Changes in participation Changes in participation include higher-level skills at the IADL level. Some examples of participation are community function, health and wellness, shopping, driving, work, quality of life, role functions, life satisfaction, home management, leisure, and recreation activities. As older adults age, an increase in health conditions that affect bodily systems generally reduces their participation. Using the appropriate outcomes will improve documentation of issues with bodily systems, activities, and participation. In a hypothetical case: A female patient is evaluated in her home after a fall. The patient suffered a broken wrist with open reduction and internal fixation (ORIF) 5 days ago. The physical therapist’s interview revealed that the patient has had two or more falls in the past year and that she is afraid she will hit her head the next time she falls. Past medical history includes hypertension, thyroid disease, and osteoporosis. The patient had been ambulating with a cane. She reported that she does not go out without help. Since the patient has an upper extremity fracture, a specific body systems outcome tool that will enable the therapist to get a good baseline that validly identifies body function level issues is the Disabilities of the Arm, Shoulder and Hand (DASH) assessment. Higher scores on the self-report DASH are representative of greater disability. In addition, the Home Falls and Accidents Screening Tool (HOME FAST) can be used to help facilitate greater detail in the assessment regarding home safety. Any item requiring action is noted and addressed during interventions; home issues are managed. Lastly, because of the fear of falls expressed by this patient, the Falls Efficacy Scale – International (FES-I) would be a great measure of participation. All of these tools are valuable and easily employed in the home environment. Another hypothetical case: A man comes to the outpatient clinic with an 18-year history of Parkinson’s disease, hypertension, osteoarthritis in both knees, and multiple falls in his home. The patient states that he is unable to count the number of falls he has had in his apartment. Since the patient reports ambulating without a device and has a falls history, a functional mobility assessment such as the Timed Up and Go (TUG) assessment would provide valuable information regarding activity limitations. The 30-Second Sit-to-Stand test would provide valuable information about lower extremity muscle strength and bodily function impairment. A higher-level participation fear of falling/falls risk measure for community dwelling older adults would be the Activities-Specific Balance Confidence (ABC) scale. These are valid and reliable tools that measure change and improvement in functional status from the baseline as well as the patient’s progress as physical therapy leads to improvement. Impact of chronic health conditions Chronic diseases are long-term illnesses that significantly affect health and participation. They negatively affect quality of life, contribute to declines in functioning, and may ultimately limit an individual’s ability to remain living independently at home (Federal Interagency Forum on Aging-Related Statistics, 2016). Prevalence in older adults is high; 80% of all people age 65 and older have at least one chronic condition, and 50% of older adults have at least two (CDC, 2011). Although Contextual factors Aging is an individual process. Given the broad heterogeneity in the presentation of adults age 65 and older, it is no surprise that there is so much variability in the number and type of activities in which they engage. ADL and IADL performance are often of greatest interest to those working with older adults, as these reflect a person’s level of independence and frequently
chronic conditions cannot be cured, the effects of many can be mitigated with behavioral interventions. The impact of chronic health conditions on limitations of function in daily living can be reduced through a combination of compensatory strategies and environmental adaptations from the perspective of varying professions. Chronic conditions are associated with morbidity and mortality. They are precursors to fatality; five of the six leading causes of death – heart disease, stroke, cancer, diabetes, and chronic obstructive pulmonary disease – are chronic conditions (Federal Interagency Forum on Aging-Related Statistics, 2016). The most common chronic conditions among older adults are hypertension (56%), arthritis (51%), and heart disease (30%). About two-thirds of all Americans will succumb to one of four primary chronic conditions: chronic heart failure, emphysema, frailty, and dementia (HealthyPeople.gov, 2015). In addition, there are many other chronic conditions affecting older adults. Besides the previously named conditions, 1% of all adults over 60 have Parkinson’s disease (Tarsy, 2012). It is the second most common neurodegenerative disease worldwide (after Alzheimer’s disease). Also, 20% of adults over 65 years of age are obese, a percentage that is expected to rise as the population ages (Li, Fisher, & Harmer, 2005). The assessment of chronic conditions can be performed in various ways, typically determined by organizational documentation procedures. Chronic conditions are initially diagnosed by medical doctors, but they are monitored and assessed by a range of professional healthcare providers. Practitioners can list and track chronic conditions of older clients through such means as reading medical records and inquiring about the status of disease management when encountering older adults. Rehabilitation professionals, especially physical therapy practitioners, can play a key role in determining how the progression of a chronic condition may be affecting mobility. In addition to offering strategies to maximize each client’s ability to participate in his or her daily activities, the physical therapy practitioner can work with caregivers and other health professionals to prevent “excess disability” – a situation in which the older adult client is not engaged in daily activities to his or her maximum potential because of social factors or environmental barriers (Hand, Law, & McColl, 2011). Assessment tools to measure participation Participation includes community function, driving, health and wellness, home management, leisure, and recreation. Measurement of participation restrictions can be accomplished with the use of Quality of Life (QoL) tools and self-report tools about community activity and self-efficacy. This section of the course describes assessment tools that are useful at the participation level. The Activities-Specific Balance Confidence (ABC) Scale is a self-report measure of confidence in performing 16 ambulatory activities without falling or experiencing a sense of unsteadiness, on a scale of 0 (no confidence) to 100 (complete confidence). This scale has been found to separate higher-mobility subjects from lower-mobility subjects and is also useful when determining falls risk. The cut-off score for falls risk in community dwellers is 67% (Powell & Myers, 1995). The Falls Efficacy Scale (FES) is a self-report measure of fear of falling. There are several versions of the Falls Efficacy Scale (FES). The subject rates his or her confidence in performing daily activities from 1 (extremely confident) to 10 (no confidence at all; Tinetti, Richman, & Powell, 1990). determine living status and need for care. Increased dependence for ADLs – -including bathing, dressing, functional mobility, and bowel and bladder management – often results in nursing home placement for older adults who had been living with caregivers in the community (Gaugler et al., 2010). In 2017, 35% of older adults (age 65 and older) required assistance with at least one
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