bedridden (Guccione et al., 2012). Alternatively, individuals in the Failure category may reside in an assisted living facility or nursing home. It takes great effort on the part of an older adult to move back up a level once his or her functioning has declined. Physical therapy practitioners need to enhance the individual’s knowledge of, and efforts to engage in, lifestyle changes such as increased exercise that sustain a patient at the highest level possible. An adult who is significantly above the threshold for his or her level of vigor is more protected against an acute decline because of having greater physiologic reserves. The role of the physical therapist is to identify impairments in bodily functions to sustain optimal functional levels with the highest possible reserves (Guccione et al., 2012). Physical therapy professionals are optimally positioned to help older adults recognize the need to keep their activity levels as high as possible.
adult recently diagnosed with rheumatoid arthritis would be categorized at this level because, although still able to engage in all activities, he or she may need to stop midday and nap. Tasks may need to be broken down and done at intervals. 3. Frailty : When ADLs require most of an individual’s physiologic reserves and his or her community activities are severely limited, the person is categorized as frail. This individual may forego outside interests because it is “just too tiring to get to church on a Sunday anymore” or because “the garden became just too much work.” Outside help may be brought in to complete many home or work activities previously handled by this individual when he or she was at the Function level. 4. Failure : Failure is when a person requires assistance with both ADLs and IADLs. Generally, these individuals are home- bound, may require an aide 24 hours a day, or be completely
MULTIDIMENSIONAL FUNCTIONAL ASSESSMENT: APPLYING THE ICF MODEL
facilitates the concept of client-centered care, a cost-effective model in health care that augments the traditional medical model, which focuses only on symptom management (Reuben & Tinetti, 2012). In addition to assessing the various domains of health as outlined in the ICF, the physical therapist will also need to ascertain what is of priority and greatest importance to the patient to establish what will be the most important goal. This goal can be determined through careful patient interviewing. may experience a number of physical changes resulting from the aging process. Age-related decline can be observed in many systems, including cardiopulmonary functioning, musculoskeletal changes, body composition/metabolism, and the integumentary system (American College of Sports Medicine et al., 2009). Assessment tools related to bodily structure and function on the ICF model will be included at the end of this section. In addition, Appendix A includes several outcome tools for assessment across the ICF domains and identifies sources for obtaining those tools. Cardiovascular and musculoskeletal changes Understanding normal age-related cardiovascular and musculoskeletal changes enables physical therapy practitioners to understand and better influence performance through remediation of function or through compensatory and adaptive measures. Specific client factors of interest include endurance, strength, balance, and flexibility. The American College of Sports Medicine (ACSM) notes that absolute age-related cardiovascular changes do influence aerobic capacity, which is a direct contributor to physical endurance (ACSM et al., 2009). Maximum heart rate and cardiac output both decline, and arterial stiffness reduces vascular functioning. In spite of these changes, however, endurance- related fatigue remains poorly understood and seems to be task-specific (North & Sinclair, 2012). Having a condition such as chronic obstructive pulmonary disease (COPD) also affects an older adult’s level of physical activity and endurance. Lifestyle changes are often needed to maximize performance (Cleveland Clinic, 2013). Evidence supports engagement in repetitive daily tasks as well as increased physical activity as ways to mitigate these age-related effects (Keysor & Brembs, 2011). Physical endurance permits older adults to sustain engagement in activities that require longer durations to complete and use of the larger muscle groups of the body. For example, a client with limited endurance may display no difficulties with a single ADL task but may become too fatigued to complete this same task when it is part of a typical daily sequence. Endurance in the ADL performance of older adults can be measured in the difference between the fatigue (if any) they experience from a single activity and the fatigue that results from a series of activities. This effort can be assessed by using the Borg Rating of Perceived
In order to maintain a broad and dynamic perspective of health when evaluating the multidimensional needs of older adults, it is essential to use an approach that ensures a focus on function as defined by the ICF model and that is dictated by the individual concerns of each older adult client. This approach attempts to understand the “big picture” of daily living for each client. It considers things they want, need, and are expected to do under specific circumstances or within a specific environment (Rosen & Reuben, 2011). Such an approach complements, supports, and Health conditions The following sections highlight some of the age-related changes that occur in the ICF domains of body structure and function, activity, and participation. These sections will also provide information on assessment tools that help the physical therapist establish a baseline and measure improvements in the health condition. These assessment tools have been found to have good validity and reliability for their respective domains of the ICF (PTNow, n.d.). While many tools are presented, it is up to the physical therapist to prioritize which of them are most appropriate for each individual. Additional assessment tools are listed in Appendix A. In addition to providing a comprehensive view of an individual’s current status in order to form a plan of care and to track progress, use of assessment tools is now an essential component of reporting patient outcomes to the Centers for Medicare and Medicaid Services (CMS) for older adults receiving outpatient physical therapy services. More in-depth information about reporting to CMS using G-codes (a coding system that identifies the primary issue being addressed by therapy, with modifiers that reflect a patient’s impairment or limitation) can be found in Appendix B. Changes in body structure and function Old age has been described as a “new” concept resulting from the increased lifespan of older adults made possible by the advanced science and technology of the 20th century (Miller, 2002). Leonard Hayflick, a well-known scientist in aging research, describes aging as an artifact of civilization (Hayflick, 2000). A multitude of theories attempt to explain the physical changes associated with aging. Many of these theories examine mechanisms internal to the human body, drawing on factors related to physiology, biology, and genetics (Cole, 2008). However, a lifetime of external considerations such as diet, lifestyle, environment, and activity levels also affect physical performance. There is a benefit to addressing functional performance as both the intervention and the outcome with older adults (Orellano, Colon, & Arbesman, 2012). Physical therapy and other rehabilitation services frequently target neuromusculoskeletal and movement-related client factors to improve function in older adults. This section will discuss changes in body structure and function as they apply to the older adults’ health conditions. Older adults
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