By Renee DiIulio

Treating the whole geriatric patient with an eye on compression of morbidity.

If we are lucky, we will grow old. If we are really lucky, we will be one of the few who reach 75 years of age without having had some major medical trauma. But we would have to be really lucky. According to Timothy Kauffman, PT, PhD, a partner at Pennsylvania-based Kauffman-Gamber Physical Therapy, “As a general rule, no one—or very few people—reaches the age of 75 or 80 years without having had some significant medical problem.”

But we need not despair. With a growing elderly population and greater numbers of people living past 100 years of age, more research on the geriatric population has been undertaken. Studies look at how to improve care and compression of morbidity to maintain seniors’ independence longer. Independence is key to a higher quality of life. “When you can’t function—you can’t fix your hair or get to the bathroom—your quality of life is clearly denigrated. Patient rehabilitation significantly keeps people independent,” Kauffman says.

Successful, long-term rehabilitation that maintains a geriatric patient’s independence often calls for a whole-body approach, rather than just a focus on the diagnosis. For instance, a patient may have an arm fracture that brought her in, but there may also be a balance problem that led to the fall that led to the fracture and that will require care, as well if further falls wish to be avoided. Unfortunately, this strategy is not necessarily supported by current payment methods. “Medicare wants a simple, discrete number associated with the diagnosis,” Kauffman says, noting that this method is inadequate because there are multiple outcomes for the same code.

There can also be multiple outcomes for the same treatments, and they depend on both the patient and the provider. “A lot of therapists do not know what the potential is. There are those who feel the geriatric patient will break. There are those who don’t pay attention because the patient is decrepit or cantankerous. But that patient is still a human being, with memories, hopes, and desires, and if you are going to make them stronger, you have to work them,” Kauffman says.

Living in Service
Kauffman was drawn to issues of strength in geriatric patients fairly early in his career. An athlete and a soldier, Kauffman injured his shoulder throwing a football and was reminded of that injury while throwing grenades during the war. Unable to throw overhead and aware that his skills were not comparable to the athlete he sought to be, he became interested in rehabilitation. He took a break from military service to obtain a physical therapy certificate from the University of Pennsylvania, Philadelphia, and then he returned to active duty. When he completed his service, he entered graduate school at the Medical College of Virginia, Virginia Commonwealth University, Richmond, Va, and completed his PhD at LaSalle University, Philadelphia.

It was in Virginia where he was first exposed to courses in geriatrics. “I entered physical therapy with a jock mentality and thought that if you exercised a muscle, it would make it stronger; but that didn’t work in geriatric patients,” Kauffman says. He saw older patients die as a result of conditions that arose after the initial injury—for instance, fatal respiratory tract infections that occurred in patients unable to walk as a result of hip fractures.

Finding this unacceptable, he began research on strength training in the geriatric population. Kauffman was enlightened by a lecture on the theories of aging that looked at the inability to synthesize proteins in old age compared to younger ages. Suddenly, he understood why it was difficult to build strength in geriatric patients.

The “aha” moment led to the research he published in 1985 on strength training of the small finger muscle. “Back in the ’70s, you did not load old people with exercise because you would hurt them. So to be able to conduct the research, I had to do something that would not be seriously injurious,” Kauffman says, explaining his choice of the little finger.

Living Longer
That work led to further research on subjects that include hip fractures, balance and falls, and osteoporosis—a current topic of interest for Kauffman. Eventually, Kauffman was asked to author a book, The Geriatric Rehabilitation Manual, which was published in 1999. The second edition is currently in production and is due out by early next year. The new edition will include the theories of aging left out of the first book, such as those on protein synthesis.

A hallmark of aging is the accumulation of chronic diseases. “For example, by age 45, almost everyone has arthritis in the spine. By 45 to 55, most everyone has visual changes. By 55, women begin to develop osteoporosis.

More people are reaching the age of 100 years, but very few—Kauffman estimates 10%—get there without disease. According to the US Census, there were an estimated 50,454 centenarians in 2000, up from 37,306 estimated in 1990. According to Kauffman, projections suggest there will be 1 million centenarians in the United States by 2080.

Living Better
Longevity is great, as long as quality of life remains high. The goal, therefore, becomes not just to extend life but to extend the quality of life, a term often referred to as “compression of morbidity.”

“Compression of morbidity keeps people independent as long as possible. Someone who is 65 or 70 years of age could have a life expectancy of 161/2 years. However, their independent life expectancy is only 10 years, meaning 61/2 years of dependency,” Kauffman says.

Advances in medical care have led to less dependency, but Kauffman believes that no other health care providers do for physical mobility what physical therapists do. Earlier intervention will have greater success.

Kauffman offers an example: A patient has arthritis of the knee that is so painful, he cannot walk. Unable to move around, the patient grows obese, a condition that soon leads to diabetes. The diabetes, in turn, brings on kidney disease, and so on. “With an approach toward compression of morbidity, the patient receives treatment for the knee arthritis that allows him to get back on his feet, avoiding the conditions that could result from lack of activity,” Kauffman says.

Treatment, however, may not be so cut and dried. “Exercise is just like a drug in that if you use the wrong one, you will not get the desired benefit,” Kauffman says. Treatment modalities are the same as with patients of other ages, though Kauffman cautions that modifications may be necessary. A hot pack may not need to be as hot for the elderly patient whose skin is more sensitive and can burn more easily.

However, the real challenge in treating geriatric patients is in treating the whole person rather than just a diagnosis. Each patient is unique, with his or her own set of chronic diseases, and these can impact the treatment pursued.

A clear example of the need for this strategy can be seen in the approach Kauffman takes to the geriatric patient with back pain. “The pain could be related to arthritis or a disk problem. A disk problem would typically be treated with extension exercises. But extension can aggravate a spinal stenosis, which should be treated with flexion. Add a hip replacement that limits the distance the patient can flex, and it becomes clear that an evaluation of the whole person is necessary before treating,” Kauffman says.

This takes more time. “It does require a tremendous amount of attention to evaluate the whole patient. One day, I saw a championship football player and a blind, 90-year-old patient with a hip fracture. I loved treating both, but the athlete was much easier to treat,” Kauffman says.

Living Well
Even if a provider recognizes the need to view the geriatric patient as a whole, he or she may encounter challenges in actually delivering care and receiving payment. Kauffman wrote a paper about the patient with the broken arm and bad balance mentioned in the introduction specifically to produce literature that would encourage changes in the system. “Medicare will ask, ‘Why are you treating her foot when she broke her arm?’ The code for a humeral fracture does not coincide with that for balance or gait training,” Kauffman says.

The code also does not change with outcome. “The number for a stroke will be the same whether that person dies from the stroke in 2 days, or is rehabilitated and walks out in a week, or has residual problems for 6 months and never walks again,” Kauffman says.

Caps are equally frustrating. Follow-up care can be key to achieving compression of morbidity. “Just as a physician can have a patient return in 6 months to recheck their blood pressure, so the PT should be able to follow up. A patient with a hip replacement may walk great following surgical rehabilitation, but let’s recheck balance in 6 months. Perhaps they slipped on a wet floor or walked across rutted grass. Let’s make sure they’ve recovered and can remain independent and avoid further injuries,” Kauffman says.

Getting patients to listen to you can also be a challenge, but Kauffman suggests talking to them about dependence versus independence. “This will often get their attention,” Kauffman says.

Respect goes a long way, too. “The person sitting in front of you is still a human being. They may have a rounded back, sunken eyes, wrinkled skin, poor hair and skin color, and twisted fingers and toes, but they also have a heart and people who love them. If you take an interest in their lives, they are very robust,” Kauffman says. Because eyesight and hearing can be affected in old age, Kauffman suggests that communication becomes more imperative and that touch can be especially important.

The approach can make a difference. Kauffman recalls an elderly male patient in a nursing home whose PT determined that the patient could not walk. Two weeks later, Kauffman had him walking.

“The interesting thing is almost all of us will see geriatric patients. We won’t necessarily see athletes or children, but we will see older patients,” Kauffman says, making the geriatric patient, just like aging, unavoidable but not untreatable.

Renee DiIulio is a contributing writer for Physical Therapy Products.