spend their final days in the facility or have
been admitted to provide respite for a carer or even for slow stream rehabili-
tation, it is the duty of the care providers to ensure best practice in all
aspects of resident management. In many respects care providers are
bound to take on an advocatory role to ensure residents are protected
from injury and are able to access all necessities for the best quality of life
possible to them. Physiotherapists possess numerous skills that enable
them to assist residents and carers to achieve this goal.
Identification of the needs and risk factors a resident presents with on
admission to a care facility allows development of the most appropriate
care plan that will enable attainment of the best quality of life afforded by
their circumstances. If all care staff adopt a clinical reasoning approach
when drawing up a care plan that incorporates the stated desires of the
resident, a harmonious and cooperative environment can be provided.
By allowing the new resident and/or their family to participate in the
planning process, trust is generated and communication of doubts and
fears are encouraged,alleviating much anxiety.
New residents often come to residential care with preconceived ideas
that are often of a negative nature.The very idea of something new is for-
eign to many as they have lived in the same house with the same people
possibly all their life and to change brings fear of the unknown. A new
environment without any of the familiar objects is very confusing to
many older people.Often the change needs interpersonal skills that have
not been developed due to previous isolation. If you consider the intim-
ate interaction that occurs when assisting a totally dependent person
with bathing and toileting some idea of the extent of adaptation neces-
sary is gained.Not only is there a new physical environment for new resi-
dents,but also new carers,new routines,new faces,new procedures and
new timetables.Add difficulty with communication to a physical depend-
ency and we can begin to understand the mental turmoil of some new
residents. Some lucky people come to a residential care facility after
having mentally prepared themselves for the lifestyle change. However,
there will be a level of stress that always accompanies anybody who
moves from one place of residency to another. Limiting the number of
new experiences can reduce stress.Therefore it is beneficial to have one
carer undertake the admission process for the new resident.They should
also continue to care for the needs of the resident at this time.To have a
family member or friend who is accepted by the resident present during
admission might help transition.
Introduction 3
On admission,an interim care plan is drawn up for each new resident.
This will enable a safe level of functioning to prevail until a full assessment
of physical,communication and behavioural status is undertaken.In real-
ity, this process takes a few weeks depending on the distress caused by
the admission to the RACF.Therefore the initial care plan should not be
seen as unchangeable nor should any care plan be considered finite. All
residents will be liable to rapid change in their medical condition simply
due to their age and frailty.Every person involved in the care of a resident
should be aware of this and be able to adapt management strategies
immediately. However, many carers lack the skill to be able to identify
when the resident’s condition changes let alone know how to adapt a
care plan to suit the change. The physiotherapist is the appropriate
practitioner to evaluate change in physical ability and to recommend
appropriate care plan modification.
Clinical reasoning is the approach used to develop the care plan for a
resident.It involves using theoretical knowledge related to ageing and patho-
logical processes seen in the elderly,the assessment of these problems and
intervention options to enhance function and quality of life for the resi-
dents. In this book we will look at physiological changes accompanying
the ageing process as well as the physiotherapist’s role in assessment,pre-
venting residents’ injuries and promoting life satisfaction.Major presenting
problems relating to being immobile,barely mobile,or ambulatory will be
examined physiotherapeutically. Information and strategies to assist with
residents suffering from pain,osteoporosis,incontinence or palliation will
be covered.A special chapter concerned with aquatic physiotherapy is also
included as pools are becoming more prevalent in aged care facilities.
Appendices have been included to cover a number of issues which are
important to physiotherapy practice. In a number of RACFs funding is
linked to proof of efficacy;therefore choosing the appropriate outcome
measurement that reflects the results of intervention (unique to an indi-
vidual resident’s care plan) is vital.The appendices include a table of use-
ful outcome measures,assessment case studies,suggestions for successful
case conferences,electrotherapy considerations in aged care practice and
mobility aids.
We hope the ideas and topics contained in our book are informative as
well as thought provoking for our readers. Working in residential aged
care as a physiotherapist is extremely challenging as our skills in clinical
practice,education,health promotion and research will be recruited and
utilized frequently as we fulfil our role.
References
Australian Bureau Statistics 2003 Australian Social 2000–01: a statistical overview. AIHW Cat. No.
Trends,Cat 4102.0,p 2 AGE 22. Canberra: AIHW (Aged Care Statistic
Australian Institute of Health & Welfare (AIHW) 2002 Series No.11).http://www.aihw.gov.au
Residential aged care services in Australia
1
Physiological changes
with age
Jennifer C. Nitz and
Susan R. Hourigan
This chapter ■ overview the changes associated with ageing in all of the
aims to: systems important to physical performance and functioning.
This information will be referred to throughout this text as we
examine clinical reasoning and physiotherapeutic treatment of
elderly people living in residential aged care facilities.
Introduction It is a common belief that both physical and cognitive function will decline
with ageing and that people must accept these changes.In many respects
this is true, but compensatory and preventive management can control
the effects of system decline. An example of this is to use corrective
lenses to accommodate for the presbyopia of middle age. Similar adjust-
ments to lifestyle can slow or negate the effect of ageing in other systems.
In this chapter the changes due to ageing will be investigated in the
context of residents in aged care.
People generally reach their peak health and performance abilities
between adolescence and 30 years of age. Functional capacity after this
age then declines throughout the lifespan depending on genetics,lifestyle
characteristics and health. All physiological measures that decline with
age do not do so at the same rate. Heart rate at rest does not change
dramatically with advancing years; however, heart rate at maximum
physical exertion decreases significantly.Nerve conduction velocity slows
10–15% from 30 to 80 years of age and maximum breathing capacity
declines by approximately 60% between 30 and 80 years. The rates of
decline in the various functions differ and are significantly influenced by
various factors including the level of physical activity and any associated
pathology. There is no doubt that regular activity and physical training
enables older persons to retain higher levels of functional capacity
(McArdle et al 1996).
Decline in the special senses can be a most disabling aspect of ageing.
As will be seen in later chapters, the resulting disability when vision,
auditory and vestibular function and somatosensation diminish with age
plays a major role in exposing the older person to an increased risk of
7
8 Physiological changes with age
injury from falling. In addition, interaction with the environment is
decreased and opportunities for choosing modalities for entertainment
are curtailed by loss of vision or hearing or the ability to safely mobilize
in the community.Thus decline in the special senses can lead to a dramatic
change in lifestyle and possibly a diminished quality of life. Therefore
understanding the ageing effects on these organs is important when
working with the elderly.
Special senses Vision
As the eye ages the lens loses clarity owing to an increase in lens density
(Jackson et al 2002). It becomes yellowed and crazed (Bron 1997). In
addition, the ageing lens can form a cataract. Cataract formation is
believed to be due to lens protein modification and reduction in antioxi-
dants (Bron 1997). The retina at the back of the eye is also affected by
ageing.Within the retina lie the rods that are responsible for vision in dim
lightand the cones that respond to bright light and colour.At the centre
of the retina lies the macula.This is a specialized area comprising a cen-
tral cone-rich fovea that is surrounded by a rod-dominated parafovea.The
photoreceptor outer segment contains the proteins of the phototrans-
duction cascade.The nutritional needs of this component are maintained
by the retinal pigmented layer. This layer is responsible for maintaining
photoreceptor health by helping to maintain ionic balance and hydration,
transport and filtration of nutrients, by providing retinoid intermediates
that replenish photopigment bleached by light exposure and also by
absorbingstray photons (Jackson et al 2002).Blood flow to the retinal pig-
mented layer and the photoreceptors is via the choroidal system, which
has the richest blood flow in the body. Between the choroid capillaries
and the retinal pigmented layer lies Bruch’s membrane.Age-related mac-
ular degeneration (ARMD) in the early stages is characterized by extra-
cellular lesions and changes in the retinal pigmented layer morphology
and damage to Bruch’s membrane in the region of the macula (Bron 1997,
Jackson 2002).Later extensive retinal pigment layer atrophy and vascular
changes with in-growth of vessels in Bruch’s membrane and under the
retinal pigmented layer accounts for blindness in ARMD (Jackson 2002).
ARMD might be demonstrated in the early stages by an increased time
for recovery of vision after exposure to bright lights. With ageing, dark
adaptation after exposure to bright light increases by about 8 seconds
per decade. Delays of an average 13 minutes have been seen in people
with early ARMD (Owsley 2001).This can lead to a considerable increase
in fall risk for older people when moving from light to dark environments
or from dark to light as the time for clear vision to return increases with
age. Thus older people should be made aware of this delay in order to
include into their lifestyle safety practices that will reduce the risk of
injury.Older people with early ARMD (Scilley et al 2002) also experience
night driving problems.
Special senses 9
Eventually with ARMD,there is central visual field loss that affects the
ability to read and perform activities requiring fine manipulation such
as sewing. Distortion of colour and shapes can occur. Together this can
affect edge perception where contrast is minimal. From a functional
viewpoint,the person is placed in danger of not seeing steps or thinking
there is a step up or down because of colour change or shadow.A door
that is ajar if it is the same colour as the surrounding walls may not be
seen nor the edge of the chair seat or the edge of the bed if contrasting
colours are not used.The older person is therefore at risk of a fall through
errors of judgement induced by decline in visual acuity or depth percep-
tion (Carter et al 1997, Pinto et al 1997). Changes in visual acuity can
affect depth perception,especially when stereopsis cannot be attained with
corrective lenses.It can also contribute to visual illusions such as not per-
ceiving moving repeated patterns such as on escalators (Harwood 2001).
With ageing,the ciliary muscles are less able to change lens curvature,
thereby slowing the ability to rapidly change focus from close work to
distance. This becomes a problem when ambulating when near and
distant sections of the environment require scanning to navigate safely
through environmental hazards.
The pupillary light reflex is slowed with age.This means that it takes
longer for the elderly to be able to see clearly when there is a change in
light conditions from dark to light or light to dark.ARMD also plays a role in
this presentation.In the younger person light accommodation takes a few
seconds.As a person ages,the time interval extends and might take as long
as 15 minutes to occur.Not allowing for the slowed light accommodation
by standing still and waiting for the vision to clear can increase the risk of
a fall.The typical time when this becomes critical is at night when putting
on the light to get up to go to the toilet or during the day when moving from
indoors to outdoors,especially on a bright sunny day (Pinto et al 1997).
Visual acuity changes with ageing. Presbyopia can increase but more
commonly ARMD and lens pathology interfere with the ability to read or
perform close work (Pinto et al 1997).The use of coloured print or paper
should be limited if using the print medium to communicate to residents
via notice boards or newsletters. Many of the oldest old residents may
find it difficult to discern coloured letters on coloured paper due to the
cumulative effect of these eye changes and so might become isolated
from the community activities.Larger font and bold black print on white
paper can limit this possibility even if it is not as attractive to the eye.
Pathological conditions that can affect vision are more common in the
elderly.These include complications arising after cataract surgery,retinal
detachment and glaucoma. All can contribute to diminished sight or
blindness.Conditions such as stroke and multiple sclerosis can also cause
visual field loss and are relatively common in residents.
Visual conflict occurs when what the person interprets they are seeing
is at odds with proprioception, touch and pressure and vestibular sens-
ory input. Difficulty in discerning reality in visual conflict situations is
10 Physiological changes with age
often related to decline in the vestibular and proprioceptive systems as
well as central integrative systems within the central nervous system
(Harwood 2001).In these instances the older person is at more risk of a fall.
Hearing and Age-related hearing loss is known as presbyacusis (Seidman et al 2002).
vestibular Cochlear degeneration occurs with ageing and signs of degeneration
function begin with decline in the ability to hear high frequency sound,followed
by progressive loss of lower frequency hearing.There is also loss of the
ability to discriminate between sounds,which leads to speech sounding
muffled, and in some instances whole words become indiscernible.
Hearing loss is not usually symmetrical and this causes difficulty in loca-
tion of sound source. Functionally this difficulty in sound location can
delay avoiding responses to danger such as moving aside to clear a skate
boarder on the footpath or an approaching car.Delayed detection of the
direction from which danger is approaching might require faster evasive
movement than can be controlled by the elderly person and a fall can
eventuate.Where possible, hearing should be tested and elderly people
with hearing loss should be encouraged to wear hearing aids at all times.
Slowed nerve conduction from the ear and within the central nervous
system can cause auditory response time to increase. This can lead to
confusion in the elderly if multiple questions are fired at them without
allowing for time to process the input and respond accordingly. Many
professionals have been guilty of this and then misinterpreting the lack or
inappropriateness of response by the older person as indicating demen-
tia.Unfortunately such labelling can stick,with far-reaching consequences.
The vestibular apparatus comprises the utricle,saccule and three semi-
circular canals that enable orientation of the head with respect to gravity
and enable response and perception of head movement (Guyton 1991).
Thus normal vestibular function is needed for a person to maintain head
stability during any movement task,to allow conjugate eye movement for
reading and the integration of visual and proprioceptive information for
environmental interaction (Di Fabio & Emasithi 1997). By the age of 70
years there has been a reduction of 40% in the number of vestibular hair
and nerve cells (Rosenhall & Rubin 1975).Ageing of the components of
the vestibular apparatus leads to a reduction in vestibular sensory input
that causes the older person to rely more on vision and less on proprio-
ceptive information to continue to move and interact in the environ-
ment.The impact of vestibular decline with age will be covered in more
detail in the chapter dealing with balance (Chapter 9).
Taste and smell With ageing there is a decline in ability to taste food.Because of this diet
is often changed by the elderly to increase taste needs.Unfortunately this
is often by increasing the sugar and salt content,thereby raising the like-
lihood of glucose intolerance and hypertension.The sense of smell also
declines. Since the aroma of food and taste are intimately connected to