successful treatment recommendations. Cultural influences may also underlie expectations of both an older adult and his or her physical therapy practitioner regarding family caregiving support in the course of goal setting and discharge planning. For example, a physical therapy practitioner may expect that the client’s son will assist his mother with toileting; however, the client knows her son’s modesty in seeing his mother complete this act will prohibit carryover of that activity upon discharge to home. The AoA (2015) has created a resource to enhance cultural competency among professionals working with older adults. A Toolkit for Serving Diverse Communities is designed to facilitate an appreciation and respect for cultural differences among professionals who work with older adults. In addition to being aware of their own cultural beliefs and biases, culturally competent professionals’ fundamental actions include demonstrating warmth, empathy, and genuineness in interactions with older adults of diverse cultural backgrounds. Behaviors illustrating respect may include taking a broad and holistic approach to treatment, keeping the treatment program flexible, and adapting treatment as needed in response to clients’ ethnicity and gender. The practitioner needs to: ● Make the environment welcoming and attractive, based on the client’s cultural leanings. ● Avoid stereotyping and misapplication of scientific knowledge. ● Use educational approaches and materials appropriate to the client’s educational and cultural background. ● Understand that there is no recipe for success that fits everyone. ● Understand that cultural competency is continually evolving. ● Find ways to communicate with individuals who are more competent in a language other than English. ● Use interpreters who have passed qualification standards and who complete continuing interpreter education programs.
Pynoos, Steinman, Nguyen, & Bressette, 2012). A study by Clemson and colleagues (2008) evaluating the effectiveness of home modifications for older adults at risk for falls concluded that changes to the physical environment were effective when combined with personalized education and behavioral training by a skilled rehabilitation professional. Assessment of the home environment may be completed through informal interview or through the use of evidence- based tools. Physical therapy practitioners who do not have the opportunity to evaluate clients in their home settings can and should still gather self-report data and/or data from caregivers to identify potential hazards that may either increase falls risk or present barriers to functional independence. Practitioners observing clients in their homes may utilize tools specifically designed for home safety such as the HOME FAST (Mackenzie, Byles, & Higginbotham, 2000) or consider performance-based assessments such as the Performance Assessment of Self-Care Skills (PASS), which evaluates safety during the performance of selected occupations (Rogers & Holm, 2009). Cultural context and cultural competence Culture reflects both commonality and diversity and is something that affects all humans. Culture, therefore, influences both the older adult and the healthcare professional who provides services to this population. Culture refers to the values, traditions, customs, and other rituals shared by a group of people. Culture goes beyond race, ethnicity, age, or religion to include “interpretation of the aging experience” (Bonder, 2001, p. 13). In the area of health and health care, culture is particularly important. For example, chronic health conditions such as diabetes may be viewed fatalistically by some groups that have a limited understanding of the role that lifestyle factors such as diet and exercise play in the course of the disease (Knowler et al., 2002). A physical therapy practitioner whose expertise may be in the area of diabetes management must be sensitive to the possibility that a member of this group may initially reject highly
ADDITIONAL CONSIDERATIONS
Unfortunately, this is not always the case. Lifestyle changes may be necessary to achieve the best outcomes. Most people do not realize that lifelong exercise is key to maintaining healthy states. Other health-related behaviors that may need a call to action for behavioral change to achieve optimal functioning are smoking cessation and healthy diets. Consider the following example of how this model can be applied to functional assessment and intervention with older adults: Mr. Rogers is evaluated by a physical therapist in his home following a recent hospitalization for a syncopal episode at church that resulted in a fall but no serious injuries. The physical therapist observes that Mr. Rogers seems unaware that he has adopted a dangerous method of getting off the toilet by pulling on the towel rack on one of the shower doors (precontemplation stage). During the goal-setting process, the physical therapist explains to Mr. Rogers that he is at risk for falling when transferring and that physical therapy can help him get stronger and teach him a safer way to get off the toilet by installing a raised toilet seat with handles on the toilet. Mr. Rogers says that he will think about it (contemplation stage). If Mr. Rogers is willing to take an active role in restoring his ability to transfer safely with the device, he will agree and allow the physical therapist to order a device, and be ready to begin using the device at his next session (preparation stage). Mr. Rogers will be compliant with the home program provided by his therapist and, when ready, will practice the transfer (action stage). Mr. Rogers will become safe and independent in this skill and will continue to use the techniques learned through physical therapy long after the therapist discharges him from the service (maintenance stage).
While the ultimate goal of any physical therapy intervention is to maximize functional independence, participation, and quality of life, there are always additional considerations that may shape or influence a practitioner’s course of action. Under the best- case scenario, the patient will be in tune with this and strive to attain optimal health and wellness in all aspects of his or her life. Changing behaviors and readiness for change A collaborative approach between practitioner and client helps identify things that the client wants, needs, and is expected to do. Once the goals are identified, it is up to the physical therapist to determine potential ways to achieve those goals. For older adults, interventions may range from restoration of function to training in compensatory strategies or adaptation of the environment. Often, more than one option exists. When using a true client-centered approach to goal setting and goal achievement, it is important for physical therapy practitioners to share these options with the client, allowing the client (when able) to determine his or her own course of action. To assist patients in this matter, the physical therapist may have to add a coaching element to the intervention (Nessen, Opava, Martin, & Demmelmaier, 2014). A useful framework for assisting older adult clients in this process is the Transtheoretical Model of Change (TTM; Prochaska & DiClemente, 1983; Prochaska & Velicer, 1997). Frequently used in health promotion, the TTM provides a framework for determining a person’s readiness and willingness to change his or her habits, behaviors, and routines. The TTM describes change as a multi-step process: ● Precontemplation. ● Contemplation. ● Preparation. ● Action. ● Maintenance.
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